BOOK OF ABSTRACTS

Abstracts

Mikel Prieto1, Andres Valdivieso1,2, Mikel Gastaca1,2, Alberto Ventoso1, Patricia Ruiz1, Ibone Palomares1, Amaia Matarranz1, Jorge Ortiz de Urbina1 1 Cruces University Hospital, Bilbao, Basque Country, Spain, 2University of the Basque Country, Bilbao, Basque Country, Spain Objectives Early diagnosis of VC during OLT may facilitate salvage of allograft, avoiding retransplantation. Intraoperative HAF and PVF could asses the adequacy of vascular reconstruction. The aim of this study is to analyse the possible correlation between intraoperative HAF and early VC within the first month.   Method We performed a retrospective study of 345 consecutive OLT between January 2007 and October 2012. 333 patients constituted the study cohort after excluding 12 patients (3 death <24h and 9 with no TTFM). HAF were measured intraoperatively by transit time flow measurement (TTFM) (MediStim VeriQ) after complete revascularizationofthegraft.AllpatientsunderwentDopplerultrasound(DU)onthefirstandseventhpostoperative day. Subsequent DU and/or angioCT were based on clinical and radiological findings. If a VC was suspected angiography was performed for confirmation and treatment if indicated. Two groups were established: HAF major or minor than 100 ml/min.   Results The main VC were arterial stenosis (3.6%) mainly treated by angioplasty (50%) and arterial thrombosis,0.6%. There were four relisted patients for retransplantation because of VC (1.2%), and three of them were retransplanted (0.9%). The majority of patients belong to the HAF>100ml/min group (96,4%) and only 12 patients had HAF<100 ml/ min. Differences in VC between the two HAF groups were not statiscally significant: 4.1% (13/321) vs 8.3% (1/12) respectively(Pearson χ2=0,5 p=0,46).   Conclusions Routine use of intraoperative TTFM for HAF could assess the adequacy of vascular reconstruction. Although we can not say that the threshold of <100ml/min is associated with a higher risk of VC in the early postoperative period, there is a trend in this way , so we recommend close monitoring of these patients.    

1 Intraoperative low hepatic artery flow (haf) in adult orthotopic liver transplantation (olt) determinates early vascular complications (vc)

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
2

E-AHPBA

Yukihiro Iso, Keiichi Kubota Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan

Objectives Background: The current standard treatment for extrahepatic distal bile duct carcinoma (EDBDC) is surgical resection, as no effective alternative treatment exists. In this study, we investigated the treatment strategies and outcomes for 77 cases of EDBDC at our department. Method Methodology: Between April 2000 and December 2011, 77 pancreatoduodenectomies (PDs) were performed for EDBDC. Results Lymph node metastasis was present in 22 patients, while it was absent in 55. The 1- and 3-year survival rates for N+ patients were 61.9% and 18.6%, respectively. Six cases showed hepatic-side ductal margin (HM) positivity for carcinoma. Median survival times for cases whose HMs were positive and negative for carcinoma were 10.5 and 57.6 months, respectively (P=0.05). Subclass analysis of 55 cases excluding 22 N+ cases revealed 5 patients with positive HMs and 50 patients with negative HMs. Median survival times for HM-f positive, HM-m positive, and negative patients were 7.0, 21.1, and 31.1 months, respectively (P=0.04). Conclusions Conclusion: HM-f positivity is an indication of poor prognosis in cases of N- EDBDC, and therefore extended bile duct resection is necessary to avoid this. However, when HM-f is positive in N+ cases, additional resection of the bile duct is not necessary for achieving HM negativity.

3

Abstracts

1.1 Clinical importance of negative hepatic-side ductal margin during surgery for extrahepatic distal bile duct carcinoma

Abstracts

Simone Conci1, Andrea Ruzzenente1, Calogero Iacono1, Francesca Bertuzzo1, Tommaso Campagnaro1, Alessandro Valdegamberi1, Orazio Ruzzenente2, Gianluca Salvagno2, Fabio Bagante1, Marco Piccino1, Alfredo Guglielmi1 1 Department of Surgery, Division of General Surgery A, G.B. Rossi University Hospital, Verona, Italy, 2Department of Life and Reproduction Sciences, Division of Clinical Biochemestry, G.B. Rossi University Hospital,, Verona, Italy Objectives Mucin 5AC (MUC5AC) is a glycoprotein protein that is expressed by different human tissues and has been identified in different epithelial cancers including biliary tract cancers (BTC). The aims of this study were to investigate role of MUC5AC as serum marker for BTC and its prognostic value after radical surgery. Method Quantitative assessment of serum MUC5AC was performed with ELISA method in a total of 94 subjects from January 2007 to July 2012. Study population included: 49 patients with BTC, 23 patients with benign biliary disease (BBD), 6 patients with other primary or secondary liver tumors (LT) and 16 healthy control subjects (HC). Among the four groups the diagnostic and prognostic values of MUC5AC were compared to levels of Ca 19-9 and CEA with ROC curves analysis. A total of 34 BTC patients underwent surgical resection with curative intent and were considered for survival analysis. Results MUC5AC was higher in BTC patients (mean 17.93±10.39 ng/mL) compared to BBD (mean 5.95±5.39 ng/mL) (p=0.02), HC (mean 2.74±1.35 ng/mL) (p<0.01), and LT (mean 10.11±12.46 ng/mL) (p<0.01). ROC curves comparing MUC5AC, Ca 19-9 and CEA showed an AUC of 90.1, 85.2 and 64.7, respectively (p<0.01). In BTC patients serum MUC5AC > 14 ng/mL was associated with lymph-node metastasis (p=0.05) and AJCC/UICC stage IVb disease (p=0.04). In 34 resected patients MUC5AC > 14 ng/mL was associated with shorter survival time compared to MUC5AC < 14 ng/mL, with a 3 years survival rate of 21.5% and 59.3%, respectively (p=0.039). Conclusions MUC 5AC seemed to be a useful new serum marker for BTC with accuracy greater than CEA and CA 19-9. Moreover quantitative assessment of serum MUC 5AC might be associated with tumor burden and long-term survival for patients with BTC undergoing surgery with curative intent.

1.2 A novel serum marker for biliary tract cancer: diagnostic and prognostic values of quantitative evaluation of serum Mucin 5AC

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
4

E-AHPBA

1.3 Adult Choledochal Cyst Excision: A single centre UK experience over 17 years

Objectives Adult choledochal cysts are rare in the West. Recent published data on malignancy rates and outcomes are mainly from Japanese and Korean centres. This study aims to show the experience of a UK tertiary referral centre and compare the results with that of the Far East. Method A retrospective observational study of all adult patients who underwent surgery for a choledochal cyst during the period 1995-2012 was performed. Patients who underwent liver transplantation for Caroli’s disease were excluded. Data was obtained from a prospectively maintained institutional surgical and pathological database. Patient’s demographics, clinico-pathological data, operative parameters and post-operative outcomes were recorded. Primary outcome was the incidence of simultaneous biliary tract malignancy in the presence of a choledochal cyst and of late onset biliary tract malignancy following resection of choledochal cyst. Complications of surgery were observed as secondary outcomes. Results  Forty adult patients underwent surgery for choledochal cyst with a male to female ratio of 1:7. Median age was 39. All had excision of an extrahepatic choledochal cyst and hepaticojenenostomy (HJ). 3 (7.5%) patients had an incidental cancer in the excised choledochal cyst. 1 of these was synchronous with a gallbladder cancer. 1 patient developed an unresectable biliary tract malignancy within 18 months of excising a benign choledochal cyst. Published data report an incidence of simultaneous malignancy of 9.7% and late malignancy of 0.7% The most frequent complications were at the HJ anastomosis with 4 leaks and 5 strictures. Conclusions Both the incidence of simultaneous and late onset biliary tract malignancy following excision of a choledochal cyst in the West seems to be similar to the results from the Far East. Surgeons should be aware of the risks and where possible these patients should be managed at specialist centres.

5

Abstracts

Edwin Faulconer, Alexander Navarro, Homoyon Merhzad, Zergham Zia, Darius Mirza, Simon Bramhall, John Isaac, Paolo Muiesan, Robert Sutcliffe, Ravi Marudanayagam Queen Elizabeth Hospital, Birmingham, West Midlands, UK

Abstracts

1.4 Insufficient safety measures reported in operative notes of complicated laparoscopic cholecystectomies 
Philip de Reuver, Klaske Booij, Thomas van Gulik, Olivier Busch, Dirk Gouma Academic medical center, Amsterdam, The Netherlands

Objectives A recent nationwide survey showed the use of the critical view of safety (CVS) technique, as addressed in the 2007 Dutch guideline for laparoscopic cholecystectomy (LC), by > 90% by the Dutch surgeons. However the use of the CVS technique in a selective group of patients with a bile duct injury (BDI)  was never investigated. The aim of this study is to analyze the accuracy of dictated operation notes and the use of CVS during LC in BDI patients before and after guideline implementation. Method Between 1990 and 2012, 801 patients were referred for treatment of BDI. All available operation notes were scored for procedural conditions, reasons for conversion, the use of safety measures and postoperative care in BDI patients. Results The 528 patients from whom operation reports were analysed, LC was started in 479 patients (91%), which was converted to open surgery in 180 patients, due to detected BDI (n=64), inflammation (n=95), and bleeding (n=21). Safety measures as performing the CVS technique or complete dissection of Calot’s triangle were reported in 7% and 17%, respectively. Cholangiography was performed in 11%. Guideline implementation after 2007 resulted in increase of reported CVS from 4% before 2007 to 17% after 2007 (p<0.01), increased consultation of a HPB colleague (2% vs 8%p< 0.01), and quicker referral to a tertiary centre from 202 days to 42 days (p<0.01). Conclusions The insufficient use of safety measures to prevent BDI during LC in this selected group of BDI patients is in contrast with the outcome of a recent survey among Dutch surgeons. Guideline implementation significantly improved the use of safety measures during LC and postoperative care in BDI patients.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
6

E-AHPBA

ANTONIO PESCE, TERESA ROSANNA PORTALE, VINCENZO MINUTOLO, ROBERTO SCILLETTA, GIOVANNI LI DESTRI, STEFANO PULEO A.O.U. Policlinico-Vittorio Emanuele, Catania, Sicily, Italy Objectives Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak and common missed bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 laparoscopic cholecystectomies (Lcs), all of which involved major biliary complications and which were performed without the use of intraoperative cholangiography, have been reviewed. Method Data were analyzed of 1,100 selected patients (728 females and 372 males) undergoing laparoscopic cholecystectomy without the use of intraoperative cholangiography from January 2003 to November 2011. 170 Lcs were performed by young surgeons during the learning curve, 930 by surgeons with over ten years of experience. Two techniques were used to create pneumoperitoneum: the Veress Technique in 319 cases (29%) and the Hasson Technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study. Results Two common bile duct injuries (0,18%) and three biliary leaks (0,27%) were detected among this group. Thirtythree patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in four cases (0,36%). There was no postoperative mortality Conclusions LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to open approach in doubtful cases are important measures which must be taken to prevent common bile duct injury.

7

Abstracts

1.5 Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1100 selected patients

Abstracts

1.6 Is the severity of bile duct injury caused after converted laparoscopic cholecystectomy worse?
Philip de Reuver, Klaske Booij, Bram Nijssen, Thomas van Gulik, Olivier Busch, Dirk Gouma Academic Medical Center, Amsterdam, The Netherlands

Objectives The benefit of conversion to open surgery during laparoscopic cholecystectomy (LC) is under discussion as experience with this procedure decreases. Conversion in difficult cases may even lead to more severe bile duct injury (BDI). The aim of this study is  to analyze type of injury according to the Amsterdam classification and height of injury (according to the Bismuth classification) of converted LC’s in BDI patients. Method Between 1990 and 2012, 804 patients were referred for treatment of BDI. Operation notes of 479 patients were available for detailed analysis as BDI patients without available operation notes (n=277) and after primary open surgery (n=49) were excluded.Classification of injury was compared between LC’s and LC’s with conversion. Results A complete laparoscopic procedure was performed in 299 (62%) patients. Conversion (n=180, 38%)  was performed due to detected BDI (n=64), due to limited overview (n=95), and due to a bleed (n=21). BDI reported before conversion was classified as a bile duct transection, in 78% (50/65) of the procedures,  compared to 56% (65/116) transections in patients in which BDI was reported after conversion (p<0.01). BDI reported after conversion is significantly worse (Type D injury in 56 %, 56/116) and more proximal (Bismuth IV-V in 50%, 58/116) versus the injury caused during a completely laparoscopic procedure (Type D injury in 37%, 110/299 and Bismuth IV-V in 36%, 109/299).      Conclusions Analysis of a selected group of BDI patients suggests that conversion to open surgery does not prevent BDI and is associated with worse outcome in terms of injury classification.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
8

E-AHPBA

Stijn van Laarhoven, Wim Drouven, Aad van den Berg, Els Haagsma, Koert de Jong University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

Objectives With an incidence up to 25%, chronic renal failure (CRF), defined as Glomerular filtration rate (GFR) < 30mL/ min/1.73m2, on chronic dialysis or after renal transplantation, is a common complication after orthotopic liver transplantation (OLT). This study investigates the incidence and risk factors (RF) for developing chronic renal disease (CRD) defined as a GFR < 60mL/min/1.73m2) after OLT in our center over a follow-up period of 20 years. Method Using our prospectively maintained database, we identified those patients (age≥18) who underwent a first OLT between April 1979 and February 2011 developing CRD or CRF. Patients with know pre-OLT CRF and those who did not survive the first three post-operative months were excluded. We used logistic regression analysis to identify RF for the development of CRD. Results 563 patients met inclusion criteria. CRF and CRD developed in 3.9% and 23.3% 10-years, and 4,3% and 20,4% 20-years post-OLT respectively. At 1- and 5-years post-OLT, age at OLT is a RF for CRD (OR 1.05, p<0.001) and (OR 1.06, p<0.001) respectively. Male gender decreases risk (OR 0.40, p<0.001) and (OR 0.55, p<0,03) respectively as does pre-OLT GFR>60 (OR 0.97, p<0.001) and (OR 0.98, p<0.001) respectively. At 10-years RF are age at OLT (OR 1.05 p=0.001) and post-OLT hypertension (OR 2.78 p=0.002). pre-OLT GFR>60 decreases risk (OR 0.98, p=0.006). At 15-years post-OLT hypertension remains a RF (OR 4.88 p=0.001). Conclusions CRD is a major major cause of morbidity in the post-OLT population.  We identified female gender, age at OLT, pre-OLT kidney function and post-OLT hypertension as risk factors. The latter is only important in the long run and is the only potentially modifiable risk factor. Calcineurin inhibitors do not significantly influence renal function in our center

9

Abstracts

2 Incidence and risk factor analysis for chronic renal disease after liver transplantation. A long term follow-up study.

Abstracts

Steffi Rombouts1, Samira Fegrachi1, Hjalmar van Santvoort1, Marc Besselink1,2, Richard van Hillegersberg1, Quintus Molenaar1 1 University Medical Center Utrecht, Utrecht, The Netherlands, 2Academic Medical Center Amsterdam, Amsterdam, The Netherlands Objectives Ablative techniques are being explored as a new treatment option for locally advanced pancreatic cancer (LAPC). Unlike radiofrequency ablation, irreversible electroporation (IRE) is a non-thermal ablation technology and might therefore preserve vascular and ductal structures. The aim of this study was to evaluate the safety and potential benefits of IRE in the pancreas, especially in patients with APC. Method A systematic search was performed in PubMed, Embase and the Cochrane Library for English articles published until February 2013 and subsequently reviewed according to the PRISMA guidelines. Included were studies reporting on the outcomes of IRE in LAPC (clinical and experimental studies) or healthy pancreatic tissue (animal studies). Exclusion criteria were: 1) studies that did not report morbidity and mortality; 2) case reports; 3) conference abstracts and 4) studies in non-English language. Baseline characteristics as well as study characteristics were extracted. Outcomes expressed as morbidity, mortality and overall survival were extracted from the articles. Results After screening 143 studies, 6 studies were included. Two experimental studies performed IRE in healthy pancreatic tissue of 10 pigs. The IRE-related mortality was 0% and overall morbidity 0-16%. The third experimental study  randomized 40 mice with orthotopic pancreatic cancer xenografts to IRE (n=24) or conservative treatment (n=16). Mice undergoing IRE showed 0% IRE-related morbidity and mortality. Median survival was 88 days in IRE-treated mice versus 42 days in the untreated group (p<0.01). The clinical studies, involving 95 patients, reported overall morbidity of 14-59%, IRE-related morbidity of 7-14%, and mortality of 0-3%. Only one study (n=139) reported median survival of 20.2 months. Conclusions IRE for locally advanced pancreatic adenocarcinoma seems feasible and safe based on experimental and small clinical studies. A large prospective, preferably randomized, study should establish whether morbidity, overall survival and quality of life is improved by IRE as compared to the alternative established treatments. 

2 Irreversible electroporation in locally advanced pancreatic cancer: a systematic review

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
10

E-AHPBA

Mogens Tornby Stender, Anders Christian Larsen, Mogens Sall, Ole Thorlacius-Ussing Aalborg University Hospital, Aalborg, Denmark Objectives To examine the impact of plasma D-dimer levels in predicting two-year survival and non-R0 resection in patients with pancreatic cancer. Method At the time of inclusion we measured D-dimer levels in 101 consecutive patients, and computed Kaplan-Meier survival curves according to the 50% and 75% percentiles of plasma D-dimer levels. Cox proportional-hazard regression analysis was used to compute hazard ratio as a measure of two-year mortality rate ratio, controlling for potential confounding factors. A non-parametric receiver operating characteristic plot was constructed to determine the optimal cut-off level of D-dimer in the diagnosis of non-R0 resection, and diagnostic accuracy indices were assessed. Results The overall two-year survival rate was 20%. The survival probabilities according to D-dimer levels categorized into three groups based on the 50% and 75% percentiles were 33%, 18% and 0%, respectively (Figure 1). The adjusted hazard ratio of death in the group of patients with highest D-dimer levels was 4.1 (95% CI: 2.2 - 7.9) when compared to the group with lowest D-dimer levels. With a cut-off level of 0.4 mg/L the positive and negative predictive values of D-dimer in the diagnosis of non-R0 resection were 96% (95% CI: 86% - 100%) and 42% (95% CI: 29% - 57%), respectively.    Conclusions An elevated D-dimer level is associated with a poor prognosis in pancreatic cancer and is strong predictor of non R0 resection

11

Abstracts

2.1 D-dimer predicts prognosis and non-R0 resection in patients with pancreatic cancer: a clinical prospective cohort study

Abstracts

2.2 Clinico-pathological features and outcomes of Solid Pseudopapillary Neoplasms of pancreas - a single centre Western experience

Bynvant Sandhu, John Isaac, Simon Bramhall, Paolo Muiesan, Darius Mirza, Robert Sutcliffe, Ravi Marudanayagam Queen ELizabeth Hospital, Birmingham, UK Objectives Solid pseudopapillary neoplasms (SPN) are rare pancreatic neoplasms. The aim of this study was to review the clinicopathological characteristics and outcomes of patients with SPN. Method A review of our institution’s surgical and pathological database from January 1996 to November 2012 was performed. All patients with a pathological diagnosis of SPN were included. Clinical, demographic, operative, pathologic and survival data were obtained. Results Ten patients were identified. All were females with a median age of 25 years. The predominant symptom was abdominal pain (90%). Most of the patients had tumour in body or tail of pancreas (70%). The median diameter of the tumour was 9.5cm. R0 resection was performed in 9 patients (90%). No patient had lymph node metastasis. 3 patients had microvascular invasion. There was no peri-operative mortality. At a median follow up of 80.5 months, 9 patients are alive. 1 patient developed distant recurrence 4 years later. The overall 5-year and 10-year survival rates were 85.7% and 80% respectively. Conclusions SPNs are rare neoplasms primarily seen in young women. They are indolent tumours with favourable biological behaviour. Surgical resection offers a good long term survival.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
12

E-AHPBA

Jean-Pierre Arnaud, Alexandra Roch, Patrick Pessaux University Hospital of Angers, Angers, France Objectives Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy. The aim of this multicenter prospective randomized trial was to compare the results of pancreaticoduodenectomy with an external drainage stent versus no stent. Method Between 2006 and 2009, 158 patients who underwent pancreaticoduodenectomy were randomized intraoperatively to either receive an external stent inserted across the anastomosis to drain the pancreatic duct (n=77) or no stent (n=81). The criteria of inclusion were soft pancreas and a diameter of Wirsung <3mm. The primary study end point was pancreatic fistula defined as amylase-rich fluid (amylase concentration > 3 times the upper limit of normal serum amylase level) collected from the peripancreatic drains after postoperative day 3. CT scan was systematically done on day 7. Results 2 groups were comparable in demographic data, presenting symptoms, comorbid illness and preoperative biliary drainage. Mortality, morbidity and pancreatic fistula rates were 3.8%, 51.8% and 34.2% respectively. Stented group had a significantly lower overall morbidity (41.5% vs. 61.7%, p=0.01), pancreatic fistula (26% vs. 42%, p=0.034) and delayed gastric emptying (7.8% vs. 27.2%, p=0.001) rates. Radiologic or surgical intervention for pancreatic fistula was required in 9 patients in the stented group and 12 patients in the nonstented group. There were no significant differences in mortality rate (3.7% vs. 3.9%, p=0.37) and in hospital stay (22 vs. 26 days, p=0.11). Conclusions External drainage of pancreatic duct with a stent reduced pancreatic fistula and overall morbidity rates after pancreaticoduodenectomy.

13

Abstracts

2.3 External Pancreatic Duct Stent Decreases Pancreatic Fistula Rate after Pancreaticoduodenectomy: Prospective Multicenter Randomized Trial

Abstracts

2.4 A pre-operative predictive score of pancreatic fistula following pancreaticoduodenectomy
Keith Roberts, James Hodson, Ravi Marudanayagam, Robert Sutcliffe, Paolo Muiesan, John Isaac, Simon Bramhall, Darius Mirza University Hospitals Birmingham NHS Trust, Birmingham, UK

Objectives Various patient and pancreatic gland factors are related to the development of pancreatic fistula (PF) following pancreaticoduodenectomy (PD). PF, recently defined by the International Study Group on Pancreatic Fistula, is responsible for the majority of morbidity and mortality following PD. This study sought to develop a preoperative predictive score of PF.  Method Factors that may affect PF were subject to univariate analysis in a modelling set of patients. A multivariable backwards stepwise logistic regression model was used to develop a predictive score of PF and tested upon a separate cohort. Results 325 patients were identified with 2:1 randomly selected to the modelling and validation sets. PF occurred in 77 patients (23.7%) and associated with twelve factors. On multivariate analysis body mass-index and pancreatic duct width (assessed by pre-operative CT imaging) were independently associated with PF. A risk score to predict PF was designed (the AUROC curve was 0.832 (95% CI: 0.768 - 0.897, p<0.001) and successfully tested upon the validation set (Fig 1: performance of the modelling/validation sets in predicting PF). The utility of the score in predicting PF is demonstrated for patients with different BMI and duct width (Fig 2). Conclusions This is the first predictive score of PF based solely on pre-operative data. Pre-operative assessment of a patient’s risk of PF is possible using simple measurements. This score facilitates an individualised approach to consent prior to PD. Furthermore it will enhance clinicians’ decision making regarding patient selection for PD and may influence intra- and postoperative management.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
14

E-AHPBA

2.5 Improving outcome after pancreaticoduodenectomy      Abstracts
Marielle Coolsen, Arwind Chigharoe, Ronald van Dam, Kees Dejong University Hospital Maastricht, Maastricht, The Netherlands

Objectives Pancreaticoduodenectomies (PDs) have been performed from the early nineties in our clinic. We adopted an enhanced recovery after surgery (ERAS) programme for pancreatic surgery since 2006. The objective of this study was to examine patient characteristics, indications and outcome after PDs in the past 16 years and to evaluate the effects of implementing an ERAS programme for pancreaticoduodenectomy.     Method Retrospective case series of 230 patients undergoing pancreaticoduodenectomy for malignant tumors in Maastricht University Medical Centre, an academic referral-based centre, between January 1995 and December 2011. Group 1 (1995-2005) received traditional care. From January 2006 we started implementing some elements of an enhanced recovery after surgery pathway for pancreatic surgery (group 2: ‘ERAS like’). From 2009 a definitive enhanced recovery after surgery pathway was implemented (group 3: ERAS).  Mortality, complications (pancreas surgery related as well as general complications), readmissions and length of hospital stay were evaluated in the subgroups in three different time periods and compared.      Results In group 3 patients were significantly older, other demographic characteristics were not significantly different.  Median length of stay (LOS) was significantly reduced from 21 days in group 1 (1995-2005) to 14 in group 2 (2006-2008) and 15 in group 3 (2009-2011). Patients discharged without complications had a median LOS of 16, 11 and 10 respectively in group 1,2 and 3 (p<0,007). Overall morbidity was not statistically different between groups (60,8%, 55,3 and 60,5% respectively). The need for re-interventions decreased, with more re-interventions managed non-operatively. Readmissions and mortality rates also decreased in time.    Conclusions From 1995 onwards, outcomes after PD have  improved in our hospital. Length of hospital stay decreased as well as readmissions and mortality. Morbidity rates remained about the same with more complications managed non-operatively. Implementing an ERAS programme resulted in a further decrease of LOS without compromising other outcomes.

15

Abstracts

S.H.E.M. Clermonts1, M. M. E. Coolsen1, R. M. van Dam1, L. P. S. Stassen1, S.W.M. Olde Damink1, I. H. de Hingh3, I.Q Molenaar4, U. P. Neumann2, C.H.C. Dejong1 1 Dept. of Surgery Maastricht UMC., Maastricht, The Netherlands, 2Dept. of Surgery Universitatsklinikum., Aachen, Germany, 3Dept. of Surgery Catharina Hospital Eindhoven., Eindhoven, The Netherlands, 4Dept. of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands Objectives  Prophylactic abdominal drainage after pancreaticoduodenectomy(PD) has been standard of care for many years. However, recent studies assessing the efficacy of such drains have shown that these drains have no advantage over avoiding prophylactic postoperative drainage or even that the use of such drainage may be harmful. Method  The PANDA trial is a multicentre, randomized controlled trial comparing prophylactic abdominal postoperative drainage versus a no drain policy after PD. 360 patients programmed for pancreaticoduodenectomy will be randomized either to receiving a prophylactic abdominal drain placed near the pancreatic anastomosis during surgery (according to routinely applied protocols) (control group). The drain will be removed on POD 4.  Or to receive no drain, the expirimental group..  All patients will be managed within an Enhanced Recovery After Surgery (ERAS) programme of perioperative care. Results   The primary outcome measure is the number of radiologic or surgical (re-)interventions, specifically for anastomosis related complications. Summerized in a PD-specific composite endpoint, consisting of: intraabdominal abscess, sepsis, intra-abdominal post pancreatic surgery hemorrhage ISGPS-B/C, bile leakage, gastrojejunostomy leakage, pancreatic anastomosis leakage ISGPF-B/C, delayed gastric emptying and operative mortality within 90 days.   All interventions for complications are documented and categorized for severity using the Clavien-Dindo classification. Re-interventions are defined as the administration of antibiotics, endovascular coiling or stenting, ultrasound or CT guided drainage or relaparotomy.  The secondary outcomes are time to functional recovery, complications, readmissions and total length of hospital stay. Conclusions  This randomized controlled trial will shed light on whether prophylactic drainage after pancreaticoduodenectomy can be abandoned.

2.6 PANDA trial - “PAncreaticoduodeNectomy   and Drainage After surgery. A multicentre, randomized controlled trial of prophylactic abdominal drain versus a no drain policy after pancreaticoduodenectomy, within an enhanced recovery after surgery pathway.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
16

E-AHPBA

Åsmund Avdem Fretland1,3, Andrey Sokolov2, Nadya Postriganova1, Andrey M Kazaryan4, Bård I Røsok3, Bjørn Atle Bjørnbeth3, Tom Eirik Mollnes2, Bjørn Edwin1,3 1 The Interventional Centre, Oslo University Hospital, Oslo, Norway, 2Department of Immunology, Oslo University Hospital, Oslo, Norway, 3Department of Gastrointestinal and Paediatric surgery, Oslo University Hospital, Oslo, Norway, 4Skien Hospital, Sykehuset Telemark Health Trust, Skien, Telemark, Norway Objectives The Oslo CoMet-study is an open, randomized, controlled trial comparing open and laparoscopic resection for colorectal liver metastases (CRLM).  The primary end point is complication rate. The aim of this sub-study was to explore differences in activation of the cytokine network, as judged by Interleukin-6 (IL-6), between the two techniques. Method The first 45 patients in the trial were included in the sub-study. All patients were operated with local resection of one or more CRLM, liver parenchyma was divided using LigaSure®, assisted by the SonoSurg Aspirator® or Endo-GIA®. Blood samples were obtained preoperatively, after induction of anesthesia, at set time points during surgery and 2, 6 and 24 hours after surgery.  EDTA-plasma was snap-frozen at -80oC and analysed for IL-6 using luminex technique after thawing. Results  In the open group, IL-6 increased significantly from 27 pg/mL before operation, to a maximum of 72 pg/mL at the end of surgery and declined to 42 pg/mL 24 hrs postoperatively (n=21). In contrast, IL-6 remained stable from start of operation (25 pg/mL) during the observation period with a slight increase to 27 pg/mL at the end of surgery in the laparoscopic group (n=21). The difference between the groups at the end of surgery was statistically significant (p=0.004).   Conclusions These data indicates that open liver resection for CRLM induces a more pronounced inflammatory response than the laparoscopic technique.  

17

Abstracts

3 Open liver resection for colorectal metastases induced a significant increase in Interleukin-6 as compared to laparoscopic technique.

Abstracts

3 Intraoperative Optical Coherence Tomography in Determining Borders of the Klatskin Tumor

Vladimir Zagainov1, Valentin Kukosh1, Sergey Vasenin1, Gleb Gorochov1, Lubov Shkalova1, Elena Zagainova2 1 Volga District Medical Centre under Federal Medical and Biological Agency, Nizhny Novgorod, Russia, 2Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russia Objectives To define the efficiency of the Intraoperative Optical Coherence Tomography (iOCT) in determination of tumor borders on the basis of the histological investigation of removed specimens after the resection of the extrahepatic bile ducts and long-term outcomes. Method To determine the borders of the Klatskin tumor iOCT was used in 27 patients with device «OCT 1300-U». Technical characteristics of the device are: length of a wave - 1300 nm; diameter of the multipurpose scanner 2,7 mm; lateral permission - 25 µm; depth of sounding - 2 mm; time of obtaining the image - 1,5-2 seconds. The scanning was performed by pressing the probe to the external surface of the bile duct without lumen opening. Considering small layer thickness of bile ducts, it was possible to obtain iOCT images of the bile duct wall. Results On the iOCT images of unchanged bile ducts a stratified structure was noticed: mucosal, muscular and adventitional layers. Unstratified structure was determined as a tumor. The border of the tumor is considered to be the appearance of the first stratified image of the duct wall by moving the probe from the centre of the tumor to the proximal direction. The resection was done 5 mm on available directions. There was no tumor growth in resection line during histological investigation in 92,6%. Studying of the long-term results from 6 months to 5 years established absence of local recurrence of a tumor. Conclusions IOCT allows to determine the proximal border of the bile duct tumor. It allows to choose necessary volume of operation and to provide radicalism of intervention. Resection of the bile ducts with the definition of the structure of the wall should be considered as a standard treatment for Klatskin tumor.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
18

E-AHPBA

Michael Sutton, Rico Bense, Ton Lisman, Erik van der Jagt, Aad van den Berg, Robert Porte University Medical Center Groningen, Groningen, The Netherlands

Objectives Although duct-to-duct anastomosis has been shown as a feasible option for biliary reconstruction in patients undergoing orthotopic liver transplantation (OLT) for end-stage primary sclerosing cholangitis (PSC), it remains unclear whether there is any difference in long-term outcome compared with reconstruction using a Roux-en-Y hepatico-jejunostomy. The aim was to evaluate the long-term outcome after OLT for PSC using either duct-to-duct or Roux-en-Y biliary reconstruction. Method Between January 1, 1991 and December 31, 2011, a total of 98 adult patients underwent OLT for PSC in our center with either a duct-to-duct anastomosis or a Roux-en-Y hepatico-jejunostomy. Median follow up was 8.2 years. Patient characteristics, postoperative complications, patient and graft survival rates, as well as shortterm and long term biliary outcome parameters were compared between groups in a retrospective analysis of a prospectively collected database. Results Duct-to-duct biliary reconstruction was performed in 45 patients and Roux-en-Y hepatico-jejunostomy in 53 patients. Overall patient and graft survival rates were similar between  groups. The incidence of biliary strictures and biliary leakage within one year after transplantation did not differ among groups, however, significantly more patients in the Roux-en-Y group suffered at least one episode of cholangitis within the first year (25% versus 9%; p=0.04). Roux-en-Y reconstruction was associated with a higher rate of late onset (>1 year post-transplant) non-anastomotic biliary strictures compared to the duct-to-duct group (24% versus 7% at 5 years and 30% versus 7% at 10 years; p=0.01). Conclusions The use of duct-to-duct biliary reconstruction in patients with PSC is associated with lower incidences of posttransplant cholangitis and late-onset non-anastomotic biliary strictures, compared to Roux-en-Y hepaticojejunostomy. If technically and anatomically feasible, duct-to-duct anastomosis should be the preferred technique of biliary reconstruction in patients undergoing OLT for PSC.

19

Abstracts

3 Duct-to-Duct Biliary Reconstruction in Liver Transplantation for Primary Sclerosing Cholangitis is Associated with Less Biliary Complications, Compared with Rouxen-Y Hepatico-Jejunostomy

Abstracts

3.1 Neutrophil-to-lymphocyte ratio is an independent predictor for severe complications after major liver resections for perihilar cholangiocarcinoma
Traian Dumitrascu, Irinel Popescu Fundeni Clinical Institute, Bucharest, Romania

Objectives To assess potential risk factors for severe complications after major liver resections (≥ 4 resected segments) for perihilar cholangiocarcinoma, without routine preoperative biliary drainage. Method Seventy patients with major liver resections for perihilar cholangiocarcinoma performed at Fundeni Clinical Institute between 1996 and 2012 were included. Severe complications were considered grade III-V, according to Dindo classification. Factors identified at univariate analysis with a p value < 0.1 were included in a multivariate binary logistic regression model. Results Severe complications rate (including postoperative mortality) was 38.5%. Preoperative biliary drainage was selectively used (15 patients - 21%). Combined portal vein resection was performed in 17 patients (24%). Neutrophil-to-lymphocyte ratio was the only independent risk factor for severe complications at multivariate analysis (HR = 1.31; 95% CI 1.06 - 1.61; p = 0.011). Right hemi-hepatectomy or right trisectionectomy, portal vein resection, cholangitis or preoperative biliary drainage were not associated with an increased risk for severe postoperative complications. Conclusions Major liver resection (with or without combined portal vein resection) for perihilar cholangiocarcinoma can be safely performed, without routine preoperative biliary drainage and with low severe morbidity rates. Preoperative neutrophil-to-lymphocyte ratio accurately predicts development of severe postoperative complications; however the clinical usefulness of this finding remains unclear.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
20

E-AHPBA

Arpad Ivanecz, Rajko Kavalar, Miroslav Palfy, Vid Pivec, Marko Sremec, Matjaz Horvat, Stojan Potrc University Medical Center Maribor, Maribor, Slovenia

Objectives There is an extensive ongoing effort to translate the basic knowledge about biological markers into clinic. The aim of this study was to assess whether these markers can provide additional information to that supplied by Memorial Sloan Kettering Cancer Center clinical risk score (CRS) for colorectal liver metastases (CRLM). Method A retrospective review of a prospectively maintained database was conducted. Patients selected for this study were treated during 1996 and 2006 with potentially curative liver surgery. p53, Ki-67, and thymidylate synthase (TS) were assayed using immunohistochemical techniques on tissue microarrays with samples from 98 patients. These markers were evaluated and compared with clinical predictors of outcome including CRS. Bivariate associations between marker expressions and clinical variables regarding overall survival (OS), progression-free survival (PFS), and hepatic progression-free survival (HPFS) were examined. Independent predictor variables were used and assessed in a multivariate Cox regression model. Results With a median follow-up of 103 months the median CRS was 2. Our analysis revealed a possible correlation between p53 protein overexpression and high CRS (P = 0.058). By multivariate analysis, only high CRS remained an independent negative prognostic predictor for survival (P = 0.018) as well as an indicator of early progression (P = 0.010) and hepatic progression of disease (P = 0.003). Among all biological markers, only Ki67 overexpression was identified as a positive predictor of survival at multivariate level (P = 0.038). TS provided no clinical information. Conclusions p53 overexpression was in correlation with high CRS. Ki-67 overexpression was a positive predictor of survival. Only high CRS remained an independent negative prognostic predictor for OS, PFS, and HPFS.

21

Abstracts

3.2 Can we improve the clinical risk score? The prognostic value of p53, Ki-67, and thymidylate synthase in patients with radically resected colorectal liver metastases

Abstracts

Christian Sturesson1,2, Per Jonas Blind1,2, Bodil Andersson1,2, Bobby Tingstedt1,2, Magnus Bergenfeldt1,2, Roland Andersson1,2, Gert Lindell1,2 1 Clinical Sciences, Lund, Sweden, 2Department of Surgery, Lund, Sweden Objectives Fast-track programs involving multi-modal measures to enhance recovery after surgery, reduce morbidity and decrease hospital length of stay (LOS), are used for different major surgical procedures. For liver resections, factors influencing recovery has been studied only to a limited extent. The aim of the present study was to identify factors prolonging LOS within a fast-track program for liver resections. Method The present study comprises the first 64 patients included in a fast-track program for liver resections introduced in March 2012. Patient outcomes were compared to a historical cohort of patients operated in 2009. LOS was used as a surrogate parameter to measure recovery after surgery. Factors prolonging LOS was analyzed by uni- and multivariate analysis. Results Median length of stay was 6 days within the fast-track program as compared to 8 days in the historical cohort (P=0.004), with no difference in morbidity or readmission rate. On multivariate analysis, factors increasing LOS were found to be the presence of complication, extent of resection and inability to drink > 1250 ml on the day after surgery.  Conclusions Implementation of a fast-track program is possible for liver resections and resulted in a reduced LOS. Patients who can only drink limited amounts of fluid the day after surgery represents a subset of patients with delayed recovery that should be given special attention.           

3.3 Fast-track program for liver resections – factors prolonging hospital length of stay

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
22

E-AHPBA

Matteo Barabino1, Nicolò Maria Mariani1,2, Roberto Santambrogio1, Maria Luisa Biondi1, Mara Costa2, Olivia Turri1, Gabriele Bormolini2, Enrico Opocher1,2 1 A.O. San Paolo, Milan, Italy, 2University of Milan, Milan, Italy Objectives Our goal was to investigate expression and prognostic value of AFP-mRNA in the blood circulation of patients with HCC and liver cirrhosis following liver resection or thermal-ablation.

Method Seventy-eight patients with Hepato-cellular carcinoma (HCC) suitable for curative treatment (resection or thermal-ablation) were prospectively enrolled in the study. Peripheral blood samples were taken immediately before (PRE) and after the operation (POST) and then at 90 days (CTRL). AFP-mRNA was extracted from all blood samples and detected with the Real-Time Reverse Transcription polymerase chain reaction (RT-PCR) procedure Results The overall rate of AFP-mRNA expression was very low (6,7%), namely 4% PRE, 5% POST, 12% CTRL. There was no difference in marker expression based on type of surgical method or clinical and pathological features. Despite the limits of the low expression rate, a more aggressive trend was observed in the positive PRE group in terms of short-term and local recurrence, namely 100% versus 33% (p=0.00001) and 66% versus 9% (p=0.00001). Moreover, patients with overall AFP-mRNA negative expression had a better survival rate (3-year survival 49% versus 26%, p=0.2862), with a significant difference for the negative CTRL group (p=0.0422). Conclusions Considering the expression rate of AFP-mRNA, its routine use as prognostic factor for patients with HCC is not justified. However, our study shows that the disease takes an aggressive course in patients with positive PRE-AFP-mRNA expression, suggesting that those markers may be effective, but only if supported by further studies

23

Abstracts

3.4 Prognostic Value of AFP mRNA in patients with HCC: Real Benefit or Academic Exercise?

Abstracts

Matteo Barabino1, Gabriele Bormolini2, Roberto Santambrogio1, Barbara Cassani1, Nicolò Mariani1,2, Matteo Virdis2, Claudia Marinaro2, Enrico Opocher1,2 1 A.O. San Paolo, Milan, Italy, 2University Of Milan, Milan, Italy Objectives Mutations at KRAS gene have been identified as effective predictive biomarker against treatment of colorectal liver metastases (CLM) with anti EGFR monoclonal antibodies. On the other hand its value as considerable prognostic biomarker is still unclear. Thus we examined this issue in a cohort of patients with colorectal liver metastases.   Method  KRAS mutation status was assessed in sixty-two resected liver metastases and in forty corresponding primitive colorectal cancers. Genotypes of KRAS were analysed by cycleave PCR. We examined the association of KRAS mutation with clinic-pathological features, recurrence rate and survival. Median follow-up after liver resection was 42.9 months.   Results KRAS mutations in CLM were detected in 18 patients (29%); the most frequent mutation was G12D (34%). A high concordance of mutations has been demonstrated between the primary and LM (90%, p=0.0001). No significant marker correlation has been revealed with clinic-pathological features. Biomarker mutations were slightly associated with extra-hepatic metastases either discovered at the time of diagnosis (p=0.07) or during the follow-up (p=0.09). The 5-years survival was not influenced by the presence of mutations in KRAS (55% Vs 59%). At regard to these little differences, is important to stress that 55% of KRAS mutated patients underwent anti-VEGF target therapy Conclusions  KRAS is not significantly associated with an aggressive metastatic behaviour of colorectal liver metastases. These results are consistent with the majority of data in literature suggesting in the “target therapy era” offering multiple effective weapons even in KRAS mutated, it’s really hard to determine plain prognostic value of KRAS.    

3.5 Prognostic Role Of KRAS In The Treatment Of Colorectal Liver Metastases.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
24

E-AHPBA

Victor van Woerden1, Edgar M. Wong-Lun-Hing1, Toine M. Lodewick1, Cornelis H.C. Dejong1,2, Ronald M. van Dam1 1 Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands, 2Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands

Objectives Routine prophylactic abdominal drainage after hepatic surgery may be unnecessary, possibly harmful and uncomfortable for patients. In recent years the quality of hepatic surgery has improved dramatically. With the introduction of an Enhanced Recovery After Surgery programme in our unit in 2005, prophylactic abdominal drain use was abandoned. Method All hepatectomies between 2005 - 2012 (N=396) were included. Prophylactic abdominal drains were only used in highly selected patients (n=32). Endpoints were resection-surface-related complications and re-interventions for resection-surface-related complications (CT or US drainage, relaparotomy or -scopy, thoracotomy, ERCP with stenting), postoperative complications (Accordion Severity Grading System), length of stay, re-admission rate and 90-day mortality. Analysis was performed on patients with high-risk for postoperative complications based on the following high-risk criteria: major liver resection, caudate segmentectomy, rehepatectomy, central resection, liver cirrhosis, portal hypertension, ASA ≥ III. Results 79% of the patients had colorectal metastasis. Multiple metastasectomies or single segmentectomies (39%) and hemihepatectomies (28%) were most frequently performed. Overall morbidity was 32% and liversurface-related complications re-intervention rate was 14%. 56% of patients could be regarded as high-risk and abdominal drains were inserted in 8%. In 25% of high-risk patients without a drain liver-surface-related complications were reported, of which 19% required re-intervention. CT-drainage was performed in 14% and re-laparotomy in 2%. Median LOS in high-risk patients was 8 days (3-120) with 3,6% mortality. Published data show that complication, re-intervention and mortality rates vary between 18-50%, 0-36%, and 0-3%, respectively. Conclusions In this study, morbidity and overall re-intervention rate after partial liver resection without prophylactic drainage in high-risk patients were comparable to published data. Prophylactic abdominal drainage after hepatectomy seems unnecessary and abandoning standard use of drains in high-risk patients is safe. Drains should therefore only be used in highly selected patients.

25

Abstracts

3.6 Abandoning prophylactic abdominal drainage after hepatic surgery; 8 years of nodrain policy in a single high-volume centre.

Abstracts

4 Is applaying artificial intelligence techniques for predicting technical difficulties during laparoscopic cholecystectomy based on routine patient work-up in a small community hospital feasible?
Miroslav Milicevic The First Surgical Clinic, Belgrade, Serbia

Objectives In a small regional hospital, which admits patients from 0 – 24h., predicting technical difficulties in laparoscopic cholecystectomy (LC) increases efficacy, cost-benefit and safety of the procedure. When a difficult laparoscopic cholecystectomy (DLC – duration of LC > 63 min) is anticipated, an experienced and skilled laparoscopic surgeon should be present and he should make the decision whether and when to convert. Method A total of 369 patients operated from February 5th 2005 to December 26th 2009 were included into the study. Conversion was done in 10 (2.7%) patients. DLC was registered in 55 (14.90%) patients. Descriptive statistics were computed, data was preprocessed by experts and feature selection algorithms to obtain reduced subset of relevant attributes. Various artificial intelligence techniques were applied and assessed by accuracy, specificity, sensitivity, area under the ROC curve (AUC) and F-measure.   Results Seven significant predictors of DLC were identified: (1) a shrunken (fibrotic) gall bladder, (2) gall bladder wall thickness on ultrasonography (USG) > 4mm,  (3) more than 5 attacks of pain lasting > 5 hours , (4) a raised total leucocyte count (WBC)>10x109 g/L, (5) Pericholecystic fluid collection, (6) Urine amylase > 380 IU/L and (7) BMI > 30kg/m2. Bayesian network with three parent nodes was selected as the best classifier with accuracy of 94.57, specificity 0.98, sensitivity 0.77, AUC 0.96 and F-measure of 0.81.   Conclusions It is possible to predict a DLC with high accuracy using artificial intelligence technics, based on routine preoperative clinical parameters and their combinations in a small regional hospital. Use of sophisticated diagnostic equipment is not necessary.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
26

E-AHPBA

Glenn Bonney, Eduardo Vinuela, Christopher Thompson, Vassil Mihaylov, Paolo Muiesan, Simon Bramhall, Thamara Perera, Hynek Mergental, John Isaac, Darius Mirza University Hospitals Birmingham, Birmingham, UK Objectives  The surgical management of Hepatocellular Carcinoma (HCC) remains challenging; with resections frequently difficult in cirrhotics and transplants requiring the use of a scarce resource on patients fulfilling pathological criteria of listing for transplantation. The aim of this study was to analyse clinico-pathological variables on outcomes following liver resection and transplantation Method A retrospective analysis of all patients undergoing liver transplantation and resection between January 2000 and Aug 2011 was undertaken. Patient demographics, biochemical variables as well as pre-operative alphafetoprotein (AFP) was collated. Pathological data including no of tumours, tumour size(s), vascular invasion, steatosis and resection margins were analysed. Clinico-patholocial predictors of in-hospital mortality, disease free survival (DFS) and overall survival (OS) were analysed. Results  413 patients underwent surgery for HCC (n= 271 transplants and n=142 resections). In the resection group, with a median age of 63 years, 71% of patients had underlying liver disease. Number of tumours, AFP and positive margins independently predicted OS (p=0.01, <0.001, <0.001 respectively). In the transplant group, with a median age and MELD of 56 years and 10 respectively, most patients had underlying viral hepatitis (51%). Sum of tumour sizes, vascular invasion and AFP independently predicted OS in this group (p=0.02, 0.02 and <0.001 respectively). The ratio of AFP/total tumour volume >1 predicted disease recurrence in both groups Conclusions We present a series of transplants and resections for HCC. An analysis of clinico-pathological predictors found that preoperative AFP and tumour variable such as tumour size and number predicted OS while a serum AFP/ cm3 of tumour predicted disease recurrence. These biological predictors may help inform surgical management of HCC.

27

Abstracts

4 The effect of tumour biology on outcomes following liver resections and transplantation for Hepatocellular Carcinoma

Abstracts

Martin Stockmann1, Johan Lock1, Steffi Hoppe1, Christian von Löffelholz2, Bruno v. Sinn1, Anja Rieger1, Daniel Seehofer1, Peter Neuhaus1 1 Charité - University Hospital, Berlin, Germany, 2German Institute of Human Nutrition, Potsdam, Germany Objectives Partial hepatectomy is a frequent procedure in liver surgery. Functional recovery is an important factor determining postoperative outcome. The aim of this study was to investigate the influence of metabolic diseases obesity (BMI≥30), non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) on functional recovery. Method Thirty-one patients undergoing partial hepatectomy were included. Liver function and functional recovery were determined by the LiMAx test on postoperative days (POD) 1, 3, 5 and 10. The LiMAx test determines maximal liver function capacity based on 13C-methacetin metabolism of cytochrome P450 1A2 (normal range >315 µg/kg/h). Liver samples were collected during surgery for pathological staging of NAFLD and NASH. Results Fifteen patients of 31 suffered from metabolic diseases. Preoperative LiMAx was lower for patients with metabolic diseases (343 vs. 395 µg/kg/h; P=0.045). Postoperative values were identical on POD 1, 3 and 5, but impaired on POD 10 (250 vs. 393 µg/kg/h; P=0.019). Length of stay was longer for patients with metabolic diseases (14 vs. 9 days; P=0.017). Furthermore, functional recovery on POD 10 was impaired for obesity (n=8; P=0.001), NAFLD (n=9; P=0.022) and most severely for NASH (n=8; P=0.003). The percentage of patients with NASH regaining normal function on POD 10 was only 17% vs. 75% in control (P=0.010). Conclusions The metabolic diseases obesity, NAFLD and NASH impair functional recovery after partial hepatectomy and are associated with prolonged length of stay.

4 Functional recovery from partial hepatectomy is delayed in patients suffering from the metabolic disorders obesity, NAFLD and NASH

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
28

E-AHPBA

Takashi Hatori, Shuji Suzuki, Masakazu Yamamoto Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan

Objectives According to the pancreatic cancer registration report of Japan Pancreas Society, the 5-year survival rate of the pancreatic cancer after surgery is 50-80% even if the tumor size is less than 2 cm. Therefore, a small pancreatic cancer alone cannot be defined as an early pancreatic cancer. The aim of this study is to evaluate a definition of the early pancreatic cancer from point of view of the surgical results, retrospectively. Method 840 patients underwent pancreatectomy for pancreatic cancer between 1981 and 2011 in our institute. Among them, 31 patients (3.7%) who had a small pancreatic cancer within 2 cm in diameter were chosen in this study. Four patients were Stage 0 (carcinoma in situ) and 27 patients were Stage1A according to the 7th edition UICC classification. Results Stage 0: One patient underwent TP, 2 patients underwent central pancreatectomy and 1 patient underwent distal pancreatectomy (DP). Although no patient died of pancreatic cancer, one patient died of lung cancer. A total resection of the remnant pancreas was required in 2 patients for a remnant pancreatic cancer. Stage IA: 13 patients underwent pancreatoduodenectomy (PD), 12 patients underwent DP and 2 patients underwent TP. The 5-year survival rate was 66%. 10 patients with tumor more than 1cm in diameter died of tumor recurrences. However, none of 4 patients with tumor less than 1 cm in diameter had tumor recurrence. Conclusions The early pancreatic cancer will be defined as a Stage 0 and a Stage IA with tumor less than 1 cm in diameter. Moreover, the regular check-up of the remnant pancreas after surgery is important to acquire more favorite prognosis in the early pancreatic cancer.

29

Abstracts

4 Early pancreatic cancer will be defined as a Stage 0 and a Stage IA with tumor less than 1 cm in diameter

Abstracts

4.1 Surgery for pancreatic pseudocysts Postoperative results and follow-up of 148 patients
Rossen Madjov, Plamen Arnaudov, Ilko Plachkov, Vasil Bojkov, Plamen Chernopolsky Medical University, Varna, Bulgaria

Objectives Pseudocysts may develop as a complication of acute pancreatitis, chronic pancreatitis or pancreatic trauma. Aim of the study was to determine the indications, suitability and long term outcome of the open surgery and alternative drainage procedures in patients with pancreatic pseudocysts. Method Retrospective study of 148 patients with pancreatic pseudocysts - 94 male and 54 female. Patients with malignancies were excluded from the study. Ages ranged from 23 to 78 (mean 45,8). All patients had clinical, laboratory and instrumental diagnostic data for pancreatitis. Most common symptoms: pain or discomfort  in the epi- or mesogastrium, dyspepsia, weight loss, palpable tumor mass in the upper abdominal region. Greatest significance for exact diagnosis had: US, CT scan, MRI, Abdominal X-ray. The location of the pseudocysts was: 25 – in the head; 16 – in the tail and 107 (72,3%) in the body. Results 132 patients underwent operative interventions. The most common procedure was internal drainage – 106 pts. From them cystojejunostomy – 64; cystogastrostomy – 28; cystoduodenostomy – 14 pts. Pancreatic resection + Splenectomy – 8; cystectomy + splenectomy – 3; external drainage + T-tube drainage – 6; external drainage + choledochoduodenostomy - 9 Percutaneous cystogastrostomy seems to be a good treatment option of PP. Percutaneous drainage was performed in 12 pts. Endocopic drainage – in 4 pts. Postoperative morbidity – 14 pts ( 9,45%) mainly in the group of the patients with external drainage and postoperative mortality – 1 patient. Conclusions Careful analysis of the indications, pros and cos of the various procedures, and especially postoperative results and long-term follow-up suggests cystojejunostomy as a procedure of choice for the internal drainage of PP. Selected cases might be successfully managed endoscopically/laparoscopically, which could be the logical continuation of minimally invasive therapy.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
30

E-AHPBA

Dorine S.J. Tseng1, Hjalmar C. van Santvoort1, Samira Fegrachi1, Marc G.H. Besselink2, Inne H.M. Borel Rinkes1, Maarten S. van Leeuwen3, I. Quintus Molenaar1 1 Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands, 2Dept. of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands, 3Dept. of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands Objectives Pancreatoduodenectomy is the only potentially curative option for patients with pancreatic or peri-ampullary cancer. One of the contra-indications for curative resection is extra-regional lymph node (ELN) metastases. Although computed tomography (CT) quality improved over the last decade, pre-operative evaluation of ELN may be difficult. This is the first systematic review that focuses on the CT in assessing ELN metastases in pancreatic or peri-ampullary cancer. Method We performed a systematic review in PubMed/Embase/Cochrane according to the PRISMA guidelines of studies published up to November 29th 2012. Studies reporting on the CT assessment of ELN in patients undergoing pancreatoduodenectomy were included. We excluded studies that did not report the number of suspected ELN on CT and number of ELN metastases during histopathological investigations; i.e. if it was not possible to construct a 2×2 contingency table. Data on baseline characteristics, CT-investigations and histopathological outcomes were extracted. Diagnostic accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were calculated for individual studies and pooled data. Results After screening 13.622 studies, 4 prospective cohort studies reporting on CT-findings and histopathological outcome in 157 patients with pancreatic or peri-ampullary cancer were included. Histopathologically proven ELN metastases were present in 28/157(18%) patients, which had been diagnosed pre-operatively on CT in 7(25%) patients. Of the remaining 129 patients without ELN metastases, CT falsely suggested presence of ELN metastases in 18 patients. Overall diagnostic accuracy varied from 63-81% and specificity, PPV and NPV ranged from 80-100%, 0-100% and 67-90%. However, sensitivity was poor with ranges from 0-38%. Pooled accuracy, sensitivity, specificity, PPV and NPV were 75%, 25%, 86%, 28% and 84%. Conclusions CT has a low diagnostic accuracy in assessing ELN metastases in patient suspected of pancreatic or periampullary cancer. We therefore propose that - in absence of other signs of irresectability, e.g. liver metastases, arterial encasement - the suspicion of ELN metastases on CT should not be a contra-indication for explorative laparotomy and, when possible, pancreatoduodenectomy.

31

Abstracts

4.2 Diagnostic accuracy of contrast-enhanced computed tomography in assessing extra-regional lymphadenopathy in pancreatic and peri-ampullary cancer: a systematic review

Abstracts

Laurent Sulpice1,2, Michel Rayar1, Cyrielle Paquet1, Damien Bergeat1, Aude Merdrignac1, Bernard Meunier1, Karim Boudjema1,2 1 Rennes Hospital, University of Rennes1, Rennes, France, 2INSERM UMR 991, University of Rennes 1, Rennes, France Objectives An aberrant right hepatic artery (ARHA) is a common anatomical variation. The risk associated with ARHA during pancreaticoduodenectomy (PD) continues to be debated. The aim of this study was to compare the clinical outcomes and survival after PD with ARHA against a matched cohort of patients without AHRA. Method All consecutive patients who underwent PD for malignant disease between January 2000 and September 2009 were entered in a prospective database and analyzed retrospectively. AHRA was defined by replaced and accessory right hepatic artery. Patients with ARHA (group 1) were matched (1/2) to patients without ARHA (group 2) according to gender, age, BMI, type of tumor and lymph nodes status. Per and postoperative outcomes were compared between the 2 groups.  Overall (OS) and disease free (DFS) survival were estimated by Kaplan-Meier method and compared with Log-rank test. Results Among the 213 patients of the study cohort, 29 (13.6%) were included in group 1 and 55 (25.8%) in group 2. In group 1, AHRA were crossed into the tumor in 6 cases (20.7%), and were sacrificed or repaired in 5 and 1 cases respectively. There was no difference concerning the rate of intraoperative variables (hemorrhage and operative time) as well as the postoperative outcomes between the 2 groups. Oncological clearance (resections margins, p=0.731) and survival (OS (p=0.752) and DFS (p=0.868)) were also similar in the 2 groups. Conclusions Our study showed that the presence of a AHRA during PD was not associated with  poorer postoperative outcomes or worst survival.

4.3 Impact of right hepatic artery during pancreaticoduodenectomy on outcomes and survival: a matched case-control study

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
32

E-AHPBA

Arja Gerritsen1,2, I. Quintus Molenaar1, Thomas L. Bollen3, C. Yung Nio4, Marcel. G. Dijkgraaf5, Hjalmar C. van Santvoort1, Egbert Sieders6, Koert P. de Jong6, Ronald M. van Dam7, Erwin van der Harst8, Harry van Goor9, Bert van Ramshorst10, Bert A. Bonsing11, Ignace H. de Hingh12, Micheal F. Gerhards13, Casper H. van Eijck14, Dirk J. Gouma2, Inne H.M. Borel Rinkes1, Olivier R.C. Busch2, Marc G.H. Besselink1,2 1 Department of Surgery, University Medical Center, Utrecht, The Netherlands, 2Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands, 3Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands, 4Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands, 5Department of Biostatistics and Clinical Epidemiology, Academic Medical Center, Amsterdam, The Netherlands, 6Department of Surgery, University Medical Center, Groningen, The Netherlands, 7Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands, 8Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands, 9Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands, 10 Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands, 11Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands, 12Department of Surgery, Catherina Hospital, Eindhoven, The Netherlands, 13Department of Surgery, OLVG, Amsterdam, The Netherlands, 14Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands Objectives Differentiation between malignant and benign pancreatic tumours can be difficult. Consequently, a proportion of patients undergoing pancreatoduodenectomy for suspected malignancy will ultimately have benign disease. The aim of this study was to identify these patients and to compare their preoperative clinical and imaging characteristics with those of patients who underwent pancreatoduodenectomy for confirmed (pre) malignant disease. Method We performed a multicenter retrospective cohort study in 1629 consecutive patients undergoing pancreatoduodenectomy for suspected malignancy between January 2003 and July 2010 in 11 high volume hospitals in The Netherlands. Excluded were patients with a history of chronic pancreatitis, pancreatic cancer, suspected duodenal carcinoma or without available preoperative digital CT scan. Preoperative clinical and imaging (CT, EUS and ERCP) characteristics were compared between patients with ultimately benign and malignant disease in a 1:3 ratio. The cases with confirmed malignant disease were randomly selected from the entire cohort. A multivariable logistic regression prediction model was constructed to predict benign disease. Results 107 patients (6.7%) were ultimately diagnosed with benign disease. 86 fulfilled the inclusion criteria and were compared to 258 patients with (pre)malignant disease. Patients with benign disease presented less frequently with jaundice (60% vs. 80%, P<0.01), pancreatic mass (54% vs. 70%, P=0.03), double duct sign on CT (27% vs. 52%, P=0.01) or on EUS (22% vs. 51%, P=0.02), but more often with pain (56% vs. 38%, P=0.04). In a

33

Abstracts

4.4 Preoperative characteristics of patients with presumed pancreatic cancer but ultimately benign disease: a multicenter series of 344 pancreatoduodenectomies

prediction model using these clinical and CT parameters, only 27% of patients with benign disease were correctly predicted and 6% of patients with malignant disease were missed.

Abstracts

Conclusions Nearly 7% of patients undergoing pancreatoduodenectomy for suspected malignancy were ultimately diagnosed with benign disease. Although some preoperative clinical and imaging signs might indicate the absence of malignancy, their discriminatory value is not sufficient for clinical use. Despite improvements in diagnostic imaging, a low percentage of unexpected benign pathology after pancreatoduodenectomy seems yet inevitable.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
34

E-AHPBA

Arja Gerritsen1, Roos W. Wennink1, Marc G.H. Besselink1,2, Hjalmar C. van Santvoort1, Dorine S.J. Tseng1, Elles Steenhagen3, Inne H.M. Borel Rinkes1, I. Quintus Molenaar1 1 University Medical Center, Utrecht, The Netherlands, 2Academic Medical Center, Amsterdam, The Netherlands, 3 Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands Objectives Pancreatoduodenectomy (PD) is associated with a high incidence of delayed gastric emptying. Data on the optimal routine feeding strategy after PD (nasojejunal versus oral feeding) are lacking. The aim of this study was to evaluate whether the introduction of an oral feeding strategy after PD improved outcomes as compared to routine nasojejunal tube (NJT) feeding. Method A monocenter before-after study was performed in 102 consecutive patients undergoing PD.  In period 1 (June 2010-September 2011,n=51) the routine postoperative feeding strategy was NJT feeding. This changed to oral feeding in period 2 (January-December 2012, n=51). The oral feeding strategy in period 2 consisted of protocolized resumption of oral intake starting on the day of surgery, a NJT was only placed in case of severe preoperative malnutrition (MUST≥2) or when oral intake was insufficient (<50% of daily required caloric/ protein intake) on postoperative day 7. Analysis was by intention-to-treat. Primary outcome was the time to resumption of adequate oral intake. Results Groups were comparable for baseline characteristics. In period 1 98% received NJT feeding versus 53% in period 2 (because of preoperative malnutrition, n=7, or insufficient intake, n=20). The time to resumption of adequate oral intake significantly decreased in period 2 (12 vs. 9 days, P=0.01) as well as hospital stay (18 vs. 13 days, P=0.01). There was no difference in the incidence of Clavien-Dindo≥3 complications (59% vs. 43%, P=0.11), delayed gastric emptying (31% vs. 35%, P=0.67), pancreatic fistula (12% vs. 12%, P=1.0), postoperative haemorrhage (12% vs. 10%, P=0.75) and mortality (6% vs. 2%, P=0.62) between both groups. Conclusions The introduction of an oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negative impact on overall morbidity, delayed gastric emptying or pancreatic fistula.    

35

Abstracts

4.5 Introduction of an oral feeding strategy after pancreatoduodenectomy enhances recovery without increasing morbidity: a before-after study

Abstracts

DavidJéremieBirnbaum1,SébastienGaujoux1,RimCherif1,AnneCouvelard2,SafiDokmak1,DavidFuks1,Fanjandrainy Rasoaherinomenjanahary1, Marie-Pierre Vuillerme0, Philippe Ruszniewski4, Jacques Belghiti1, Alain Sauvanet1 1 Departement of HPB Surgery - AP-HP, Clichy, France, 2Departement of Pathology - AP-HP, Clichy, France, 3 Departement of Radiology - AP-HP, Clichy, France, 4Departement of Gastroenterology - AP-HP, Clichy, France

4.6 Prognostic significance of incidentally diagnosed  non-functioning pancreatic neuroendocrine tumors

Objectives Non-functioning pancreatic neuroendocrine tumors (NF-PNET) are increasingly incidentally diagnosed. Resection is usually performed but prognostic significance of this diagnosis feature is poorly investigated, and management controversial. Clinical and pathological characteristics as well as prognosis of resected incidentally diagnosed NF-PNET were compared with resected symptomatic NF-PNET to assess their biological behavior. Method From 1994 to 2010, 108 patients underwent resection for sporadic, non-metastatic, NF- PNET. Diagnosis was considered as incidental in patients with no abdominal symptoms or symptoms unrelated to tumor mass. Tumors were classified according to the 2010 WHO classification and assigned to a European Neuroendocrine Tumor Society/TNM-based stage and grading score. Postoperative mortality included all deaths before hospital discharge. Morbidity rate included complications until discharge and/or readmission and included all grades from the Clavien-Dindo classification. Patients with incidentally diagnosed NF-PNET (PInc group) were compared with symptomatic patients (Symp group), regarding demographic, postoperative course, pathology, overall (OS) and disease-free survival (DFS). Results Of the 108 patients, 65 (61%) were incidentally diagnosed. Pancreas-sparing pancreatectomies (enucleation and central pancreatectomy) were more frequently performed in the PInc (62% vs 30%, p=0.001). PInc tumors were more frequently below 20mm (67% vs 42%, p=0.019), staged T1 (62% vs 33%, p=0.003), node negative (N0) (60% vs 44%, p=0.008), and graded 1 (66% vs 33%, p=0.0006). One postoperative death occurred in the PInc group, and postoperative morbidity was similar between both groups (60% vs 65%, p=0.59). DFS was significantly better in PInc group (5-y DFS = 91% vs 82%, p=0.0016), with no difference in OS.   Conclusions Overall, incidentally diagnosed NF-PNET are associated with less aggressive features, compared to symptomatic lesions but cannot always be considered as benign tumors. Surgical resection remains recommended for most of them. Incidentally diagnosed NF-PNET represents good candidates for pancreas-sparing pancreatectomies with an excellent long-term DFS.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
36

E-AHPBA

Gabriella PITTAU1, Maximiliano GELLI1, Eric VIBERT1,2, Oriana CIACIO1, Petru BUCUR1, François FAITOT1, René ADAM1,2, Denis CASTAING1,2, Antonio SA CUNHA1,2 1 AP-HP Hopital Paul Brousse, Villejuif, France, 2Univ Paris-Sud, Le Kremlin-Bicêtre, France Objectives Hepatic artery thrombosis (HAT) after liver transplantation (LT) is a serious complication that leads to bile duct necrosis followed by uncontrolled sepsis and then re-transplantation. Portal vein arterialization (PVA) is a salvage procedure that could be used in that case as an alternative to re-transplantation. We present results of our series of PVA performed for post LT HAT. Methods: From May 2008 to August 2012 nine patients (6 men/3 women) underwent PVA because of post LT HAT. The median age is 60 years (range 29-63). Indications for LT were: hepatocellular carcinoma (n=4) cirrhosis (n=3), acute liver failure (n=1),   Method cholestatic hepatitis (n=1), hepatic metastases from neuroendocrine tumor (n=1). In 6 patients (66%) HAT occurred within three months (median: 25 days (1-76d)), and after 3 months in remaining 3 (105,582,937 days). In 6 cases the arterio-portal shunt has been created between a brunch of the superior mesenteric artery and portal vein tributaries (66,66%), in 3 cases between the gastroduodenal artery and the portal vein. A daily color doppler ultrasound (CDUS) and a Contrast Enhanced scan (CT-scan) at 7 post-operative day (POD) have been performed to verify the shunt patency or the development of collaterals shunts. Results Results With a median follow-up of 21 months 7 patients are alive, 2 retransplanted and 5 with a working graft. Two patients died (22%), one of them 2 months after re-transplantation because of uncontrolled sepsis due to duodenal fistula. The second one, with early HAT, died because of bleeding due to splenic artery rupture with a patent shunt. Three patients (33,33%) underwent re-transplantation due to uncontrolled ischemic biliary duct injury. They have been retransplanted 40, 62 and 132 days after portal arterialisation in good health without uncontrolled sepsis. Among 5 patients that did not require a re-transplantation, 4 had early HAT. Conclusions In those patients, CT scan showed the appearance of collaterals at 6, 12 and 19 POD. The shunt was found patent in 3patients without portal hypertension and spontaneously occluded in 1patient. The only complication of PVA was the appearance of ascites in one case. The shunt was embolized by coils with resolution of ascites. Conclusion In our experience PVA allows organ salvage in more than half of cases, and 4 of 6 patients with early HAT. PVA should be considered as an alternative procedure to re-transplantation or a way to delay it in order to perform this operation in safe condition.

37

Abstracts

5 Portal vein arterialization for hepatic artery thrombosis in liver transplantation: an alternative to re-transplantation?

Abstracts

Erik Schadde1, Victoria Ardiles2, Gregory Sergeant1, Ksenija Slankamenac1, Christoph Tschuor1, Kris Croome4, Janine Baumgart3, Hauke Lang3, Roberto Hernandez-Alejandro4, Eduardo de Santibanes2, Pierre-Alain Clavien1 1 Swiss HPB Center University Hospital Zurich, Zurich, Switzerland, 2Department of Surgery, Division of HPB Surgery, Italian Hospital, Buenos Aires, Argentina, 3Department of Visceral Surgery and Transplantation, University Hospital Mainz, Mainz, Germany, 4Department of Surgery, Division of HPB Surgery, Western University Medical Center, London, Ontario, Canada Objectives Extensive liver tumors are traditionally removed using portal vein embolization(PVE) or portal vein ligation (PVL) to increase the future liver remnant, followed by resection after 4-8 weeks. ALLPS combines PVL and parenchymal transection followed by early hepatectomy. A multicenter analysis evaluates whether ALPPS is better at achieving complete resection (R0). Method  Patients undergoing ALPPS in four international centers were compared with patients who underwent PVE or PVL . Primary endpoint was complete (R0) resection at three months without recurrence or progression of disease. Secondary endpoints include 90-day mortality, complications, volume increase of the FLR and tumor recurrence. Multivariate analysis was performed to adjust for potential confounders. Results 47 patients undergoing ALPPS were compared with 83 patients who underwent conventional PVE/PVL. 77% of ALPPS patients achieved R0 resection at three months compared to 58% in the conventional arm (odds ratio 2.74, p=0.031). 90-day mortality in ALPPS and PVE/PVL were 14.9% and 6.0% respectively (p=0.20). Volume increase per day was 11 times more rapid in ALPPS (35 cc/day, IQR 26.2-49.5) compared with PVE/PVL (3 cc/ day, IQR 1.7-5.8) (p=0.001). Complications ≥IIIB after stage one had a negative impact on volume growth (p=0.004). Recurrence within 6 months after resection in both groups was comparable. Conclusions  This study suggests that ALPPS is better than conventional two-stage procedures to achieve complete resection but at the price of a high mortality. These results support the need for longer follow-up and  randomized controlled trials (RCT) to definitively delineate the role of ALPPS in liver surgery.

5.1 ALLPS is more likely to achieve complete resection of  primarily non-resectable Liver Tumors 

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
38

E-AHPBA

Victoria Ardiles, Fernando Alvarez, Pablo Argibay, Juan Pekolj, Eduardo de Santibañes Hospital Italiano de Buenos AIres, Buenos Aires, Argentina

Objectives Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a surgical strategy to induce a rapid future liver remnant (FLR) hypertrophy. To date, the cellular changes and biological substrate of this novel phenomenon remains unknown. Method Patients with liver malignancies considered unresectable due to an insufficient FLR were selected. During the first stage, liver partition and PVL were performed (S1). The completion surgery (S2), was carried out after volumetric studies demonstrated a sufficient FLR. Biopsies of both hemilivers were taken in both surgeries. Hystoarchitecture and morphological changes as well as immunohistochemistry expression of the proliferating cell nuclear antigen (PCNA), were studied. Results Twenty patients, 12 male with a mean age of 56 y/o, were treated. The mean FLR volume increase was 80%. All resections were R0. Morbidity and mortality rates were 50% and 5%. At S2, PCNA expression was significantly increased (66.6%). Also at S2, PCNA expression had an inverse correlation (r=-0.56) with patient´s age and a direct correlation (r=0.50) with the S2 prothrombin time.  In addition, we observe at S2, a significant increase of the hepatocyte volume (90%) and the nucleus volume (87.5%). Both of this measures had a direct correlation (r=0.9) with the improvement in liver volume analyzed through CT-scan. Conclusions This report demonstrates for the first time molecular and morphological changes associated with the ALPPS hypertrophic phenomenon. Both, proliferative and architectural changes seem to be associated with the FLR hypertrophy and its function. The patient’s age seems to negatively influence hepatocyte proliferation.

39

Abstracts

5.2 The ALPPS approach: biological substrate of liver volumetric changes observed in an emergent surgical strategy to induce rapid liver hypertrophy

Abstracts

5.3 How to increase the liver hypertrophy ratio: single center experience with the Insitu-split procedure.
Janine Baumgart, Hauke Lang Department of General, Visceral Surgery and Transplantation, University of Mainz, Mainz, Germany

Objectives Liver failure due to a too small remaining functional liver volume is the most frequent cause for postoperative mortality after extended liver resection. Recently, a new technique has been developed, enabling a more rapid increase in functional remnant volume - the In-situ-split procedure. Method This new technique is a two-step procedure including a complete portal vein dissection and transsection of the hepatic parenchyma in a first step - leaving the right lobe in-situ only perfused via the hepatic artery and drained via the right hepatic vein and right bile duct - and then, after hypertrophy of the future remnant, consecutively resection of the right lobe in a second procedure. Here, the clinical results of 10 cases of this new surgical two stage technique are presented.  Results Underlying diseases were primary liver tumors (4 intrahepatic cholangiocarcinomas and 1 malignant haemangioendothelioma) or liver metastases (4 colorectal and 1 non colorectal liver metastases). Preoperative CT-volumetry of the future remnant left liver lobe showed a median volume of 380 ml (range 250 ml to 536 ml) which increased to 643 ml (range 500 ml to 982 ml) during a waiting period of 6 days. The maximum rate of increase was 125 % (range 58 to 125%, median 83%). No patient developed any clinical sign of postoperative liver failure. 30-day mortality was 0 %. Conclusions The presented in-situ-split procedure induces a rapid hypertrophy of the left lateral liver lobe and enables safe extended liver resections in patients with advanced tumor volumes. Therefore, this new surgical technique is an innovative and promising approach in augmenting the number of liver resections with curative intent.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
40

E-AHPBA

5.4 ALPPS basic research model: development and initial results of a novel technique.

Objectives To develop an experimental ALPPS rat model and compare with portal vein ligation (PVL). Method  30 rats for PVL and 30 for ALPPS group were used. We performed portal vein ligation of right, left and paracaval lobe with arterial flow preservation. After this we performed ligation of the left portal branch of the medium lobe (ML), thus demarcates the left sector (LSML) and right (RSML); therefore in ALPPS group parenchyma transection troughout the ischemic line was performed. ML, RSML and LSML volume, weights of ML were compared between grups and day of sacrifice.  Animals were sacrificed at 3, 7 and 14 days (10 per group). Biochemical (ALT, AST) and histological evaluation was performed Results  Increase on liver volume is show in Table 1. There were no significant differences between groups relation to biochemical and histological analysis Conclusions ALPPS technique can be successfully performed in rats.  As it was describe in the clinical setting a major liver volume was achieved with ALPPS technique at postoperative day 7. Nevertheless, no differences could be observed on day 14. Further research might increase the knowledge on surgically induced liver regeneration.

41

Abstracts

Pablo Barros Schelotto, Luis Moulin, Hector Almau-Trenard, Pablo Stringa, Ana Cavanne, Valeria Descalzi, Guillermo Pfaffen, Juan Padin, Gabriel Gondolesi Favaloro Foundation, Buenos Aires, Argentina

5.5 One-stage major hepatectomy following portal vein embolization vs. ALLPS Abstracts

Yoshihiro Sakamoto, Yoshihiro Mise, Suguru Yamashita, Ryuji Yoshioka, Nobuyuki Takemura, Takeaki Ishizawa, Junichi Kaneko, Taku Aoki, Kiyoshi Hasegawa, Yasuhiko Sugawara, Norihiro Kokudo Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, The Tokyo University Hospital, Tokyo, Japan Objectives  To ensure sufficient future liver remnant (FLR) volume remains a necessary condition to accomplish successfully major hepatectomy. Recent innovation of 2 stage hepatectomy (ALLPS, Associating Liver Partition and Portal vein ligation for Staged hepatectomy) has been reported to have facilitated liver regeneration following first operation, thus accelerated the timing hepatectomy. However, the associated mortality rate has been reported up to be 12%, and the real efficacy of ALLPS remains unclear. Major hepatectomy following portal vein embolization has established an acceptable short term outcome. Method  We have applied one-stage hepatectomy following portal vein embolization (PVE) in principle. The indication of PVE is FLR volume is less than 40%. Results  Among the 115 patients with colorectal hepatic metastasis, 49 underwent one-stage hemihepatectomy following PVE. The remaining 66 patients underwent hemihepatectomy without PVE. The incidence of morbidity after hepatectomy was higher in the group of PVE, however there was no significant difference in the survivals of patients. We have applied ALLPS in a patient with marginally resectable colorectal metastasis. During the first operation we evaluated the resectability along the umbilical portion adjacent to the tumor in segment IV and ligated the right portal vein. The patient underwent staged right hemihepatectomy. Postoperative bile leakage was treated conservatively. Conclusions Our policy for resectable colorectal metastasis necessitating right hemihepatectomy or more major hepatectomy; preoperative PVE and one-stage hepatic resection would be acceptable. The indication of ALLPS should be strictly limited at the moment. 

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
42

E-AHPBA

Safi Dokmak, Fanjandrainy Rasoaherinomenjanahary, François Cauchy, Béatrice Aussilhou, Jacques Belghiti Beaujon Hospital, Departement of HBP surgery and liver transplantation, Clichy, France Objectives ALPPS is a new innovative surgical technique aiming to perform major liver resection without postoperative liver failure (LF) by sequential procedure including liver splitting with portal vein section followed some days latter by liver resection.  Our aim was to study in a monocentric center the rate of future remnant liver (FRL) regeneration and the incidence of LF after each step. Signs of LF were defined according to 50/50 criteria or prolonged jaundice (>85mmol/l) on POD 5. Method From April 2011- October 2012, eleven patients (10 men) with a median age of 59 years old (37 – 63) underwent ALPPS for CRLM (n=6) and biliary cancer (n=5). Underlying liver disease was present in 5 including one PSC and 4 with CRLM who received > 12 cycles of chemotherapy. Patients underwent right trisectionnectomy (6) or hepatectomy (5) and 4 had associated pancreaticoduodenectomy. All except one underwent the second step within a mean time of 10 days (6-20) with a mean blood loss of 300ml (100-1500) and operation time of 235 (75-480) minutes.  Volumetric assessment was done on POD7. Results RLV increase from 408 ml (208-754) to 553 ml (320-821) with a median hypertrophy rate (HR) of 69% (8-175), including 4 with HR < 25% (8-24). These 4 patients had a mean FRL volume at 21% (13-31) and 3 received > 12 cycles of chemotherapy. After the first step, four had signs of LF and one had portal thrombosis. After the second step, six (60%) showed signs of LF. Major morbidity was observed in 40% with an average hospital stay of 40 days (5-120). Mortality was observed in 3 patients (27%), all had small FRL (<25%) and insufficient HR (<25%). Conclusions ALPPS do not regularly induce accelerated hypertrophy, especially in patients with small FRL and/or intense chemotherapy, with the increased risk of postoperative mortality.

43

Abstracts

5.6 Does ALPPS regularly increase the future remnant liver and prevent postoperative liver failure?

Abstracts

6 Anesthetic Conditioning in Liver Transplantation. Results of a Multicenter Randomized Controlled Trial

Stefan Breitenstein1, John Bonvini1, Erik Schadde1, Philipp Dutkowski1, Christian Oberkofler1, Mickael Lesurtel1, Michelle De Oliveira1, Estela Figuera2, Joel Rocha Filho2, Jose Costa Auler2, Luiz D’Albuquerque2, Koen Reyntjens3, Patrick Wouters3, Xavier Rogiers3, Luc Debaerdemaeker3, Michael Ganter1, Achim Weber1, Milo Puhan4, Pierre-Alain Clavien1, Beatrice Beck-Schimmer1 1 University Hospital Zurich, Zurich, Switzerland, 2Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil, 3Ghent University Hospital, Ghent, Belgium, 4Johns Hopkins Bloomberg School of Public Health, Baltimore, USA Objectives  In the age of organ scarcity and the increased use of older and steatotic organ grafts, protective strategies during transplantation are gaining importance. Volatile anesthetics such as sevoflurane attenuate ischemiareperfusion injury in liver resection and lead to improved clinical outcome. Whether volatile anesthetics change clinical outcome in liver transplantation is unknown.                                                                                                                                         The aim of the present trial was to evaluate the impact of pharmacological conditioning with the volatile anesthetic sevoflurane in liver transplantation. Method Cadaveric liver recipients were randomized from 03/2009 to 08/2012 at three University Centers (Zurich, Sao Paulo, Ghent). Standard liver transplant patients were randomly assigned to propofol anesthesia (control group) or conditioning with sevoflurane (sevoflurane group), the anesthetic was accordingly applied for the entire liver implantation surgery. Postoperative peak of the aspartate transaminase (AST) was defined as primary endpoint. Secondary endpoints were in-hospital complications, hospital- and ICU stay. Results Ninety-eight patients, who underwent liver transplantation, were randomized to propofol (n=48) or sevoflurane (n=50). Peak AST after transplantation was 925 U/l (512-3274) in the propofol group (p=0.73) and 1097 U/l (interquartile range 540-2633) in the sevoflurane one. While the overall complication rate was not different, there was a trend towards less severe complications in the sevoflurane group: median complication score was grade IIIa (IQR II-IVb) for the propofol and grade II (IQR 0-IIIb) for the sevoflurane group (p=0.08). In the propofol arm 11 patients (23%) experienced delayed graft function, 7 (14%) in the sevoflurane one (p=0.45). Conclusions This first multicenter trial with different anesthesia regimens in liver transplantation showed comparable surrogate markers postoperatively, but a trend towards less severe complications in the sevoflurane group. Future trials should be adequately powered to assess complications and identify subgroups, which might benefit from anesthetic conditioning.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
44

E-AHPBA

David Petermann, Takashi Kokudo, Nermin Halkic, Emilie Uldry, Nicolas Demartines, Markus Schäfer University Hospital CHUV, Lausanne, Switzerland Objectives The technical feasibility of portal vein (PV) and superior mesenteric vein (SMV) resection has been proven, but oncological benefits in patients with histologically proven venous tumor infiltration remain unclear. This study analyzed the results after PV-SMV resection in patients with histologically proven venous tumor infiltration. Method Out of 340 pancreatic resections performed at our institution from January 2000 to June 2012, twenty-nine patients were identified who underwent a pancreaticoduodenectomy with PV and/or SMV resection with histologically proven venous tumor infiltration. A case-matched analysis of these 29 patients vs. another 29 patients with similar tumor characteristics but without venous resection was performed. Each group was matched for age, gender, R status, N status and tumor size representing the most important predictors of survival. Results There were 16 male and 13 female patients in each group. In each group, 16 patients (55%) had R0 resection, 27 patients (93%) had N1 status, and mean tumor size was 38mm and 34 mm, respectively. Postoperative mortality occurred in 3 patients after PV-SMV resection and in 2 patients without venous resection. Postoperative morbidity was 83% and 65%, respectively (p=0.23). Of note, bleeding complications were not significantly different. Median survival, 1-year survival and 3 year-survival was 23 months, 60% and 33% in case of PV-SMV invasion compared to 12 months, 56% and 28% without venous resection (p=0.68). Conclusions Histologically proven venous invasion in patients with pancreatic adenocarcinoma, who undergo pancreaticoduodenectomy with vascular resection, is not associated with an impaired long-term survival. Portal vein infiltration can probably be considered as late phenomenon, and it is rather associated with local tumor growth than with biologic aggressiveness of pancreatic adenocarcinoma.

45

Abstracts

6.1 Pancreatic adenocarcinoma with histologically proven portal vein infiltration: what is the outcome?

Abstracts

6.2 Acutesuperiormesentericveinthrombosisafterextendedpancreaticoduodenectomy: 2 cases of successfully conservative treatment

Andrea Sagnotta, Andrea Police, Andrea Palmieri, Simona Di Filippo, Daniele Crocetti, Andrea Scarinci, Marco d’Annibale, Gian Luca Grazi Department of HBP surgery, Regina Elena National Cancer Institue, Rome, Italy Objectives Extended pancreaticoduodenectomy (PD) includes resection of SMV-PV confluence and it is now commonly applied. Acute (<30 postoperative days) thrombosis is a complication with poorly defined incidence, radiological work up and therapy. We report two cases of SMV thrombosis after extended PD successfully managed with a conservative approach. Method  Two patients underwent PD with SMV resection: in the first case an autologous vein patch reconstruction was carried out, while a primary end-to-end anastomosis was performed in the latter. Early Doppler US showed in both an acute SMV thrombosis. In the first case a totally asymptomatic aneurysmatic dilatation of the reconstructed SMV was detected at CT. Ascites, transient abdominal pain, diarrhea and CT findings consistent with bowel wall abnormalities appeared in the second case.   Results Conservative treatment with heparin sodium and diuretics was established. Both showed the development of a significant collateral circulation at control CT. Patients are in good condition and without symptoms after 6 and 4 months of follow up respectively. Conclusions Early postoperative thrombosis of the SMV after extended PD is a potentially lethal complication. Once the diagnosis is made, treatment is determined by the clinical situation. In both our cases, conservative management with systemic anticoagulation has proved effective. The need for additional therapeutic intervention is less clear.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
46

E-AHPBA

Objectives Major arterial involvement is considered an absolute contraindication to resection in pancreatic cancer (PDAC). We herein report our experience with 27 patients undergoing pancreatectomy plus resection of major peripancreatic arteries (with and without reconstruction). Method  Between January 1993 and March 2012, 27 patients were selected for pancreatectomy plus resection of major peripancreatic arteries: celiac axis (CA), common hepatic artery (CHA) and superior mesenteric artery (SMA). Patients undergoing simulatenous resection of arterial and venous segments were excluded from this analysis. Data were extracted from a prospectively maintained database and analyzed retrospectively. Survival was analyzed by Kaplan-Meier survivor functions, Cox proportional hazard models, and the log rank test.   Results 15/27 were females; mean age was 64ys. 2/27 total pancreatectomy, 6/27 pancreaticoduodenectomy, 19 distal splenopancreatectomy. CA was resected in 14/27, CHA in 9, CA-plus-CHA in 3, SMA in 1. Overall-morbidity was 54.2%. Final pathology disclosed PDAC in 18/27. 74% had positive lymph node. 27/27 were R0. 10/27 had arterial involvement. After a mean-follow-up-period of 115months, median-overall-survival was 22months. Survival at 1, 3, 5 years was 66.7%, 29.6%, 10%. 27/27 died from metastatic spread without local recurrence. PDAC-positive-survival at 3, 5 years was 25%, 5% (median-survival 22.5months). Comparing negative-arterialinfiltration vs. positive-arterial-infiltration, no statistical difference was in median-overall-survival neither in PDAC-diagnosed-median-survival. Conclusions Pancreatic resection remains key to achieve long-term survival. Isolated involvement of major peripancreatic arteries usually involves the CA and/or CHA, possibly reflecting tumor location rather than enhanced tumor biology. Under these rare circumstances resection may be worthily pursued especially in the modern era of neoadjuvant therapies

47

Abstracts

Nelide De Lio1, Mario Antonio Belluomini1, Francesca Costa1, Stefano Signori1, Fabio Vistoli1, Franco Mosca0,1, Ugo Boggi1 1 Division of General and Transplant Surgery, University of PIsa, Pisa, Toscany, Italy, 2Division of General Surgery 1, University of Pisa, Pisa, Toscany, Italy

6.3 Pancreatectomy with major arterial resection

Abstracts

BELINDA SANCHEZ PEREZ1, NURIA PELAEZ SERRA2, LAIA FALGUERAS VERDAGUER3, CRUZ ZAZPE RIPA4, JOSE LUIS GARCIA SABRIDO5, ELENA MARTIN PEREZ6, TRINIDAD VILLEGAS HERRERA7, MANUEL BARRERA GOMEZ8, RAFAEL MORALES9, JUAN MANUEL SANCHEZ HIDALGO10, MIGUEL ANGEL SUAREZ MUNOZ1, JULIO SANTOYO SANTOYO1 1 Hospital Carlos Haya, MALAGA, Spain, 2Hospital de Bellvitge, L’Hospitalet de Llobregat - BARCELONA, Spain, 3 Hospital Josep Trueta, GIRONA, Spain, 4Hospital de Navarra, Pamplona - NAVARRA, Spain, 5Hospital Gregorio Marañón, MADRID, Spain, 6Hospital La Princesa, MADRID, Spain, 7Hospital Virgen de las Nieves, GRANADA, Spain, 8 Hospital Nuestra Señora de la Candelaria, TENERIFE, Spain, 9Hospital Son Llatzer, MALLORCA, Spain, 10Hospital Reina Sofía, CORDOBA, Spain Objectives To evaluate the incidence, surgical technique and outcomes of patients who underwent vascular resection in the treatment of pancreatic diseases. Method Retrospective observational study of patients operated on 16 Spanish centers, between 1993 and 2012. A total of 262 patients, 150 men and 112 women, met the inclusion criteria, ranging between 25 and 84 years old. Considered variables were type of pathology (benign, malign), type of pancreatic resection (pancreaticoduodenectomy, total pancreatectomy, distal pancreatectomy), type of vascular resection (venous, arterial, combined -venous + arterial-), type of vascular reconstruction (suture, anastomosis, graft), morbidity (Clavien-Dindo classification), and outcomes (overall survival and incidence of vascular complications). Results Ninety four percent of patients exhibit malign tumors. Pancreaticoduodenectomy was the most frequent surgical procedure (77 %), followed by total pancreatectomy  (15 %), and distal pancreatectomy  (8 %). Venous resection was performed in 92 % of patients. Arterial resection was necessary in 3 %, and combined in 5%. Regarding type of venous reconstruction, end-to end anastomosis or transverse reparation was performed in 87 % of cases. In 13 % was necessary to use a graft (prosthetic or autologous). Overall morbidity reached 52 %, with a 90 days mortality of 14 %. Actuarial survival at 3 years was 35%. Conclusions Vascular resection in pancreatic surgery is most often associated with malignant disease. Venous resection is the most common, and is burdened with significant morbidity and mortality. However, the short and medium term outcomes are encouraging, taking in account that these patients were considered, once, unresectable and therefore incurable.

6.4 Vascular resection in pancreatic surgery: indications, operative technique  and outcomes. Spanish  multicenter  study.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
48

E-AHPBA

Miroslav Ryska1, Ladislav Dusek2, Pavel Zaruba1 Surgery department, 2. Faculty of Medicine, Charles University and CMH, Prague, Prague, Czech Republic, 2Institute for biostatistics and analysis, Faculty of Medicine, Brno, Brno, Czech Republic
1

Objectives Pancreatic cancer still is a significant, unresolved therapeutic challenge with nearly similar incidence and mortality rates. The aim of study is to compare results of  high volume centers to population data in Czech Republic. Method Standard descriptive statistics were used to summarize primary data; absolute and relative frequencies of categories for categorical variables and median supplemented by 5th and 95th percentile ranges for continuous variables. Maximum likelihood chi-square test was applied for the analysis of relationship between categorical variables. Kaplan Meier methodology was applied for the visualization of survival of patients; log rank test was used for comparison of survival among stratified groups. Results 576 patients with panceratic adenocarcinoma were enrolled to multicentric study in five high-volume centers in Czech Republic (2007-2011): 317 male and 259 female, average age of 64: radical surgery in 199 (34,5 %), palliative resection in 9 (1,6 %), by-pass procedures in 210 (36,5 %), exploration 114 (19,8 %) and endoscopic stenting in 44 (7,6 %). 3 year survival + 95 % CI was in stage I-50,0 (37,0 - 62,9), in stage II-17,5 (12,0-24,4), stage III-12,4 (6,7-18,0). In population-based overall survival (2005-2008) was 3y survival in stage I,II and III: 29,9 (17,9-41,7), resp. 18,2 (11,2-26,3), resp. 8,3 (4,1-14,6). Conclusions There is significantly higher 1y, 2y  and 3y survival in high volume centers compare to population based overall survival in Czech Republic in patients with pancreatic adenocarcinoma in stage I and III. Independent risk factors were stage of disease and age of patient.

49

Abstracts

6.5 Pancreatic cancer in high volume centers - survival case multicentric study in Czech Republic

Abstracts

6.6 Aggressive surgery for pancreatic neuroendocrine tumors: an institutional experience

Nadia Russolillo, Luca Vigano’, Alessandro Ferrero, Paola Razzore, Francesca Bertuzzo, Manuela Motta, Lorenzo Capussotti Mauriziano Hospital, Turin, Italy Objectives The role of surgery for advanced  pancreatic neuroendocrine tumor (pNET) requiring extended resections is not well defined.  Aim of study was to clarify whether aggressive surgical approach  influenced long term results and to identify survival prognostic factors in the light of the 2010 WHO classification Method Between 01/2000 and 03/2012 37 patients with pNET underwent pancreatic resection alone (Group I:27 patients) or associated to extended  resection (Group II:10 patients). All tumors were reclassified according to the 2010 WHO classification. Results 23 patients were male, median age was 57years (26-81). Median size was 3±1.9cm and median Ki67 3.3±10. Associated  resections were 6 hepatectomies, 3 vascular resections,1 colectomy and 1 nephrectomy. R0 was achieved  in 33(89%)patients. The rates of T3-4(22%vs80%)and N+(11vs60%)were higher in Group II. Mortality (3.7%vs0)and major morbidity (11vs10%) rates were similar. After a median follow-up of 51 months 5-years overall survival of whole series was 81%. The 5-years overall survival was 92% in group I and 56.2% in group II (p=0.051). The Group II developed tumor recurrence significantly earlier (32.5vs47.6%, p=0.039). At multivariate analysis negative prognostic survival factor was liver metastases (OR 17.3,1.007-299.032 p= 0.049). Conclusions Surgery represents a crucial point in the management of pNET. Aggressive approach for locally advanced or metastatic tumor is safe offering long term survival

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
50

E-AHPBA

Hipólito Durán, Emilio Vicente, Yolanda Quijano, Benedetto Ielpo, Eduardo Díaz, Isabel Fabra, Ramón Puga, Catalina Oliva, Riccardo Carusso, Valentina Ferri, Sergio Olivares, José Carlos Plaza Hospital Madrid Norte Sanchinarro, Madrid, Spain Objectives Reduced absorption of chemotherapy might play a role in the poor prognosis of pancreatic cancer, maybe due to the stromal barrier surrounding the tumor. Nab-paclitaxel stablishes a disruption in this stromal barrier. Determine the efficacy of Nab-paclitaxel/gemcitabine in patients with operable pancreatic adenocarcinoma, assessing stromal matrix by ecoendoscopic elastography.   Method Prospective study including 15 patients from March 2011 that underwent neoadjuvant treatment with gemcitabine and nab-paclitaxe prior to surgery. Six patients have been escluded because of malignancy progression during neoadyuvancy (2), liver metastasis at surgery (1), well differentiated neuroendocrine tumor (2) and PAN 1(1) at anatomo-pathologic exam. Tumors were monitored with elastography before and after the two cycles and all the specimens were evaluated to assess tumor regression rate (TRR) (Ryan score). Results Nine patients were included: 1 with complete pathological response (TRR 0) and 7 near complete (TRR 1); 1 patient had no response at all (TRR 3). Specimen TRR 3 was poorly differentiated, while the remaining were well (n = 4; 50%) and moderately differentiated (n = 4; 50%). Specimen TRR 3 showed a decrease of only 6% of tissular stoma with elastography whereas the remaining 8 showed a significantly higher decrease with an average of 71% (range: 11.42-90.19%) (p = 0.003). Conclusions Neoadjuvant treatment with infusion of gemcitabine plus nab-paclitaxel induced a high rate of response in patient with pancreatic adenocarcinoma, which can be easily monitored by elastography. Further study is needed to confirm these results.

51

Abstracts

6.7 Gemcitabine plus Nab-paclitaxel shows a significant antitumor activity in resectable pancreatic cancer, assessed by elastography.

Abstracts

Georgios Sotiropoulos1, Federica Dondero2, Roberto Troisi16, Umberto Cillo4, Jan Lerut14, Laszlo Kobori6, Marek Krawczyk15, Frank Lechner7, Hynek Mergental10, Bo-Göran Ericzon9, Gerd Otto8, Helena Isoniemi13, Ernesto Molmenti5, Fabrice Muscari12, Gonzalo Sapisochin3, Robert J. Porte11, Jacques Belghiti2, Andreas Paul1, Francis Y. Yao3 1 University Hospital Essen, Essen, Germany, 2Beaujon Hospital, Clichy, France, 3University of California San Francisco, San Francisco, USA, 4Padua University, Padua, Italy, 5North Shore University Hospital, New York, USA, 6Semmelweis University Hospital, Budapest, Hungary, 7Medizinische Hochschule Hannover, Hannover, Germany, 8Johannes Gutenberg University Hospital Mainz, Mainz, Germany, 9Karolinska University Hospital Huddinge, Stockholm, Sweden, 10Queen Elizabeth Hospital, Birmingham, UK, 11University Medical Center Groningen, Groningen, The Netherlands, 12University Hospital of Rangueil, Toulouse, France, 13Helsinki University Central Hospital, Helsinki, Finland, 14University Hospitals St Luc-UCL, Brussels, Belgium, 15Medical University of Warsaw, Warsaw, Poland, 16 Ghent University Hospital Medical School, Ghent, Belgium Objectives To determine patient survival and tumor recurrence in cases of liver transplantation (LT) for mixed hepatocellular-cholangiocarcinoma (HCC-CC). HCC-CC is a rare and unexpected finding in patients transplanted for hepatocellular carcinoma (HCC). Long-term outcomes for these patients are unknown.   Method An Excel-database encompassing 27 parameters was constructed using centrally sampled data obtained from a multi-national 15-center survey. Patients with double primary hepatic malignancies (HCC and cholangiocarcinoma) were excluded. Kaplan-Meier, Cox proportional hazards, and logistic regression analyses were employed. Results Seventy recipients were included in the study. Median follow-up was 17 months. Median values for maximal tumor size, AFP, CA 19-9 levels and labMELD-Score were 4cm, 7ng/ml, 40U/ml and 14, respectively. Twentyseven tumors were solitary. Forty were within the Milan criteria. Median survival was 53 months. Milan criteria (p=0.0026), tumor number (p=0.0355), tumor size (p=0.0168), vascular invasion (p=0.0074) and UICC-stage (p=0.0103) achieved statistical significance by univariate Cox proportional hazards regression. 3- and 5-year survival for patients within and beyond the Milan criteria was 74% and 59%, and 17% and 17%, respectively (p=0.0014). Milan criteria were prognostic of tumor recurrence (p=0.029). Conclusions LT in the setting of HCC-CC is associated with unfavorable overall outcomes in comparison to LT for other indications. However, the Milan criteria have prognostic value in LT for this tumor entity both for patient survival and tumor recurrence and patients within them experience acceptable outcomes. 

7.1 Liver transplantation for mixed hepato-cholangiocellular carcinoma: A multicentric survival and recurrence analysis

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
52

E-AHPBA

Johannes Drouven, Stijn van Laarhoven, Ernst Buiter, Paul Peeters, Marieke de Boer, Robert Porte, Egbert Sieders, Koert de Jong University medical center Groningen, Groningen, The Netherlands Objectives Routine peritoneal drain placement to prevent ascites accumulation after orthotopic liver transplantation (OLT) is controversial. The aim of this study was (1) to quantify post-transplantation ascites formation and (2) to identify predictive factors in order to rationalize drain placement after OLT. Method Included were 238 adult patients who underwent primary OLT. Closed suction drains were routinely left behind and were removed when the daily production was less than 50-100 mL. The amount of ascites present at the start of OLT was measured. Primary outcome variables were the cumulative amount of postoperative ascites formation, and the total duration of ascites drainage. Predictive variables were categorized in donor, recipient and transplantation-related variables. Results Median amount of ascites present at the start of OLT was 1,000 mL (0-21,000 mL, IQR 2,000 mL). The median length of postoperative drainage was 12 days (1-112 days, IQR 12 days) and the median cumulative postoperative ascites production was 6,240 mL (0-123,820 mL, IQR 13,716 mL). Multivariate regression analysis identified the length of the anhepatic phase and the Child-Pugh score as significant predictors. The model only predicted 7% of the postoperative ascites volume. Conclusions  Our data signify that postoperative ascites production is highly variable and that predictive factors cannot be identified.

53

Abstracts

7.2 How to rationalize peritoneal drain placement after orthotopic liver transplantation?

Abstracts

7.3 Early re-operation for bleeding after liver transplantation has a severe prognostic impact on prognosis in the modern era
Riccardo Memeo, Chady Salloum, Nicola de’Angelis, Philippe Compagnon, Alexis Laurent, Daniel Azoulay Hepato-Biliary and Liver Transplant Unit, Henri Mondor Hospital, Creteil, France

Objectives Bleeding remains a common complication in the early period following liver transplantation (LT). The objective of the study was to analyse the impact early re-operation for bleeding after LT on short term course and long term patient and graft survival Method 372 consecutive LT performed at our centre since 2005 were analysed. Patients who needed re-operation for bleeding within 30 days of LT (Reopgroup, n = 25 (7%)) where compared to patients without this event (NonReopgroup, n = 347). Only complications graded III to V according to Clavien classification were considered. Results The origin of haemorrhage was a vascular anastomosis (44%), nonspecific intrabdominal bleeding (36%), rupture of subscapsular liver hematoma (12%) and abdominal wall bleeding (8%). Postoperative mortality was significantly higher in Reopgroup (17% vs 5%, p=0.02). Postoperative morbidity was significantly increased in Reopgroup (64% vs 27%, p=0.0001). Arterial complications were significantly more frequent in Reopgroup (44% vs 15%, p=0.001). The rate of retransplantation in Reopgroup was significantly increased (28% vs 5%, p=0.0001). At 1 year, graft survival rate (41% vs 85% respectively, p=0.0001) and patient survival rate (67% vs 89%, p=0.02 respectively) were lower in the Reopgroup compared to the NonReopgroup. Conclusions Re-operation for bleeding following LT impacts negatively on overall morbidity, patient and graft survival. The identification of independent predictive factors of this event is needed to minimize its incidence

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
54

E-AHPBA

Riccardo Memeo, Nicola de’ Angelis, Chady Salloum, Philippe Compagnon, Alexis Laurent, Daniel Azoulay Hepato-Biliary and Liver Transplant Unit, Henri Mondor Hospital, Creteil, France

Objectives The large and global imbalance between the supply of donor organs for orthotropic liver transplantation and the pool of potential liver transplant recipients led to extend the liver donor criteria. The aim of the study was to compare the clinical outcomes of adult split liver donor and old death whole-organ donor.   Method Liver transplantations were performed between 1st January 2001 and 1st January 2011 at the Henri-Mondor Hospital of Creteil, France. The adult split liver donor after brain death group (SLD-DBD) comprised 18 split extended right lobe donations and 53 right lobe donations after brain death. The old death donor group (ODD) comprised 89 elderly (>70 years) whole-organ donations. All recipients were aged < 65 years without demographic differences between groups. Shot-term and long-term (at 3 years) transplantation outcomes were evaluated at the patient’s and graft level Results Early re-transplantation (<2 months) was required for 3 SLD-DBD grafts , and for 4 ODD grafts. No difference was observed for cold ischemia time (8.9±2.7 vs. 9.5±2.6 min; p=0.2), hospitality stay (15.4±11.4 vs. 16±19.1 days; p=0.8) and post-operative mortality (6% vs. 3%; p=0.25). Kaplan-Meier analysis demonstrated no group difference with patients 1-year and 3-year overall survival at  92% and 84% in SLD-DBD group vs 86% and 74% in ODD group (p=0.2)(Figure 1). Kaplan-Meier analysis demonstrated no group difference with graft  1-year and 3-year survival at  84% and 74% in SLD-DBD group vs 79% and 67% in ODD group (p=0.4)(Figure 2) Conclusions Liver transplant outcomes were better for ODD grafts, which presented a higher survival rate at 3 years followup. Extended-criteria donor grafts should be considered as viable option to expand the liver donor pool.

55

Abstracts

7.4 Extended-criteria liver donor: comparisons between liver transplantation outcomes from adult split liver and old death donors

Abstracts

Andreas Andreou1, Safak Gül1, Martin Stockmann1, Ruth Neuhaus1, Fritz Klein1, Timm Denecke2, Gero Puhl1, Eckart Schott3, Peter Neuhaus1, Daniel Seehofer1 1 Department of General, Visceral and Transplant Surgery, Charité - Universitätsmedizin Berlin, Campus VirchowKlinikum, Berlin, Germany, 2Department of Radiology, Charité - Universitätsmedizin Berlin, Campus VirchowKlinikum, Berlin, Germany, 3Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany Objectives Patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) are expected to have poor prognosis and are currently not considered for liver transplantation (LTX). The purpose of this study was to identify predictive factors for overall survival (OS) following LTX for HCC that may support MC in the selection of appropriate transplant candidates. Method Clinicopathological data of 367 patients with HCC who underwent LTX in a high-volume transplant center between 1989 and 2010 were retrospectively evaluated. Predictors of overall survival in the entire cohort as well as in subsets of patients within (n=217) and beyond (n=150) the MC were analyzed. After a median follow-up time of 77 months the median survival (MS) was 100 months. Results Factors associated with OS in univariate analysis included patients’s age, tumor DNA-index, α-fetoprotein level (AFP), MC, bilobar lesions, vascular invasion, tumor differentiation, and hepatitis C. In multivariate analysis, DNA-index>1.5 (P<.0001), AFP>200ng/mL (P=.009), and MC (P=.003) independently predicted worse OS. In patients within the MC (MS=170 months), DNA-index>1.5 (P<.0001) was the only predictive factor for OS in multivariate analysis. In patients beyond the MC (MS=44 months), DNA-index>1.5, AFP>200ng/mL, vascular invasion, and DNA-index>1.5 concomitant with AFP>200ng/mL (Figure) were associated with worse OS in univariate analysis. Multivariate analysis identified DNA-index>1.5 concomitant with AFP>200ng/mL (P<.0001) as the only independent predictor of worse OS. Conclusions DNA-index and AFP level predict OS following LTX in patients with advanced HCC beyond the MC. Combined assessment of these markers during the evaluation of transplant candidates can contribute to the selection of patients with HCC who may benefit from a liver transplantation independently from their tumor burden.

7.5 Tumor DNA-Index and α-Fetoprotein Level Predict Survival beyond the Milan Criteria in Liver Transplantation for Hepatocellular Carcinoma

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
56

E-AHPBA

François Faitot1, René Adam1,2, Denis Castaing1,2, Antonio Sa Cuhna1,2, Gilles Pelletier1,2, Didier Samuel1,2, Eric Vibert1 1 Hôpital Paul Brousse, Villejuif, France, 2Université Paris Sud, Kremlin-Bicêtre, France Objectives Drop-out due to tumoral progression alters the results of LT for hepatocellular carcinoma (HCC) in intentto-treat analysis. Portal hypertension (PHT) increases the incidence of HCC on cirrhosis and recurrence after hepatectomy but no data exist regarding PHT impact in patient listed for LT for HCC.  Method 245 patients consecutively listed for LT for HCC on cirrhosis in Milan criteria between January 2000 and January 2010 were included. PHT was defined as the association of splenomegaly and esophageal varices (grade≥2). Patients with or without PHT were compared and a logistic regression analysis was conducted to identify risk factors of tumor progression (TP) and drop out (DO) for TP. The impact of PHT on overall survival (OS) and recurrence was evaluated from listing and from LT. Results PHT was not a risk factor for not having TACE. There were 22% DO for TP in the 115 patients with PHT versus 6% in the 130 patients without PHT (p=0.0001). PHT was an independent factor of TP and DO (OR=3.1 [1.75.7], p=0.0003 and OR=4.6 [1.9-11.1], p=0.0007). The absence of chemoembolization was a risk factor for DO (OR=3.1 [1.2-8.3], p=0.025). Intent-to-treat OS was significantly lower in patients with PHT (76% versus 61% at 5 years, p=0.011). After LT, PHT was not associated with worse OS and HCC time to recurrence. HCC histological features were not different between the 2 groups.             Conclusions Despite a similar rate of pre-LT treatments, PHT is associated with higher risk of tumor progression and/or an associated high risk of drop out. However, PHT was not associated with worse results in transplanted patients.  

57

Abstracts

7.6 Portal hypertension in patients waiting for liver transplantation for hepatocellular carcinoma on cirrhosis

Abstracts

Alain Sauvanet1, Sébastien Gaujoux1, Safi Dokmak1, Benjamin Blanc1, Anne Couvelard2, Marie-Pierre Vullierme3, Philipe Ruszniewski4, Philipe Lévy1, Jacques Belghiti1 1 Department of HPB surgery - AP-HP, Clichy, France, 2Department of Pathology - AP-HP, Clichy, France, 3Department of Radiology - AP-HP, Clichy, France, 4Department of Gastroenterology - AP-HP, Clichy, France Objectives For non-invasive Intraductal Papillary and Mucinous Neoplasms (IPMN) of the pancreas, pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) are associated with a significant perioperative morbidity and morbidity and a high-risk of pancreatic insufficiency. Because pancreas-sparing pancreatectomy are supposed to be associated to excellent postoperative and functional long-term results, enucleation (EN), and medial pancreatectomy (MP) could be considered as alternative to standard resection. The aim of this study was to assess feasibility and results of parenchyma-sparing pancreatectomies for preoperatively supposed non-invasive IPMN. Method From 1997 to 2010, 379 patients had resection for suspected IPMN, including 83 (22%) attempts to EN or MP. Surgery was indicated for suspected main duct (MD) involvement (n=22), BD > 30 mm (n=16) or with mural nodule (n=11), otherwise for symptoms. BD eligible for EN were localized on the uncus (n=31), head (n=9), neck/distal pancreas (n=12). Intraoperative frozen section (FS) was routinely done and resection was converted to PD or DP if FS revealed involvement of MD or at least border-line IPMN on communicating duct. Follow-up included clinical and biological assessment, with imaging (mainly MRI) on a yearly basis. Results Of 52 EN attempts, 7(13%) were converted to PD (inflammation or FS findings), and 2 to MP. Of 31 MP attempts, 4(13%) were converted to PD/DP. Overall, 72 (87%) patients had EN/MP. Overall mortality was  1,2% and morbidity 63%, including a 52% rate of pancreatic fistula (grade B+C=19%). Accuracy of FS was 95%. Definitive pathologic examination revealed non-IPMN diagnosis (n=3;4%), non-invasive IPMN (n= 67; 93%), and minimally invasive IPMN (n=2;3%). During follow-up (41[12-156]), 2 (3%) patients developed recurrent pancreatic symptoms, 2 developed diabetes, and 2 exocrine failure; 4 pts (6%) were reoperated for persistant (n=1) or recurrent (n=3) IPMN. Conclusions Parenchyma-preserving pancreatic resections for presumed non-invasive IPMN have a high feasibility and avoid inappropriate resections for lesions mimicking IPMN. Preoperative selection is accurate with very few missed invasive IPMN. Early morbidity is counterbalanced by a low rate of symptom recurrence, and very rare de novo functional disorders. The rate of tumor recurrence is equivalent to that commonly observed after PD/DP.

8.11 Parenchyma-sparing pancreatic resections for presumed non-invasive Intraductal and Papillary Mucinous Tumors of the Pancreas

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
58

E-AHPBA

8.12 A Reduction in circulating tumour cells during “no-touch” pancreatic resection

Objectives  To determine the levels of circulating tumour cells (CTCs) in the portal circulation following both the no-touch isolation technique and the conventional technique for pancreaticoduodenectomy and to observe whether the number of CTCs in the circulation influences survival.   Method  12 consecutive patients with a preoperative diagnosis of PDAC underwent pancreaticoduodenectomy. They were randomized into 2 groups: standard technique (group I) and “no-touch” technique (group II).  Blood was taken from the portal vein intra-operatively, before and after manipulation.  The samples were processed using the bead-based fluorescence CellSearch system.   Results Six patients were randomised to group I, and 6 to group II.  All patients had a whipples procedure for resectable PDAC tumours.  There was no difference in operative time, length of stay, complication rate, resection margin status, tumour size, positive:negative lymph node ratio or in the initial number of CTCs detected (median = 1; ratio 0-6).  An increase in CTCs was seen in 5/6 (83%) patients in group I but 0/6 in group II (p=0.003).  Overall survival was 13 months (95%CI 10.1-15.9) in group I and 16.7 months (95%CI 12.6-20.8) in group II (p=0.328).   Conclusions This is the first paper to show that the no-touch isolation technique for pancreaticoduodenectomy reduces the number of CTCs detected in the portal vein compared to a standard procedure.  Further, these patients trend towards a better overall survival.

59

Abstracts

Tamara Gall, Adam Frampton, Jimmy Jacob, Jonathan Krell, Nagy Habib, Justin Stebbing, Long Jiao Imperial College, London, UK

8.13 Expression of Fas and Fas ligand (FasL) in experimentally-induced acute pancreatitis Abstracts
Vassilios Pardalis, Helen Bolanaki, Christina Tsigalou, Panagoula Oikonomou, Erchan Moustafa, Ilias Themelidis, Constantinos Simopoulos, Anastasios Karayiannakis Second Department of Surgery, Democritus University of Thrace, Medical School, Alexandroupolis, Greece Objectives The role of Fas/Fas ligand (FasL) system in apoptosis induction in severe acute pancreatitis was evaluated by studying the tissue expression of Fas and FasL by immunohistochemistry after experimentally-induced acute pancreatitis. Method Seventy Wistar rats were randomly allocated into three groups: acute pancreatitis (n = 30), sham-operated (n = 30) and controls (n = 10). Acute pancreatitis was induced by intraductal injection of sodium taurocholate. Animals were sacrificed at 6, 12, 24, 48, 72 hours and 1 week after the operation (5 animals at each time point). Pancreatic tissue samples were evaluated for pancreatitis severity and immunohistochemical expression of Fas and FasL. Results   The severity of pancreatitis peaked at 72 hours. The expression of Fas was increased significantly after pancreatitis induction while FasL expression was significantly reduced. A peak for Fas expression was detected at 24 hours with a gradual reduction thereafter. Conclusions The Fas/FasL system is induced in acute pancreatitis and constitutes an important pathway mediating the apoptosis of pancreatic acinar cells.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
60

E-AHPBA

MIGUEL ANGEL SUAREZ MUNOZ1, NURIA PELAEZ SERRA2, LAIA FALGUERAS3, JAVIER HERRERA4, LUIS MUNOZ BELLVIS5, MARIA ISABEL GARCIA DOMINGO6, MARIA EUGENIA BARRIOS7, IGNACIO POVES PRIM8, ANGEL MOYA9, JOSE MARIA ALAMO10, JULIO SANTOYO SANTOYO1 1 Hospital Carlos Haya, MALAGA, Spain, 2Hospital Bellvitge, L’Hospitalet de Llobregat - Barcelona, Spain, 3Hospital Josep Trueta, Girona, Spain, 4Hospital de Navarra, Pamplona - Navarra, Spain, 5Hospital Clínico de Salamanca, Salamanca, Spain, 6Hospital Mutua de Terrassa, Terrassa - Barcelona, Spain, 7Hospital Clínico de Valencia, Valencia, Spain, 8Hospital del Mar, Barcelona, Spain, 9Hospital La Fe, Valencia, Spain, 10Hospital Virgen del Rocío, Sevilla, Spain Objectives To present the results obtained in the treatment of patients undergoing surgery for pancreatic cancer and who had vascular involvement

Method Retrospective, case-control, multicenter Spanish study. 516 patients met the inclusion criteria (resective surgery for pancreatic carcinoma). In 202 patients a vascular resection was performed in association with pancreatic resection (study group) , and in 314 patients only pancreatic resection was performed (control group). The sex distribution was male in 61% of patients and female in 39%, ranging between 23 and 85 years old. Considered variables were type of pancreatic resection (pancreaticoduodenectomy, total pancreatectomy, distal pancreatectomy), type of vascular resection (venous, arterial, combined -venous + arterial-), type of vascular reconstruction (suture, anastomosis, graft), endothelial invasion by tumor, morbidity and overall survival Results Pancreaticoduodenectomy was the most frequent surgical procedure (86 %), followed by total pancreatectomy  (9 %), and distal pancreatectomy  (5 %). Venous resection was performed in 93.5 % of patients, and arterial in 3 %. Overall morbidity reached 55 %, with a 90 days mortality of 13 % in study group vs 7 % in control group (p <0.01). Actuarial survival at 1, 3 and 5 years was 69%, 28%, 18% and 80%, 39%, 26% in the study and control group respectively (log rank test p: 0.002). Vascular (endothelial) invasion by tumour exhibits statistic trend as bad prognosis factor (p <0.06) Conclusions Need for vascular resection in pancreatic cancer surgery should not be considered a contraindication for treatment of these patients. Venous resection is the most common, and neoplastic endothelial invasion is a bad prognosis factor

61

Abstracts

8.14 Results of treatment of pancreatic carcinoma in patients with vascular involvement. Spanish multicenter study.

8.15 Laparoscopic enucleation of benign and borderline pancreatic neoplasms Abstracts

Giuseppe Malleo, Giovanni Marchegiani, Despoina Daskalaki, Isacco Damoli, Claudio Bassi, Giovanni Butturini The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy Objectives Minimally invasive enucleation of pancreatic neoplasms is a very uncommon procedure. Here we describe the short- and long-term results of laparoscopic enucleations performed at our institution for benign to borderline lesions of the pancreas. Method Patients scheduled for a laparoscopic enucleation between March 2006 and January 2012 were included in the study. The decision on whether to choose the laparoscopic approach was taken at the surgeon’s discretion in patients with small lesions presumed to be benign or borderline. Demographic, surgical, pathological and follow-up details were recorded. Results The procedure was attempted in 14 patients, but two patients ultimately underwent totally laparoscopic middle pancreatectomy because of intraoperative damage to the pancreatic duct or close distance between the lesion and the duct itself. In the remaining 12 patients the planned operation was performed. Of these, only one developed an indolent pancreatic fistula, no other morbidity was observed. The mean hospital stay was 6.3 days. Histological examination showed seven insulinomas, four non-functional neuroendocrine neoplasms and one undetermined cystic neoplasm. At a median follow-up of 39 months, no patient exhibited endocrine or exocrine pancreatic insufficiency, tumor recurrence or port site hernia. Conclusions When feasible, laparoscopic enucleation of pancreatic benign to borderline neoplasms and can be carried out with excellent short- and long-term results in well-selected cases.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
62

E-AHPBA

Paolo Regi1, Roberto Girelli1, Matilde Bacchion2, Isabella Frigerio1, Alessandro Giardino1, Claudio Bassi2 1 Department of Surgery, HPB Unit, CDC Dott. Pederzoli, Peschiera Del Garda, Verona, Italy, 2Department of General Surgery B, Pancreas Institute, University of Verona, Verona, Italy Objectives  To assess and evaluate the correlation between expected (E-NA) and effective (NA) necrosis area after single probe radiofrequency ablation (RFA) for locally advanced pancreatic cancer in a tertiary referral center.   Method  A retrospective analysis of our electronic database was performed between the date October 2011 and June 2012 searching for those patients who had undergone RFA for stage III (UJCC classification) pancreatic cancer. Inclusion criteria were considered: use of a single probe through a single-stage ablation, a multi-axial CT scan estimation of tumor size before surgery, and of the necrotic area at postoperative day 7. The probe opening and length of ablation were used to calculate the E-NA according to device setup (RITA Uniblate TM).   Results  Fifteen patients were finally enrolled for a pilot study. Mean age of the study group was 58 years (SD±9). Eight (53.3%) patients were female and seven (46.7%) male. The ablation temperature was setup on 80°C for all cases, while mean length of procedure was 5.6 minutes (SD±1). Median E-NA and NA were 3 cm2 (range: 3-5) and 3.8 cm2 (range: 2-7), respectively. Effective necrosis area was greater than expected in 73% of cases (n=11), with a median rate of overtreatment equal to 33.8% (range: 5-81).     Conclusions Radiofrequency ablation should be warranted as a safe and immunomodulating surgical procedure for patients suffering from locally advanced pancreatic cancer. In this setting, the risk of inappropriate ablation and unnecessary complications makes the surgeons to reasonably contain the extent of the procedure.    

63

Abstracts

8.16 Postoperative CT-scan estimation of tumor necrosis after radiofrequency ablation for locally advanced pancreatic cancer. A pilot study on 15 cases.

Abstracts

Safi Dokmak1, Béatrice Aussilhou1, Fadhel Samir Ftériche1, Philippe Levy0,2, Philippe Ruszniewski0,2, Olivier Farges1, Jacques Belghiti1, Alain Sauvanet1 1 Beaujon Hospital, Departement of HBP surgery and liver transplantation, Clichy, France, 2Beaujon Hospital, Departement of gastroenterology and pancreatic diseases, Clichy, France Objectives Aim: Report the results of laparoscopic pancreatic resections (LPR) in a specialized centre. Method  Between January 2008 and December 2012, 130 LPR were performed and studied prospectively. Only the vascular invasion was considered as contraindication for the laparoscopic approach. Pancreatic fistula (PF) was defined according to ISGPF. There were 85 (65%) distal pancreatectomies, 17 (13%) pancreaticoduodenectomies, 10 (8%) middle pancreatectomy, 16 (12%) enucleations and 2 (2%) total pancreatectomy. There were 80 female (62%). The mean age and BMI were 54 years (18 -78) and 25 kg/m2 (18-39), respectively. The indication of resection was for malignancy in 70 cases (54%), low potential malignant diseases in 45 cases (35%) and benign diseases in 15 cases (11%).   Results The mean operation time and blood loss were 205 minutes (30-540) and 225 ml (0-1500), respectively. Conversion or hand assisted were necessary in 9 and 13 cases, respectively. There was no mortality with an overall morbidity in 90 patients (70%), represented mainly by PF (B+C) (42%), bleeding (13%) and pulmonary complications (9%). A re-intervention was necessary in 11 patients (8%) mainly for bleeding (n=8). The mean hospital stay was 21 days (6-104) and a rehospitalisation was necessary in 8 patients. For malignant diseases the average number of retrieved lymph nodes was 12 (0-59). R0 resection was achieved in 92%. Conclusions Whatever its modality, the laparoscopic pancreatic approach is feasible with no mortality and high morbidity but without severe complications. The prolonged hospital stay is still related to the high rate of pancreatic fistula. For malignancy and in selected patients, the oncological results are comparables to the open approach. 

9.1 130 laparoscopic pancreatic resections in a specialized centre.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
64

E-AHPBA

9.2 Comparison of robotic, laparoscopic and open distal pancreatectomy.

Objectives  Although there are data in the literature about the safety and efficacy of robotic distal pancreatectomy, studies comparing laparoscopic versus open and robotic approaches are lacking. The purpose of this study is to compare the peri-operative outcome of laparoscopic versus open versus robotic distal pancreas resections from a single institution. Method Nine patients underwent distal pancreas resections between October 2010-July 2012. These  patients were compared with 10 and 9 consecutive patients undergoing laparoscopical and open distal pancreasectomy, respectively. Five surgeons performed surgeries and all relevant data about the 28 patients were entered in a retrospectively maintained database. Ultrasonography, abdomino-pelvic computed tomography scan, magnetic resonance imaging, PET/CT and endoscopy ultrasound technique were performed as part of the routine preoperative staging workup. Patients with adenocarcinoma were staged using the clinical tumor node metastasis (TNM) and received longcourse neoadjuvant therapy. The surgery was performed 3 - 4 weeks of radiation therapy.   Results  A total of 28 patients were included in this study (9 Robotic, 10 Laparoscopic and 9 Open). There was no significant difference among the three groups concerning patient demographics, indications and pathology. Interestingly, the percentage of malignant desease was over 50% in the three goups: 77% robotic, 70% laparoscopic. 77% open. The conversion rate was lower in the robotic group versus laparoscopic group (11% Vs 30%; p<0.05).   Lymph nodes harvested mean was 12,5 (robotic), 5 (laparoscopic), 13,2 (open) p<0.05. Clavien III-IV complications were 0% (robotic), 50% (laparoscopic) and 44% (open). Subsequently, hospital stay was longer in open group (p<0,05) Conclusions Robotic distal pancreatectomy is safe and feasible in selected patients. Oncological resections are achieved with advantages regarding to major complications and hospital stay.  In the future, prospective case-matched studies will need to be performed to validate our initial findings and assess long-term oncological and functional outcomes for pancreatic cancer treatment.  

65

Abstracts

Hipólito Durán, Emilio Vicente, Yolanda Quijano, Benedetto Ielpo, Isabel Fabra, Catalina Oliva, Eduardo Díaz, Valentina Ferri, Sergio Olivares, Riccardo Caruso, Ramón Puga, José Carlos Plaza hospital madrid norte sanchinarro, madrid, Spain

Abstracts

9.3 Laparoscopic distal Pancreatectomy With or Without Splenectomy: Indications and Long Term Outcomes. Results of A Single Center Consecutive Series of 95 cases

Giovanni Marchegiani, Giuseppe Malleo, Isacco Damoli, Despoina Daskalaki, Claudio Bassi, Giovanni Butturini Department of Surgery, Pancreas Institute, University of Verona, Verona, Italy Objectives There is increasing evidence that spleen preservation is of clinical value for patients undergoing distal pancreatectomy. Here we present the early and long term outcomes of a consecutive series of laparoscopic distal pancreatectomies with or without splenectomy and discuss the pros and cons of spleen preservation Method All patients undergone laparoscopic distal pancreatectomy at our institution between May 1999 and December 2011  were included in the study. Demographic and clinical characteristics were analyzed. Postoperative complications were prospectively recorded in an institutional database. Long term follow up was assessed by outpatient clinic and direct contact. Follow up ended on May 2012 Results Study population consisted of 95 patients. Splenectomy was performed in 56 patients (59%). Among the 39 patients undergoing spleen preservation, 9 had a Warshaw procedure. Mortality was nil. A pancreatic fistula developed in 26% while a re-operation was necessary in 10.5%. In three patients emergency splenectomy was required for splenic infarction. In the long term, asymptomatic gastric varices developed in 19% of patients in whom spleen had been preserved. 68% of splenectomized patients adhered to vaccine prophylaxis. One patients who did not developed a severe sepsis; 13% had a persistent reactive thrombocytosis requiring antiaggregation therapy. No thromboembolic accident was reported. Conclusions Spleen preservation (with or without splenic vessels sacrifice) during laparoscopic distal pancreatectomy was associated with specific early (splenic infarction) and late (gastric varices) complications. Splenectomy, on the other hand, may lead to an increased rate of infectious and vascular accidents, adequately preventable by vaccination and anti-aggregation therapy.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
66

E-AHPBA

1

Stephanos Pericleous1, Nicos Middleton2, Siobhan McKay1, Robert Hutchins1 Barts and the London, London, UK, 2Cyprus University of Technology, Nicosia, Cyprus

Objectives Cumulative evidence suggests that laparoscopic distal pancreatectomy (LDP) is as safe as the open (ODP) equivalent. The aim of this study was to systematically review the relevant literature and perform a metaanalysis, to provide the strongest and most up to date evidence available. Method A systematic review was performed of all relevant published articles in PubMed (between 1992 and 2013) with subsequent meta-analysis. We excluded studies that had included data from alternative minimally invasive approaches, such as laparoscopic hand assisted or robotic surgery. Results No randomised controlled studies were identified.  A total of nine case-control studies matched our inclusion criteria offering a total of 965 patients. Statistically significant differences were observed in recorded intra operative blood loss (316 mls less in LDP) and in patient post-operative hospital stay (2.64 days less in LDP). There were no statistically significant differences in operative time, pancreatic leaks, overall morbidity and mortality. Conclusions This meta-analysis provides the strongest evidence to date as to the safety of laparoscopic approach to distal pancreatectomy.

67

Abstracts

9.4 Laparoscopic vs open distal pancreatectomy: systematic review and meta-analysis of case matched series.

9.5 Laparoscopic pancreatectomy in benign lesions of the pancreas Abstracts
Ilya Kozlov, A. Kriger, S. Korolev, A. Kochatkov Vishnevsky Institute of Surgery, Moscow, Russia

Objectives To estimate possibility of performance and results of the laparoscopic pancreatic resections. Method Thirty patients were scheduled for laparoscopic technique of pancreatectomy. Laparoscopic distal pancreatectomy (18) without splenectomy (13) and with splenectomy (4), combined with partial splenectomy (1) were performed. Laparoscopic medial resection of the body (6), duodenum-preserving total resection of the head of the pancreas (3) and pancreaticoduodenectomy (1) were performed. In one case we found it possible to execute simultaneous medial and proximal pancreatectomy. Laparoscopic Frey procedure was performed in 2 cases of chronic pancreatitis. The operation was performed in a supine position with the legs apart. Mobilization and excision of the pancreatic tissue was performed with a Harmonic instrument. Results  Mean operative time was 280 minutes, the estimated blood loss was 300 ml. There were no reoperations and mortalities. The overall postoperative morbidity rate consisted of pancreatic fistula (8). There were two cases among the patients in which intraabdomenal seroma was developed. The mean cystic size was 4 cm (range, 1.2-8.5 cm). The surgical specimens included serous (8) and mucinous (6) cystadenomas, chronic pancreatitis (6), true cysts (1), neurofibroma (1), neuroendocrine adenomas (5), branch-duct intraductal papillary mucinous (2) or solid pseudopapillary (1) tumors. All patients had no evidence of disease recurrence. Conclusions Laparoscopic pancreatectomy is an operation that can be performed technically feasible. Our experience demonstrates that laparoscopic technique is safe in benign-appearing lesions of the pancreas.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
68

E-AHPBA

9.6 Laparoscopic Distal Pancreactectomy for Primary Pancreatic Adenocarcinoma

Objectives Laparoscopic distal pancreatectomy has been shown to be feasible and safe, many would agree it should be the gold standard approach in centres with available expertise, in malignant lesions however, oncological efficiency remains questioned. We aim to analyse our experience in laparoscopic distal pancreatectomy for ductal adenocarcinoma of the pancreas. Method Data on 66 patients undergoing laparoscopic distal pancreatectomy (LDP) and splenectomy by a single surgeon between 06/2007 and 03/2013 were reviewed in a prospectively kept database. Data was collected on demographics, indications for surgery, operative details, associated resections, complications (defined as Clavien-Dindo score 3 or higher), postoperative pancreatic fistula grade B/C according to the ISGPS definition, post operative stay and histopathology. Of 66, 9 patients had adenocarcinoma of the pancreas, in 4, malignancy was suspected pre-operatively and in 5 it was suspected intra-operatively or on histopathological examination of resected specimen. An anterior RAMPS was performed when malignancy was suspected.   Results Average age was 65, male:female ratio was 5:4. Conversion rate was 0%, average operative time 230 minutes and mean blood loss 253ml. Median high care and hospital stay was 1 and 3 days respectively, complication rate 11% and pancreatic fistula rate 22%. Average nodal sample was 13. Stapler line resection margin was clear in all patients, posterior margin was involved in 2 patients (R1 in 22%), both occurring in the first half of the experience and both associated with decreased nodal sample, 1 did not have suspected malignancy preoperatively and 1 underwent standard LDP and malignancy was found at histology. Conclusions Our series has shown that laparoscopic distal pancreatectomy for primary pancreatic malignancy is feasible, safe and oncologically efficient. Positive margins can be associated to pre-operative miss-diagnosis and is associated with reduced number of nodes. Careful pre-operative assessment is needed and formal anterior RAMPS performed when there is minimal doubt.

69

Abstracts

JohnRichardson,EleonoraDimovska,JuliaBurkert,HaniAlsaati,MarcBesselink,ArjunTakhar,MohammadAbuHilal University Hospital Southampton, Southampton, UK

Abstracts

Jean-Philippe ADAM1, Alexandre JACQUIN1, Christophe LAURENT1, Denis COLLET1, Antonio SA-CUNHA2 1 Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France, 2Centre Hépato-Biliaire, Hôpital Paul Brousse, APHP, Villejuif, France Objectives  To analyze the clinical characteristics and the outcomes of our large series of consecutive laparoscopic distal pancreatectomies performed for 15 years.   Method From January 1997 to May 2012, we reviewed all laparoscopic distal pancreatectomies at Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France, from prospectively maintained database. The clinicopathological features, operative findings and postoperative outcomes were evaluated.   Results Of the 91 consecutive laparoscopic distal pancreatectomies performed, 33 (36%) were laparoscopic distal splenopancreatectomies   and 58 (64%) laparoscopic spleen-preserving distal pancreatectomies, 37 (41%) with division and 21 (23%) with preservation of the splenic vessels. The most common diagnoses were neuroendocrine neoplasms in 27 patients (30%), mucinous cystadenoma in 21 (23%), serous cystadenoma and intraductal papillary mucinous neoplasms respectively in 11 (12%). Postoperative complications occurred in 28 (31%) patients, including 14 (15%) with pancreatic fistula (ISGPF grade B, C), without deaths. Median operative time was 225 (range, 153-420) min and median hospital stay was 11 (6-56) days.   Conclusions  Laparoscopic distal pancreatectomy is safe and effective and should become the standard approach in patients with presumably benign lesions in the body-tail of the pancreas.  

9.7 Single-center experience of laparoscopic distal pancreatectomy in 91 consecutive patients

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
70

E-AHPBA

9.8 Benefit of pancreatic resections in octogenerians Abstracts
Odo Gangl, Uwe Fröschl, Reinhold Függer Elisabethinen Hospital, Linz, Austria

Objectives Although pancreatic resections are performed safely irrespective of age the benefit in octogenerians tends to be questioned   Method  From a prospectively maintaned database of all pancreatic resections (2001-2010; n=251) we identified 16 patients aged over 80. Points of interest were length of stay, complications, reinterventions, reoperations and 30 day in hospital mortality. For overall survival a query of the national register of residents (Statitistik Austria) was made with the cutoff date of 31.12.2010.   Results  Resections were performed for malignancies in 81% and benign lesions in 19%. There were 63% pancreaticoduodenectomies 4 distal pancreatectomies (3 open, one laparoscopic), one Kausch Whipple and one total pancreatectomy. Postoperative mortality was nil, median length of stay 23 days (16-49). Complications occured in 19% of patients, one angiography, no reoperation. With a median follow up of 295 days (41-3250) 46% (6/13) of patients had a median survival of 684 days (41-3250). 54% (7/13) of patients died after a median of 292 days (226-623).     Conclusions In our experience pancreatic resections are safe and reasonable therapeutic options for octogenarians  

71

9.9 Radiofrequency ablation of the pancreas: two-week follow-up in a porcine model Abstracts

Samira Fegrachi, Quintus Molenaar, John Klaessens, Marc Besselink, Johan Offerhaus, Richard Van Hillegersberg UMC Utrecht, Utrecht, The Netherlands Objectives Radiofrequency ablation (RFA) is a novel treatment strategy in patients with unresectable locally advanced pancreatic cancer. The histological effect and risk of postoperative complications has not been systematically addressed in an experimental model. This study determines the impact of RFA of pancreas after two-week follow-up in a porcine model. Method RFA was performed with previously determined optimal settings in pigs (n=6) during laparotomy with a bipolar RFA probe of 30mm active length at 30W until a total energy of 15KJ was administered. The probe was inserted in the pancreas at a distance of 10mm from duodenum and portomesenteric vessels (PMV). RFA nearby the duodenum was performed with continuous duodenal cooling using 100ml/min saline of 5˚C. During two weeks the clinical condition was evaluated daily using a clinical evaluation list and blood analyses. After two weeks, a total pancreatoduodenectomy was performed and the obtained tissue histopathologically assessed. Results No mortality occurred during or after RFA. A reduced food intake occurred in 2 / 6 animals in the first days. Two animals had a serum amylase increase more than threefold the pre-intervention value without clinical manifestations. Hemoglobine, liver enzymes and glucose remained normal in all animals. Histopathologic assessment showed total ablation within the ablation zone (diameter 2cm, length 3cm) with loss of normal pancreatic acinar cell outlines and necrosis. In one animal focal necrosis of the duodenal submucosa was seen and in another animal focal fibrosis in the muscular layer of the superior mesenteric vein without clinical manifestations. Conclusions In this porcine model no major morbidity and no mortality was seen during a period of two weeks after RFA of the pancreas with previously validated settings including duodenal cooling and 10mm distance to portomesenteric vessels.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
72

E-AHPBA

Charalampos Iakovidis1, Yeh Chun-Chieh0,2, Maria Lampropoulou1, Maria Panopoulou1, Fotini Papachristou1, Helen Bolanaki1, Alexandros Kortsaris1, Constantinos Simopoulos1, Anastasios Karayiannakis1 1 Second Department of Surgery, Democritus University of Thrace, Medical School, Alexandroupoli, Greece, 2Graduate Institute of Clinical Medical Science, China Medical University,Department of Surgery, China Medical University Hospital, Taichung, Taiwan Objectives The effect of obstructive jaundice on intestinal permeability was evaluated by studying the changes in the expression of the tight junction proteins occludin and claudin-4 in the intestinal epithelium after experimentally-induced obstructive jaundice. Method Fifty male Wistar rats were divided into three groups: I (n=5), controls; II (n=15), sham operated; III (n=30), bile duct ligation. Animals were sacrificed at 3, 7 and 14 days after intervention. Endotoxin levels in the portal vein, the presence of pathogens in the mesenteric lymph nodes, mucosal morphometry and immunohistochemical expression of occludin and claudin-4 in the terminal ileum were evaluated at the aforementioned time-points.   Results Obstructive jaundice resulted in portal vein endotoxinaemia, positive mesenteric lymph node cultures and changes in the height and density of the intestinal villi. Occludin expression was significantly decreased in the upper third of the villi in jaundice rats while Claudin-4 expression was significantly increased in the upper third of the villi.   Conclusions Experimentally-induced obstructive jaundice induces differential changes in the expression of the tight junction proteins occludin and claudin-4 resulting probably in gut barrier dysfunction, increased intestinal permeability and bacterial and endotoxin translocation.

73

Abstracts

10.1 Altered expression of occludin and claudin-4 in the intestinal epithelium after experimentally-induced obstructive jaundice

Abstracts

10.2 Minimally invasive surgical procedures under ultrasound in the treatment of obstructive jaundice

Faruch Makhmadov, Karimhon Kurbanov, Zokir Nurov, Atoboi Sobirov, Alisher Gulahmadov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan Objectives Improve treatment outcomes in patients with obstructive jaundice by the differential application of different options of minimally invasive surgery under ultrasound guidance. Method The present study is based on an analysis of clinical findings in 39 patients who were on treatment for jaundice of benign and malignant origin between 2009 and 2012. Among the studied patients were 23 men and 16 women. Senile elderly persons and the age category of 53 to 79 years accounted for 64.1%. Percutaneous transhepatic cholecystostomy under ultrasound was performed using a “free hand”. The contents of the gall bladder was subjected to macroscopic evaluation, bacteriological test, the cavity was washed dekasana bubble. To clarify the origin of obstructive jaundice in 13 (33.3%) were performed cholecystocholangiography. Results In 13 (33.3%) patients, the cause of jaundice served gallstone disease in 26 (66.7%) - malignant lesions hepatopancreatobiliary zone, of which 17 (65.4%) cases, there was an advanced stage of cancer. In 16 patients with biliary decompression by percutaneous transhepatic biliary drainage is designed as a stage of preparation of patients for radical surgery in 6 (15.4%) - palliative. In 17 (43.6%) cases, drainage of bile duct was the final operation. To 7-9 days in the condition of patients stabilized. Died 3 (7.7%) patients in the presence of inoperable cancer. Postoperative complications were observed in 2 (5.1%). Conclusions Percutaneous transhepatic cholecysto and holedohostomiya under ultrasound is less traumatic, highly effective decompression and rehabilitation biliary tract, which extends the treatment of heavy contingent, creating favorable conditions for radical and palliative surgery. Minimally invasive intervention is easy to carry seriously ill patients, with the presence of multiple comorbidities.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
74

E-AHPBA

Gregory Christodoulidis1, Dionyssis Dimas2, Fotis Constantinidis3, Konstantinos Tepetes1 1 University Hospital of Larissa, General Surgery Dep., Larissa, Greece, 2Elpis Hospital, General Surgery Dep, Athens, Greece, 3Elpis Hospital, Radiology Dep., Athens, Greece Objectives Percutaneous cholecystostomy is an alternative treatment option for patients with severe cholecystitis with serious comorbidities not responding to conservative treatment or those unfit to undergo surgery Method In a period   of 4 years (2008-2012) fifty-two patients were included in this study. All the patients were diagnosed with calculous cholecystitis. Medical comorbidities, technical success, complications and recurrence of cholecystitis were evaluated Results The mean age of patients was 70,5 years of age. There was a male predominance. Twelve patents were admitted in shock. In 50 patients the insertion of cholecystotomy tube under computed tomography guidance was succesfull. The average time of cholecystitis to resolve was 2,2 days. Nine patients were subjected to surgery during inhospital stay. The overall complication rate was 32% while the mortality rate was 14%. Eight patients (16%) had early recurrence of cholecystitis. Conclusions Percutaneous cholecystotomy seems an effective treatment option for severe acute cholecystitis in patients with increased surgical risk.

75

Abstracts

10.3 Percutaneous cholecystotomy as an alternative treatment option for acute cholecystitis. Clinical outcomes.

Abstracts

10.4 Comparative study of early versus late cholecystectomy following endoscopic clearance of common bile duct stones
mohan narasimhan, mayank gupta, srishail chiniwalar, meenakshi mission hospital and research centre, madurai, tamilnadu, India ramesh ardhanari

Objectives cholecystectomy after ERC can be early within 24 hrs or any time later. timing is always a matter of debate. this study is to evaluate difference in outcome  timing of cholecystectomy following ERC. Method A one year comparative study of 132 cases from January 2010 to January 2011. All the patients were divided into 2 groups, early laparoscopic cholecystectomy (ELC) and late laparoscopic cholecystectomy ( LLC) group . ELC group patients had ERC with stone extraction and NBD placement. Laparoscopic cholecystectomy was done between 24 to 72 hours NBD was removed if cholangiogram was normal. Stent removal was done at 6 weeks. The LLC group had ERC with stone extraction with stent placement and discharged. Later readmitted for elective cholecystectomy. Stent removal was done at 6 weeks. Results Total 132 cases, 16 patients were excluded. 116 cases included in study, 65 in ELC group and 51 in LLC group.  mean interval between ERC and cholecystectomy was 1.5 days  ELC group and 27 days  LLC group. Mean operating time was 45 minutes in ELC group and 63 minutes in LLC group. No patient in either group required intra-operative blood transfusion or conversion to open surgery. LLC group patients had two or more hospital admissions and an average hospital stay of 6.2 days. In Post operative course 1 patient in ELC and 2 patients in LLC had subhepatic fluid collection. Conclusions early cholecystectomy following ERC clearance of common bile duct stone was as good as or may be better than late cholecystectomy.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
76

E-AHPBA

Charalampos Iakovidis, Maria Lampropoulou, Fotini Papachristou, Maria Panopoulou, Eleni Lazoudi, Helen Bolanaki, Alexandros Kortsaris, Constantinos Simopoulos, Anastasios Karayiannakis Second Department of Surgery, Democritus University of Thrace, Medical School, Alexandroupolis, Greece, Alexandroupoli, Greece

Objectives Changes in the expression of the cell adhesion molecules E-cadherin and desmoglein in the intestinal epithelium were evaluated after experimentally-induced obstructive jaundice. Method Fifty male Wistar rats were divided into three groups: I (n=5), controls; II (n=15), sham operated; III (n=30), bile duct ligation. Animals were sacrificed at 3, 7 and 14 days after intervention. Endotoxin levels in the portal vein, the presence of pathogens in the mesenteric lymph nodes, mucosal morphometry and immunohistochemical expression of E-cadherin and desmoglein in the terminal ileum were evaluated at the aforementioned timepoints. Results Obstructive jaundice resulted in portal vein endotoxinaemia, positive mesenteric lymph node cultures and changes in the height and density of the intestinal villi. E–cadherin expression in the intestinal epithelium decreased and Desmoglein expression increased in the bile duct ligation group only. Conclusions Experimentally-induced obstructive jaundice induces changes in the expression of cell adhesion molecules resulting in altered intercellular cohesion, gut barrier dysfunction and increased intestinal permeability.

77

Abstracts

10.5 The effect of obstructive jaundice on the expression of E-cadherin and desmoglein in the intestinal mucosa

10.6 The proteomic analysis of intra and extrahepatic cholangiocarcinoma cell lines. Abstracts

Stephanos Pericleous1,2, William Mathieson2, Siobhan McKay2, Duncan Spalding2, Robert Hutchins1 1 Queen Mary, University of London, London, UK, 2Imperial College London, London, UK Objectives Cholangiocarcinoma (CCA) is a rare and devastating neoplasm that, globally, accounts for approximately 15% of all primary liver cancers. Although often managed in a similar fashion, there is growing consensus that intra and extrahepatic CCA should be considered as distinct diseases. The aim of this study was to identify differences between intra and extrahepatic CCA cell lines at a proteomic level with a view to translating these into diagnostic or therapeutic targets. Method Two CCA (HUCC - intrahepatic, SkChA1 - extrahepatic) and one immortalised cholangiocyte cell line (H69) were cultured to adequate volumes. Four replicates of each cell line were used. Following extraction, protein was labelled with Cy dyes and separated using 2 dimensional gel electrophoresis. Differentially expressed gel spots were identified, excised and analysed using matrix assisted laser desorption ionisation (MALDI ToF/ToF) mass spectrometry. Results When comparing intra and extrahepatic CCA head to head, several differentially expressed proteins were identified. These included: alpha-enolase , endoplasmin, nucleophosmin and protein 14-3-3 sigma. Conclusions We have identified several differences between intra and extrahepatic CCA cell lines that have diagnostic and therapeutic potential. Further studies are needed to verify these findings on patient samples.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
78

E-AHPBA

Objectives Gallbladder cancer (GBC) is a disease with an increasing incidence. The majority of cases present with advanced incurable disease but increasingly GBCs are being diagnosed incidentally after routine cholecystectomy. Our aim was to evaluate retrospectively our experience of incidental GBC according to surgical approach and TNM staging.   Method 330 patients with GBC were admitted in our Liver Unit between March 1997 and October 2012. Incidental gallbladder cancer (iGBC) was identified in 66 (20%).   Results In the iGBC group median age was 62.3years,48 female  and 18 males.13 patients had an open cholecystectomy (Tis=2, T1=6, T2=5),19 had a gallbladder bed resection (GBR) (T1=2, T2=14, T3=5);32 had a gallbladder bed resection + extrahepatic biliary duct excision (GBR+EBDE) (T1=2, T2=21, T3=9).The choice was made considering each time bile duct invasion on the extemporary histological finding.The overall 5 year survival in the iGBC group it was 45,5%:in T1 group it was 70%, in T2  48.7% and in T3 14.3%.In patients who had only GBR and patients who had GBR+EBDE the 5 years survival was 35 and 46.9% respectively (p<0,03). Conclusions Radical re-operation in patients with incidental gallbladder carcinoma appears to improve survival. Extrahepatic bile duct excision when added to gallbladder bed resection also appears to improve survival.

79

Abstracts

Luca Toti2, Irene Scalera1, Tommaso Maria Manzia2, Robert Sutcliffe1, Ravi Marunadayagam1, Simon Bramhall1, David Mayer1, John Isaac1, Darius Mirza1 1 Queen Elizabeth hospital, Birmingham, UK, 2La Sapienza, Roma, Italy

10.7 Incidental Gallbladder Cancer: Radical Surgery offers Longer Survival

10.8 Prognostic significance of lymph-node ratio after resection of gallbladder cancer Abstracts

David Birnbaum, Luca Vigano’, Alessandro Ferrero, Serena Langella, Nadia Russolillo, Lorenzo Capussotti Ospedale Mauriziano Umberto I, Torino, Italy Objectives Lymph-node status is one of the strongest prognostic factors after gallbladder cancer (GBC) resection. However, stratification of prognosis in patients with metastatic lymph-nodes (LN+) is debated. To assess the prognosis of patients operated on for GBC according their lymph-node status, with special focus on site, number and ratio of LN+. Method 126 patients operated on for GBC between 1989 and 2011 were considered. Lymph-node dissection was performed in 115. Patients with operative mortality (n=6), simultaneous other organ cancer (n=2) and R2 resection (n=1) were excluded. 106 patients were included in the present analysis. Lymph-node dissection was confined to the hepatic pedicle (D1) in 25 (23.6%) patients, while was extended to the celiac and retropancreatic area (D2) in 81 (76.4%). N stage was classified according to the 7th edition of the AJCC manual. Lymph-node ratio (LNR) was computed as follows: number of LN+/number of retrieved lymph-nodes. Results Median number of retrieved LN was 8 (3.5 after D1 vs. 8 after D2,p=0.022). Fifty-five (51.9%) patients had LN+ (19 N2), median LNR=0.32 (0.08-1). LN+ worsened prognosis (median survival 15.1 vs. 48.9 months if N0,p<0.0001), but N1 and N2 patients had similar survival (14.3 vs. 15.1 months).Neither the LN+ number (1-3 vs. ≥4) nor the dissection extension (D1 vs. D2) impacted prognosis. LNR well stratified outcome in LN+ patients: median survival 25.6 months if LNR£0.15 vs. 13.5 if LNR>0.15 (multivariate analysis p=0.009); median disease-free survival 17.5 vs. 6.8 months (p<0.0001). LNR impact was independent from dissection extension. Conclusions LN status is a major prognostic factor after resection of GBC. Among LN+ patients, LNR=0.15 rather than metastases site or number should be adopted to stratify prognosis.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
80

E-AHPBA

Athanasios Petrou1, Kyriakos Neofytou1, Konstantinos Bramis2, Evangelos Felekouras3 1 Nicosia Surgical Department/Div. HPB, Nicosia General Hospital, Nicosia, Cyprus, 2Department of Hepatobiliary Surgery, Surgery and Diagnostics Centre, Churchill Hospital. Headington, Oxford, UK, 3First Department of Surgery, University of Athens Medical School, LAIKO General Hospital, Athens, Greece Objectives  Bile duct injuries (BDI) remain the most serious complication following laparoscopic cholecystectomy (LC). Therapeutic options include drainage, stenting and surgical reconstruction. The aim of this study is to evaluate long-term outcomes after repair regarding the timing of intervention.   Method We retrospectively analyzed 92 patients managed to LAIKO General Hospital  between 1993 and 2012. Forty-one (41) injuries occurred in our department while the rest were referred from other units. Data retrospectively recorded concerned patient’s demographic characteristics, type of injury(according to Bismuth Strasberg classification), time to referral, diagnostic procedures, timing of surgical management and final outcome. Early reconstruction and late reconstruction were defined as surgical reconstruction in a time of period less than 14 days or more than 14 days after the injury respectively. We evaluated the effect of timing of management on postoperative complications.   Results Three patients were treated conservative, 3 patients with percutaneous drainage, and 19 patients underwent PTC or ERCP(with or without stent placement). A total of 56 (61%) patients were repaired by specialist hepatobiliary surgeons [timing of repair: early  n = 34;  and late  n = 22], whereas 11 (12%) underwent repair by nonspecialist surgeons before specialist referral [early, n = 3 and late, n = 8]. Outcomes after early repairs were better to late repairs when performed by specialists [stricture: 12%vs36% P=0,045, cholangitis: 6%vs14% P=0,371, NS;  nonsurgical intervention: 9%vs36% P=0,017; redo reconstruction 0%vs9% P=0,15, NS; overall morbidity: 21%vs50% P=0,021].   Conclusions Early repair after BDI results in better long-term outcomes compared to late repair when performed by specialists. Patients should be referred, as soon as possible after the diagnosis of BDI following laparoscopic cholecystectomy,   to tertiary centers possessing the appropriate expertise and experience.  

81

Abstracts

10.9 Early or late intervention on bile duct injury after laparoscopic cholecystectomy? A dilemma looking for an answer. A single center 20 years experience.

Abstracts

Miltiadis Lalountas1, Eleutheria Rachmani1, Byron Asimakopoulos2, Sotirios Vlahos1, Konstantinos Simopoulos1, Despina Vasilou2, Fotini Papachristou1, Konstantinos Charalabopoulos2, Alexandra Tsaroucha1 1 MSc in HPB Surgery, Second Department of Surgery, Medical School, Democritus University of Thrace, Alexandroupolis, Greece, 2Laboratory of Physiology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece Objectives The adhesion molecules Selectin-L, Selectin-E, Selectin-P, and PECAM-1 play an important role in acute inflammation and particular in acute pancreatitis. The aim of this randomized clinical trial (RCT) was to investigate the possible changes of their concentrations in the blood serum of patients with acute pancreatitis. Method In this study included 150 patients with acute pancreatitis, of any etiology and severity, as well as 70 healthy volunteers - matched controls with similar epidemiological characteristics. Recorded the age, sex, etiology, severity according to the Atlanta’s criteria as well as the Glasgow’s criteria, and the outcome of the disease. Alongside, laboratory measured the blood serum concentrations of the adhesion molecules Selectins-L, -E, -P and PECAM-1 (ELISA method) in the healthy controls and in the patients at the time of hospital admission, and after 24, 48 and 120 hours. Results The concentration values of the adhesion molecules Selectins-L, -E, -P, and PECAM-1 in the blood serum of patients with acute pancreatitis altered significantly, reduced for the Selectin-L and increased for the rest, compared to healthy controls (P<0.001, P<0.001, P=0.006, P<0.001, respectively). The concentrations of Selectin-L are a predictive laboratory tool to Atlanta’s severity criteria, with 70.2% sensitivity and 48.7% specificity, 48 hours after the admission (P=0.009), but also can predict the heaviest 5th scale of Glasgow’s criteria (P<0.001). Variations all of the adhesion molecules from the time of admission, at 24, 48 and 120 hours after, were not significant (P=NS). Conclusions The laboratory measurement of the adhesion molecules Selectins-L, -E, P, and PECAM-1 in blood serum represent a useful diagnostic tool of acute pancreatitis. Even more, the values of Selectin-L constitute a prognostic marker of the severity of acute pancreatitis.

11.1 Adhesion molecules Selectins-L, E, P and PECAM-1 in acute pancreatitis. Randomized controlled trial in 150 patients.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
82

E-AHPBA

Christina Purcell1, Amy Gillis0, Marie Egan0, Sinead Duggan0, Niamh Murray0, William Torreggiani0, Ronan Browne0, Paul F Ridgway0, Kevin C Conlon0 1 Trinity College, Dublin, Ireland, 2Adelaide & Meath Hospital incorporating the National Children’s Hospital, Dublin, Ireland Objectives Despite a move from open to minimally invasive surgery (MIS) mortality among  patients with severe NP remains approximately 20%.  Since 2007 our unit has adopted non-operative management approach to the treatment of these patients using Interventional radiological drainage as required.  The aim of this study was to analyse our results. Method A retrospective review of a prospective database of patients with severe necrotising pancreatitis admitted to our unit between January 2007 and August 2012 was performed. Demographic, clinical and radiological data were analysed. Results Seventy-eight patients with severe AP were admitted (52 male, median age 48yrs).  Alcohol was the predominant aetiology (51%).  46 patients (59%) had a Balthazar CT grade >C.  Pancreatic necrosis occurred in 30 patients (37%). 16 (53%) underwent IR drainage.  Median number of procedures was 1(range 1-7).  Interval to first drainage was 17 +/- 10 days.  Open necrosectomy was performed in 2 cases on the index admission.  All patients received nutrition support (median 29 days). Twelve (40%) received enteral nutrition and seven received enteral + parenteral nutrition. 4 patients managed non-operatively died (14.3%). One patient in the surgery group (50%) died. Conclusions This study suggests that a conservative approach is successful in the management of patients with severe necrotising pancreatitis and is at least comparable to current operative techniques.  A future trial comparing a non-operative approach with surgical or NOTES necrosectomy is warranted.

83

Abstracts

11.2 Surgical Necrosectomy May Not Be Required For Patients With Necrotising Pancreatitis

Abstracts

11.3 Endoultrsound Guided endoscopic Necrosectomy and Temporary cystogastrostomy for Infected Pancreatic Necrosis with self-expanding metallic stents: A Preliminary Report
Arunkumar Krishnan, Ravi Ramakrishnan Apollo Hospitals, Chennai, Tamilnadu, India

Objectives Pancreatic pseudocyst with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy but is associated with significant morbidity, mortality, and prolonged hospital stay. Endoscopic cyst drainage with necrosectomy is an alternative and less invasive technique. Here we report our experience using pseudocyst drainage with cystogastrostomy and endoscopic necrosectomy for infected pancreatic necrosis with fully covered self-expanding metallic stents (CSEMS). Method 12 patients underwent endoultrsound guided endoscopic necrosectomy and temporary cystogastrostomy for infected pancreatic necrosis by using CSEMS. Patient details, disease severity scores, treatment procedures, and outcome were recorded. Patients proceed to intervention if infection is strongly suspected on clinical and radiological grounds or is confirmed bacteriologically. After the necrosis cavity had been accessed, a large orifice was created and necrotic debris was removed using special short fully covered 15mm diameter CSEMS with large flares was deployed across the tract under radiological control. Completeness of the necrosectomy procedure was ascertained by visualization of a clear pseudocyst cavity on endoscopy. Results A total of 12 patients (10 men, 2 women; median age 39) who were treated successfully. Median APACHE 2 score on presentation was 11. Two patients presented with organ failure and needed intensive care.  Necrosis was successfully treated endoscopically in all patients, requiring a median of 2 endoscopic interventions (range 1±4). The tissue samples obtained at the first necrosectomy confirmed infection in 12 patients. Complication included superinfection in patient who made an uneventful recovery. After median of 5 weeks the metal SEMS was extracted by endoscopy. The patients have remained asymptomatic and median follow-up was 4 months. Conclusions Endoscopic necrosectomy and temporary cystogastrostomy with self-expanding metallic stent approach is feasible, safe, and effective in patient with infected pancreatic necrosis. The benefits of this endoscopic approach using fully covered self-expandable metallic stent in terms of less morbidity is conceivable and our report demonstrates that such an approach is feasible.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
84

E-AHPBA

Benoy I Babu, Aali J Sheen, Ajith K Siriwardena Greater Manchester and Cheshire Cancer Network Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, UK

Objectives Acute pancreatitis is a relatively uncommon acute illness with an incidence of approximately 1 in 10,000 and an episode-related mortality in the range of 10%, mainly in patients with the severe necrotizing form of the disease.  Recognition that open surgical necrosectomy is associated with  high morbidity led to the development of minimally invasive necrosectomy (MIN) techniques.  Logically, if pancreatic necrosis can be managed by MIN, many may be even more simply managed by percutaneous catheter drainage (PCD).  This study reports outcome in acute pancreatitis managed in a tertiary referral unit with an active policy of PCD as first intervention. Method The Hepato-Pancreato-Biliary surgical service of the Manchester Royal Infirmary is one of two UK-accredited HPB services serving a predominantly urban population of 3.2 million.  The service treated patients admitted directly to this hospital and tertiary transfers for the specialist HPB team.  1179 adult and paediatric in-patient episodes of acute pancreatitis were identified for the period 8th July 2008 to 5th July 2012 using the International Classification of Disease (ICD-10) code E85. Use of critical care, incidence of intervention - either radiological or surgical (and type of surgical intervention), in-patient stay and outcome are reported. Results The median (range) number of hospital inpatient days was 6 (1-268).  114 (9.6%) patients were admitted to critical care. The median (range) number of days in High dependency (Level II) and intensive care (level III) were 5 (1-37) and 7 (1-154) respectively. 28 (2.37%) patients had radiologically-guided percutaneous catheter drainage with a median (range) of 2(1-8) procedures per patient.  Eight (0.7%) patients underwent pancreatic necrosectomy of which one had laparoscopic surgery.  There were 2 (25%) deaths in patients undergoing surgery.  Overall 41 (3.4%) of 1179 patients died in-hospital with 39 deaths in 1171 (3.3%) non-operated patients Conclusions In this unselected series of patients with acute pancreatitis, the requirement for surgical intervention was low at 0.7%.  It is likely that these patients undergoing surgery represent a critically-ill cohort as they carry a procedure-related mortality of 25%.  However, the main finding of this study is that the majority of patients with acute pancreatitis can be managed without intervention with a low mortality rate of 3.3%.

85

Abstracts

11.4 Good outcomes can be achieved in acute pancreatitis with very low use of surgical necrosectomy

Abstracts

Hakan Canbaz1, Altan Yildiz2, Nurcan Doruk3, Handan Birbicer3, M. Musa Dirlik1 Mersin University Medical Faculty, Department of General Surgery, Mersin, Turkey, 2Mersin University Medical Faculty, Department of Interventional Radiology, Mersin, Turkey, 3Mersin University Medical Faculty, Department of Anesthesiology, Mersin, Turkey
1

11.5 Portal Vein Erosion, Portal Septic Debris Emboly and Intraabdominal Hemorrhage As Complications of Acute Necrotizing Pancreatitis: Report of a Case

Objectives Mortality rate of acute pancreatitis with Ranson score 5-6 and portal vein(PV) bleeding are 40% and 50% respectively. Major venous bleeding represents a therapeutic challenge and needs individualization. We aimed to present a case of acute necrotizing pancreatitis(ANP) with an unreported complication and extraordinary treatment approach for potentially fatal complications. Method A 50 years old female having ANP with Ranson score of 5 had disseminated necrosis of pancreas in CT(CT severity index:9/10), and was operated for abdominal compartment syndrome and suspect of infected pancreatic necrosis. Because of widespread necrosis distal subtotal pancreatectomy and skin closure were performed, and histopathological report was necrosis and suppurative inflammation in pancreas. She developed infected pancreatic fistula and experienced a successfully resuscitated cardiac arrest after mobilization. During mechanical ventilation a hemorrhagic shock necessitated emergency surgery which was unsuccessful to access and locate bleeding site; a foley catheter with inflated balloon inserted through drain tract stopped bleeding. Results Soon, she developed sepsis and hepatic failure(WBC:99000/mm3; CRP:323mg/L(0-5); Procalcitonin:42 ng/ mL(0-0.5); ALT/AST:90/327 U/L; INR:1.4; Total/Direct Bilirubin:9/6 mg/dl). CT aimed to locate bleeding site showed thrombosis and bleeding from PV. Immediate percutaneous transhepatic portography revealed PV thrombosis and bleeding erosion. Stent-graft implantation covering PV erosion site stopped bleeding. During aspiration of thrombosis fatty necrotic debris, histopathologically reported as necrotic fat and dystrophic calcification, came out of PV lumen. After successful antibiotherapy, patient was discharged on 110th day of admission with low output pancreatic fistula which stopped spontaneously within one month. Patient in 16th month of discharge is healthy except for pancreatic insufficiency. Conclusions Portal septic debris embolism causing PV thrombosis, sepsis and hepatic failure is a life-threatening complication of ANP that was not reported previously. Interventional radiological approach with stent-graft to PV bleeding and to debris with thrombosis is a lifesaving procedure. Multidisciplinary treatment of complicated ANP is necessary for successful outcome.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
86

E-AHPBA

Stefan Hofmeyr, Carel Meyer, Brian Warren University of Stellenbosch and Tygerberg Academic Hospital, Western Cape, South Africa

Objectives Serum lipase and/or amylase elevations are a non-specific finding with respect to acute pancreatitis. Extrapancreatic abdominal emergencies are uncommonly associated with marked elevations. We aimed to show that the differential diagnosis of acute pancreatitis narrows at rising multiples of the upper limit of normal (ULN). Method Between February 2010 to July 2012 data were collected on cases presenting to the surgical admission unit with acute abdominal pain of less than 5 days duration and a raised serum lipase and/or amylase test. Clinical, endoscopic, radiographic, operative and laboratory data were captured and subjected to standard descriptive statistical analysis. The endpoint of the study was to determine the degree to which serum lipase and amylase elevations occurred in extrapancreatic causes of abdominal pain, and to what extent they comprised the differential diagnosis of acute pancreatitis at rising multiples of the ULN. Results Inclusion criteria were fulfilled by 489 cases; 322 (66%) presented with 25 aetiologies other than acute pancreatitis. Below 3 X ULN, specificity for acute pancreatitis was poor coupled with a vast differential diagnosis. Serum lipase and amylase were 85% and 81% specific above 3 X ULN, with perforated peptic ulcers, intestinal obstruction, mesenteric ischaemia, abdominal tuberculosis and acute cholecystitis the main extrapancreatic causes. The range of extrapancreatic causes diminished rapidly at further rising multiples of the ULN, with only perforated peptic ulcers remaining in the differential diagnosis at elevations above 6 and 8 X ULN for lipase and amylase respectively. Conclusions These data show that at rising multiples of the ULN, is not only the specificity of serum lipase and amylase increased with respect to acute pancreatitis, but the differential diagnosis of extrapancreatic causes of acute abdominal pain is narrowed as well.

87

Abstracts

11.6 The degree of serum lipase and amylase elevations and their utility in the differential diagnosis of acute pancreatitis

Abstracts

11.7 Outbreak of antibiotic-resistant klebsiella pneumoniae in a high-volume pancreatic surgery unit
Giuseppe Malleo, Giovanni Marchegiani, Eleonora Morelli, Valentina Todaro, Harmony Impellizzeri, Laura Maggino, Roberto Salvia, Giovanni Butturini, Claudio Bassi Department of Surgery, Pancreas Institute, University of Verona, Verona, Italy

Objectives  The threat of infections due to multidrug-resistant organisms is increasing. No effective drugs are available to treat some  life-threatening infections caused by  multidrug-resistant gram-negative rods, including klebsiella pneumoniae. In 2012, a strain of Klebsiella pneumoniae resistant to multiple antibiotics, including carbapenems, was identified in our hospital. Such outbreak impacted on postoperative outcome after major surgical procedures. Here we estimated the burden of multidrug-resistant klebsiella pneumoniae infections after pancreatic resections.   Method During institutional morbidity and mortality audits, the frequency and the impact on postoperative outcome of multidrug-resistant klebsiella pneumoniae infections after pancreatic resections performed in 2012 was evaluated.   Results In 2012, 261 pancreatic resections were performed at our institution. The rate of postoperative complications was 54.4%. There were 6 postoperative deaths (2.2%). Postoperative mortality doubled in comparison with 2011 (3/257, 1,1%), although this did not reach statistical significance (p=0.257). Among the six patients who died, five had a sepsis caused by a multidrug-resistant klebsiella pneumoniae, mostly superimposed to a grade C pancreatic fistula. Two other patients with a severe multidrug-resistant klebsiella pneumoniae eventually survived. No postoperative death in 2011 was owing to a sepsis from multidrug-resistant organisms.   Conclusions Multidrug-resistant organisms, and in particular klebsiella pneumoniae, severely impacted on postoperative mortality after pancreatic resections performed at a highly experienced tertiary care centre. Adequate information among health care professionals and strategies to prevent the outbreak of these gram-negative rods, includind hand washing and isolation of infected patients, are essential. No deaths from multidrugresistant organisms occurred as of February 2013.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
88

E-AHPBA

ANDREU ROMAGUERA, FRANCISCO JAVIER GARCIA BOROBIA, RAUL GUERRERO, NATALIA BEJARANO, FERNANDO ESTREMIANA, ANGEL CORCUERA, DAMIAN GIL, ANISIO MORON, NEUS GARCIA, SALVADOR NAVARRO PARC TAULI SABADELL HOSPITAL UNIVERSITARI, BARCELONA, Spain Objectives Management of patients (p) with acute necrotizing pancreatitis (ANP) has evolved to treatments less aggressives even in cases that become infected. These approach has been called “step-up”. We present our experience with the application of this approach in our Hospital Method We retrospectively collected data from all consecutive acute pancreatitis treated in our Hospital from 2009 to 2012. ANP included: pancreatic necrosis and/or peripancreatic necrosis (defined as a grade D/E Balthasar) in a specific CT. Infection was confirmed by culture or presence of gas in CT. P were divided into two groups: infected and non infected ANP. Variables studied were: parenteral nutrition, use of antibiotics, bacteriology of infected ANP, intensive care admission, hospital stay and mortality. Infected ANP were treated as follow: 1) only antibiotics, 2) antibiotics+drainage, 3) antibiotics+drainage+surgery and 4) antibiotics+surgery Results  One hundred thirty two out of 628p. admitted with acute pancreatitis were ANP. Thirty-eight p(29%) become infected. In this group antibiotic with or whitout drainage was effective in 16 p(42%), and surgery was needed in only 22p(58%). Antibiotic use in non infected ANP were due to extrapancreatic infection or doubts while waiting cultures. See other results in table.1 Conclusions Management of infected ANP has evolved to treatments that begins with antibiotics and, in case of failure, adds a more agressive procedure, with a low mortality (11%). Up to 42 % of p can be cured without surgery. The “dogma” of infected necrosis must be always operated has fallen.

89

Abstracts

11.8 Changing strategies in the management of acute necrotizing pancreatitis. Four years experience in a universitary hospital

Abstracts

11.9 Prognostic factors in patients undergoing surgery for severe necrotizing pancreatitis
Pedro Nuno Brandão, Vítor Costa Simões, Donzília Sousa Silva, José Davide HEBIPA - Hepatobiliopancreatic Unit, Hospital de Santo António, Porto, Portugal

Objectives Pancreatic necrosectomy remains an important treatment modality for the management of infected pancreatic necrosis but is associated with significant mortality (6 to 61%). The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis. Method Between January 2001 and March 2013, 3353 patients were admitted to our Unit with acute pancreatitis, 134 (4.0%) being severe forms. Fifty-five patients who underwent 161 surgical pancreatic necrosectomies were reviewed retrospectively. Thirty-four (61.8%) were male. Mean age was 54.2 years. Twenty-seven (49.1%)  came  from other hospitals. Admission, pre and postoperative variables, severity scores (Ranson, Glasgow and Acute Physiology And Chronic Health Evaluation - APACHE II) and mortality were assessed. The χ2 and Fisher’s exact tests were used for categorical and Mann-Whitney test for continuous data. Logistic regression was used to determine factors with independent levels of significance. Results Initial mean values were 10 to APACHE II score, 4 to Glasgow, 2 and 4 to Ranson criteria, on admission and at 48 hours, respectively. Mortality was 32.7%. Patients having ≥ 2 organ dysfunctions on admission, de novo dysfunctions (p<0.001), APACHE II ≥ 8 (p=0.037), Glasgow ≥ 3 (p=0.038), Ranson on admission ≥ 3 (p<0.001) and at 48 hours ≥ 4 (p=0.001) had higher mortality. Those requiring mechanical ventilation (p=0.007) and operated earlier (<14 days) also (p=0.047). Patients who died were older (p=0.011). Logistic regression analysis showed development of new dysfunctions as an independent predictor of mortality (p=0.029). Conclusions Age, organ dysfunctions, APACHE II score, Ranson and Glasgow criteria were the most important predictors of outcome after surgical pancreatic necrosectomy. The procedure is associated with poorer outcome when performed within 2 weeks of presentation of acute pancreatitis.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
90

E-AHPBA

Petru Bucur1, Marc-Antoine Allard1, Irene Vignon-Clementel2, Ludovic Cazenave3, Benoit Decante4, Denis Castaing1, Eric Vibert1 1 Hopital Paul Brouse, Villejuif, France, 2INRIA, Rocquencourt, France, 3MID, Dardilly, France, 4CCML-LCI, Le Plessis Robinson, France Objectives Posthepatectomy liver failure and small-for-size are two related conditions that share a common pathological mechanism : portal hyperperfusion and hypertension. The aim of this study was to investigate the results of temporary portal vein flow modulation with an adjustable vascular ring onto a model of 75% hepatectomy in pigs.   Method 17 pigs had a 75% hepatectomy and 8 of them received before the resection an adjustable vascular ring, MIDAVRTM, inflated to reduce the portal flow by half during the first 3 postoperative days.  The device was deflated in all pigs and removed percutaneously in 3 of them. Liver biopsy was scheduled at day 3 and sacrifice at day 7. All pigs had continuous hemodynamic monitoring (including cardiac output and hepatic hemodynamics) during hepatectomy and sacrifice. Results MID-AVRTM produced a stable reduction of the portal vein diameter. Percutaneous inflation, deflation and ablation were simple and safe. 2 of 8 (25%) pigs in the MID-AVRTM group and 4 of 9 (45%) controls died before day 3 (p=NS). In surviving pigs the portacaval gradient was significantly smaller at the end of the hepatectomy in the MID-AVRTM group (1.3 vs 5.2 mmHg, p<.01). With respect of plasmatic bilirubin level (µmol/L),MID-AVRTM improved significantly postoperative liver function in the first week after 75% hepatectomy (3 5.7 vs 9.2, p<.01 at day 3 and 3.8 vs 6.6, p<.05 at day 5). Conclusions MID-AVRTM may be an effective preventive treatment for posthepatectomy liver failure after major liver resection

91

Abstracts

12.1 Portal Pressure Modulation with an Adjustable Vascular Ring for Prevention of Liver Failure - Experimental Study

Abstracts

12.2 Hypothermic perfusion during total vascular exclusion improves postoperative liver and renal function.
Safi Dokmak, Fadhel Samir Ftériche, Béatrice Aussilhou, Jacques Belghiti Beaujon Hospital, Departement of HBP surgery and liver transplantation, Clichy, France

Objectives Evaluate the outcome of patients who underwent liver resection under total vascular exclusion (TVE) > 60 mn with or without in situ hypothermic perfusion (ISHP). Method From 2000-2012, among 2535 liver resections, 34 patients underwent liver resection under TVE >60 minutes, with ISHP (n=16) or without (control group: n=18). There was no significant difference regarding demographic data, malignancy (75% vs 83%), vascular reconstruction (44% vs 50%), extent of resection (100% vs 94%), abnormal liver (24% vs 18%) and TVE duration (81 vs 96) minutes. Liver injury was assessed by transaminases level on POD1 and liver and renal tolerance were assessed on POD 5 for bilirubin (μmol/L) and PT and on POD1 for creatinine (μmol/L). (ISHP vs no ISHP) were compared. The preservation solution was HTK (custodiol). Results No difference regarding blood loss (2041ml vs 3269 ml), transfusion (66% vs 58%) and operation duration (376 vs 439). Mortality was higher in the control group (12% vs 28%, p = 0.27). Although major morbidity was similar (75% vs 78%, p=0,84), ISHP was associated with less liver injury  [ASAT (267 vs 808, p=0,039), ALAT (469 vs 728, p=0.046)] and better liver and renal tolerance [bilirubin (14 vs 131, p = 0,047), PT (74% vs 56%, p=0,039), creatinine μmol/L (75 vs 120, p= 0,021)]. No difference regarding bleeding (18% vs 6%), reintervention (50% vs 33%) and hospital stay (19 vs 17).   Conclusions IHSP improves dramatically the tolerance of total vascular clamping and questioning its use in patients requiring complex liver procedures regularly performed under prolonged intermittent vascular clamping.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
92

E-AHPBA

12.3 Genetic profiling of the Th17 response during hepatic ischemia/reperfusion injury

Objectives Ischemia/reperfusion (I/R) injury is a potentially life-threatening complication of major liver surgery characterized by a massive innate immune response. T helper 17 (Th17) cells possibly facilitate this response by controlling neutrophil accumulation. The aim of this study was to investigate whether Th17 cells drive the hepatic I/R immune response.  Method Male C57Bl/6J mice (25-30g) were subjected to 60min of partial liver ischemia (70%) or sham operation (n=58/group). After 1, 6, or 24h of reperfusion, blood was obtained by cardiac puncture and the liver was harvested. Following mRNA isolation, expression profiles of 84 genes involved in the Th17 response were generated by qRT-PCR using PCR arrays (Qiagen, n=3-4/group). To confirm the mRNA results, the circulating levels of two key cytokines of the Th17 response, IL-23 and IL-17A, were assayed by ELISA in heparin-anticoagulated plasma samples (n=5-8/group).  Results On mRNA level, the genes encoding the prototypical Th17-acitiving cytokines IL-23 and IL-1b were upregulated 3.4±1.54-fold and 10.08±5.74-fold, respectively, after 6h of reperfusion compared to sham-operated animals. However, the genes encoding the signature cytokine of Th17 cells, IL-17A, and the Th17 lineage-specific transcription factor Rorg were not upregulated during reperfusion. These results were corroborated by ELISA, which showed 34.5±20.4pg/mL of circulating IL-23 after 6h of reperfusion compared to 8.3±4.1pg/mL in the sham group ( p<0.05). There were no differences in circulating IL-17A between I/R and sham groups. Conclusions Despite the presence of IL-23 and IL-1b, there was no active Th17 response, as indicated by the lack of Rorg gene transcription and absence of circulating Il-17A. Additional experiments are under way to determine the IL-17Aindependent effects of IL-23 in hepatic I/R injury.

93

Abstracts

Rowan F. van Golen, Lindy K. Alles, Thomas M. van Gulik, Michal Heger Department of Experimental Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

12.4 Long-term results after liver surgery for benign lesions - is surgery justified? Abstracts
Michael Josef Lipp, Maximilian Jusufi, Gregor Stavrou, Karl-Jürgen Oldhafer Departement for General- and Visceral Surgery Asclepios Clinic Barmbek, Hamburg, Germany

Objectives Benign liver lesions are rarely operated on. Indications are mostly pain, progression of lesion size and doubts concerning the benign histology. Compared to malignant lesions, there are no standardized follow up plans. Postoperative long term follow up is usually forgone, quality of life after resection of benign lesions has been rarely reported in the literature. Method Between October 2002 and September 2012 we operated on 45 patients because of  benign liver lesions. Patients with malignant disease were excluded from this study. 13 patients were operated solely for benign lesions including liver adenoma, haemangioma and follicular nodular hyperplasia of the liver - in two of them the lesions were detected incidentially. They were excluded from study group. In 7 patients the indication for surgery was pain, in 4 cases size or doubtful histopathology. All patients were followed up with a questionaire in 2012 asking for reduction of quality of life caused by pain before and after operation. Results 57,1% of the patients suffering from painful symptoms before surgery thought their quality of life was better after the operation, 28,6 % could not find a difference. 14,3% stated though, that they had a worse quality of life postoperatively. Only 25% of the patients operated on because of tumor size or doubtful histopathology stated an improvement of quality of life after surgery; another 25% did not experience any change in their quality of life, 50% however stated a considerable decline of their quality of life. Most interestingly 93% of all patients would choose to be operated again. Conclusions Although this study includes only a small number of patients it seems to indicate that patients suffering from pain because of benign liver tumors profit most from operation. Therefore it seems to be reasonable to recommend operation. However, patients operated because of size of differnt reasons seem to experience a decline of their quality of life in a substantial part of our study population. Therefore the indication has to be an individually tailored decision together with the patient. The high degree of acceptance of the surgical approach by the patients nevertheless underlines the importance of a surgical treatment of these lesions.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
94

E-AHPBA

Edgar M. Wong-Lun-Hing1, Ronald M. van Dam1, Fenella K.S. Welsh3, John K.G. Wells3, Timothy G. John3, Adrian B. Cresswell3, Cornelis H.C. Dejong1,2, Myrddin Rees3 1 Department of Surgery, Maastricht Univertsity Medical Center, Maastricht, The Netherlands, 2Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands, 3Hepato-biliary Unit, Hampshire Hospitals FT, Basingstoke, UK Objectives There is debate concerning the commonly used epidural analgesia after major liver resection. Continuous intermuscular bupivacaine infusion has been suggested as an alternative method. This study investigated the analgesic value of continuous intermuscular Bupivacaine infusion plus patient-controlled intravenous analgesia (CIB+PCA) compared with continuous epidural analgesia (CEA) after major hepatic surgery.

Method 498 patients undergoing major hepatectomy between July 2004 - July 2011 were included in this study. L- or J-shaped subcostal incisions were used in all patients. Group I received CIB+PCA (n = 429) and Group II CEA (n = 69). Groups were analysed on baseline patient and surgical characteristics: age, sex, BMI, ASA, indication, operating time, blood loss and surgical procedure. Primary endpoints were VRS-pain scores and total opioid consumption. Secondary endpoints were pain management failures, need for rescue medication, (opioidrelated) morbidity, day of NG-tube removal, first oral intake, urinary catheter removal, mobilised out of bed and length of stay. Results In both groups postoperative pain was well controlled and >70% had no or minimal pain on POD 1 and 2. The number of patients in the CIB+PCA group that experienced severe pain (VRS 3-4) was similar to the CEA group: POD 1 at rest (0.3% vs. 0%, P=NS) and on movement (8% vs. 2%, P=NS); POD 2 at rest (0% vs. 2%, P=NS) and on movement (5% vs. 5%, P=NS). Importantly, the CIB+PCA group required less opioids on POD 0-3 (P≤0.001), had lower overall morbidity (25% vs. 39%, P=0.018) and shorter LOS (7 vs. 8 days, P=0.005). Conclusions Continuous intermuscular Bupivacaine infusion with patient-controlled intravenous analgesia provides equivalent pain control with less opioid consumption compared with continuous epidural analgesia in the immediate period after major hepatectomy. It has the potential to replace epidural analgesia with improved postoperative outcomes and reduced length of hospital stay.

95

Abstracts

12.5 Postoperative pain using continuous intermuscular bupivacaine infusion with PCIA versus epidural analgesia after major hepatectomy.

Abstracts

12.6 A new technique for selective in situ hypothermic perfusion of the future remnant liver during right hemihepatectomy.
Megan Reiniers, Rowan van Golen, Michal Heger, Thomas van Gulik Academic Medical Center, Amsterdam, The Netherlands

Objectives A new method for selective in situ hypothermic perfusion (IHP) of the future remnant liver (FRL) during right hepatectomy was developed and analyzed for technical feasibility.  Method Prior to parenchymal transection, the right branches of the portal vein (PV) and hepatic artery proper (HAP) are clamped and cut. Following cannulation of the cut end of the HAP, the portal triad as well as the middle and left hepatic veins are clamped. The FRL is perfused through the HAP with cold (4°C) Ringer’s lactate solution, with retrograde outflow via the cut end of the right PV branch. Following resection, IHP is terminated and blood flow into the liver remnant restored. Laboratory parameters (i.e., AST, ALT, total bilirubin, and PT), transfusion requirements, and hospital stay were monitored postoperatively.  Results Five patients were treated with IHP. A liver core temperature of 28°C was reached within the first 20 min of perfusion in three patients and within 10 min in one patient. The median ischemia time was 50 min (40–60) and the median duration of IHP 45 min (25–55). Median peak ALT = 819 U/L (294–1557), peak AST = 702 U/L (224–1933), peak total bilirubin = 22 mmol/L (19–37), and peak INR = 1.27 (1.22–1.34). The median transfusion requirement (red blood cells/plasma) was 1 unit (0–5) and hospital stay was 9 days (6–13). Conclusions IHP of the FRL is technically feasible in patients undergoing right hemihepatectomy. Notably, this method allows cold perfusion of the liver without clamping of the inferior vena cava, which broadens the applicability of hypothermic perfusion during liver resection. 

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
96

E-AHPBA

Andrie Westerkamp, Hendrik Mantel, Annette University Medical Center Groningen, Groningen, The Netherlands

Gouw,

Robert

Porte

Objectives Frozen section analysis of bile duct margins, lymph nodes and parenchymal margins is performed during surgical resection of hilar cholangiocarcinoma (HCCA) to achieve a maximum resection status for improvement of the prognosis. Despite the routine use of this technique, its clinical consequences are unclear. In this study we examined the accuracy of frozen section analysis as well as the clinical implications on the definitive prognosis of patients with HCCA. Method The accuracy of intraoperative frozen section analysis was calculated for 62 patients who underwent combined extrahepatic bile duct resection and partial liver resection for HCCA. The results of frozen section analyses were compared with the final pathology results. We determined the impact of frozen section analysis on the rate of additional resections and on the final resection status. Results Sensitivity and specificity of frozen section analysis of proximal bile duct margins was 68% and 97%, respectively. Sixteen of 62 patients (26%) displayed a positive bile duct margin at frozen section analysis, of which 10 underwent an additional resection to achieve negative histological margins. Ultimately, three patients obtained a secondary radical resection (R0) of which only 1 (1.6%) patient did not have concomitant lymph node metastases and therefore a rational chance of improved survival. Conclusions Although intraoperative frozen section analysis during resection of HCCA has a reasonably high sensitivity and specificity, its clinical implications are limited. In this study retrospective evaluation showed that 1 patient (1.6%) ultimately benefited of frozen section analysis since in this patient additional negative resection margins were obtained together with a negative nodal status. There is a need for more accurate diagnostic tools to identify tumor free margins during surgical resection of HCCA.

97

Abstracts

14.11 Limited clinical value of frozen section analysis during resection of hilar cholangiocarcinoma

Abstracts

14.12 R1 resection, low serum albumin and positive lymph nodes predict poor outcome in cholangiocarcinoma.
Jennifer Watt, Giles Bond-Smith, Prabhu Arumugam, Leonardo Solaini, Robert Hutchins, Ajit Abraham, Hemant Kocher, Satya Battacharya Barts Health NHS Trust, London, UK Objectives To assess the outcomes in patients with cholangiocarcinoma for treatment at a HPB centre. Method We identified patients referred to our service for treatment of cholangiocarcinoma between January 2007 and December 2012 from a prospectively maintained database. Patients were selected on the basis of final histology. Using this database and supplementary information from electronic patient records, patient demographics, details of surgery, histology, postoperative complications and subsequent follow-up information was collected. Patient survival times were correlated final histology and preoperative blood test results was carried out using PRISM for patients undergoing resection with curative intent.   Results  143 patients(Median age:65(range 39-84)years, M:F 5:4)were included. 68(Median age: 57(range 39-78) years, M:F 1:1)underwent resection. Overall median survival was 524 days (range 19-1096). Resected patients survived longer than unresected(median 724 days vs 498 days)(p=0.02).   Procedures were 37(53%)PPPD, 5(7%)Kausch-Whipple, 20(29%)Liver resection, 8(12%)bile duct excision. 48(70%)distal bile duct, 10(14%)hilar and 11(16%)intrahepatic lesions. 38(55%)of resected tumours were stage 1, 29(42%)and 2(3%)were stages 2 and 3 respectively.   Patients with intrahepatic tumours were more likely to undergo R0 resections compared with hilar or distal bile duct lesions(10/11(82%),6/9 (66%) and 34/48(71%) respectively). Reduced survival time was associated with R1 resection(P=0.01), lymph node positivity(p=0.04), and pre-operative albumin<28(p=0.01).   Conclusions Resection prolongs survival for patients with cholangiocarcinoma. Survival duration was reduced if patients had low pre-operative serum albumin levels, R1 resection, or histologically positive lymph nodes.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
98

E-AHPBA

14.13 Isolated sectoral, segmental and right hepatic bile duct injuries

Objectives Objectives. Dangerous anatomical variants appearing in 15-20% of patients are particularly responsible for operative sectoral and segmental bile ducts injuries (SSBDI). The frequency of SSBDI is not known, but it is probably higher than it is believed as some of them may pass without significant symptoms or stayed unrecognized. However, SSBDI may cause serious complications such as cholangitis and liver abscess or biliary fistula and biliary peritonitis.The treatment of SSBDI is controversial. Method Material and method. Over 33 years period we treated 20 patients with SSBDI divided   in four groups. The first included 5 patients in whom SSBDI was recognized at original surgery. Primary repair in 2 ways was performed in all 5 patients. The second included 5 patients in whom the injured duct was ligated. The third included 4 patients, sent from elsewhere for  biliary peritonitis, lasting for several weeks. All were submitted to laparotomy, lavage and drainage deloping external biliary fistula. The forth group included 6 patients, sent from elsewhere for external biliary fistula lasting from two to eight weeks. Results Results. First group patients had an uneventful recovery, 4 stayed well while one developed late anastomotic stricture requiring hepaticojejunostomy. Four patients of the second group developed cholagitis, 2 requiring drainage and biliary repair.The third required repair but developed late stricture requiring new repair. The fourth patient developed leak which ceased   requiring no further surgery. The fifth patient developed series of complications and died. All patients of the third group developed biliary fistula, 3 of which ceased spontaneously while 1 required   repair. Four patients of  forth group required to Roux-en-Y repair while 2 had their fistula ceased spontaneously. Conclusions Conclusion. Primary repair, if possible seems to be better solution for SSBDI recognized at original surgery. The patient with ligated SSBDI may develop an infection so that they have to be followed up closely. Infected ducts will require further surgery. The patients with biliary peritonitis are to be treated with lavage and drainage of the abdominal cavity. There is 50% chance that the following biliary fistula will close spontaneously. The patients whose biliary fistula did not cease within 6 to 8 weeks will probably have to be submitted to Rouxen-Y anastomosis.

99

Abstracts

Radoje Colovic1 1 Medical Faculty University Belgrade, Belgrade, Serbia, 2Professor Emeritus, Medical Faculty University Belgrade, Serbia

14.14 Does surgical procedure for liver hydatid cyst affect recurrence rate? Abstracts

PINAR SARKUT, SADIK KILICTURGAY, BARIS GULCU, ISMAIL TIRNOVA, EKREM KAYA, YILMAZ OZEN, HALIL BILGEL ULUDAG UNIVERSITY, BURSA, Turkey Objectives Hydatid cysts are a crucial health problem in endemic territories like Turkey. Therapeutic interventions range from medical to surgical and even radiological. Nevertheless, there are conflicting opinions on the most effective treatment modality. Here we compare the impact of palliative as aganist radical resections, on relapse and complications. Method We carried out a retrospective analysis of patients who were operated in our clinic between the years 1996 and 2012 for hydatid cyst of the liver. Patients were divided into two groups; Group A received conservative surgery and Group B received radical surgery. Patients who underwent pericystectomy and liver resection were included in the latter arm. Demographic data, hydatid cyst classification, localization, period of hospitalization, applied surgical intervention, recurrence, and morbidity and mortality rates of the patients were examined. The WHO categorization was used for cyst hydatid classification. The chi-square test was used for statistical analysis. Results 428 patients, of which 301 underwent conservative surgery, were studied. Mean age in Group A and B was 46.8±14.9 (18-80) and 46.3±15.6 (17-72), respectively. Both groups showed more prevalent right lobe localization with CE2-CE3 dominance. Group A had 70 cases of morbidity with 10 of these due to biliary fistulas. Group B had 27 cases of morbidity with one case of biliary fistula ( p = 0.28). On follow up, recurrences in group A and B were 52 and 2 respectively ( p = 0.0001). There was no statistically significant difference in the period of hospitalization or mortality between the two groups. Conclusions Though conservative surgery was an easier and more frequently used intervention in our study, the rate of post-operative recurrence was found to be significantly lower in patients undergoing radical surgery. Liver resection performed using modern techniques are definitely a superior and effective surgical intervention in the treatment of hydatid cyst.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
100

E-AHPBA

14.15 Hydatid Liver Cysts: PAIR or Surgery ?

Objectives Hydatidosis is endemic in Sardinia (>100 cases/year). Although various treatments have been described, the best continues to be debated. The Informal Working Group on Echinococcosis of WHO currently supports PAIR (percutaneous aspiration, injection and re-aspiration) as an effective alternative to surgery although now day its use is not widely adopted. Method We conducted a retrospective analysis of patients with hydatid disease of the liver who were managed at our Institute during the period 2000-2012. The treatment options included PAIR or surgery, both associated with chemotheraphy (Mebendazole or Albendazole). The cyst were all radiologically studied and classified according with the WHO-IWGE classification. Treatment indications were based on patient characteristics (age, co-morbidities, individual preference), cyst characteristics (number, type, size, locations, presence of complications), available medical/surgical expertise and resources and tailored to the individual patient. The immediate and long-term outcomes following management were analyzed. Results 78 patients with hydatid cysts of the liver were managed with PAIR (n=29) or surgery (n=49). The overall clinical cure rate was high in both group (> 95%). Disease recurrence was greater in surgery group (n=6) but not statistically significant. Major complications, such as anaphylaxis, biliary fistula and liver/intra-abdominal abscess occurred more frequently among surgical group (10/49). The reduced cost and shorter hospital stay was associated with PAIR group. In some case ERCP was useful to rule out possible cysts communication with the biliary tree (pre-treatment) or to solve a biliary fistula. Conclusions PAIR is associated with good clinical efficacy, less morbidity and a shorter hospitalization. PAIR is comparable to surgery to minimizes the risk of long-term recurrence. Morbidity is still the crucial point for surgical treatment. PAIR is especially indicated CE1 and CE3a; surgery is mandatory for complicated liver cysts.

101

Abstracts

Giovanni Rizzo, Ruiu Francesca, Alessandra Cherchi, Vincenzo Migaleddu, Alberto Porcu 2° General Surgery Clinic, Sassari, Sardinia, Italy

Abstracts

Jose M. Ramia1, Alejandro Serrablo2, Roberto de la Plaza1, Vicente Borrego2, Luis Gijon1, L Sarria2, Farah Adel1, I Talal2, Jorge Garcia-Parreño1, Joan Figueras3 1 HPB Unit. Dept. of Surgery. Hospital Universitario de Guadalajara, Guadalajara, Spain, 2HPB Unit. Dept. of Surgery. Hosp.Univ.Miguel Servet, Zaragoza, Spain, 3HPB Unit. dept. Of Surgery. Hospital Josep Trueta, Girona, Spain Objectives Liver Hydatid cysts (LHC) contacting with inferior cava vein (IVC) are a surgical challenge for HPB surgeons. There is a lack of evidence-based medicine about the best surgical approach of these cysts. Clasically a conservative approach (CS) was performed in these patients but in some cases radical surgery (RS) (total cystectomy or liver resection) is feasible. Two HPB Units working in endemic areas of liver hydatidosis that always try to perform radical surgery present our experience in this topic and makes a proposal of classification of LHC contacting IVC Method Retrospective study. January2007- August2012. We have operated on 103 patients with active cysts (CE1 to CE3) and CE1 to CE5 complicated cysts due to infestation by Echinococcus Granulosus. Thirty-two patients had a LHC contacting with IVC. Abdominal CT and hydatidosis serology was done in every patient. We have performed a classification of LHC contacting IVC in three groups: type I, cysts in segment VIII, I y IVa, and IVC between hepatic veins to right atrium; type II: cysts located in segments VI and/or VII  or II/III/IV with lateral contact; and type III central cysts with massive circunferencial contact with IVC. Results We have operated on 32 patients with 37 cysts. Female: 69%. Age: 55.6 years. Relapsed cases (40.6 %). Size cyst: 11.8 cm (r:5.5-23). Cysts were type I (n=7), II (n=17) and III (n=8). Length of IVC contact was 37 mm (r:10-100 mm). Degrees of involvement was 90° (r:20-245°). RS surgical techniques were performed in 62,5 %. Morbidity: 28%. Mortality: 3.1%. Hospital stay: 10 days. In follow up: no relapsed and no problem related to IVC flow. Hospital stay and transfusion were higher in CS group, but morbidity lower. Lower percentage of RS was performed in I and III cysts.   Conclusions LHC contacting con ICV are huge cysts located on right liver. They usually do not cause clinical symptoms related to ICV contact. Radical surgery is feasible (60% in our serie), but it is technically demanding. If the surgeon thinks that RS is too risky for a benign disease, near total cystectomy is a rationale option. Other concomitant local complications (biliary or portal system), age or co-morbidities not only ICV contact could lead to decide not to perform RS. We have made a cyst contacting-ICV classification with therapeutical implications that could be useful to decide the best surgical procedure.

14.16 A new classification of liver hydatid cysts contacting inferior vena cava

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
102

E-AHPBA

Federica Cipriani, Francesca Ratti, Annalisa Gagliano, Marco Catena, Michele Paganelli, Luca Aldrighetti San Raffaele Hospital, Milan, Italy Objectives Laparoscopic hepatectomies implie fast-track management, while open resections do not traditionally benefit from programs for postoperative course optimization. Recently, ERAS was applied to open hepatectomies to optimize postoperative course. The aim is to clarify whether the advantages of laparoscopic hepatectomies are related to the technique itself or the fast-track management.   Method Eighteen open liver resections managed with an ERAS perioperative protocol were carried out at our institution (open group). They were compared with 54 liver resections performed by laparoscopic approach (lps group). The two groups were comparable in terms of sex, age, extent of liver resection (minor resection), severity of possible liver function impairment, primary diagnosis (benign and malignant) and concomitant diseases, to obtain a case-matched study. The following outcomes were analyzed and compared within the two groups: mortality, morbidity, amount of blood transfusions, length of hospitalization, amount of postoperative analgesia, timing of bowel function recovery and refeeding with unrestricted diet. Results  There were no significant differences between the open and lps group in mortality (0 vs 1 case, p NS), blood transfusions (150 vs 200 mL, p NS), rate of complications (23% vs 18%, p NS) and length of hospitalization (7 vs 6 days, p NS). The open and lps group showed significant differences in timing of bowel function recovery (3rd vs 1st POD, p < 0.005), timing of refeeding with unrestricted diet (3rd vs 1st POD, p < 0.005) and amount of postoperative analgesia (interrupted in 5th vs 3rd POD, p < 0.005), which were higher for the open group. Conclusions  Laparoscopic approach to liver resections maintains its advantages in terms of postoperative course even when compared with open liver resections treated with fast-track management programs.  

103

Abstracts

16.11 Open liver resections in eras setting versus laparoscopic liver resections:  a casematched study.

Abstracts

16.12 A prospective randomized study comparing open versus laparoscopic liver surgery in colorectal liver metastasis.
Ricardo Robles, Roberto Brusadin, Asunción López-Conesa, Israel Abellan, Pascual Parrilla Virgen de la Arrixaca University Hospital, Murcia, Spain

Objectives  No randomized prospective studies have been carried out to prove the safety and efficacy of laparoscopic liver surgery (LLS) for colorectal liver metastasis (CRLM). Our objective was to compare the results of open surgery (OS) versus hand-assisted laparoscopic surgery (HALS) in CRLM patients using a prospective randomized study.   Method Between January 2003-April 2012, we performed 339 liver resections for CRLM. Of these, 188 patients unable to receive LLS, were directly treated by laparotomy. Of the remaining 151 patients, who could have been treated laparoscopically, 3 patients were excluded due to cirrhosis and another 4 because of receiving a two-stage liver resection. The remaining 144 patients were randomized into 2 groups: 72 resections were performed using LLS and 72 by OS. The patients with LLS were treated using HALS following the original technique introduced by our surgical unit. The OS technique used was bilateral subcostal laparotomy.   Results The following variables were not statistically significant; age, sex, comorbidity, primary tumour localization, TNM, primary tumour differentiation, preoperative CEA, hilar lymph nodes, peritoneal implants, preoperative portal embolization, major resections, transfunded patients, intraoperative radiofrequency, morbidity and mortality, metastasis differentiation, microsatelitosis, vascular invasion, resection margin, one month postoperative CEA, neoadjuvant and adjuvant chemotherapy. Differences detected: the Pringle maneuver (52% in HALS, 19% in OS) (p= 0.01); surgical time (162±78 min in HALS vs. 125±61 OS) (p=0.02); hospital stay (4± 1.4 days in HALS vs. 7±3.5 days OS) (p=0.05). There were no differences in 5-year-survival between the two techniques:  HALS (41%)  OS (47%).   Conclusions In selected cases, according to the results obtained in retrospective studies and in this randomized prospective study, laparoscopic surgery for CRLM reproduces the results of open surgery in terms of safety (morbidity and mortality) and efficacy (survival at 5 years).  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
104

E-AHPBA

Santiago López-Ben1, Oscar German Palacios2, Antoni Codina-Barreras1, M Teresa Albiol1, Laia Falgueras1, Ernest Castro1, Berta Pardina1, Joan Figueras1 1 Hospital Universitari Dr Josep Trueta, Girona, Spain, 2Universidad CES, Medellin, Colombia

Objectives Benefits of minimally invasive hepatectomy: case-control study of 50 laparoscopic liver resections   Method A single center, 1-to-2 case-control study was designed, comparing patients with laparoscopic or open liver surgery. 50 laparoscopic hepatectomies were performed(LAP). Indications were liver metastases(34) patients, hepatocellular carcinoma(7), hydatid disease(2), benign tumors(5). These cases were compared with 100 controls(AB) matched according to the following selection criteria: diagnosis, number of lesions, type of resection, age, surgical risk according to the ASA classification and ECOG performance status. We evaluated intraoperative and postoperative parameters, with special emphasis on morbidity and mortality. Results The preoperative characteristics of both groups were identical. No statistically significant differences in overall morbidity 17(34%)vs29(29%) p=0.32; intraoperative bleeding 401(18-2192)vs475(20-2000) mL p=0.89;   need for pedicle clamping 37(74%)vs88(88%) p=0.55; surgical margin wide 0.6(0-5)vs0.65(0-5) cm p=0.94 nor mortality 1(2%)vs1(1%) p=0.65 respectively for the LAP group and AB. There was a trend of less severe complications 4(8%)vs15(15%) p=0.07 and fewer readmissions 0vs7(%) p=0.09,  and a significant drop in surgical site infections  1(2%)vs18(36%) p=0.007 in laparoscopic surgery. Operative time was longer 295(120-600)vs200(70-450) minutes p=0.0001 and hospital stay was significantly shorter 4(1-60)vs7(3-44) days p=0.0001 in the LAP group. Conclusions In patients adequately selected, laparoscopic  liver resection  is  feasible, safe, shortens hospital stay  and diminishes surgical site infections.

105

Abstracts

16.13 Benefits of minimally invasive hepatectomy: case-control study of 50 laparoscopic liver resections

Abstracts

Delphine Ribes1,4, Mathias Worni2, Vanessa Banz2, Christian Toso3, Pietro Majno3, Francesco Volonté3, Daniel Candinas2, Stefan Weber0 1 University of Bern, ARTORG Center for Biomedical Engineering Research,, Bern, Switzerland, 2Department of Visceral Surgery and Medicine, Clinic for Visceral and Transplantation Surgery, Inselspital, Hospital and University of Bern, Bern, Switzerland, 3Clinic for Visceral and Transplantation Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland, 4CAScination AG, Computer Assisted Soft Tissue Surgery, Bern, Switzerland

16.14 Fast and locally accurate ultrasound to MeVis-CT registration for instrument guided liver surgery

Objectives A prerequisite to stereotactic i.e. image-guided surgery utilizing preoperative CT/MRI-data is a precise alignment of the image data with the patient. In order to utilize the concept of image-guided surgery during liver surgery, a fast and locally accurate patient-to-image registration method using ultrasound (US) and MeVis-CT data was developed. The method was applied during the surgery of four patients and available accuracy was identified. We present here the framework, the required time, as well as the navigation accuracy reached. Method Seven 3D-datasets of corresponding MeVis-CT and US imagery were collected during 4 surgeries by using the CAS-One system (CAScination AG, Switzerland) and the following protocol: 1) Identification of a suitable vein bifurcation in MeVis-CT close to a site of interest (SOI), 1.1) CAS-ONE automatically simulates the corresponding US image (Figure 1); 2) Acquisition of 3D-US around the predefined bifurcation; 3) Automatic calculation (locally rigid) of overlay between US and MeVis-CT; 4) Intraoperative assessment of the accuracy; 5) Postoperative Assessment of resulting accuracy. Results Effective accuracy within the recorded and subsequently recorded US volume was 6.87 +/- 2.5 mm (n=7). Mean time for recording and preparation of the data was 55 sec. Mean calculation time of registration was 20 sec. After registration, anatomical information from MeVis-CT was overlaid to the US (enhanced US) and a 2D-US image was displayed within the 3D MeVis-CT (Figure 1). Surgeons reported, that the enhanced US view helped to correctly identify vein bifurcations and to maintain overall orientation in the parenchyma. Additionally, visual inspection helped initially to assess the available navigation accuracy and thus the quality of the image-guidance.   Conclusions Preliminary results indicate, that utilization of a US-to-CT based registration approach is both feasible and sufficiently accurate for local treatment. Furthermore, US-to-CT offers unprecedented accuracy even within the parenchyma, when compared to surface based registration approaches. However, further refinement of the algorithm for a faster, more converging calculations as well as improvements in the workflow are required. Ultimately, we aim to reduce the amount of US data required for registration while at the same time increasing the procedural overload.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
106

E-AHPBA

Francesco Di Fabio1,2, Eleonora Dimovska2, Joseph Davids2, Neil Pearce2, Mohammed Abu Hilal2 1 Colorectal surgery, University Hospital Southampton, Southampton, UK, 2Hepatobiliary and pancreatic surgery, University Hospital Southampton, Southampton, UK Objectives Laparoscopic liver surgery (LLS) for colorectal carcinoma liver metastasis (CRCLM) is expanding. Most liver resections for CRCLM are staged procedures, bringing into question the safety of LLS in the context of a nonvirgin abdomen. We assessed the impact of prior open (OCRR) vs. laparoscopic colorectal surgery (LCRR) on short-term outcome after subsequent LLS for CRCLM.   Method A prospectively collected database of 323 patients undergoing pure LLS was reviewed. Patients undergoing LLS for CRCLM were analyzed with respect to the approach (laparoscopic vs. open) adopted for the primary colorectal cancer resection. One-hundred and one patients were included. Seventy-six (75%) had open and 25 (25%) had laparoscopic colorectal resection. Results Median length of stay (LoS) after LLS was significantly higher in patients who had OCRR vs. LCRR (5 vs. 4 days; p=0.042). No difference in complication rate was found. Laparoscopic major hepatectomy was performed in 40(40%) patients. In this group, median intraoperative blood loss was significantly higher in patients who had OCRR vs. LCRR (1000ml vs. 425ml; p=0.009). Multivariate analysis showed that blood loss during LLS was significantly associated with ASA grade (p=0.027), major hepatectomy (p<0.001) and prior OCRR (0.002), while LoS after LLS was significantly associated with conversion rate (p<0.001), major hepatectomy (p=0.002), early LLS experience (p=0.041), and prior OCRR (p=0.039). Conclusions LLS for CRCLM can be safely performed in patients who had previous OCRR in centres with adequate expertise in advanced laparoscopic surgery. However, laparoscopic colorectal surgery may maximize the advantages of subsequent minimally-invasive liver surgery, particularly when major hepatectomy are required.

107

Abstracts

16.15 Impact of laparoscopic vs. open colorectal surgery on the subsequent laparoscopic resection of liver metastases

16.16 Laparoscopic major hepatectomy: techniques and outcome in Kwong Wah Hospital Abstracts
Yuk-Pang Yeung Kwong Wah Hospital, Hong Kong, Hong Kong

Objectives To describe the techniques and outcome of first 30 patients who underwent laparocopic major hepatectomy Method Laparoscopic major hepatectomy is defined as hemihepatectomy and right posterior or anterior sectionectomy. The technical steps include diagnostic laparoscopy and  laparoscopic ultrasound,  hilar dissection to isolate the  Glissonian sheath  to the liver segments to be removed, hepatotomy and exposure of intersegmental vein and finally control of the outflow hepatic vein. Thirty consecutive patients who underwent laparoscopic hepatectomy between 2009 and 2012 were prospectively studied, with respect to total operative time, blood loss, perioperative blood transfusion, intraoperative and postoperative complications, conversion to open and mortality. Results Patients’ median age was 67. The median total operating time was 350 minutes (range 240 to 580 minutes). Median blood loss was 650mL (range 200 to 2800 mL) and ten patients (33.3%) required  perioperative transfusion. Five patients required conversion to open (16.7%). There was no intraoperative complication and the overall postoperative morbidity was 20%. Three patients suffered from bile leakage (10%), two managed with percutaneous drainage and one needed re-operation. Another patient was re-operated for massive bowel gangrene and dead, hence the overall mortality was 3.3%.   Conclusions Laparoscopic major hepatectomy remained a challenging procedure. More experience and studies are required to further delineate the applicability of laparoscopic surgery in major liver resection.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
108

E-AHPBA

Renato Lupinacci, Evandro Mello, Fabricio Coelho, Jaime Kruger, Marcos Perini, Paulo Herman University of Sao Paulo, Medical School, Sao Paulo, Brazil

Objectives The purpose of our study was to determine the usefulness of routine IHC analysis in establishing CRCLM lymphatic dissemination, and thus to evaluate the relationship between the pathological mode of dissemination and outcomes Method The medical records of  patients who underwent a first resection of colorectal cancer liver metastases (CRCLM) during the period between 2000 and 2009 were reviewed. Resected specimens were submitted to conventional histological evaluation. The number of hepatic deposits was determined in each patient by both preoperative imaging and macroscopic examination of multiple slices from each resected specimen, and did not include satellite lesions. Intrahepatic lymphatic invasion was determined after immunohistochemical staining with D2-40 monoclonal antibody (specific for lymphatic vessels). Two experienced pathologists blinded to clinical details assessed each section. Results 112 patients underwent liver resection for CRCLM.  Median age was 59 years. Mean postoperative hospital stay was 10 days and the mean follow-up after resection was 38 months. Tumor recurrence was observed in 76 patients (68%). The cumulative overall and disease-free survival (DFS) at 3-, and 5-yeras were 62%, 56%, and 26%, 24% respectivelly. Eighty-eight percent were considered R0. Intrahepatic lymphatic invasion was observed in 33 patients. Multivariate analysis demonstrated that intra-hepatic lymphatic invasion was related to recurrence (HR=5.63; 95% CI=1.18-26.9). DFS was associated with the presence of intra-hepatic lymphatic invasion (p=0.006) in multivariate Cox regression.   Conclusions The association IHC and serial sections as performed in our study allows the precise identification of micrometastatic lymphatic involvement and seems to be an interesting way to evaluate H&E negative margins. More than a prognostic factor it may help clinical decision such as the need for postoperative chemotherapy and/or its duration.

109

Abstracts

17.1 Immunohistochemically detected intrahepatic lymphatic invasion is a major prognostic factor after resection of colorectal cancer liver metastases 

Abstracts

17.2 Pattern of Recurrence following Non-Anatomical Resection for Colorectal Liver Metastasis

AbdulHakeem,GabrieleMarangoni,AmitNair,RichardYoung,ErnestHidalgo,GilesToogood,PeterLodge,RajPrasad Department of HPB and Transplant Surgery, St James’s University Hospital NHS Trust, Leeds, UK Objectives Non-anatomical resection (NAR) for colorectal liver metastasis (CRLM) has become more common in an attempt to preserve liver parenchyma. Pattern of recurrence (POR) following NAR has been reported previously, but there has been no detail on the hepatic recurrences with respect to previous NAR. We aim to investigate pattern of hepatic recurrence in patients who underwent NAR for CRLM, especially looking at the recurrences in the context of previous resected segment. Method 1580 CRLM resection were performed in our centre between 1993-2010. 591 (37.4%) were NAR and 989 (62.6%) were AR. Patients who underwent simultaneous Anatomical Resection (AR) were excluded (95 out of 591). All NAR were grouped as either unilobar or bilobar metastatectomy and POR studied in relation to previous resected segment. Results 495 NAR were included. There were 291 recurrences (58.7%). 188 were hepatic (37.9%) and 103 extra-hepatic (20.8%). In 11 patients with hepatic recurrence, data was not available for recurrence segment and therefore excluded from POR analysis. The POR following unilobar metastatectomy (n=127): same segment (n=32, 25.2%), same sector (n=9, 7.1%), ipsilateral hemi-liver (n=48, 37.8%), contralateral hemi-liver (n=15,11.8%) and bilobar (n=23,18.1%).  The POR following bilobar metastatectomy (n=50): same segment (n=1, 2%), hemi-liver with equal number of segments resected previously (n=15, 30%), hemi-liver with lesser involved segments previously (n=7, 14%), hemi-liver with more segment involved previously (n=10, 20.0%) and bilobar (n=17, 34.0%). Conclusions This retrospective study shows that following unilobar CRLM resections, 70.0% recur in the ipsilateral hemiliver. In bilobar resections, 22.0% recur in the same segment or hemi-liver with previous multiple resections. Our data supports a more aggressive approach for unilobar disease. Further studies need to be done on pattern of recurrences in patients undergoing parenchyma preserving surgery to develop best surgical strategies.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
110

E-AHPBA

Jai Seema Bagia St George Hospital, Sydney, Australia

Objectives Currently there is no consensus on optimal approach to preoperative staging of patients with CRCLM.    The aim of the study is to: a) Assess accuracy of characterisation of liver lesions seen with Primovist MRI and CTAP, comparing sensitivity and specificity.  b) Assess inter-observer variability of Primovist MRI and CTAP. Method Patients evaluated at St George hospital liver unit had CTAP and Primovist MRI for pre-operative assessment of CRCLM.  Four radiologists were involved in reporting: two reported CTAP and another two reported primovist MRI, to allow blinded assessment of CTAP and primovist MRI.  Inter-observer variability within both modalities was assessed.  Sensitivity and specificity data on CTAP and primovist MRI using histopathology as reference standard was calculated using generalised estimate equations to assess accuracy of these two imaging modalities.  Results Interim results of 63 patients recruited July 2011 to October 2012, are evaluated. Data was available for 43 patients who had 44 operations, 146 lesions confirmed on histopathology. Interobserver agreement per lesion for CTAP using interclass correlation was 0.69 vs. 0.81 for primovist MRI using correlation coefficient Kappa. Sensitivity for lesion detection was similar for CTAP and Primovist MRI (0.86 vs. 0.83, p = 0.937), specificity was also similar (0.79 vs. 0.86, p= value of 0.098).  14 patients had chemotherapy before evaluation with study imaging. In this group primovist MRI demonstrated better specificity, but similar sensitivity compared to CTAP. Conclusions Preliminary results showed equivalent sensitivity and specificity of CTAP and Primovist MRI, though a trend toward improved specificity with Primovist MRI was seen. Comparison of accuracy of CTAP and primovist MRI in the subgroup who have had chemotherapy suggests primovist MRI is more specific than CTAP.  Further numbers may strengthen these observations.

111

Abstracts

17.3 Diagnostic test accuracy comparison of CT during arterial portography (CTAP) and Primovist MRI in preoperative assessment of colorectal cancer liver metastases (CRCLM)

Abstracts

17.4 Multivariate analysis of risk factors for early recurrence after resection of colorectal liver metastases: potential impact on preoperative staging protocols

Ricky Bhogal, Simon Bramhall, John Isaac, Ravi Mararudanayagnam, Darius Mirza, Paolo Muiesan, Robert Sutcliffe University Hospitals of Birmingham, Birmingham, UK Objectives Early recurrence after resection of colorectal liver metastases may reflect suboptimal preoperative staging. The role of MRI and PET in the preoperative work-up of patients has not been defined. Our aim was to identify patients at risk of early liver-only or systemic recurrence, who may benefit from preoperative MRI or PET scan, respectively. Method Retrospective analysis of prospective database of patients undergoing liver resection (LR) for colorectal metastases (CLM) between 2004 to 2006. Early recurrence was defined as within 18 months of LR. Patients were classified into three groups: early liver-only recurrence, early systemic recurrence and recurrence-free. Preoperative factors (primary tumour stage, number/size of liver tumours, synchronous/metachronous, extrahepatic disease, preoperative chemotherapy) were compared between patients with and without early recurrence. Multivariate analysis was carried out to identify risk factors for early liver-only and systemic recurrence. Results 243 patients underwent LR for CLM.  27 patients (11%) developed early liver-only recurrence. Dukes C stage and male sex were significantly associated with early liver-only recurrence on multivariate analysis (p<0.05). 66 patients (27%) developed early systemic recurrence. Tumour size ≥3 cm and tumour number were significantly associated with early systemic recurrence on multivariate analysis (p<0.001). Conclusions It is possible to stratify patients according to risk of early liver-only or systemic recurrence after resection of colorectal liver metastases. High risk patients should be targeted for preoperative MRI and/or PET scan, and may also be candidates for intensive postoperative surveillance.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
112

E-AHPBA

David Hunter, Thalis Christophides, Ashish Shrestha, Madhava Pai, Duncan Spalding Imperial College NHS Trust, London, UK

Objectives To determine if radiologically disappearing liver metastases (DLMs) after chemotherapy correspond to a complete clinical response.  The treatment of DLMs was also assessed to determine whether they should be resected or left insitu. Method A retrospective review was carried out on 342 patients referred for surgery between January 2001 and January 2012.  Twenty-eight patients showed evidence of at least one metastasis disappearing radiologically after chemotherapy.  Sixteen patients were subsequently eligible for review with a median follow up of 27.6 (range 5.2 – 113.9) months. Results Thirty five metastases were identified in 16 patients.  Twenty-eight metastases disappeared radiologically.  Ten patients had 15 DLMs left insitu and 6 patients had 13 DLMs resected.  Complete clinical response was observed in 15 DLMs (53.6%) on follow up.  Five showed no recurrence within one year in those left insitu (33.3%) and 10 showed complete pathological response after resection (76.9%).  A significantly reduced recurrence free survival was observed in the insitu group, [6.3 vs 19.4 months (p<0.001)], but overall survival was not significantly different between the two groups (p=0.12). Conclusions Radiologically DLMs do not necessarily confer a complete clinical response. They should be resected when possible but leaving them insitu can be warranted.  

113

Abstracts

17.5 Determining complete clinical response of radiologically disappearing colorectal liver metastases after chemotherapy and how they should be managed

Giulio Belli5, RT Groeschl1, RK Wong1, CHC Pilgrim1, M Bloomston2, ME Lidsky3, BM Clary3, RCG Martin4, JF Buell6, TC Gamblin1 1 Medical College of Wisconsin, Milwaukee, WI, USA, 2Ohio State University, Columbus, OH, USA, 3Duke University Medical Center, Durham, NC, USA, 4University of Louisville, Louisville, KY, USA, 5Loreto Nuovo Hospital, Naples, Italy, Italy, 6Tulane University, New Orleans, LA, USA Objectives Fibrolamellar carcinoma (FLC) presents in young, otherwise-healthy individuals. This study examined recurrence and survival characteristics after surgical resection for FLC by utilizing an international multiinstitutional database. Method Consecutive patients undergoing hepatectomy for FLC from 6 institutions (1993-2010) were reviewed retrospectively. Survival was studied with Cox proportional hazards models.   Results Thirty-five patients were included. Lesions were solitary in 26 patients, median size was 7.5cm. R0 resection was achieved in 30 resections. 5 patients had palliative operations. Morbidity were 22% and mortality 3%. Overall survival were 77% (3 years) and 62% (5 years). 15 patients had a recurrence. Recurrence-free survival were 54% (3-years) and 45% (5-years). There were no recurrences or cancer-related deaths more than 4 years after surgery. No patient with extrahepatic disease lived beyond 3 years. This factor independently predicted overall (HR: 5.58, 95% CI: 1.38-22.55, p=0.016) and recurrence-free survival (HR: 5.64, 95% CI: 1.48-21.49, p=0.011) in multivariable models.   Conclusions Aside from those with extrahepatic disease, patients with surgically amenable FLC had encouraging long-term survival. In our study population, recurrence-free survival to 4 years suggests possible freedom from disease thereafter.  

17.6 Multi-institution analysis of survival after hepatectomy for fibrolamellar carcinoma

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
114

E-AHPBA

Santhalingam Jegatheeswaran1, James Mason0,2, Helen Hancock0,2, Ajith K Siriwardena1 1 Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK, 2Durham Clinical Trials Unit, University of Durham, Durham, UK Objectives Options for the management of patients with colorectal cancer with synchronous liver-limited metastatic disease include synchronous (liver and bowel) resection or sequential surgery: either the classic bowel-first approach or the newer liver-first strategy.  This latter approach is popular but has relatively little evidence underlying it.  This study undertakes a pooled analysis of protocol and outcome of all reports of the liver-first approach for synchronous metastases. Method PubMed, Embase, science citation index, social sciences citation index and the Derwent innovations index were searched using terms describing colorectal cancer, liver metastases and surgery. The literature search identified 417 articles of which 4 cohort study reports described the liver-first approach and reported survival data and constitute the study population.  A pre-defined protocol for data extraction was utilised to retrieve data on design, distribution of primary and hepatic metastatic disease, chemotherapy, surgery, patients completing treatment algorithm, outcome and survival. Data were extracted to populate a PRIZMA quality-control chart. Results The 4 studies comprised 121 patients starting treatment of whom 90 (74%) completed the specified treatment protocol (83 rectal primary, 33 colon primary and primary site unreported in 5).  Disease progression during the protocol period occurred in 23 (19%).  Ninety six (79%) of the starting cohort of 121 reached the stage of liver resection with disease progression or death during chemotherapy being the principal causes of failure. Preferred algorithm was systemic chemotherapy (median 3 to 6 cycles) followed by hepatectomy with colorectal resection as the last step. There was wide variation between the reports in terms of their survival data. Conclusions The liver-first approach is technically feasible in patients with colorectal cancer and synchronous hepatic metastases.  About 20% will fail to complete the full treatment protocol because of disease progression. To date, there are no data to suggest superiority of outcome over the classic approach or synchronous surgery.

115

Abstracts

17.7 Pooled survival analysis of series using the liver-first approach to the management of colorectal cancer with synchronous hepatic metastases demonstrates wide variation in outcome.

Abstracts

17.8 Prognostic score for colorectal liver metastases: the external validation of the”Basingstoke Predictive Index”

ArpadIvanecz,JasminaGolc,JasnaZakelsek,MarkoSremec,MiroslavPalfy,TomazJagric,MatjazHorvat,StojanPotrc University Medical Center Maribor, Maribor, Slovenia Objectives Prognostic scoring systems for patients undergoing resection of colorectal liver metastases (CRLM) are believed to be reproducible between institutions. The aim of the present study was to asses the predictive value of “Basingstoke Predictive Index” (BPI) in an independent patient cohort for the purpose of external validation. Method Study subjects were identified from prospectively maintained database of 406 liver procedures for CRLM from 2000 to 2011 at our department. A total of 284 patients underwent their primary hepatic resection and were analyzed in detail. According to the BPI, 7 risk factors were evaluated: number of hepatic metastases >3, node positive primary, poorly differentiated primary, extrahepatic disease, tumor diameter ≥5cm, CEA level >60 ng/mL, and positive resection margin. The first 6 of these criteria were used in a preoperative scoring system and the last 6 in the postoperative setting. The endpoint of the study was the progression-free survival (PFS). Results With a median follow-up of 30 months the median PFS was 11.3 months. The 5-year and 10-year PFS were 15.9% and 12.4%, respectively. Patients with the best preoperative BPI had an expected median PFS of 22 months and a 5-year PFS of 33.3%. Conversely, patients with the worst preoperative BPI had an expected median PFS of 7.4 months and a 5-year PFS of 1.5%. Postoperative BPI predicted a median PFS of 19 months (5-year PFS of 27.9%) for the best group, and a median PFS of 9.7 months (5-year PFS of 2%) for the worst group of patients, respectively. Conclusions In our patient cohort, PFS was accurately predicted pre- and postoperatively by BPI. These findings highlight the importance of validating scoring systems in independent patient groups. Such data may be useful for riskstratifying patients who may benefit from intensive surveillance and selection for adjuvant therapy.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
116

E-AHPBA

17.9 Predicting 10 year survival following resection of colorectal liver metastases

Objectives Ten years of follow up following resection of colorectal liver metastases (CRLM) is required to define cure. Various scores to predict outcome of patients with CRLM at five years exist. The aim of this study was to apply these scoring systems to a cohort of patients with 10 years of actual follow up following resection of CRLM to assess their utility. Method Consecutive patients (n=286) between 1992 and 2001 underwent resection of CRLM at a single institution. Post operative deaths (n=18) were excluded.  Actual follow up was available for 99% of patients and was cross checked with cancer registry data to yield disease free and disease specific survival (DFS and DSS). Six different scoring systems were applied to the cohort and analysed using the C statistic at 1, 3, 5 and 10 years following initial resection. Results  The 1, 3, 5 and 10 year actual DSS was 87, 58, 39 and 24%. Seventy patients underwent 105 resections for recurrent disease; 86% within 5 years of follow up. Using the C statistic one score was significant at all time points for DFS and DSS (the Basingstoke postoperative index). Two scores were significant at all time points for DSS and all but one for DFS (Basingstoke preoperative index and Nordlinger score). The remaining scores performed less well being significant at half or less of the time points measured (the Fong CRS, Nagashima and Konopke scores).   Conclusions Providing surveillance beyond 5 years of follow up is advantageous. Comparing the predictive ability of available scores upon an external cohort of patients demonstrates which are most useful to determine patient selection for liver resection and which patients require the most intensive post operative surveillance.

117

Abstracts

Keith J Roberts1, Alan White1, Andy Cockbain1, James Hodson2, KRA Prasad1, Giles J Toogood1, Peter Lodge1 1 St James University Hospital, Leeds, UK, 2Medical statistician, University Hospital Birmingham, Birmingham, UK

Abstracts

18.1 Future remnant liver function after portal vein occlusion measured with 99mTcmebrofenin SPECT/CT.
Ibolyka Dudás1, Tamás Györke3, Csaba Korom1, Péter Pajor2, Attila Zsirka-Klein2, Éva Horváth3, Anna Bozó2, Péter Kupcsulik2, Oszkár Hahn2 1 Semmelweis University Department of Radiology and Oncotherapy, Budapest, Hungary, 2Semmelweis University 1st Department of Surgery, Budapest, Hungary, 3Semmelweis University Department of Nuclear Medicine, Budapest, Hungary

Objectives To compare the results of 99mTc-mebrofenin SPECT/CT and CT volumetry after portal vein occlusion techniques i.e. portal vein embolization (PVE), portal vein ligation (PVL) prior to extended liver resections.   Method Between March 2011 and September 2012 forty patients presenting with primary or secondary liver tumors were included. The estimated future liver remnant volume (FLRct) of these patients after the planned extended hepatectomy measured with CT-volumetry were less than 30% (normal liver), or 40% (cirrhosis). To increase the FLR portal vein occlusion techniques (31 PVE, 9 PVL) were performed. Eight weeks after portal occlusion CT-volumetry and to measure functional future liver remnant volume (fFLR) SPECT/CT with 99mTc -mebrofenin were performed. 17 of the 40 patients underwent SPECT/CT also prior to portal occlusion. Postoperative complication rates (using the Clavien criteria) were measured.   Results Eight weeks after portal vein occlusion, fFLR was significantly higher than FLRct (mean fFLR: 39,0±10,5% vs FLRct: 30,7±7,8%; p<0,05). The functional and volumetric percentage values were also compared before and after occlusion, and the fFLR growth rate was higher than FLRct growth rate (mean fFLR: 12,6% vs. mean FLRct: 7,6%). 33 patients were operated. Among those who had minimum 5% difference between fFLR and FLRct postoperative complications rates were singificantly lower, than among those who had similar values.   Conclusions 99m Tc -mebrofenin SPECT/CT can be useful in the measurement of future liver remnant function after portal vein occlusions. This can provide more precise functional information than CT volumetry in planning extended hepatectomies.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
118

E-AHPBA

Martin Stockmann, Johan Lock, Tilman Westphal, Maciej Malinowski, Antje Schulz, Peter Neuhaus Charité - University Hospital, Berlin, Germany Objectives Downstaging of liver metastases using Chemotherapy might be beneficial before liver resection but is known to cause hepatic injury in some cases. A new approach is presented here for the preoperative evaluation of functional impairment due to chemotherapy by the LiMAx test. Method Patients intended for liver resection of colorectal liver metastases were included into an observational clinical trial. Liver function was prospectively determined by biochemical parameters and the LiMAx test. The LiMAx test measures the metabolic capacity of the cytochrome P450 1A2 system based on the metabolism of 13C-labelled methacetin by a non-invasive breath test. Patients’ history of chemotherapy during 12 months prior admission was retrospectively collected from clinical records and the patients’ physicians. Results 174 patients were included and analyzed between 2007 and 2011. Out of these, 103 patients (59%) had received chemotherapy (FOLFOX, FOLFIRI, FOLFOXIRI, other). A significant correlation between LiMAx and therapy free interval was found (P=0.001). Those patients that had been treated with oxaliplatin had lower LiMAx values. Patient receiving chemotherapy during four weeks before admission showed a reduced LiMAx of 295 (206452) vs. 360 (79-1066) µg/kg/h (P<0.001). Simultaneously no alterations in conventional biochemical tests were observed. Conclusions The LiMAx test allowed individual assessment of hepatic impairment due to chemotherapy. The test is more sensitive to detect slight changes in comparison to biochemical tests. According to published cut-offs this might help to individualize the decision for therapy free interval and timing as well as extend of surgery for colorectal liver metastases. Thus, therapy management and safety could be improved.

119

Abstracts

18.2 Individual Quantification of Hepatic Impairment after Chemotherapy prior to Liver Resection of Colorectal Metastases using the novel LiMAx test

Abstracts

Daniel Bos1, Toine Lodewick1,3, Ronald Dam, van1,3, Ulf Neumann2,3, Cornelis Dejong1,3 1 Maastricht University Medical Center, Maastricht, The Netherlands, 2RWTH Aachen, Aachen, Germany, 3Surgical HPB collaboration Aachen-Maastricht, Maastricht/Aachen, The Netherlands Objectives When liver resection for a centrally located tumour is performed, repeat resection might be needed to treat recurrent lesions in the remnant liver. These resections appear to be safer when remnant liver volume is large. We investigated the difference in liver regeneration after central and extended liver resections. Method From 2002 to 2012 all patients who underwent anatomic central or extended hepatectomy were included in this study. Central hepatectomy was defined as complete resection of Couinaud segments 4, 5 and 8. Complete resection of segments 4-8 ± 1 or segments 2-5 + 8 ± 1 were considered extended liver resections. Inclusion was regardless of surgical indication. Volumetry of the preoperative total liver (TLV), future remnant liver (fRLV), tumor (TV), non tumor total liver (ntTLV) and postoperative remnant livers (RLV) was then performed using CT- or MRI-scans and Osirix® software. Total regeneration was calculated as RLV/ntTLV*100%. Results Twenty-three patients were included in the present study, 10 underwent  central and 13 extended hepatectomy. Patients who underwent central and extended liver resection had comparable ntTLV’s (1915 [1109-2161] mL and 1580 [1219-2670] mL respectively, p=0.58). The preoperatively anticipated RLV as percentage of ntTLV was significantly smaller in patients with extended hepatectomy, 28.4 versus 50.4% (p<0.001). Total regeneration after 3, 6 and 12 months was 97.3, 100.5 and 104.5% for central liver resections and 76.3, 79.0 and 83.2% for extended liver resections (p<0.01, p=0.01 and p=0.04, respectively (Mann Whitney U)). Conclusions It appears that liver regeneration after extended hepatectomy ceases before the preoperative liver volume is reached. After central hepatectomy, the post-resectional liver volume reaches the preoperative volume within 6 months. Therefore, central hepatectomy seems to be beneficial for future liver surgery in case of recurrence.

18.3 Liver regeneration after central and extended hepatectomy

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
120

E-AHPBA

Rocco Scalzone1, Joan Figueras2, Matteo Barabino1, Santiago Lopez-Ben2, Roberto Santambrogio1, Enrico Opocher1 1 Ospedale San Paolo, Università degli Studi di Milano, Milan, Italy, 2Hospital Josep Trueta, Girona, Spain Objectives TSH is a safe and effective procedure, but timing of hepatectomy in case of synchronous bilobar hepatic metastases is still discussed. A retrospective analysis was performed on 51 patients with a TSH planned, in order to identify factors related to outcome.

Method Patients in which a TSH was planned were divided into two groups: the first group composed by simultaneous primary tumor resection and first stage hepatectomy; the second group with colon resection first, chemotherapy and TSH. Prognostic factors were identified for this population and for the patients with a twostage hepatectomy procedure completed. Results Extrahepatic disease (EHD) (p = 0,00001) and TSH not completed (p=0,00001) were related to a worse survival. Multivariate analysis showed that EHD (p = 0,021), pre-operative chemotherapy (p = 0,04) and TSH complete (p = 0,02) were independent predictor of survival. Cases with TSH complete, EHD (p = 0,036), more than 1 line of pre-hepatectomy chemotherapy (p = 0,016), blood loss (p = 0,003) and post-operative complications (p = 0,017) influenced survival; independent factors were operative time (p = 0,014) and post-operative complications (p = 0,027). Group has not demonstrated in any case to be a negative prognostic factor. Conclusions EHD is a negative prognostic factor in TSH, but it gives a chance to patients otherwise unresectable and with a poor survival; timing of resection is not a negative prognostic factor if TSH is completed. More than one line of chemotherapy and operative outcome are the most important prognostic factor in patients with a complete TSH procedure.

121

Abstracts

18.4 Two-stage hepatectomy (TSH) procedure for synchronous colorectal liver metastases: timing and treatment strategies

Abstracts

DUILIO PAGANO1, MARCO SPADA1, VISHAL PARIKH2, FABIO TUZZOLINO1,3, DAVIDE CINTORINO1, LUIGI MARUZZELLI1, GIOVANNI VIZZINI1, ANGELO LUCA1, ALESSANDRA MULARONI1, BRUNO GRIDELLI1, SALVATORE GRUTTADAURIA1 1 Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT) - University of Pittsburgh Medical Center (UPMC), Palermo, Italy, 2School of Medicine, University of Pittsburgh, Pittsburgh, USA, 3Silvio Vianelli Department of Statistical and Mathematical Sciences, Palermo, Italy

18.5 Impact of Infection on Early Liver Regeneration after Resection for Hepatic Tumors: A Generalized Linear Regression Analysis

Objectives Early liver regeneration after resection in patients with hepatic tumors but no underlying liver disease may not be influenced by health-care-associated infections (HAIs ) and post-operative complications. Method A retrospective analysis of 27 liver resections for tumors performed in a single referral center from November 2004 to January 2010. Regeneration was evaluated by multidetector computed tomography at a mean follow-up of 43.85 days. The Clavien-Dindo classification was used to evaluate postoperative events in the first 6 months after transplantation, and Centers for Disease Control and Prevention definitions were used for healthcare associated infections data. Results  Regeneration ≥100% occurred in 10 (37%) patients. The predictors were smaller future remnant liver volume (-0.002; P<0.001), and a greater spleen volume/future remnant liver volume ratio (0.499;P=0.01). Patients with a resection of ≥ 5 Couinaud segments experienced greater early regeneration (P=0.04). There were no significant differences between patients with primary or secondary tumors and either onset or infections or severity of surgical complications. HAIs were significantly associated with the onset of surgical complications: 9 patients experienced HAIs, and in 7 cases Clavien-Dindo Grade 3a to 4 complications were detected (p=0.016). Conclusions Regardless of the onset of HAI’s and severity of surgical complications, future remnant liver volume and spleen volume, as measured by multidetector computed tomography may be reliable predictors of early liver regeneration after hepatic resection of primary or secondary tumors on an otherwise healthy liver.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
122

E-AHPBA

18.6 Prognostic factors in two-stage liver surgery for colorectal liver metastases

Objectives Small future left liver remnant volume is one of the reasons for irresectability of colorectal liver metastases. Two-stage liver surgery gives a chance to achieve R0 resection with low risk of liver insufficiency. Two techniques are used for liver hypertrophy–right portal vein ligation/embolization and ligation plus in-situ liver split. Method Between 2007 and 2012, two-stage liver surgery (TSLS) was performed in 73 patients (median age 57,4±8,3) with colorectal liver metastases (CLM) and small future left liver remnant volume (FLLR). Bilobar metastases were diagnosed in 58,9% of patients; 53,4% patients received preoperative chemotherapy. Right portal vein ligation (n=61)/embolization (n=9) and in-situ liver split plus right portal vein ligation (n=3) were performed as first step of surgical treatment. Initial FLLV was 25,3% (range 15,8-41,2%) from total liver volume. Right hemihepatectomy was the second stage of TSLS approach. Results There were no morbidity and serious complications after I stage related to procedure. After first stage FLLV was 36,6% (range 16,9-51,5%). TSLS was completed in 74% of patients; the rest were excluded mostly because of disease progression (n=16). R0-R1 liver resection was done in 94,8% patients. 1 patient died after stage II (1,8%); morbidity was 37%; no liver insufficiency was observed; 3-year survival was 68,3%. By univariant analysis 3 factors influenced long-term outcomes: number of metastases >3 (р=0,002), bilobar lesions (p=0,03), completeness of TSLS (p=0,0004). Multivariable analysis revealed one independent prognostic factor: completeness of TSLS (p=0,015; hazard ratio 0,315). Conclusions Two-stage liver surgery increases resectability in majority patients with colorectal liver metastases and small future left liver volume. Completion of two-stage approach is very important factor for good long-term outcome in this group of patients.

123

Abstracts

Nikolay Bagmet, Lilia Polishchuk, Marina Sekatcheva, Arkadiy Bedzhanyan, Oleg Skipenko FSBI Petrovsky national research center of surgery RAMS, Moscow, Russia

Abstracts

Gregory Sergeant1, Erik Schadde1, Christoph Tschuor1, Ksenija Slankamenac1, Victoria Ardiles2, Kris Croome4, Janine Baumgart3, Hauke Lang3, Roberto Hernandez-Alejandro4, Eduardo de Santibanes2, Pierre-Alain Clavien1 1 Swiss HPB center, University Hospital Zurich, Zurich, Switzerland, 2Department of Surgery, Division of HPB Surgery and Liver Transplant Unit, Buenos Aires, Argentina, 3Department of Visceral Surgery and Transplantation, Mainz, Germany, 4Department of Surgery, Division of HPB Surgery, London, Ontario, Canada

18.7 Pre-embolisation sFLR < 20% predicts failure to grow future liver remnant volume after portal vein embolization

Objectives  Portal vein embolization (PVE) is used to induce liver hypertrophy in patients with small future liver remnant (FLR) precluding safe hepatectomy. In some cases PVE fails to induce liver hypertrophy resulting in excessive waiting times and tumor progression. Aim was to describe factors associated withthe pattern of failure to grow the FLRof hypertrophy after PVE. Method Patients undergoing PVE for malignant disease were extracted from an international multicenter database containing 160 patients who underwent treated with different methods to induce liver hypertrophy between 2002 and 2012. Demographics, comorbidity, disease-related parameters, pre- and post-PVE FLR volumes and tumor progression data were analyzed. Standardized FLR (%) was determined using a formula based on body surface area. Logistic regression analysis was performed identifying risk factors for failure to reach 30% sFLR prior to hepatectomy.for safer liver surgery. Results   Forty-eight patients underwent PVE for malignant disease. Complete FLR volume data were available in 46 patients. Pre-embolization sFLR was 24%(IQR 20-29). After a waiting time of 42(range21-168) days, FLR increased to 32%(IQR27-40). 19(41%) patients did not reach the cut-off of 30%sFLR prior to hepatectomy. High body mass index (kg/m2) (p=0.02), chemotherapy prior to PVE or in waiting interval (p=0.05),pre-embolization sFLR<20% (p=0.0024) and high INR (p=0.03) were retained as risk factors for not reaching the cut-off of 30% sFLR after PVE in univariable analysis. In multivariable analysis only pre-embolization sFLR<20% (adjusted OR (95%CI):0.09 (0.008 - 0.60),p=0.01) was retained as independent variable. Conclusions  Despite proven success in a large number of patients, PVE fails to induce sufficient growth of the FLR in almost half of the patients in this multicenter study.   Especially in patients with pre-embolization sFLR < 20%, alternative portal vein manipulation strategies such as ALPPS may be a better approach.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
124

E-AHPBA

AndreaRuzzenente,SimoneConci,CalogeroIacono,AlessandroValdegamberi,GuidoMantovani,AlfredoGuglielmi Department of Surgery, Division of General Surgery A, G.B. Rossi University Hospital, Verona, Italy

Objectives  The purpose of this study was to identify preoperative factors that affect short- and long-term outcome in patients with resectable synchronous colorectal liver metastases (SCRLM) in order to clarify the optimal timing of liver resection.   Method A total of 205 patients with synchronous and metachronous colorectal liver metastases (CRLM) underwent liver resection at our institution from 2006 to 2012. Eighty patients with SCRLM underwent surgical resection with curative intent and were included in the study. Demographic and clinicopathological features were prospectively collected and compared between, patients having simultaneous colorectal and liver resection (n=45, group A) and patients treated by staged strategy, colorectal resection first and delayed liver resection (n=35, group B). Results Mortality and morbidity rate were similar between groups A and B with 2.2% vs 0% (p=0.584), and 64.4% vs 57.1% (p=0.521), respectively. In subgroup analysis morbidity was higher for group A compared with B in elderly patients (over 75 years) (p=0.025) and in rectal cancer patients (p=0.047). Five years survival rate in groups A and B were 35.1% and 46.4%, respectively (p=0.156). Overall 5-years survival of group A compared with group B was shorter in patients with more than 3 metastases (p=0.015), metastases larger than 50 mm (p=0.015) or involving both hepatic lobes (p=0.016) at the time of diagnosis. Conclusions Short-term and long-term outcome were similar in patients with SCRLM treated with simultaneous or delayed resection. However, staged strategy seemed to be preferred in patients older than 75 years, with primary-atrectum disease and with larger liver involvement, in terms of number (more than 3) and size (more than 50 mm).

125

Abstracts

18.8 Timing of liver resection in patients with synchronous colorectal liver metastases: simultaneous or staged surgery?

18.9 2012 Liver resections in the new millennium: we are far from zero mortality Abstracts

Safi Dokmak, Fadhel Samir Ftériche, Béatrice Aussilhou, Olivier Farges, Alain Sauvanet, Jacques Belghiti Beaujon Hospital, Departement of HBP surgery and liver transplantation, Clichy, France Objectives Evaluate with a large unicentric series the surgical risk of elective liver resection in the new millennium. Method From 2000, 2012 elective liver resections were prospectively analysed and evaluating the surgical risk with 90 days mortality according to patients risk (age >60 years and ASA score), nature of the disease [benign (n=561; 27.8% ) or malignant (n=1451; including metastasis (n=751), HCC (n=450) and biliary cancer (n=194)], underlying liver parenchyma [normal (n=480; 33%), diseased  ( steatosis > 30%, fibrosis, chemotherapy related toxicity, steatohepatitis, cholestasis) or cirrhosis (n=363; 18%)] and the extent of the liver resection [minor (n=928; 46% ) or  major (≥3 segments)] subclassified  without or with  (n = 367; 18.2% ) biliary, vascular or gastrointestinal associated procedure.   Results Overall mortality and major morbidity rate was 3.5 % and 24.4%, respectively. Mortality for benign lesion was 0.7% vs 4.5% (p<0.001) for malignant tumors ranging from 8.2% for biliary tumors to 1.7% for metastasis. In malignant subgroup, multivariate analysis showed that the mortality was significantly influenced by age > 60 years (p<0.024); ASA score ≥ 3 (p<0.015); presence of diseased parenchyma (p<0.001); cirrhosis (p<0.001); major resection (p=0.011) and associated procedure (<0.001) especially when associated with vascular resection (p<0.001). Conclusions This persistent important high mortality rate after elective liver resection for malignant disease is explained by resections performed in high risk patients with diseased liver requiring complex major procedure. A significant decrease of operative risk in this population requires a reappraisal of major procedure in diseased liver.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
126

E-AHPBA

1

Yaojun Zhang1,2, Adam Frampton1, Long Jiao1, Charis Kyriakides1, Jan Bong1, Nagy Habib1 Imperial College, London, UK, 2Sun Yat-sen University Cancer Center, Guangzhou, China

Objectives Loco (regional) recurrence rate after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) remains high and the efficiency of adjuvant chemoradiotherapy is still debated. We aimed to assess predictors of loco-recurrence in order to tailor the indications for adjuvant chemoradiotherapy. Method Patients who underwent PD for PDAC between January 2001 to December 2010 were retrieved from a prospective database. Tumor recurrence was categorized as either loco-recurrence or distant recurrence. Clinico-pathological characteristics and survivals were compared between patients with different recurrence patterns. The predictors for loco-recurrence were assessed. Results 79 patients were included. Loco-recurrence alone was identified in 22 patients, distant recurrence alone in 33, both loco- and distant recurrences in 17 and no recurrence in 7. Median survival after recurrence (SAR) was significantly better in patients with loco-recurrence alone than distant recurrence alone (10.4 vs. 5.0 months, P=0.002) or both recurrences (10.4 vs. 5.8 months, P=0.044). Patients with early recurrence had a significantly poorer SAR than late recurrence (median, 5.5 vs. 9.0 months, P=0.001). Logistic regression analysis revealed that positive resection margin,  T stage and large tumor size were the determinant factors directly related to loco-recurrence alone. Conclusions Patients with PDAC loco-recurrence alone had a significantly better SAR than those with distant recurrence. Adjuvant chemoradiotherapy should be considered to reduce loco-recurrence further and improve long-term survival.

127

Abstracts

19.1 Loco-recurrence after resection for ductal adenocarcinoma of the pancreas: predictors and implications for adjuvant chemoradiotherapy

Abstracts

19.2 Tumor infiltration in the medial resection margin predicts survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

yaojun zhang1,2, Adam Frampton1, Long Jiao1, Patrizia Cohen1, Charis Kyriakides1, Jan Bong1, Nagy Habib1, Duncan Spalding1, Raida Ahmad1 1 Imperial College, London, UK, 2Sun Yat-sen University Cancer Center, Guangzhou, China Objectives Microscopic tumor involvement (R1) in different surgical resection margins after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been debated. Method  Clinico-pathological data for 258 patients who underwent PD between 2001-2010 were retrieved from a prospective database. The rates of R1 resection in the circumferential resection margin (pancreatic transection, medial, posterior and anterior surfaces) and their prognostic influence on survival were assessed. Results For PDAC, the R1 rate was 57.1% (48/84) for any margin, 31.0% (26/84) for anterior surface, 42.9% (36/84) for posterior surface, 29.8% (25/84) for medial margin, and 7.1% (3/84) for pancreatic transection margin. Overall and disease-free survival for R1 resections were significantly worse than those for R0 resection (17.2 vs. 28.7 months, P=0.007; and 12.3 vs. 21.0 months, P=0.019 respectively). For individual margins, only medial positivity had a significant impact on survival (13.8 vs. 28.0 months, P <0.001). Multivariate analysis demonstrated R0 medial margin was an independent prognostic factor (P=0.002, HR=0.381; 95% CI 0.2070.701). Conclusions The medial surgical resection margin is the most important after PD for PDAC and a R1 resection here predicts poor survival.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
128

E-AHPBA

GANG ZHAO Union Hospital, WU HAN, China

Objectives Inflammation-induced epithelial to mesenchymal transition (EMT) is proved to be involved in carcinogenesis. However, whether this process also involved in the carcinogenesis of pancreatic cancer (PC) is largely unknown. Since evidence demonstrates that miR-34a involves in PC and EMT, here, the potential effects of miR-34a on EMT in carcinogenesis of PC was investigated. Method The EMT profile of chronic pancreatitis (CP) and pancreatic cancer was compared to normal pancreatic (NP) tissue. Pancreatic cancer cells were incubated with TGF-β to imitate the inflammatory microenvironment in CP and PC, and the changes of miR-34a, SIRT1, NOTCH1 and EMT profile were detected in those cells.  Moreover, knock in and knock out experiments of miR-34a were performed in pancreatic cancer cells, of which the EMT profile was evaluated. Further, the correlation betweenn miR-34a and clinic characteristics of PC were analized. Results We  demonstrated that both CP and PC tissues displayed obvious EMT phenotypes compared to NP. After incubated with TGF-β,  the pancreatic cancer cells exhibited EMT profiles with down-regulated miR-34a as well as up-regulated SIRT1 and NOTCH1 which are the downstream targets of miR-34a. Inhibition of miR-34a promoted expression of SIRT1 and NOTCH1, and the pancreatic cancer cells displayed EMT-like transformation as well as enhanced invasion and migration ability. Ectopic expression of miR-34a prevented TGF-β induced EMT process by down-regulating SIRT1 and NOTCH1.  Further, down-regulation of miR-34a was related to tumor stage, lymphatic invasion, vascular infiltration and distant metastasis. Conclusions In conclusion, inflammation-induced deregulation of miR-34a might promote EMT depending on absenting inhibition of SIRT1 and NOTCH1 signaling pathways, which involves in carcinogenesis of PC from CP. And the deregulated miR-34a might be served as a novel target for prevention and treatment of PC.

129

Abstracts

19.3 Deregulated microRNA-34a involves in the carcinogenesis from chronic pancreatitis to pancreatic cancer by promoting EMT

Abstracts

19.4 The feasibility and efficacy of laparoscopic repeat liver resection; Analysis of 16 patients. 
Hani Al-Saati, Kursat Serin, Paolo Di Gioia, Neil Pearce, Mohammad Abu Hilal Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, UK

Objectives Laparoscopic liver resection especially after previous liver surgery can be challenging due to adhesions and peri hepatic scaring. We herein aim to evaluate the feasibility and outcomes of laparoscopic redo liver resection. Method We reviewed characteristics and outcomes of 17(7 female, 9 male) laparoscopic repeat liver resectionin 16 patients (11 CRLMs, 3 NET, one HCC and one adenoma).Initial resections were 5 monosegmentectomy, 4 bisegmentectomy, 5 lateral sectionectomy and 2 right hepatectomies. Later on, 10segmentectomy, 2 lateral sectionectomy, 4 right hepatectomy and 1 trisegmentectomywas performed. Results Median operative times was165 min (55-540) and 240 min (60-360) for the initial and the second resection respectively. Median blood loss  was100mL (10-1200) for the first procedure and 300 mL (75-3000) for the second. All procedures were completed laparoscopically.One patient required relaparotomy  forbleeding after the first procedure with no major complication related to repeat liver resection,. Postoperative median HDU stay was 1 day (0-3) for the first resection and 1 day (0-8) for repeat resection. And the median hospital stay was 4 days (1-8) after the first resection and 4 days (1-11) after the repeat resection. Conclusions Redo laparoscopic liver resections are feasible and safe with not associated increase risk and no impact in conversion. It can be speculated that the first laparoscopic resection accounts for less adhesions and per hepatic fibrosis, however larger studies especially if randandomized is needed before withdrawing firm conclusions.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
130

E-AHPBA

Tung Yu Tsui1, Andreas Koops2, Oliver Stöltzing3, Gerhard Adam2, Jakob Izbicki1 1 Dept. of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 2Dept. of Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 3Dept. of General, Visceral, and Oncological Surgery, Helios Hospital Berlin-Buch, Berlin, Germany

Objectives The in situ split of the liver and portal vein ligation/transection represents an innovative surgical technique to induce rapid liver regeneration. The future liver remnant increased significantly after the procedure. In the present study we compared the perioperative data of the new technique with the conventional portal vein embolization. Method we collected the data of the consecutive 31 patients underwent extend right hepatectomy from 2009-2012. Twenty of 31 patients received right portal vein and Seg IV portal vein embolization to induce the hypertrophy of future Seg 2 and 3 liver remnants (PVE). Eleven of 31 patients received the in situ split and right portal vein transection after implementation of the new technique (ISS). The efficacy of two techniques for the induction of the hypertrophy of future liver remnant was analyzed. Results There is no significant difference in terms of patient characteristics. In situ split induced comparable hypertrophy of future liver remnant (median: 526mL in ISS group vs. 428 mL in PVE group) in significantly shorter interval (median 8 days vs. 30 days). The percentage of the volume of the future liver remnant was 35% of estimated standard liver volume (ESLV) that was higher than those in PVE group (26.8%). The delta% of ESLV was 16 in ISS group, which is significantly higher than those in PVE group (median 8.2%). There is no difference in comparing the perioperative data of groups. Conclusions The ISS is a safe and flexible procedure to induce rapid hypertrophy of future liver remnant. The selection of patients might be of crucial to achieve the optimal outcome.

131

Abstracts

19.5 Safety and tolerance of a two-step extend right hepatectomy with in situ split technique and right portal vein transection for rapid liver regeneration: a comparison study with portal vein embolization

Abstracts

19.6 Volume/Function Analysis allows Accurate Calculation of Future Remnant Liver Function prior to Hepatectom
Martin Stockmann, Maciej Malinowski, Johan Lock, Antje Kirchstein, Sven-Christian Schmitt, Peter Neuhaus Charité - University Hospital, Berlin, Germany

Objectives The future remnant liver function (FRLF) is the crucial limiting factor by patients undergoing extended liver resection. Due to low predicted future remnant liver volume as many as 80% of the patients are unresectable. However i.e. chemotherapy or NASH leads to liver function depletion and change of volume/function ratio. Thus prediction of FRLF would be extremely useful for the patient management prior to liver resection. Method Data was assessed from a prospective clinical study. The preoperative functional capacity of the liver was determined by the novel LiMAx test, based on a cytochrome P450 1A2 metabolism of 13C-methacetin. Prior to resection virtual hepatectomy with volumetric analysis was performed using a 3-dimensional reconstruction of a 4-phase contrast-enhanced computer tomography (3D-CT). FRLF was calculated from preoperative function and predicted remnant volume. This analysis was evaluated and fixed prior to operation in cooperation with the responsible surgeon. Directly after the operation (1-4 hours) an additional CT-scan and LiMAx test was performed again and values compared to preoperative calculations. Results Until now 17 patients undergone liver resection were enrolled. Indications for surgery were: hepatocellular (n=7) or cholangiocellular carcinoma (n=4), and colorectal metastasis (n=6). Predicted remnant volume correlates with measured volume (r=0.96, p<.001). Predicted FRLF correlates with measured FRL function (r=0.87, p<.001). The difference between predicted and measured FRLF using LiMAx was -27 µg/kg/h. Pringle manoeuvre was identified as an important factor influencing this difference. Conclusions FRLF analysis using the LiMAx test and virtual liver resection using 3D-CT has the potential to accurately predict residual liver function and could improve the preoperative planning. Thus, individual point-of-care calculation of FRLF enables liver resection of larger number of patients with increased safety.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
132

E-AHPBA

Ivan Vasilevski, Ivelin Takorov, Sergei Sergeev, Nikola Vladov Clinic of hepatobilliary, pancreatic and transplant surgery, Military Medical Academy, Sofia, Bulgaria

Objectives The aim of this study is to analyze influence of different multimodal approaches for patients with primary unresectable synchronous liver metastases (LM) from colorectal carcinoma (CRC) over patient’s morbidity, mortality and survival. Method From January 2004 to December 2011, 96 curative resections on the occasion of synchronous LM from CRC were performed as in 24 (25%) with primary unresectable LM, different multimodal approaches (two–stage liver resections with portal vein ligation, RFA and chemotherapy) for increasing resectability were applied. Reasons for the initial unresectability were multinodularity (37%), size of metastases (21%), the location next to major vascular structures (25%) or extrahepatic disease (17%). We evaluate the potential impact of different variables on survival in the group with multimodal approaches (group A) and in the group with synchronous LM (group B), using Kaplan-Meier analysis. Results Overall survival data calculated by Kaplan-Meier showed that the median survival in patients in group A (30.1m) is higher than in group B (23.5 m), but this difference is not statistically significant (p=0.898 ). Statistically significant results from univariate analysis showed only parametric variables in group B for better survival when performing small LR-39.5 months, right hepatectomy - 29 months and > 3 LN around the primary tumor - 22.7 months (p <0.030, p <0.001, p <0.005). Conclusions In the presence of multiple synchronous LM radical surgery is not always possible. The application of right algorithm and multimodal methodologies for achieving resectability in initially unresectable synchronous liver metastases increases survival in this group of patients

133

Abstracts

19.7 Results from combined multimodal approaches to initially unresectable synchronous liver colorectal metastases

Abstracts

19.8 Totally laparoscopic major-complex liver resections with and without intermittent vascular clamping

Marcello Spampinato1, Francesco Puleo2, Marianna Arvanitakis2, Diletta Cassini1, Teresa Filosa1, Simone Orlandi1, Federico Selvaggi1, Barbara Gnoccato1, Farshad Manoochehri1, Gianàndrea Baldazzi1 1 Policlinico di Abano Terme, Abano Terme, Italy, 2Erasme University Hospital, Brussels, Belgium Objectives Encouraging results have been reported in term of feasibility, safety and oncologic outcomes for major (≥ 3 segments) or complex for location (right posterior segments) totally laparoscopic liver resections (TLLR). In these setting technical issues such as use of intermittent vascular clamping has not been clearly investigated. Aim of our study was to assess perioperative outcome of totally laparoscopic liver resections (TLLR) performed with or without Intermittent Pringle’s Manoeuvre (IPM). Method  From October 2008 to October 2012 a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in two groups according to use of PM during the operation: Group A (PM series) 13 patients;  Group B (without PM series) 11 patients; data from a prospectively collected database were retrospectively analysed and compared for perioperative and short term oncologic outcome.   Results The two groups were found similar for patient characteristics, neoplasm and type of resections performed. Assessing the perioperative outcome, a statistic significant improvement was found in Group B in terms of number of perioperative blood transfusion ( p= 0.05) and first flatus ( p=0.013). Postoperatively, there was no difference in terms of morbidity-mortality rate, hospital stay and oncologic outcomes between group A and B. Conclusions Our data suggest that major-complex TLLR performed without IPM receive less blood transfusions and have a quicker recovery of bowel function following surgery. Prospective studies are needed to clarify this issue on a large scale.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
134

E-AHPBA

20.11 Management of spontaneous rupture HCC in the post RFA era Abstracts
Tan To Cheung, Ronnie Poon, Sheung Tat Fan, Chung Mau Lo The University of Hong Kong, Hong Kong, Hong Kong

Objectives To investigate the outcome and prognosis of spontaneous ruptured HCC by analysis of a cohort of 189 patients. Method All patients who presented with ruptured HCC and required hospitalisation from 1991 to 2010 were recorded amongst the 5283 patients with the diagnosis of HCC. The patients were categorised into two 10-year periods. (Period 1 n=70), (Period 2 n= 119). Both groups were managed according to standard treatment protocol and RFA devices become available in the second period. Results Both groups of patients were hepatitis B virus predominant. There was no different in terms of age, liver function, preoperative morbidities and stage of disease in the two groups of patients.  In period 2 patients, the 30 days hospital mortality rate was 2.5% (3 out of 119) vs 14.2% (10 out of 70) in period 1 (p=0.011). In period 2 73.1% patients received RFA as a haemostasis modality. The one year survival in period 2 was 18.9% vs 18.8% in period 1 (p=0.348). After multivariate analysis by cox regression model haemostasis by RFA provided a favorable survival outome. Conclusions RFA effectively reduced surgical mortality with this disease entity even in a population where hepatitis B related cirrhosis was common.

135

Abstracts

20.12 Expression and Clinical significance of extracellular matrix protein 1 in hepatocellular carcinoma
hao chen, jiansheng li Affiliated Provincial Hospital of Anhui Medical University, and Anhui Key Laboratory of Hepatopancreatobiliary Surgery, hefei, anhui, China

Objectives To elucidate the expression of extracellular matrix protein 1 (ECM1) in hepatocellular carcinoma (HCC) and its association with clinicopathological characteristics and prognosis, including exploring the biological function and mechanism of ECM1 in the process of metastasis and recurrence of HCC. Method (1) RT-PCR and Western blotting was used to evaluate ECM1 expression in HCC and corresponding adjacent tissues, and three HCC cell lines with various metastatic potentials. (2) The preoperative serum ECM1 levels with HCC by ELISA to elucidate the serum levels of ECM1 in HCC and its association with clinicopathological characteristics and prognosis. (3) In addition, it is also to evaluate the ECM1 and matrix metalloproteinase 9 (MMP-9) expressions in a hospital-based cohort of patients with HCC by immunohistochemistry, and to elucidate the expression of ECM1 and MMP-9 in HCC and them correlation and association with clinicopathological characteristics and prognosis. Results (1) The expresson level of ECM1, the cell line with the highest metastatic potential was significantly higher than that with lower, and  significantly increased in HCC tissues. (2) The median serum ECM1 level in HCC patients was significantly higher than that in healthy volunteers, the patients with invasive phenotypes were higher. High serum ECM1 level was found to be an independent prognostic factor for HCC patients. (3) The expression of ECM1 in HCC tissues was significantly correlated with vascular invasion and TNM stage.  The patients with both ECM1 and MMP-9 positive have significantly poorest prognosis. There was a positive correlation between ECM1 and MMP-9. Conclusions ECM1 level in HCC patients are significantly associated with invasive phenotypes, it may present a diagnostic marker for predicting the prognosis and recurrence of HCC patients after surgery, and may via correlated with MMP-9 to promote the invasion of HCC.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
136

E-AHPBA

Marc-Antoine Allard, AntonioSa-Cunha, EricVibert, Mylène Sebagh, Catherine Guettier, Denis Castaing, René Adam Centre Hépato-biliaire, Paul Brousse Hospital, Villejuif, France

Objectives To assess the ability of the 90-day postresection Alpha-Fetoprotein (AFP) in cirrhotic patients with hepatocellular carcinoma (HCC) to predict overall survival (primary end-point) and recurrence beyond Milan Criteria (MC) among the subgroup of initially transplantable patients (secondary end-point). Method All patients with cirrhosis resected for HCC between January 1990 and December 2010 in a single institution and presenting an AFP elevation (≥ 15 ng/ml) at diagnosis were included. The 90-day postresection AFP was analyzed as a dichotomized variable (normalization or not). Results Among 271 resected patients, 141 patients (52%) had a level of serum AFP ≥ 15 ng/ml at diagnosis. Fiveyear overall overall survival and median survival were 42% and 52 months in patients with postoperative AFP normalization versus 20% and 23 months for patients without postoperative AFP normalization, respectively (P=0.009). On multivariate analysis, the absence of AFP normalization was an independent factor of poor overall survival as well as microvascular invasion, and satellites nodules. Among initially transplantable patients, independent predictors of recurrence beyond MC were the absence of AFP normalization (HR 5.02 [1.53-16.34] and microvascular invasion (HR 4.76 [1.42-15.34]). Conclusions The 90-day postresection AFP is a independent prognostic factor of OS, which also enables to predict recurrence beyond MC among transplantable patients. Transplantable patients resected for HCC without AFP normalization should be considered for early liver transplantation provided that extensive and close imaging studies have ruled out any extrahepatic disease.

137

Abstracts

20.13 Postresection Alpha-Fetoprotein predicts overall survival and recurrence beyond Milan criteria in patients with hepatocellular carcinoma on cirrhosis.

Abstracts

Roberto Santambrogio1, Matteo Barabino1, Rocco Scalzone1, Mara Costa1, Solange Romagnoli2, Marco Maggioni3, Enrico Opocher1 1 Chirurgia Epato-bilio-pancreatica e Digestiva - Osp San Paolo, Milan, Italy, 2Servizio di Anatomia Patologica Ospedale San Paolo, Milan, Italy, 3Servizio di Anatomia Patologica - Ospedale Maggiore Policlinico, Milan, Italy

20.14 Microinvasive small hepatocellular carcinoma and indication for radical treatment

Objectives Intrahepatic disease recurrence is observed frequently after radical therapies for patients with very early hepatocellular carcinoma (HCC) (diameter <2 cm). However, the choice of therapy for very early (VE) HCC is still unclear. To clarify the indication for therapy for VE HCC tumors, the authors evaluated the results of hepatic resection (HR) and laparoscopic radiofrequency ablation (LRFA) in VE HCC patients with or without the presence of microinvasion (MI) such as portal venous, hepatic vein, bile duct infiltration, and/or intrahepatic metastasis. Method A retrospective review was undertaken of 192 patients with primary solitary VE HCC who underwent either HR or LRFA between 1997 and 2013. The presence or not of MI was detected by intraoperative ultrasound according a personal classification [1]. Long-term results (survival and local recurrences) of patients with VE HCC accompanied by MI was compared to that of patients with HCC without MI and was analyzed on the basis of the different therapies. Results Sixty-seven patients (35%) had MI HCC (36% in LRFA and 33% in HR group). Actuarial survival rates of patients with VE HCC with MI (5 year 36%) were significantly worse than those for VE HCC without MI (5 year 64%) (p=0.0312). This disadvantage of overall survival rate of patients with VE HCC with MI could be dissolved by performing HR (5 year 61%) instead LRFA (5 year 22%; p=0.036). This result could be secondary to higher rate of local recurrences in patients with VE HCC with MI following LRFA (34%) than in those without MI (17%; p=0.028). Conclusions Even in patients with VE HCC, intraoperative ultrasound is able to identify more aggressive form of tumor. VE HCC with MI has a worse prognosis than VE HCC without MI: in cases of VE HCC with MI, HR is able to guarantee better overall survival rates than does LRFA, reducing the risk of local recurrences. 1] Santambrogio R et al. Ultrasound Med Biol 2011; 37: 7-15

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
138

E-AHPBA

Yeh Chun-Chieh1,2, Charalampos Iakovidis11, Lin Jaw-Town4,6, Jeng Long-Bin2, Yang Hong-Ren2, Chen Tzu-Ting7, Lee Teng-Yu1,7, Wu Ming-Shiang4, Kuo Ken N.6, Wu Chun-Ying8,10 1 Graduate Institute of Clinical Medical Science, China Medical University,, Taichung, Taiwan, 2Department of Surgery, China Medical University Hospital, China Medical University,, Taichung, Taiwan, 3School of Medicine, China Medical University,, Taichung, Taiwan, 4Division of Gastroenterology, National Taiwan University Hospital,, Taipei, Taiwan, 5Department of Internal Medicine, E-Da Hospital and I-Shou University, Kaohsiung County, Taiwan, 6Center for Health Policy Research and Development, National Health Research Institutes, Miaoli, Taiwan, 7Division of Gastroenterology, Taichung Veterans General Hospital,, Taichung, Taiwan, 8Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, 9Department of Public Health, China Medical University,, Taichung, Taiwan, 10Department of Life Sciences, National Chung-Hsing University, Taichung, Taiwan, 11Second Department Of Surgery,General Hospital of Thessaloniki Georgios Papanikolaou, Thessaloniki, Greece Objectives The association between uremia and survival outcome in patients receiving hepatic resection for hepatocellular carcinoma (HCC) has not been well investigated, especially regarding the perioperative complications. This nationwide cohort study was aimed to compare survival outcomes as well as perioperative mortality and morbidity between uremia and non-uremia HCC patients after hepatic resection. Method Using Taiwan’s National Health Institute Research Database, 149 uremia-HCC patients who underwent hepatic resection between 1996 and 2008 were enrolled. The control group comprised 596 HCC patients who also received hepatic resection during the same time period. The two groups were matched for age, gender, viral hepatitis status, and underlying liver cirrhosis. Disease-free survival, overall survival and perioperative complications were compared between both groups. Results For uremia-HCC cohort, the 1-, 5-, and 10-year overall and disease free survival rates were 86%, 52% and 38%, as well as 77%, 27% and 18%, respectively. The survival outcomes were comparable between uremia-HCC and HCC cohort, regardless of extent of hepatic resection. As for perioperative complications, uremia-HCC cohort had a higher risk of postoperative infections requiring invasive interventions as well as increased risk of lifethreatening heart-associated complications, compared to non-uremia HCC cohort. Conclusions Uremia did not influence survival outcomes between uremia-HCC and non-uremia HCC cohorts, irrespective of extent of hepatic resection. This study urges a better perioperative care strategy to avoid potential cardiac and infectious complications in uremia-HCC patients.

139

Abstracts

20.15 Hepatic resection for hepatocellular carcinoma patients on maintenance hemodialysis for uremia: a nationwide cohort study

Abstracts

Wladimir Faber1, Martin Stockmann1, Timm Denecke2, Johannes Kruschke1, Andreas Möllerarnd1, Cosima Schirmer1, Bruno Sinn3, Eckart Schott4, Fritz Klein1, Peter Neuhaus1, Daniel Seehofer1 1 Department of General-, Visceral- and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany, 2Department of Radiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany, 3Department of Pathology, Charité - Universitätsmedizin Berlin, , Campus Virchow Klinikum, Berlin, Germany, 4Department of Gastroenterology and Hepatology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany

20.16 Implication of microscopic and macroscopic vascular invasion for liver resection in patients with hepatocellular carcinoma

Objectives Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. Vascular invasion is well accepted independent risk factor for tumor recurrence and survival after liver transplantation for HCC. However, long term data after liver resection in HCC with vascular invasion are rare for non-asian patients. The aim of this study is to analyze those long term results in patients with with and without liver cirrhosis. Furthermore, the differences in outcome between micro- and macroinvasion should be analyzed. Method From January 2000 to September 2010, 288 patients without extrahepatic metastases underwent curativeintent hepatic resection for HCC. In 107 of 288 patients (37%) vascular invasion was found in the final pathological analysis. The perioperative course and the long term outcome of these patients was retrospectively analyzed using a prospective database. Results The 1-, 3- and 5-year cumulative survival rates were 64.3%, 41.4% and 23.9%, respectively. The median survival was 19 months (range: 1 to 132 months). In the multivariate analysis, cumulative survival was decreased by Clavien grade (p < 0.01), lymph vessels invasion (p < 0.01), number of intraoperative blood transfusions (p < 0.01), number and general need of fresh frozen plasma units intraoperative (p < 0.01 and p = 0.05), ICU stay (p = 0.01) and preoperative bilirubin value (p = 0.03). Interestingly, no significant differences between patients with micro- and macorvascular invasion were observed. Conclusions In view of an otherwise poor prognosis liver resection seems to be justified also for selected patients with macrovascular invasion. This is in accordance with asian guidelines like the Asia-Pacific Association for the Study of the Liver (APASL) recommendations, although vascular invasion remains an accepted risk factor for impaired survival. ,Complete cessation of liver resection in patients with vascular invasion, as suggested in the BCLC algorithm seems not to be justified.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
140

E-AHPBA

Yiqun Yan, Liang Huang, Jing Li, Jie Cao Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China

Objectives There are few reports concerning the risk factors associated with spontaneous rupture of hepatocellular carcinoma (HCC) and the best approach in cases of ruptured HCC. This retrospective study tries to investigate the risk factors for spontaneous rupture of BCLC stage A and stage B HCC, and reveal the surgical outcomes. Method From April 2002 to November 2006, 89 patients who had spontaneous ruptured HCC of BCLC stage A and stage B were included in the case group. A control group of 171 cases was selected by matching the sex, age and BCLC stage. Clinical data and survival time were collected and analysed. Results On multivariate analysis, hypertension (HR 7.38, 95%CI: 1.91-28.58, p=0.004), liver cirrhosis (HR 6.04, 95%CI: 2.83-12.88, p<0.001) and tumor location of segments II, III & VI (HR 5.03, 95%CI: 2.70-6.37, p<0.001) remained predictive for spontaneous rupture of HCC. In the case group, the overall survival rates and disease-free survival rates at 1-, 3- and 5-year were 66.3%, 23.4% and 10.1%, and 57.0%, 16.8% and 4.5%, respectively. Only radical resection remained predictive for overall survival (HR 0.32, 95%CI: 0.08-0.61, p=0.015) and disease-free survival (HR 0.12, 95%CI: 0.01-0.73, p=0.002). Conclusions Tumor location, as well as hypertension and liver cirrhosis, is associated with spontaneous rupture of HCC. Onestage hepatic resection should be recommended to patients with ruptured HCC of BCLC stage A and stage B.

141

Abstracts

20.17 Risk factors and surgical outcomes for spontaneous rupture of BCLC stage A and stage B hepatocellular carcinoma: a case-control study

Abstracts

20.18 Use of the coagulative power of radiofrequency for life-threatening ruptured hepatocellular carcinoma.

Alfonso Recordare1, Giordano Bruno1, Alessandro Mardegan1, Paolo Callegari1, Giovanni Morana2, Nicolo’ Bassi1 1 IV Division of Surgery, Treviso Regional Hospital, Treviso, Italy, 2Department of Radiology, Treviso Regional Hospital, Treviso, Italy Objectives Spontaneous rupture is a life-threatening complication of hepatocellular carcinoma (HCC). The common policy is to treat this condition in the emergency setting by trans-catheter arterial embolization (TAE). We describe a case treated with open radiofrequency (RF) because of a severe stenosis of the celiac axis that hampered TAE. Method A 75 years man was admitted for abdominal pain, distension and shock. The patient was under anticoagulation therapy for atrial fibrillation. Laboratory test showed: hemoglobin 5.5g/dl and INR of 5.2. CT scan demonstrated advanced cirrhosis with massive ascites, a protruding HCC of 6 cm in Couinaud segment 4 and a nodule of 4 cm on segment 8. A marked stenosis of the celiac trunk was recognized. Due to the stenosis of the celiac trunk, that was considered a contraindication to TAE in emergency, and the active haemorrhage worsened by anticoagulation, it was decided to stop the bleeding using the coagulative power of RF. Results Under general anesthesia, a ultrasound guided small incision of the abdominal wall just over the tumor was performed, and the protruding ulcerated part of the HCC was treated with a cool-type RF electrode until observing the complete stop of the bleeding under direct visual control. The patient recovered the emergency phase, and then underwent TAE 10 days after operation, but it was very difficult and time spending the attempt to pass the celiac trunk, thus confirming that the transarterial approach would be risky for this case in the emergency conditions. The patient died from liver failure 11 months after surgery. Conclusions There are only 3 reported cases in literature in which RF was used to stop recurrent bleeding after TAE. When surgery is contraindicated for multicentricity of HCC and/or advanced liver disease, RF coagulation can be considered an effective option to stop bleeding in cases of unavailable or recurrent bleeding after TAE, also in patient with coagulative disorders.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
142

E-AHPBA

Anne-Sophie Schneck1, Daren Subar1,2, Riccardo Memeo1, Francesco Vittore1, Philippe Compagnon1, Alexis Laurent1, Daniel Azoulay1 1 AP-HP Henri Mondor Hospital, Creteil, France, 2Department of surgery, Royal Blackburn Hospital, Lancashire, UK Objectives Patient survival with intrahepatic cholangiocarcinoma (IHCC) after resection depends on histopathological factors such as T stage, N stage and resection margin status. One study has reported on preoperative predictive factors. This study assesses a preoperative model in predicting survival of patients with IHCC who have undergone curative resection.

Method This is a retrospective single institution study of patients who had curative hepatic resection between September 1990 and December 2012 for IHCC. Preoperative factors including patient sex, age, body mass index (BMI), performance status (PS), serum bilirubin, serum alkaline phosphatise (ALP), Ca19.9, tumour size and number of tumour nodules on preoperative computed tomography (CT) were converted to categorical variables and analysed. Significant predictive factors on univariate and multivariate analysis was then scored as 0 or 1 based on the cut-off value for each significant variable and entered into a model. Results 78 patients had hepatic resection for IHCC. The male to female ratio was 50:28 and the mean age was 60 years (range 26-85 years). The median survival was 12.2 months (range 0.03-244.5 months). Factors predictive of survival in univariate and multivariate analyses were BMI > 30kg/m2, ALP>115 IU/L, tumour size > 6cm, CA19.9> 35IU/ml and greater than 1 nodule present on preoperative CT. Patients were then classified based on a predictive model using a score of 1 for low risk, 2-3 for intermediate risk and greater than 3 for high risk patients was predictive of survival (p<0.05). Conclusions The TNM system predicts survival after resection in patients with IHCC. Our model based on preoperative factors can predict long term survival in patient undergoing resection for IHCC. The model needs to be validated in a prospective trial and may help in patient selection for surgical intervention.

143

Abstracts

20.19 Preoperative Predictive Model of Survival after Resection for Intrahepatic Cholangiocarcinoma (IHCC)

Abstracts

Omer Vedat UNALP1, Azer Ismayilov1, Batuhan Demir1, Alper Uguz1, Taylan Ozgur Sezer1, Gurhan Adam3, Celal Cinar2, Halil Bozkaya2, Mustafa Parildar2, Ahmet Coker0 1 Ege University School of Medicine Department of General Surgery, Izmir, Turkey, 2Ege University School of Medicine Department of Radiology, Izmir, Turkey, 3Canakkale 18 Mart University School of Medicine Department of Radiology, Canakkale, Turkey

21.1 Efficiency of Percutaneous Cholecystostomy  in acute cholecystitis patients  with high comorbidity score

Objectives Mortality of acute cholecystitis (AC) increases by age. Treatment of acute cholecystitis is cholecystectomy by using antibiotics. Medical and supportive treatment can sometimes be insufficient. We aimed to investigate the effect of performing percutaneous cholecystostomy additionally to medical treatment on overcoming the acute phase of acute cholecystitis in patients with comorbidities. Method The datas of 50 patients with comorbidities that were treated medically only (Group1) between 2009 and 2011 in the department of general surgery and 29 patients with comorbidities that were performed percutaneous cholecystostomy (PC) additionally to the medical treatment were analysed retrospectively. ASA scoring was used to determine the high comorbidity in patients. ASA 3 and 4 was accepted as high comorbidity and those patients were enrolled to the study. PC was performed by Seldinger method using 8F pigtail catheter. Comorbidity point, demographic datas, laboratory findings, duration of stay in ICU and hospital and mortality rates were analysed. Results Mean age in group 1 is 75.7 where 79.66 in group 2. In group 1, 38 of 50 patients were ASA III where rest were ASA IV. In group 2 18 patients were ASA III where rest were ASA IV. There wasn’t any significance between the groups. CRP, leukocyte and creatinin levels were compared between the groups on the first, third and discharge day. There was a significant difference between the groups in CRP levels on third day. (group1:14.6, group2: 7.91). There was a significant difference between the groups in terms of duration of stay in hospital and ICU. Conclusions PC doesn’t change the mortality and morbidity rate but accelarates the response to the medical treatment in acute cholecystitis. Although PC increases the duration of hospital stay, it is a safe drainage method that can be used alternatively in patients with high comorbidities safely.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
144

E-AHPBA

Kotambail Venkatesha Udupa, Tom Gallagher, Ronan Kelly, Sarah McErlean, Aimee O’Farrell, Oscar Traynor, Justin Geoghegan, Donal Maguire, Emir Hoti St. Vincent’s University Hospital, Dublin, Ireland

Objectives Involvement of the Inferior vena cava (IVC) by neoplasm has been considered a limiting factor for curative surgery because of high surgical risks and poor long-term prognosis. Advances in surgical techniques have made this feasible. Aim of this study is to evaluate the outcome of combined IVC and visceral resection. Method Clinicopathological data of 14 consecutive patients over a seven-year period undergoing combined IVC and visceral resection was reviewed (from a prospectively maintained database). Surgical indications included: one each of Hepatocellular carcinoma, Cholangiocarcinoma, recurrent Non seminomatous germ cell tumor, Colorectal liver metastases, Adrenocortical carcinoma, Benign neoplasm, recurrent Pheochromocytoma, Paraganglioma and three each of Renal cell carcinoma & Sarcoma. Results IVC resection was associated with major hepatectomy (n=8), nephrectomy (n=6) and multivisceral resection (n=3). Venovenous bypass was used in 7 cases. Post resection IVC was reconstructed primarily (n=3); with PTFE tube graft (n=9) and Gore-tex patch graft (n = 2).  There were two postoperative deaths - respiratory failure secondary to pneumonia (n=1) and sepsis induced multiorgan failure (n=1). Six patients had postoperative complications (successfully treated). With a median follow up of 20 months (range 5 - 84 months), two patients died of tumor recurrence and ten are alive with (n=5) or without (n=5) disease. Conclusions IVC and visceral resection can be safely performed in selected patients. Surgery provides the possibility of negative margins, acceptable perioperative morbidity/mortality and prolonged survival. These factors combined with lack of alternative treatments justify this approach. However, specialist teams should perform the surgery preferably in centers with expertise in liver transplantation.

145

Abstracts

21.2 Combined inferior vena cava and visceral resection for neoplasms with or without prosthetic replacement - The St. Vincent’s University Hospital Experience

21.3 Barts and the London experience with primary duodenal adenocarcinoma Abstracts

Leonardo Solaini, Jennifer Watt, Prabhu Arumugam, Karen Mawire, Robert Hutchins, Ajit Abraham, Satya Bhattacharya, Hemant Kocher Barts and the London HPB centre, London, UK Objectives Duodenal adenocarcinoma is a rare. Heterogeneous results have been published so far. This study analyzed the experience of a single high volume HPB centre and compared with the worldwide published series of primary duodenal adenocarcinoma to define factors influencing postoperative outcome and patient survival. Method A retrospective review of a prospectively collected database for patients referred to the HPB centre, Royal London Hospital between 2005 and 2012 identified 33 patients with a primary duodenal adenocarcinoma of which 26 (78.8%) had a curative resection. Demographics, operative and postoperative variables, pathologic findings, and survival data were analyzed and compared with results published in literature. Results Among resected patients disease-free survival was 16.6 months. Twelve patients (46.1%) underwent adjuvant chemotherapy. Patients undergone palliative bypass had a median survival of 14.6 months. Upon logistic regression analysis performed on resected patients only the stage of the tumour was demonstrated as a risk factor for recurrence (95% CI 1.2-44.6 p=0.02). World-wide experience review suggested that stage of tumour, curative resection were the commonest prognostic factors. Conclusions A curative surgical approach should always be considered for patients with primary duodenal adenocarcinoma to improve survival. According to our results and to literature, the tumour stage is the most powerful predictive factor . 

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
146

E-AHPBA

Amit Sharma1,2, Leonardo Solaini1, Sofia Iosifidou1, Ali Qureishi2, Joanne ChinAloeng1, Hemant Kocher1 1 Barts and the London HPB centre, London, UK, 2Nottingham university hospital nhs trust, Nottigham, UK Objectives No factors identifying the patient at risk for gallbladder dysplasia (GBD) have been found so far. This study aims to analyse clinical characteristics and demographics of all patients submitted to cholecystectomy in a tertiary referral centre in order to determine risk factors associated with GBD. Method A retrospective analysis of all patients undergone cholecystectomy in a single tertiary Institution from 2005 to 2012 was performed. Clinical and histological characteristics and patients’ demographics were analysed in a logistic regression model to determine predictors of GBD. 868 patients (M:F=1:2.3) with median age 49 years (IQR: 36-62 years) were included in the analysis. Three main racial groups were identified: 430 Caucasian (49.5%), 352 Asian (40.5%) and 77 Afro-Caribbean (8.8%) patients. 773 patients underwent laparoscopic cholecystectomy with 28 conversions to open surgery (3.6%). 97 patients (11%) underwent open cholecystectomy. Results At final pathology GBD was found in 18 patients (2%; median age 45years, IQR: 42.5-63.5M:F=1:2; 6 Caucasians, 12 Asians) while adenocarcinoma in 9 patients (1%, median age 69 years, IQR:69-72; 2 Afro-Caribbeans, 5 Caucasians, 2 Asians). Low grade dysplasia was found in 10 patients, high grade in 2, mixed in 1 and adenomaassociated in 5. Logistic regression analysis revealed Asian patients at higher risk of GBD (OR 2.9, 95% CI 1.1-8, p=0.02). Only age was significantly associated with gallbladder cancer (OR:1.05 CI 95% 1.02-1.08 p<0.01). ROC curve analysis demonstrated that age>68 years was positively correlated to gallbladder adenocarcinoma. Conclusions Dysplasia and gallbladder adenocarcinoma are fairly common incidental histological finding after cholecystectomy. When evaluating cholecystectomy specimens, patients’ demographics, in particular patient’s age and race, should always be considered, as this might help the pathologist and then the surgeon to address the patient to the appropriate treatment or follow-up.

147

Abstracts

21.4 Predictors of incidental gallbladder cancer and dysplasia: Barts and the London experience

Abstracts

Fritz Klein1, Dietmar Jacob2, Marcus Bahra1, Gero Puhl1, Andreas Andreou1, Safak Gül1, Peter Neuhaus1, Olaf Guckelberger1 1 Department of General, Visceral, and Transplantation Surgery - Charité Campus Virchow Universitätsmedizin, Berlin, Germany, 2Visceral and Vascular Surgery – Center for Minimally Invasive Surgery, Vivantes Klinikum Spandau, Berlin, Germany Objectives Although ampullary carcinoma has the best prognosis among all periampullary carcinomas, its long-term survival remains low. Prognostic factors are only available for a period of 10 years after pancreaticoduodenectomy. The aim of this retrospective study was to identify factors that influence the long-term patient survival over a 15year observation period. Method From 1992 to 2007, 143 patients with ampullary carcinoma underwent pancreatic resection. 86 patients underwent pylorus-preserving pancreaticoduodenectomy (60%), and 57 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (40%). 2 patients underwent pancreaticoduodenectomy that included portal vein resection (1%). Results The overall 1-, 5-, 10- and 15-year survival rates were 79%, 40%, 24% and 10%, respectively. Within a mean observation period of 30 (0-205) months, 100 (69%) patients died. Survival analysis showed that positive lymph node involvement (p=0.001), lymphatic vessel invasion (p=0.0001), intraoperative administration of packed red blood cells (p=0.03), a CA 19-9 higher than 37 U/l (p=0.03), jaundice (p=0.04) and an impaired preoperative patient condition (p=0.01) are strong negative predictors for a reduced patient survival. Conclusions Patients with ampullary carcinoma have distinctly better long-term survival than patients with pancreatic carcinoma. Long-term survival depends strongly on lymphatic nodal and vessel involvement. Moreover, a preoperative elevated CA 19-9 proved to be a significant prognostic factor. Adjuvant therapy may be essential in patients with such a risk constellation. 

21.5 Prognostic factors for long-term survival in patients with ampullary carcinoma – the results of a 15-year observation period after pancreaticoduodenectomy

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
148

E-AHPBA

Objectives Short courses of antibiotics have been suggested for resectable surgical infections. Early surgical operation is the treatment of choice for acute cholecystitis. Adjuvant antibiotic treatment is always given, but the optimal choice, timing and duration of antibiotics in operated cholecystitis remain unclear. Aim: To compare the early postoperative results in terms of surgical site infection (SSI), other morbidity and hospital stay between two groups of patients operated for acute cholecystitis with different length of antibiotic therapy. Method Multicenter prospective randomised clinical trial comparing a short course of antibiotic treatment (SC: preoperative treatment until 24 hours of operation) with a long course (LC: treatment prolonged for 5 days after surgery) for cholecystitis treated by early cholecystectomy. Inclusion criteria: acute cholecystitis confirmed by ultrasonography, admitted < 2 days after onset of symptoms, and operated <4 days of admission. Exclusion criteria: subhepatic abscess, biliary peritonitis, cholangitis and confirmed bacteraemia. Patients were followed for 30 days. An intention-to-treat analysis was used. The chi-square and Student-Fischer tests were used for statistical analysis. Level of significance was stated at p<0.05. Results One-hundred sixty-four patients entered the study. Fourteen were excluded, 78 were allocated to SC group and 72 to LC group. Both groups were comparable in sex, age, weight, level of inflammation encountered at surgery, surgical technique (open or laparoscopic), and duration of operation. ASA level were higher in SC group (ASA I-II: 54 SC vs. 49 LC, p=0.01). No statistical differences were found in non-infectious postoperative complications (4.5% SC vs. 6.8% LC, p=0.7) or SSI: overall (SC 13.5% vs. LC 8.2%, p=0.4), superficial wound infection (SC 10.6% vs. LC 8.2%, p=0.8), and organ-space infection (SC 3% vs. LC 1.4%, p=0.6). Conclusions No significant differences were found between a short course of antibiotic treatment -covering the preoperative period and the day of operation- and a long course after early cholecystectomy in uncomplicated cases of acute cholecystitis. Disclosure of Interest: None Declared

149

Abstracts

21.6 Short course of postoperative antibiotic therapy in low-risk acute cholecystitis. Results of a randomised multicenter trial. Josep M Badia1,4, Aurora Aldeano1,4, Lluis Oms3, Xavier Guirao1,4, Esther Nve1,4, Nuria Roson1,4, Jaime Jimeno2 1 Hospital Universitari de Granollers, Granollers, Spain, 2Hospital de Sant Boi, Sant Boi, Spain, 3Consorci Sanitari de Terrassa, Terrassa, Spain, 4Universitat Internacional de Catalunya, Barcelona, Spain

Abstracts

21.7 Technical implications of the “external notch” and the proper hepatic vein draining the caudate lobe (prcv) in caudate lobe resection for liver metastases of colorectal adenocarcinoma and living donor transplants.
VICENTE-MANUEL BORREGO-ESTELLA, Rafael Fernández-Atuan, Paolo Bragagnini-Rodríguez, Irene MolinosArruebo, Issa Talal-El Abur, Gabriel Inaraja-Pérez, Sef Saudí-Moro, Jose-Luis Moya-Andía, Natalia Peña-de Buen, Alejandro Serrablo Hepatopancreatic biliary Surgical Unit. General Surgery Department. Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives Presence of an “external notch” in caudate lobe corresponds with a vestige of portal segmentation, a true internal portal fissure which separates Spiegel portion from paracaval. Presence of a proper hepatic vein of caudate lobe (PRCV) circulates through an intersegmental plane that separates caudate lobe from the rest liver segments. Method 51 year old female with rectal adenocarcinoma (T3N1Mx) treated with abdominoperineal amputation. Adjuvant chemotherapy 4-XELOX, 3-FOLFOX4 and 2-FOLFIRI. A follow up lung CT scan 13 months later identifies a pulmonary nodule of 5 mm., segment I of the liver of 7 mm. confirmed with PET-CT. Multidisciplinary committee decides caudate lobe resection, the lesion is intraoperatively identified using IOUS; an “external notch” and proper hepatic vein (PRCV) were observed, 3 pringle’s maneuvers were performed without needing transfusion; discharged in postoperative day 6. Currently, the patient is awaiting the pulmonary resection of her lung metastases.   Results  Isolated and combined resections of the caudate lobe have increased usually due to extended liver resections to achieve R0 resections and consequently greater survival. Living donor transplantations have increased in our country and caudate lobe possesses proper hepatic veins such as the PRCV which draining the blood from these two territories and must be rebuilt during a living donor transplant implantation, in order to preserve the caudate lobes venous return to the IVC. With the development of the “hanging maneuver” by IOUS, this uses the PRCV as a reference to avoid damaging small hepatic veins from the caudate lobe. Conclusions  Knowledge of both the PRCV and its “external notch” is essential for safe liver resections, for the practice of the “hanging maneuver” and to be able to properly maintain venous return in cases of extended left hepatectomy when rebuilding the caudate lobe in Living donor transplants. The IOUS is essential.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
150

E-AHPBA

Arunkumar Krishnan, Jayanthi Venakataraman Stanley Medical College, Chennai, Tamilnadu, India

Objectives Idiopathic portal hypertension(IPH) is characterized by a long-standing non-cirrhotic portal hypertension(NCPH) because of the intrahepatic block of small portal vein branches. NCPH is due to various causes that generally are extrahepatic, involving the prehepatic or the post hepatic circulation. NCPH  includes Extra Hepatic Portal Vein Obstruction (EHPVO) and Non-Cirrhotic Portal Fibrosis (NCPF). The natural history of NCPH is not clear.  Aim: To determine prospectively the changes in the portal venous system in patients with NCPH Method Patients with a diagnosis of NCPF and EHPVO registered since 2001 were serially followed at an yearly interval for changes in liver size, its echotexture, and in the intra and extrahepatic portal venous system. Baseline demographic details, LFT, and co-morbid illness including virological profile were noted. Patients with comorbid illness and those with known etiology of cirrhosis were excluded from the study. Results There were 34patients with NCPF(M: F 1:1.8) and 30 patients with EHPVO(1.6:1). The mean age was 24.9yrs and 41.2yrs respectively.  During follow up, 20 out of 34 and 16 out of 30 patients with NCPF and EHPVO respectively had no progression of disease.  14patients with NCPF progressed to cirrhosis over a mean period of 5.21years.  Eight patients developed ascites and required diuretics. 14 patients with EHPVO progressed to NCPF over the mean period of 8.6 years, 12patients further progressed to cirrhosis over a mean period of 5.1years. Overall 40% of EHPVOpatients progressed to cirrhosis over a mean period of 13.7years. Conclusions NCPH is a spectrum wherein EHPVO progresses to NCPF and further to cirrhosis over a period of 13.7 years at least in a proportion of patients. Conversely, identifying these changes may suggest to the clinicians the need to work-up a patient for portal hypertension  

151

Abstracts

21.8 Natural history of Idiopathic non-cirrhotic portal hypertension: A prospective long term follow-up

Abstracts

Tamás Szaniszló1, István Kenessey2, Júlia Balog1, Zoltán Takáts3, Péter Kupcsulik4 1 Medimass Ltd, Budapest, Hungary, 22nd Department of Pathology, Semmelweis University, Budapest, Hungary, 3 Imperial College, London, UK, 41st Department of Surgery, Semmelweis University, Budapest, Hungary Objectives Rapid and simple tumor resection margin identification has long been a problem in the surgical treatment of various liver tumors. Rapid Evaporative Ionization Mass Spectrometry (REIMS) is capable of in vivo, in situ tissue identification, by the analysis of real-time collected - highly tissue specific - spectroscopic data. Method The method is based on the rapid electrosurgical evaporation of tissues which produces gaseous ions of metabolic constituents. The partially ionized electrosurgical aerosol is transferred to the mass spectrometer using PTFE tubing and a Venturi pump for direct analysis. Standard electrosurgical equipment was used in “coagulation”, “spray coagulation” and “cut” mode at 30-100 W. The data was analysed using multivariate statistical methods including principal component analysis (PCA) and linear discriminant analysis (LDA). Statistical models were built using histologically assigned datasets, and used for classification of spectra with unknown histological origin. Results Data has been collected during 157 resections from healthy and cancerous tissues. Current paper focuses on 20 colorectal and 47 liver (27 colorectal metastases, 14 hepatocellular carcinoma, 6 focal nodular hyperplasia) cancers. The most relevant data was acquired using “cut” mode during surgery. The statistical method PCA combined with LDA has proven to be successful in the separation of healthy and cancerous tissue and different tumour types (colorectal metastases and colon tumours show high similarity) with 98.8% sensitivity and 93.8% selectivity. Based on the phospholipid fingerprint of tissues, identification of each tissue type was successfully performed during surgical interventions. Conclusions The REIMS technique is capable of rapid and simple tissue identification during surgical interventions. Result statistics can be presented in a 3D LDA space using developed software. The method has the potential to provide help in the determination of resection margins during surgical interventions to significantly influence ‘on table’ decision-making.

21.9 In vivo, in situ identification of liver tumors

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
152

E-AHPBA

Arunkumar Krishnan, Jayanthi Venaktaraman Stanley Medical College, Chennai, Tamilnadu, India

Objectives Liver transplant often results in hemodynamic and biochemical changes in the immediate postoperative period, often causing concern to the treating physician. To study the pre-operative clinical profile, the hematological and biochemical changes in the immediate postoperative period up to 7 days following DDLT patients. Method A detailed assessment of the patients pre operative clinical diagnosis, presence of co-morbid illness and postoperative hematological, biochemical, microbiological and clinical events was made between survivors and those who died. Various parameters were compared between two groups to understand the various that determined early postoperative outcome in DDLT patients. Results 35 patients, categorized into group I-26 patients (Survivors) and group II-9(mortality). There was no difference in the hemoglobin levels between the two groups. Early leukocytosis( p<0.01) and persistent azotemia (p<0.01) predicted early morbidity and mortality. A significant fall of platelet count predicted mortality (p<0.01). Transaminases showed a significant rise between the 2nd,3rd postoperative days and stabilized and downwards trends by the 7th-9th postoperative days in both group. Hypernatremia predicated early mortality. Cause of death was intra-operative events like cardiac arrhythmias, ischemic cardiac events(3),pulmonary thromboembolosm(1), hepaticartery thrombosis(1),sepsis and multiorgan failure(4).Two patients required renal replacement therapy for  renal failure in group II. Conclusions High white blood cell count; platelet and serum creatinine levels were the independent risk factors for mortality. Pre-operative co-morbid illness, postoperative worsening azotemia, persistent leukocytosis, and sepsis and cardiac events in the immediate postoperative period predicts an outcome post DDLT.

153

Abstracts

22.1 Early post operative deceases in deceased donor liver transplantation: A Clinical Profile

22.2 ERGONOMICS OF THE VIRTUAL BENCHING OF THE LIVER GRAFT Abstracts

Constantinos S. Mammas, Georgia Kostopanagiotou, Spyros Geropoulos National and Kapodistrian University of Athens, Surgical Laboratory C.TOUNTAS, Athens, Greece Objectives Telemedicine Systems (TS) applies image processing and real-time remote collaboration. The  project aims to describe the ergonomy of the virtual benching of liver graft for remote evaluation. Method  Feasibility and reliability study, based on 20 human cadaveric liver remote examination on the electronic space of the Exp.-TS. Results The virtual benching study of 20 human cadaveric liver left lobes, showed that liver graft images were sufficient with regard to recognition of a. surface anatomy, b. damages and c. diseases (sensitivity=100%, specificity=100%). Conclusions  The virtual benching of the liver graft, is a feasible and reliable new process in liver graft procurement. It combines the current process with TS for remote evaluation of the liver graft. High tele-communication technology networks and well trained transplant surgeons for remote anatomic pathology evaluation of the graft and for remote transplant preoperative planning, are among the prerequisites for routine application.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
154

E-AHPBA

Georgios Sotiropoulos1, Andreas Paul1, Massimo Malago2, Markus Neuhäuser3 1 University Hospital Essen, Essen, Germany, 2University College London, London, UK, 3Koblenz University of Applied Sciences, Remagen, Germany Objectives To compare patient survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) with either live donors (LD) or extended criteria donors (ECD). Although LD and ECD represent reliable alternatives to expand the donor pool in LT for HCC, very limited information is currently available on their comparative outcomes. Method We reviewed data on 109 consecutive LT for HCC with either LD (n=57) or ECD (n=52). Patient survival was our primary outcome.  Re-LT, Ischemic Type Bile Lesions (ITBL), and tumor recurrence represented secondary outcomes. Kaplan-Meier, Cox, and logistic regression analyses were used for statistical analysis. Propensity score was calculated based on patient age, gender, hepatitis C viral infection (HCV), laboratory Model for End Stage Liver Disease (labMELD) score, bridging treatment, Milan criteria, Alpha Fetoprotein (AFP) levels, and tumor grade. Results LT procedure (HR=2.349, 95%CI=1.151-4.794, p=0.0190), age (HR=1.075, 95%CI=1.020-1.133, p=0.0074) and labMELD (HR=1.082, 95%CI=1.021-1.147, p=0.0075) reached significance by Cox proportional hazards regression. Propensity score (based on age, gender, HCV, Lab-MELD, bridging, Milan criteria, AFP and tumorgrade) was the stratification variable with 5 strata (HR=2.401, 95%CI=1.114-5.175, p=0.0253). Tumor grade (OR=9.628, 95%CI=1.120-82.752, p=0.0391), labMELD score (OR=1.224, 95%CI=1.019-1.471, p=0.0306), and Milan criteria (OR=6.375, 95%CI=1.239-32.796, p=0.0267) gained statistical significance by logistic regression analysis for Re-LT, ITBL and tumor recurrence, respectively. Conclusions LT for HCC showed superior patient survival with ECD rather than LD grafts. Re-LT, Ischemic Type Bile Lesions (ITBL), and tumor recurrence showed no differences among both groups.

155

Abstracts

22.3 Liver transplantation for hepatocellular carcinoma with live donors or extended criteria donors: a propensity score-matched comparison

Abstracts

22.4 First results on end-ischemic hypothermic oxygenated machine perfusion (HOPE) of human liver grafts donated after cardiac arrest 
Philipp Dutkowski, Andrea Schlegel, Michelle DeOliveira, Olivier DeRougemont, Fabienne Neff, Pierre-Alain Clavien University Hospital Zurich, Zurich, Switzerland

Objectives Respecting national ethical rules, long donor warm ischemia times may occur in controlled DCD liver transplantation, with potentially high risk of graft failure and bile duct injury. In an attempt to improve these extended criteria DCD liver grafts, we applied hypothermic oxygenated perfusion before implantation. Method Five adults received human livers, donated after controlled cardiac death (Maastricht category III), with an extended true warm ischemia time of 30 minutes (MAP<50 mm Hg to flush). After declaration of death and waiting times, standard cold flush and storage were performed using IGL-1® solution (4 °C). In addition, hypothermic oxygenated perfusion (HOPE) was applied through the portal vein for 1-2 hours during recipient hepatectomy. Perfusate was cooled (10 °C), recirculated and oxygenated (pO2 50 kPa) using an ECOPS® device (Organ Assist) and UW machine solution (KPS®).Perfusion pressure was maintained below 3mm Hg. Results All machine perfused DCD livers showed an excellent and immediate function after transplantation. Liver enzyme release and kidney function were comparable with matched DBD liver grafts. Median ICU and hospital stay were 2 and 16 days. Within a follow up of at least 6 months, no signs of intrahepatic biliary complications occurred. Conclusions This is the first worldwide report on cold machine perfusion of human DCD liver grafts and transplantation. End-ischemic hypothermic oxygenated liver perfusion appears safe, and has a great potential for clinical use due to its easy approach. In our early experience we observed no evidence of graft failure or dysfunction despite extended DCD criteria. Further studies are warranted.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
156

E-AHPBA

Andrea Schlegel, Rolf Graf, Jens Brockmann, Pierre-Alain Clavien, Philipp Dutkowski University Hospital Zurich, Zurich, Switzerland

Objectives The use of livers from donors after cardiac arrest (DCD) is increasing in many countries to overcome organ shortage. Due to an inherent period of warm ischemia before preservation, those grafts are at higher risk of failure or bile duct injury. Rescue strategies with machine perfusion have been developed with two competing concepts: continuous normothermic oxygenated perfusion vs.end-ischemic Hypothermic Oxygenated PErfusion (HOPE), applied only 1hr prior to graft implantation. While several groups have claimed success with either technique, no comparison is currently available. Method Rat livers were subjected to 30 or 60min in situ warm ischemia, followed by subsequent 4hr cold storage, mimicking DCD-organ procurement followed by conventional organ transport.  After warm ischemia, animals in the normothermic group received a 4hr normothermic oxygenated perfusion through both the portal vein and hepatic artery, while in the HOPE group, livers underwent passive cold storage for 4hr followed by 1hr HOPE. Outcome after reperfusion was tested in isolated rat liver perfusion (IPRL) and liver transplantation (LT) models. Results All control animals died after transplantation of a liver graft subjected to 60min warm ischemia followed by 4hr cold storage. Consistent with this observation, those livers disclosed very poor function in the IPRL. Normothermic oxygenated perfusion after 60min warm ischemia failed to prevent lethal injury. In contrast, 1hr HOPE after cold storage was associated with 70% animal survival after transplantation with good function in the IPRL. Reduction of warm ischemia to 30min resulted in survival in all groups, with again significantly reduced injury for HOPE treated grafts. Grafts subjected to HOPE were also protected against later biliary injury. Conclusions This is the first study comparing cold vs. normothermic machine perfusion. The impressive superiority of the HOPE technique can now be tested in human trials.

157

Abstracts

22.5 Rescue of Liver Grafts after Cardiac Arrest: First Study Comparing Warm vs. Cold Machine Perfusion Strategies in Rodent Models of Liver Transplantation

Abstracts

Andreas Andreou1, Gero Puhl1, Safak Gül1, Ruth Neuhaus1, Martin Stockmann1, Fritz Klein1, Timm Denecke2, Eckart Schott3, Peter Neuhaus1, Daniel Seehofer1 1 Department of General, Visceral and Transplant Surgery, Charité - Universitätsmedizin Berlin, Campus VirchowKlinikum, Berlin, Germany, 2Department of Radiology, Charité - Universitätsmedizin Berlin, Campus VirchowKlinikum, Berlin, Germany, 3Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany Objectives Recurrence of hepatocellular carcinoma (HCC) in patients treated with orthotopic liver transplantation (oLTX) is associated with diminished survival. Particularly extrahepatic localization of HCC recurrence contributes to poor prognosis. The purpose of this study was to examine factors associated with the development of extrahepatic recurrence (ER) of HCC following oLTX. Method Clinicopathological data of 367 patients who underwent oLTX for HCC between 1989 and 2010 in a highvolume transplant center were retrospectively evaluated and predictors of ER were identified. After a median follow-up time of 77 months, 93 patients (25%) were diagnosed with a recurrence. Median time to recurrence was 15 months. Recurrence was located exclusively in the liver in 19 cases (20%) and 74 patients (80%) had ER. Results  Factors associated with ER in univariate analysis included the Milan criteria (MC), major vascular tumor invasion (MVI), poor differentiation of the primary tumor und tumor DNA-index>1.5. In multivariate analysis, HCC beyond the MC (P<.0001) and the presence of MVI (P=.035) predicted ER. In patients with HCC beyond the MC who developed a recurrence (n=73), poor tumor differentiation and MVI were associated with ER. However, MVI was the only positive predictor of ER in multivariate analysis (P<.0001). In patients with HCC within the MC who recurred after oLTX (n=20), DNA-index>1.5 (P=.04) was the only predictive factor for ER.   Conclusions Advanced HCC beyond the MC and the presence of MVI are associated with an increased risk for ER and are currently considered as contraindications to oLTX. In patients with HCC within the MC, the DNA-index represents a valuable prognostic marker for the development of ER and may support the selection of patients for intensive postoperative tumor surveillance.

22.6 Predictive Factors for Extrahepatic Recurrence of Hepatocellular Carcinoma Following Orthotopic Liver Transplantation

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
158

E-AHPBA

Daniel Cherqui1,2, Benjamin Samstein1, Fernando Frotellar1, James Guarrera1, Jean Emond1 1 Columbia University Medical Center, New York, NY, USA, 2Hepatobiliary Center-Paul Brousse Hospital, Villejuif, France Objectives In recent years different, efforts at minimal access strategies have been designed for donor hepatectomy in living donor liver transplantation (LDLT). Whereas in pediatric transplantation, totally laparoscopic donor left lateral segment graft procurement have been reported, hybrid approaches have been reported for adult to adult LDLTbecause they require a larger graft, representing a more complex procedure.  These consist in laparoscopic mobilization of the liver, followed by  liver transection through a 10-14 cm midline incison. In this video we present a totally laparoscopic retrieval of a full left liver including the middle hepatic vein for an adult to adult LDLT. Method The donor was the healthy 28 year-old daughter of the 52 yo female recipient. The donor weighed 52 kg and the left lliver volume was estimated at 461 mL on CT volumetry. The recipient weighed 59.5 kg and had cryptogenic cirrhosis with ascites and encephalopathy underserved by a MELD score of 11. Estimated graft weight to donor weight recipient ratiobased on volumetric CT was 0.77. Donor anatomy was favourable with a left hepatic artery arising form the left gastric artery and a long extrahepatic left bile duct. Results The donor operation used 5 ports and included mobilization of the left liver lobe, dissection of the left hepatic artery and portal vein, division of the left bile duct and liver transection using a combination of Harmonic, CUSA and Ligasure. The operation lasted 4 hours and blood loss was 125 mL. The graft was removed through a Pfannenstiel incision. The graft weight was 400g (actual GW/RW of 0.68) and it was successfully transplanted in the recipient. The donor had an uneventful outcome and left the hospital at postoperative day 3. The recipient left the hospital without complications 3 weeks after surgery. Conclusions Totally laparoscopic living donor left hepatectomy for adult to adult LT is a feasible alternative to the hybrid approach in selected donors with favourable anatomy.  Reducing the donor incision and the graft size in adult to adult LDLT are designed to reduce invasiveness and donor  morbidity. Specific expertise and traing are required to assure donor safety.

159

Abstracts

22.7 Totally laparoscopic donor full left hepatectomy including the middle hepatic vein for adult to adult living donor liver transplantation.

22.8 Pattern of recurrence after liver transplantation for HCC Abstracts

Marco Dioguardi Burgio, David Fuks, Francois Cauchy, Maxime Ronot, Federica Dondero, Sebastien Gaujoux, Safi Dokmak, Valerie Paradis, Francois Durand, Jacques Belghiti, Valerie Vilgrain Beaujon hospital, Clichy, France Objectives Liver transplantation (LT) remains the best curative option for early stage HCC but is hampered by recurrence in 15% of the cases. The aim of this study was to analyze the radiological characteristics of HCC recurrence and determine whether initial Milan Criteria (MC) status influenced these characteristics. Method Among 343 patients undergoing LT for HCC between 2000-2011, 25 (7.2%) developed recurrence. On pre-LT imaging (median: 1.2 months prior LT) 12 (48%) patients were within MC. Radiological characteristics of their recurrences were compared to that of the 13 others patients transplanted beyond the MC. Results Recurrences were multiple in 22 (88%), disseminated in 12 (48%), and delayed (≥24 months) in 8 (32%). No patients experienced exclusive intra-hepatic recurrence. Patients within MC had similar recurrence size (31 vs. 41mm, p=0.26), number of involved organs (1.5 vs. 1.7, p=0.41) and overall number of lesions (17 vs. 15, p=0.87) compared to patients beyond MC. The median time to recurrence was 20 months (1-75) without significant difference between the 2 groups (16 vs. 29 months, p=0.10). Conclusions The pattern of recurrence after LT for HCC is not affected by the initial MC status. Because almost 50% of HCC recurrences after LT are disseminated at the time of diagnosis, we suggest a close follow-up, including body CT scan, beyond the first 2 years after LT.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
160

E-AHPBA

David Fuks, Francois Cauchy, Federica Dondero, Sebastien Gaujoux, Francois Durand, Safi Dokmak, Claire Francoz, Catherine Paugam, Jacques Belghiti Beaujon hospital, Clichy, France Objectives Although the application of extended criteria for liver procurement has allowed reducing time on the waiting list, the impact of the use of such marginal grafts on postoperative outcomes remains unclear particularly in patients with high MELD scores. The aim of the present study was to analyse the outcomes of patients with high MELD receiving extended criteria allografts. Method Among 467 patients who underwent LT between January 2007 and August 2012 all 59 (13%) cirrhotic patients with a MELD score ≥30 were selected from a prospectively maintained database. Extended criteria included prolonged hypotension, donor age ≥65 years, BMI ≥30, chronic alcohol consumption, high doses of vasopressor, hypernatremia, ICU stay ≥5 days, maximum AST/ ALT ≥500 UI/L, cold ischemia >12 hours, warm ischemia time >40 minutes and macrovesicular steatosis >30%. Short and long term outcomes of 21 (35%) recipients receiving extended criteria grafts (EC patients) were compared to that of 38 (65%) patients receiving non extended criteria grafts (Non-EC patients). Results Postoperative liver tests were similar between the two groups. While immediate postoperative prothrombin level was significantly lower in EC patients compared to non-EC patients (39% vs.46%, p=0.01) its increase paralleled that of non-EC patients. Mortality and morbidity rates were similar in the 2 groups. Neither intensive care unit (EC-patients: 18 days vs. Non-EC patients: 24 days, p=0.57) nor hospital stay (EC patients: 24 days vs.Non-EC patients: 29 days, p=0.37) were significantly different between the 2 groups. One-, 3-, or 5-year survivals were not significantly different between EC patients and Non-EC patients (90% vs.94%; 82% vs.90%; and 78% vs.87%; p=0.34). Conclusions Extended criteria liver grafts can be used in recipients with MELD score ≥30 with outcomes comparable to those with non extended criteria grafts and should be no longer discarded for LT for transplanting the sickest cirrhotic patients.

161

Abstracts

22.9 Impact of extended donor criteria on the postoperative outcome in liver transplant recipients with a MELD score over 30

Abstracts

23.1 Outcome of extended right hepatic lobectomy with portal vein resection and reconstruction for advanced Klatskin tumor
Yukihiro Iso, Keiichi Kubota Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan

Objectives Background: Hilar cholangiocarcinoma (also known as “Klatskin tumor”), occasionally requires concurrent extended right hepatic lobectomy with portal vein resection and reconstruction (ERHL with PV), depending on the manner of progression and anatomical characteristics. In the present study, we reviewed the cases of ERHL with PV performed at our department.   Method In our department, ERHL for Klatskin tumor is performed after transileocolic right portal vein embolization (TIPE) and involves D2 lymphadenectomy (dissection of the lymph nodes of the hepatoduodenal ligament). Between April 2000 and December 2012, liver resections for 71 cases of Klatskin tumor were performed at our department. Of these, 47 cases underwent TIPE-ERHL. Patients were divided to 2 gourps; ERHL with PV resection (PV group, n = 7), and ERHL without PV resection (non-PV group, n = 40). Clinicopatholoical data were compared between the two groups. Data were expressed as PV group to non-PV group in order. Results Results: Mean ages were 71.3 and 68.8 years old, mean operation times were 659.3 and 614.7 minutes (P=0.28), operative blood losses was 877.8 and 1002.4 ml (P=0.53), post-operative hospital stays were 62.8 days and 51.4 days (P=0.65), and mean survival periods was 28.9 months and 20.8 months (P=0.43) (Fig.1), respectively.   Conclusions Conclusion: Since PV resection and reconstruction does not increase the risk of surgery, PV resection should be performed with ERHL if PV invasion is suspected.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
162

E-AHPBA

23.2 Surgical treatment of perichillar cholangiocarcinoma

Objectives Surgical treatment of perichillar cholangiocarcinoma is one of the most difficult and not till the end of the resolved problems of modern surgical hepathology. Despite essential progress in diagnostics, to introduction of innovative technologies preoperative preparation, to modern methods of a transsection of a parenchyma and liver transplantation, results of surgical treatment remain unsatisfactory. Special complexity is represented by cases with a tumor invasion of a portal vein and a hepatic artery. Method The purpose of the present research was studying of results of surgical treatment of perichillar cholangiocarcinoma with invasion of the main vessels. Results 89 patients underwent resection for perichillar cholangiocarcinoma.  Median age was 60 ±/12 years. Five tumors were classified as Bismuth Type 2, 27 - Type 3a, 30 - Type 3b and 17 - Type 4, respectively. From 89 patients in 54 cases have executed a resection of a portal vein with the subsequent reconstruction. At 7 patients it is made hepathoduodenoligamentectomy with resection and reconstruction of  portal vein and hepatic artery. At prevalence of tumoral process on intrapancreatic part of choledoch at 6 patients is executed hepathopancreatoduodenectomy. The postoperative lethality has made 14,2 %, 5-year survival rate - 25 %.   Conclusions Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with hepatic artery and portal vein resection can be performed safely with acceptable lethality and long term survival rate.  

163

Abstracts

Oleg Kotenko, Alexey Popov, Alexanger Korshak, Alexanger Grinenko, Denis Fedorov, Andrey Gusev, Marat Grigorjan National Institute of Surgery and tTransplantology, Kiev, Ukraine

Abstracts

23.3 Comparative analysis of left versus right sided resection in patients undergoing liver surgery for Klatskin tumor: is the side of resection a prognostic factor?

Francesca Ratti, Federica Cipriani, Fabio Ferla, Annalisa Gagliano, Michele Paganelli, Marco Catena, Luca Aldrighetti San Raffaele Hospital, Milano, Italy Objectives Achievement of negative margins in Klatskin tumor surgery has been advocated as a main goal of curative intent treatment: a more aggressive treatment, including hilar and left or right sided liver parenchyma resection, allows to obtain a better long term outcome. Considering the anatomical relationships between the vascular hilar structures and  bile duct, this study aims to compare short and long term outcome  of left and right sided resections. Method From January 2004 to December 2012, 104 patients with preoperative diagnosis of Klatskin tumor were candidated to surgery at the Hepatobiliary Surgery Unit of the Hospital San Raffaele in Milan: of these, 85 underwent major liver resection. The data of all patients were prospectively collected and are retrospectively reviewed. 51 patients underwent right sided resections (Right Group), while the remaining 34 left sided resections (Left Group). The two groups were compared in terms of perioperative morbidity and mortality and overall and disease free survival. Results The two groups were comparable in terms of patient and disease characteristics. Patients in Right Group needed more frequently preoperative PVE. The postoperative morbidity and mortality was greater in Right Group (56.6% and 8.7% respectively) than in Left Group (34.5% and 3.4% respectively) (p <0.005). The most frequent cause of death was postoperative liver failure. R1 resections were 26.1% in Right Group and 31.5 % in the Left Group (p NS). 5-years survival rate was 32% in Right Group and 25% in Left Group (p NS). Recurrent disease was found in 70.6% of patients, without significant differences between groups. Conclusions Right sided resections for Klatskin tumors are associated with a significantly higher postoperative morbidity compared with left sided, probably related to a greater parenchymal sacrifice. Despite this, they seem to be associated with better long-term survival (data require a validation on a larger scale), since resection of the right hepatic pedicle, which anatomically lies behind the biliary carrefour, may allow a full radicality in right sided lesions.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
164

E-AHPBA

Francesco A Ciarleglio1, Alberto Brolese1, Giacomo Zanus0,2, Patrizia Boccagni0,2, Enrico Gringeri0,2, Alessandro Vitale0,2, Francesco D’Amico0,2, Francesco E D’Amico0,2, Davide F D’Amico0,2, Umberto Cillo0,2 1 General Surgery Unit II and HBP Surgical Center – Santa Chiara Hospital, Trento, Italy, 2Hepato-Biliary Surfery Unit and Liver Transplantation Center-University of Padova, Padova, Italy Objectives The aim of this retrospective study was to identify useful prognostic factors for patients with hilar cholangiocarcinoma (HC) treated with enlarged liver resection(ELR) by assessing clinical outcomes of cases treated at a single institution. Method Between January 1999 and December 131 patients affected from HC are observed in the Hepato-Biliary and Liver Transplantation Surgery Center, University of Padua (Italy). They underwent surgical exploration were resected with curative intent. Study population was divided in two groups(G1 minor liver resection; G2 ELR) and compared in terms  of results and influence on survival and DFS. Results ELR were performed in 98 pts (74%). 81 pts (61.7%) were R0, 50 R1 (38.3%), Morbidity index was 8.3% vs 7.2% in G1 vs G2 respectively. Actuarial 5y-surv G2 vs G1 was 90%, 47% e 21% vs 60%, 29% e 0% respectively. G2 median surv was 16.7 mth with a median follow up of 13.5 mth (range 6-63). Group I/II DFS was 10.7 vs 8.7 mth (standard dev 16 vs 17.1). Extended liver resection, R0, positive node, perineural invasion, extrahepatic metastasis may be influence postoperative survival by univariate survival analysis. Conclusions Surgical management of HC remains a challenge Extended liver resection with caudate lobectomy can offer a better chance of long-term survival in some selected patients with HC

165

Abstracts

23.4 May extended liver resection for hilar cholangiocarcinoma improve survival ? Prognostic factors and management in genomic age.

23.5 Liver parenchyma-sparing techniques for resection of hilar cholangiocarcinoma Abstracts
Jimme Wiggers, Anthony Ruys, Olivier Busch, Dirk Gouma, Thomas van Gulik Academic Medical Centre, Amsterdam, The Netherlands

Objectives Hilar resection in combination with extended liver resections has resulted in a higher rate of R0 resections and increased survival in patients with hilar cholangiocarcinoma (HCCA). This aggressive surgical approach is, however, associated with a high rate of postoperative liver failure, resulting in substantial morbidity and mortality. The objective of this study was to assess postoperative liver failure and R0-resection rate using parenchyma-sparing techniques in liver resections for HCCA. Method From 2003 until July 2012, 100 consecutive patients underwent resection on the suspicion of HCCA. Preoperative workup included preoperative biliary drainage and assessment of volume/function of future remnant liver. As of 2008, a modified surgical approach for right and left extended hemihepatectomies was applied, preserving parts of segments 4 and 8, respectively. Patients were analysed according to period of resection, i.e. period 1 (2003-2007) and period 2 (2008-mid 2012). Postoperative liver failure was defined as postoperative peak serum bilirubin level higher than 7 mg/dL. Postoperative mortality was defined as in-hospital mortality. Results There were 38 patients undergoing resection in period 1, including 27 (71%) major liver resections (>3 segments), i.e. 17 (63%) standard and 10 (37%) extended hemihepatectomies. Sixty-two patients underwent resection in period 2, including 52 (85%) major liver resections. Liver resections in period 2 consisted of 14 (27%) standard, 11 (21%) extended, and 28 (45%) modified hemihepatectomies. R0 resection rate (58% versus 83%; p=0.008) and postoperative liver failure (16% versus 5%; p=0.08) had improved in period 2. Overall postoperative mortality was 10%, ranging from 13% in period 1 to 8% in period 2. Conclusions Use of modified, parenchyma-sparing liver resections for HCCA is associated with a lower rate of postoperative liver failure without compromising R0-rate, compared to use of standard extended hemihepatectomies.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
166

E-AHPBA

Alessandro Valdegamberi, Andrea Ruzzenente, Calogero Iacono, Simone Conci, Tommaso Campagnaro, Fabio Bagante, Michela De Angelis, Alfredo Guglielmi Department of Surgery, Division of General Surgery A, G.B. Rossi University Hospital, Verona, Italy Objectives Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumors. Surgical resection is the only treatment to reach long-term survival, however the reported median survival is lower than 35 months. The aim of this study was to identify  prognostic factors influencing long-term survival (>5 year) after surgical resection of ICC. Method From January 1990 to November 2012 80 patients with ICC were submitted to surgery with curative intent. Eleven patients survived more than 5 years (group 1) and 43 died within 5 years (group 2). Clinical and pathological data of the two subgroups were compared. Results Overall 3- and 5- years survival for the entire study group was 45% and 27% respectively. The corresponding disease-free survival was 28% and 23%. At univariate analysis independent factors associated with survival longer than 5 years were absence of macrovascular invasion (p=0.04), absence of lymph-node metastases (p=0.01), and preoperative Ca19.9 level lower than 50 ng/dL (p<0.05). Nodule size and presence of satellite nodules were not significant prognostic factors. Recurrence rate was 70% for group 1 and 65% for group 2 (p=1.0), however median disease-free survival was longer in group 1 than in group 2 (33.9 months vs. 9 months, p=0.01). Conclusions Long-term survival can be reached also in ICC after surgical resection. Serum Ca 19.9 low level, absence of macroscopic vascular involvement and of lymph node metastases are favorable prognostic factors for long term survival.

167

Abstracts

23.6 Clinical-pathological features of intrahepatic cholangiocarcinoma patients surviving more than 5 years after surgical resection

Abstracts

23.7 Liver resection for intrahepatic cholangiocarcinomaSingle center experience with 49 resections in 64 patients over a 4-year period
Janine Baumgart, Fabian Bartsch, Philipp Kaudel, Hauke Lang Department of General, Visceral Surgery and Transplantation, University of Mainz, Mainz, Germany

Objectives Due to the lack of early clinical symptoms, ICC is mostly diagnosed at a locally advanced stage and therefore often requires an extended surgical approach. Although a complete resection offers the only chance for cure and an improvement of long-term survival the impact of extended liver resections is still controversial. Method Between January 2008 and December 2012, a total of 64 patients with ICC underwent surgical exploration in our department.  Data of patients undergoing liver resection (n=49), especially focused on extended hepatectomies (n=19), were analyzed retrospectively with regard to patients’ characteristics, operative details, perioperative morbidity and mortality, clinical outcomes and pathological findings.  Results Resectability rate was  76,5 %. 19 patients received an extended hepatectomy including 9 extended right and 7 extented left hepatectomies, 2 ALLPS and 1 mesohepatectomy. In 25 patients additional procedures were performed as following: partial resection of diaphragma (n=4) and pericardium (n=1), resection of hilar bifurcation (n=10) or caudate lobe (n=13), right adrenalectomy (n=1), partial resection of vena cava (n=8), resection/ reconstruction of major hepatic veins (n=9) and portal vein resection (n=8).  Complete tumor removal (R0) was achieved in 85,7 %. Complication rate requiring radiological intervention or reoperation was 14 % and 6 %, respectively. 30- and 60-day mortality were 4,7 % and 1,6 %. Conclusions Achieving a complete tumor removal in 85,7% which leads to a prolonged survival in patients with ICC, the presented results support the opinion that an extended surgical approach is justified in well selected patients.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
168

E-AHPBA

M.S. Khubutiya1, A.N. Lotov1, K.N. Lutsyk1, S.A. Bugaev1, O.A. Belyaeva2, V.M. Rozinov2, A.V. Chzhao3, O.I. Zhavoronkova3, S.A. Kondrashin4, I.V. Goremykin5 1 Emergency institute n.a. N.V. Sklifosovsky, Moscow, Russia, 2Moscow scientific research institute of Pediatrics and Children’s Surgery, Moscow, Russia, 3Institute of surgery n.a. A.V. Vishnevsky, Moscow, Russia, 4First Moscow state medical university n.a. I.M. Sechenov, Moscow, Russia, 5Saratov state medical university, Saratov, Russia Objectives The possibility of application of minimal invasive surgery (MIS) in the treatment of cystic echinococcus (CE) of liver is widely discussed till now. Thus the attitude of majority of surgeons to percutaneous and laparoscopic methods till now is skeptical. Results of the analysis of the literature and own supervision testify to growth of number of echinococcus among inhabitants of the central regions of Russia, out of endemic areas of traditional animal industries. Especially puts on guard the growth of disease among children. Method From 1985 to 2011 y-s. MIS techniques have been used for treatment of 392 adult patients and 38 children in several hospitals of Central Russia . The complex application of serological tests (IHA, ELISA, antibody units), ultrasound (US), MRI with MRCP was performed. The indication to perform the MIS was based on US numerical of H. Gharbi et al., 1981 y., and the WHO recommendations of 2003 y. The MIS is applicable for: 1 - CL; 2 - CE1, I; 3 - CE3a, II; 4 - CE4, IV; 5 - suppuration of the monovesicular cist, 6 - recurrent and residual monovesicular cist. Results The percutaneous transhepatic echinococcectomy with US and X-ray TV control have been performed for 233 (59 %) adults and 12 (14 %) pediatric p-s. Percutaneous punction treatment - 86 (22 %) and 16 (18 %). Laparoscopic interventions with preliminary drainage and cystic cavity processing by the 85-87% liquid glycerin have been performed for 74 (19 %) adults and 9 (10 %) pediatric p-s. Cistobiliary fistulas have been revealed in 20% of patients. Cistobiliary fistulas have been revealed in 20% of patients  None required a traditional operation. An obligatory point of complex treatment of CE is the anti-relapse chemotherapy by albendazole. Conclusions Application of a modern combination of highly informative and safe methods of diagnostics (US and MRI) with serological tests allows to diagnose CE of liver in 95% cases. The MIS methods for treatment of CE of liver (with strict indications) with use of the modern equipment, highly effective germicides (liquid glycerin of 8587 %), perform in special hospitals, with obligatory anti-relapse therapy (albendazole) - are not worse than traditional methods of treatment.

23.8 Minimal invasive surgery of cystic echinococcus of a liver for adults and children.

169

Abstracts

Abstracts

24.1 Reconstruction method after pancreatoduodenectomy-Idea to prevent serious complicationsShinji Osada, Hisashi Imai, Yoshiyuki Sasaki, Kazuhiro Yoshida Gifu University School of Medicine, Gifu, Japan

Objectives  Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents a critical trigger of potentially lifethreatening complications and is also associated with markedly prolonged hospitalization.  Lysolecithin, which is converted to be activated by phospholipase A, and phospholipase A itself is also activated by lysolecithin, indicating that these enzymes strongly interact.  Therefore, the safest type of anastomosis is one in which the mixture of pancreatic and biliary enzymes is contained, such as in a jejunojejunostomy.  A novel modified type of reconstruction, the separated loop (SL) method, has been selected in our department. Method The jejunum is transected at about 20 cm from Treitz’s ligament, and anastomosed end-to-side with the choledochus.  At 20 cm distal to this biliary anastomosis, the jejunum is interrupted, and the end of the pancreas is inserted into the bowel by means of an invagination technique.  The pancreatojejunostomy is made in one layer to hold the end of the pancreas in place in the invaginated bowel.  At 20 cm distal to this pancreatojejunostomy, the jejunum is anastomosed to the stomach, and  20 cm distal to the gastrostomy, a Y-type reconstruction is made with the distal end of  biliary route. Results Of 70 for the SL method, a high amylase level in their drainage fluid was detected in 5.1% of the patients, but no problematic clinical events, such as delayed gastric empty, were observed. Conclusions There is still no agreement as to which reconstruction method is best, but early-term observation after PD indicates that the SL method might be expected to prevent serious complications.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
170

E-AHPBA

Francesco Giovinazzo1,2, Daniela Monsellato1,2, Sara Zanini2, Giulia Turri2, Paolo Goffredo3, Giovanni Marchegiani1, Giovanni Butturini1, Claudio Bassi1,2 1 Pancreas Institute, Hospital of ‘G.B.Rossi’, University of Verona, Piazzale ‘LA. Scuro’, IT-37134 Verona, Italy, 2 Department of Surgery, Laboratory of Translational Surgery-LURM, Piazzale ‘LA. Scuro’, IT-37134 Verona, Italy, 3 Department of Surgery, Yale University School of Medicine, New Haven, CT 06520-8062, USA

Objectives  Post-operative Pancreatic Fistula (POPF) after pancreaticoduodenectomy ranges between 2-30%. Amylase levels in drains are the best methods to diagnose POPF. The role of cytokine levels in drain is still an unexplored field. We investigated TGF-β, IGFI, EGF and IL6 after pancreaticoduodenectomy to assess biological markers associated to POFP.   Method 66 not consecutive patients who underwent pancreaticoduodenectomy were included in the study. Levels of amylases, TGF-β, IGF-I, EGF, IL6 were measured in abdominal drains in post-operative day I and correlated to POFP as well as post-surgical outcomes. POPFs were graded in A, B, and C according to the International Study Group of Pancreatic Surgery (ISGPS). General complications were categorized according to Clavien-Dindo classification and to accordion severity grading system as suggested by the Pancreas Club website. We defined elevated amylase levels in drains above the cut-off of 5000 µ/L in a subgroup analyses to test the cytokines value. Results POPF was present in 11 (16%) patients and no grade C fistulas were observed in the group. Overall complications were in 29 (43.9%) patients graded as I according to the Clavien-Dindo Classification and I mild according to the Accordion Classification. Amylases levels were statistically significant in patients that developed POPFs (p<0.001). High levels of TGF-β were associated with POPF (mean=85.11 vs 64.48, p= 0.092). IGF, IL6 and EGF levels were not differently expressed in patients with post-operative complications (p= ns). Using an arbitrary cut-off (70th percentile) of TGF-beta at 83 pg/ml, 2 (14%) POPFs with Amylases <5000 UI/L were identified. Conclusions The current study confirmed that Amylases in drains are associated to POPF (p>0.001) and TGF-ß levels tend to be significant (p=0.092). Additionally, TGF-ß identified 2 (14%) patients with POPFs and Amylases <5000 UI/L. Measuring cytokines in drains might increase the accuracy of traditional tools in predicting POPF after pancreatic surgery.

171

Abstracts

24.2 Prospective study of peritoneal cytochines release and clinical risk factors of postoperative complications after pancreaticoduodenectomy.

Abstracts

Kestutis Urbonas1, Antanas Gulbinas1,2, Vytautas Aukstakalnis1, Giedrius Barauskas1, Juozas Pundzius1 1 Dept. of Surgery, Lithuanian University of Health Sciencies, Kaunas, Lithuania, 2Institute for Digestive Research, Lithuanian University of Health Sciencies, Kaunas, Lithuania

24.3 Different tumor-related factors influence survival following R0 and R1 resections for pancreatic adenocarcinoma.

Objectives Curative resection is considered to be effective treatment for pancreatic adenocarcinoma. Number of studies has already identified R0 resection and some tumor factors influencing survival following pancreatoduodenectomy. The aim of our study was to identify these independent factors for R0 or R1 resection separately. Method The data of 251 patients who underwent major surgery for adenocarcinoma of the head of the pancreas was prospectively collected and analyzed. Values of results were presented as means +/-SD and as medians. Survival rates were summarized using the Kaplan-Meier method, and the log-rank test was used to compare differences in survival between groups. Cox proportional hazard model was applied to indentify prognostic factors that were independently associated with survival. Results Median overall survival of 14,9mo was observed. Overall multivariate analysis of tumor related factors revealed that poor tumor differentiation grade (HR 1,533; CI (1,085-2,165)) perineural spread (HR 1,710 CI (1,184-2,470)) and positive lymphonodes (HR 1,703; CI (1,155-2,512)) were the factors associated with worse survival. There were 60,15% of R0 and 39,85% of R1 resections. Positive lymphonodes were independent factor for survival in both R0 and R1 resections (HR 1,900; CI (1,167-3,093) and HR 1,700; CI (0,912-3,170) respectively). Perineural spread was independent factor for R0 resection (HR 1,037 CI (1,037-2,528)), though differentiation grade - for R1 respectively (HR 1,695; CI (1,057-2,719)). Conclusions Our study revealed that positive lymphonodes are an independent tumor factor influencing the overall survival. Furthermore perineural spread is an independent factor for R0 resection and poor differentiation of a tumor is an independent factor for R1 respectively.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
172

E-AHPBA

Johanna Tol, Wietse Eshuis, Marc Besselink, Thomas van Gulik, Olivier Busch, Dirk Gouma Academic Medical Center, Amsterdam, The Netherlands Objectives Non-radical resections (R1/R2) for cancer in the pancreatic head area may limit long-term survival. Discrepancy exists on the presumed survival benefit for patients after R1/R2 resection compared to patients undergoing palliative bypass procedure due to locally advanced disease. Survival and postoperative outcomes for these patients were analyzed in this study. Method The study population consisted of all patients who underwent surgical exploration with intent to perform a resection between 1992 and 2012, with a histopathologically proven cancer in the pancreatic head area: pancreatic head, distal common bile duct, duodenum or ampulla. Patient characteristics, postoperative outcomes and median overall survival between patients with an R1/R2 resection and patients with locally advanced disease without metastasis undergoing a palliative bypass (PBP) were compared. R1 was defined as microscopically non-radical, tumor cells within 1.0 mm of the resection margin; R2 was defined as macroscopically non-radical. Results 1195 patients underwent surgical exploration for a malignancy; 716 resections and 479 PBPs were performed. In 33% of the resected patients (n=234) an R1/R2 resections was performed, 222 patients underwent PBP due to locally advanced disease. Age and gender did not differ between R1/R2 group and PBP group. Morbidity rates (ISGPS grade B/C, Clavien-Dindo ≥II) were 53% in R1/R2 group and 35% in PBP group (p=0.001), mortality was 1.3% vs. 3.2% respectively (p=0.1). Median survival for patients after R1 resection was 17.2 months vs. 9.3 months after PBP (log rank p<0.001). Median survival after R2 resection (n=10) was 8.5 months. Conclusions Although morbidity after non-radical resection is higher than after PBP, survival of patients after R1 resection is significantly better than after PBP in case of locally advanced disease. Therefore palliative R1 resection can be accepted as adequate palliative treatment. However R2 resections, probably confirmed by positive frozen sections performed perioperatively, should be discouraged.

173

Abstracts

24.4 Long-term survival after palliative resection and bypass procedure in patients with periampullary adenocarcinoma

Abstracts

24.5 Clinical utility of drain fluid amylase on the first postoperative day after pancreatico-duodenectomy: a comparison between pancreatico-gastric and pancreatico-jejunal reconstruction
Senthil Kumar, Mustafa Mourad, Simon Bramhall, John Isaac, Ravi Marudanayagam, David Mayer, Darius Mirza, Paolo Muiesan, Robert Sutcliffe Queen Elizabeth Hospital, Birmingham, UK

Objectives Early exclusion of a pancreatic fistula (PF) after pancreatico-duodenectomy (PD) may allow early drain removal and oral nutrition, which may facilitate recovery and improve outcomes. Our aim was to identify cut-off values of drain fluid amylase on the first postoperative day (DFA1) to exclude pancreatic fistula after PD in patients with either pancreatico-gastric (PGA) or pancreatico-jejunal (PJA) anastomoses Method  Prospective study of 64 consecutive patients who underwent PD (PGA 25; PJA 39) in a tertiary centre. Drain fluid amylase was measured on the first (DFA1) and fifth postoperative days (DFA5). PF was defined by either ISGPF criteria (DFA on day 5 >300iu/l) or a peri-anastomotic fluid collection on CT scan in association with a suggestive clinical course. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) were derived. Receiver operating characteristics curve (ROC) analysis was performed to identify the ideal cut off value of DFA1 to exclude a pancreatic fistula after either PGA or PJA. Results 16 patients (25%) developed a pancreatic fistula, based on ISGPF criteria in 12 patients; CT/clinical course in 3 patients (with normal DFA5), and operative findings at relaparotomy in one patient. After PGA, PF was excluded in 14/15 patients (93%) with a DFA1<250iu/l (AUC 0.81; sensitivity 83.3%; specificity 73.7%; PPV 50%; NPV 93%). After PJA, PF was excluded in 18/19 patients with a DFA1<450iu/l (AUC 0.78; sensitivity 90%; specificity 65%; PPV 47%; NPV 95%). Conclusions  A low drain fluid amylase (<250iu/l after PGA and < 450iu/l after PJA) on the first postoperative day after pancreatico-duodenectomy accurately excludes a pancreatic fistula and may be used to select patients for early drain removal as part of an enhanced recovery pathway.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
174

E-AHPBA

24.6 Predictors of recurrence after pancreatic resections for neuroendocrine tumors

Objectives Neuroendocrine tumors (NET) of pancreas have a good prognosis after radical resection and adjuvant chemo. The recurrence rate is 10-20% and several predictors are recognised but have been investigated in heterogeneous and small series. The aim of this study was to identify the clinical-pathological predictors of recurrence after pancreatic resection of all patients with a diagnosis of NET. Method Retrospective data was collected on all the patients who underwent pancreatic resections for neuroendocrine tumors between October 2001 to September 2012, excluding the inoperable cases and peripancreatic tumors. We analysed the potential clinical-pathological predictors of recurrence (age, functioning/non functioning, size, positivity of margins and nodes, vascular invasion and Ki67). Results Ninety-one patients (61 males, 30 females) who underwent pancreatic resection (24 excisions, 26 pylorus preserving pancreatic-duodenectomy, 37 distal pancreatectomy, 3 total pancreatectomy) were identified: 60% with a diagnosis of non-functioning NET. The overall survival at 1, 3 and 5 years was 82, 87 and 78% respectively; the DFS was 90% at 3 years and 81% at 5 years with median follow up of 16 months. Significant factors that predicted survival was size, positive lymph nodes and functioning tumours; the non-functioning tumours larger than 2cm with positive nodes had the highest risk of recurrence.   Conclusions Small functioning NET, with negative nodes have a better outcome. As resection margin positivity was found not to be significant, it may have a role in surgical decision making. Further studies are warranted.

175

Abstracts

Irene Scalera, Giorgia Catalano, John Isaac, Ravi Marudanayagam, Paolo Muiesan, Robert Sutcliffe, Darius Mirza, Simon Bramhall Queen Elizabeth Hospital, Birmingham, UK

Abstracts

Nicola Zanini1,2, Raffele Lombardi1,2, Michele Masetti2, Luca Valeriani2, Alessia Fiorito2, Stefania Lega2, Paola Baccarini2, Luisa Zoni2, Elio Jovine2 1 Istituto Ortopedico Rizzoli, Bologna, Italy, 2Maggiore-Bellaria Hospital, Bologna, Italy Objectives Surgery is generally not indicated for metastatic periampullary cancer because it does not appear to improve survival. However, only small surgical series on this issue have been published, and large datasets are lacking. Is metastastic periampullary cancer an absolute contraindication to surgery? Who could benefit from resection? Method Our prospectively collected database (2003-2012) lists 21 patients who underwent liver resection for metastastatic periampullary adenocarcinoma. Resection was offered in young patient, fit for surgery, with few metastases. Fifteen patients were affected by synchronous metastases and they underwent simultaneous pancreatectomy and liver resection, 6 patients experienced metachronous metastases. A potential prognostic score was applied to the study population to predict survival. Results Pancreatic ductal carcinoma was the primary tumor in 15 patients, the remaining patients were affected by ampullary carcinoma or distal bile duct carcinoma. One right hepatectomy, 2 bisegmentectomies and 18 atypical resections were performed.  Simultaneous liver and pancreatic resection did not significative improve postoperative morbidity and mortality if compared to standard pancreatic resection. Median OS of patients with synchronous and metachronous disease was 11.4 months (95%CI: 6.0-16.9) and  28.5 months (95%CI: 1.7-55.2) respectively, p=0.12. The proposed score was able to identify three classes of prognosis in which estimated median OS resulted significantly different (30.8 months, 12.4 months and 6.4 months, p<0.05). Conclusions Surgery for liver metastases from periampullary tumors is a minefield. It is a wrong step for most patients and death may occur even earlier if compared to palliative cure. However, a small group of patients could benefit from surgery and find a path to long-term survival.

24.7 Liver metastases from periampullary cancer: who could benefit from resection?

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
176

E-AHPBA

Muneer Junejo1, James Mason1,2, Aali Sheen1, John Moore1, Dougal Atkinson1, Paul Foster1, Michael Parker1, Ajith K Siriwardena1 1 Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK, 2Durham Clinical Trials Unit, Durham University, Durham, UK Objectives Pancreaticoduodenectomy is the standard of care for tumours confined to the head of pancreas and can be undertaken with low operative mortality. However, the procedure has a high morbidity, particularly in older patient populations with pre-existing co-morbidities. Many of the currently available methods for assessment of pre-operative risk rely on either scoring systems or indirect measures of cardiopulmonary function.  In contrast, pre-operative cardiopulmonary exercise testing (CPET) provides a direct functional assessment of heart and lung performance.  This study evaluates the role of CPET for prediction of post-operative morbidity and outcome after pancreaticoduodenectomy. Method In a prospective cohort undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with co-morbidity) were categorized as high-risk and underwent preoperative assessment by CPET according to pre-defined protocol. Data were collected on functional status, postoperative complications and survival. The predictive potential of CPET-derived markers was assessed. Results 143 patients underwent preoperative assessment of whom 50 were deemed low-risk for surgery per protocol. Of 93 high-risk patients 64 proceeded to surgery after preoperative CPET. CPET-derived ventilatory equivalent of carbon dioxide ( VE/ VCO2) at anaerobic threshold (AT) was a predictive marker of postoperative mortality with an AUC of 0.85 (95% CI 0.63 to 1.07, p=0.020); a threshold of 41 was 75% sensitive and 94.6% specific (PPV 50%, NPV 98.1%). Above this threshold, raised VE/ VCO2 was a predictor of poor long-term survival (HR 1.90, 95%CI: 1.02 to 3.57, p=0.045). Conclusions CPET is a useful adjunctive test for predicting post-operative outcome in patients being assessed for pancreaticoduodenectomy.  CPET-derived VE/ VCO2 above a threshold of 41 predicts early post-operative death and poor long-term survival. CPET should be considered in the pre-operative work-up prior to pancreaticoduodenectomy.

177

Abstracts

24.8 Pre-operative cardiopulmonary exercise testing (CPET) identifies patients at high risk for adverse outcome after pancreaticoduodenectomy.

Abstracts

24.9 Influence of bile duct obstruction on the results of Frey’s procedure for chronic pancreatitis
Francois Cauchy1, Jean Marc Regimbeau2, David Fuks2, Pierre Balladur1, Emmanuel Tiret1, Paye Francois1 1 Saint-Antoine Hospital, Paris, France, 2CH Nord, Amiens, France

Objectives To evaluate the influence of a biliary obstruction (BO) requiring biliary bypass (BB) on the outcomes of patients undergoing Frey’s procedure for chronic pancreatitis (CP) Method From 1999 to 2010, 33 consecutive patients underwent Frey’s procedure for CP in two centers. Seventeen (54%) patients underwent a BB to treat an associated BO. Characteristics and outcomes of these patients were compared to those of the 16 others without BO. Results Patients with BO had more severe disease reflected by lower BMI and larger pancreatic head (4 cm vs.6 cm, p=0.021). The operative mortality was nil. Patients with BO experienced more overall postoperative complications (71% vs.31%, p=0.024) but similar major complication rates (18% vs.6%, p=0.316) compared to those without BO. After a median follow-up of 51 (1-96) months, 91% of the patients had either partial or complete relief of their symptoms and 36% exhibited deterioration of their endocrine function. On multivariate analysis, preoperative BO was associated with long-term impairment of the endocrine function (OR: 43.249; 95% CI 2.221-84.277; p=0.013) Conclusions In patients undergoing Frey’s procedure for CP, associated BO can be safely managed using BB. However, the severity of CP in these patients is responsible for a higher risk of long-term endocrine insufficiency.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
178

E-AHPBA

25.1 Allps technique for bilateral colorectal metastases: theme and variations

Objectives To evaluate the possibility of technical variations on the ALPPS technique (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) with three different ways of liver splitting. Patients with liver metastases from colorectal cancer, only resectables with a two stage technique were enrolled. Method ALPPS technique was performed in the CLASSIC form as described by E de Santibanes and PA Clavien. First variation was “LEFT ALLPS”: ligation of left portal vein, multiple resections on right hemiliver and splitting along the main portal fissure. Second variation was “RESCUE ALPPS”: splitting of liver along the main portal fissure after insufficient radiological embolization. Third variation was “RIGHT ALPPS” (fig1): ligation of posterolateral branch of right portal vein, left lateral sectionectomy, multiple resections on right anterior and left medial section and splitting along right portal fissure. In all cases the auxiliary liver was removed 7 days later. Results The study included 4 patients with colorectal metastases. Perioperative morbidity was defined according to the Clavien-Dindo classification: grade 1 (2 events), grade 3b (1 event). Postoperative mortality was nil. No case of postoperative liver failure was observed in the postoperative period. Median follow-up was 3 months and to date all patients are still alive. Most important hypertrophy of future liver remnant was observed in CLASSIC form (presplit future remnant liver 400cc, postsplit 800cc), while in LEFT ALPPS there was a modest hypertrophy (+ 100cc) Conclusions ALPPS technique, in the “Classical” and modified forms, is a good option for selected patients with bilateral colorectal metastases and represent a possible alternative to the classical two stage hepatectomy. Technical variations are performed modifying the lines of in situ liver splitting along the different portal fissures.

179

Abstracts

Riccardo Gauzolino, Pierre De Wailly, Thomas Courvoisier, Marie Line Barussaud, Marion Castagnet, Jean Pierre Faure, Jean Pierre Richer, Michel Carretier University Hospital, Unit of liver Surgery, Poitiers, France

25.2 In situ split for parenchyma-sparing liver resection Abstracts

Tung Yu Tsui, Jakob R. Izbicki University Medical Center Hamburg Eppendorf, Dept. of General, Visceral and Thoracic Surgery, Hamburg, Germany Objectives The ultimate goal of metastasis liver surgery is the oncological and liver parenchyma-sparing resection.  A portion of patients might need a major liver resection or lose the surgical option due to the unfavorable location of tumors. Here we propose a new surgical strategy that may substantially improves the resectability of tumors.   Method Since anatomical splitting of a liver can achieve a maximal exploration of tumor that located near the main vessels, an oncological resection without a major liver resection becomes possible. In a pilot (proof-ofprinciple) study, three patients with colorectal liver metastases located near the main liver vessels (one in bifucation of anterior and postperior branches of right portal vein, two in confluence of common hepatic duct with segmental infiltration of middle hepatic vein). Two patients after right hemihepatectomy developed new metastasis that located in left portal vein, one in segment 2/3 and one in seg 2/3/4). Results All tumors were explored with in situ split of liver along the cantlie’s line or Lig. falciforme. A modified clampand-crash technique with or without hanging maneuver were applied for the parenchyma transection. R0 resection of tumors could be achieved in all cases without a need of major liver resection.  All patients recovered well and discharged shortly after the surgery.   Conclusions In conclusions,  in situ split liver resection represents a save and flexible method to 1) converse the respectability and 2) to achieve parenchyma-sparing resection.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
180

E-AHPBA

jiansheng li, hao chen Affiliated Provincial Hospital of Anhui Medical University, and Anhui Key Laboratory of Hepatopancreatobiliary Surgery, hefei, anhui, China Objectives To study the feasibility of liver functional reserve assessment by SPECT scan and investigate the preliminary criteria. Method Clinical data of 46 cases of hepatocellular carcinoma undergoing hepatic resection between July 2009 and July 2010 were enrolled. SPECT radionuclide scanning line was measured before operation 2 days, radiation peak count , peak time (min),5 minutes heart liver index (HLI5), blood clearance index (HH15), receptor index (LHL15) and the other variables were all calculated, the relations of them with postoperative complications were studied. Results 1. There was a significant difference between the mean of HH15 in liver failure and recovered well group. 2. When cut-off of HH15 is 0.533, the incidence of postoperative liver dysfunction was significantly different. 3. Divided the patients to three groups according the segments resected: no more than 1segment(A), >1and ≤2 segment(B), more than 2 segment(C), When HH15 <0.533, there were no statistically significant of the incidence of postoperative complications among them. When HH15 ≥ 0.533, the incidence of postoperative complications were significant difference between group A and group B or C, no difference between group B and group C. Conclusions HH15 is a sensitive indicator to predict the incidence of liver dysfunction. 0.533 can be used as the critical value of HH15.

181

Abstracts

25.3 Dynamic SPECT imaging to measure liver function reserve Clinical Application and Research

Abstracts

25.4 A case matched analysis of hepatic resection candidates with inadequate Future Liver Remnant (FLR) treated by portal vein embolization or by ALPPS. How to magnify ALPPS benefits.  

Francesca Ratti, Federica Cipriani, Annalisa Gagliano, Michele Paganelli, Marco Catena, Luca Aldrighetti San Raffaele Hospital, Milano, Italy Objectives A limit to the chance of surgical treatment for patients with hepatic tumors is represented by the inadequate volume of residual hepatic parenchyma (FLR - Future Liver Remnant) and the resulting high risk of postoperative liver failure. Portal vein embolization (PVE) and ligation (PVL) are standardized techniques to increase FLR while a two stage technique has been developed with the acronym ALPPS (Associating Liver Partitioning and Portal Vein Ligation for Staged hepatectomy) to obtain a more rapid and effective increase in FLR, thus reducing the rate of patients excluded from surgery after PVE/PVL for disease progression or inadequate FLR growth. Method  Between January and December 2012, 6 patients were candidates to ALPPS at the Hepatobiliary Surgery Unit of San Raffaele Hospital, Milan. Among these, three underwent right hepatectomy for colorectal liver metastases (Group A) and were compared, in a case matched analysis with 12 patients undergoing PVE and subsequent right hepatectomy for metastases (Group B). The groups were matched according to patients and disease baseline characteristics, including data regarding preoperative chemotherapy.    Results In both groups,FLR volume increased to a FLR/TLV ratio of more than 20%. In Group A growth was observed within 7 days, with a FLR increase of 64% (median). The FLR/TLV ratio increased from 19% to 27%. In Group B, the median FLR increase was 59%, after a median of 35 (range 28-44) days. The FLR/TLV ratio increased from 19% to 26%. The growth of FLR did not differ significantly , but Group A reached volume increase after a significantly shorter period of time (7 versus 35 days, p=0,024). Conclusions FLR effectively increases after both PVE and ALPPS. ALPPS should not therefore be proposed as a complete replacement of vascular occlusion techniques, but it should be considered a further option to obtain the growth of FLR, suitable for those specific subsets of patients where surgery is otherwise planned and/or a significant FLR volume increase in a short period seems crucial (candidates to two stage hepatectomy or patients with intraoperative finding of bilobar disease, patients with high risk of disease progression, patients with severely indadequate FLR or who require associated colorectal surgery).

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
182

E-AHPBA

25.5 Risk factors of hepatic failure after major  hepatic resection
1

Objectives Hepatic failure after major hepatic resection remains a significant concern. The role of different  risk factors predisposing and producing   hepatic failure after major hepatic resection from among preoperative and intraoperative variables were investigated. Method The subjects comprised 230 consecutive patients with malignant and benign liver diseases, who underwent major hepatic resections (more than 3 segments according to Couinaud’s classification) between 2000 and 2010 at our institution.  Multivariate analysis was conducted to identify the risk factors for post-operative hepatic failure. Results After major hepatic resection(69-right hepatectomy,  46-right extended hepatectomy, 65-left hepatectomy, 18-left extended hepatectomy, 32-central hepatectomy) in -35(15,2%) patients developed hepatic failure(determined according 50/50 criteria). Mortality was 5,6% (n=13). Hepatic failure was the main cause of mortality, 92,3%(n=12). Multivariate  analysis identified  that the following variables were significantly related to the postoperative hepatic failure: anamnesis of virus hepatitis B or C infection,  intraoperative  bleeding more than 1500 ml, preservation or reconstruction  of the middle hepatic vein during partial hepatectomy. Conclusions This experience shows   that  predisposing risk factor such as virus hepatitis B or C  in anamnesis should be taking into account before major hepatectomy.  Maximum efforts   to minimize intraoperative bleeding and adequate outflow preservation may decrease the risk of    the hepatic failure after major hepatectomy.

183

Abstracts

Ruslan Alikhanov1,2, Vladimir Vishnevsky1, Michail Efanov1, Ivan Kozirin1, Ravshan Ikramov1 Vishnevskiy Institute of Surgery, Moscow, Russia, 2M.V. Lomonosov Moscow State University, Moscow, Russia

Abstracts

Victoria Heller1, Maciej Malinowski1, Sina Lehmann1, Lina Demirell1, Bernhard Gebauer2, Gero Puhl1, Daniel Seehofer1, Peter Neuhaus1, Martin Stockmann1 1 Department of General, Viseral, and Transplantation Surgery, Charité, Berlin, Germany, 2Department of Radiology, Charité, Berlin, Germany

25.6 Factors influencing hypertrophy of the left liver lobe after portal vein embolization, a clinical study.

Objectives An extended right hemihepatectomy is often the only curative therapy in patients with liver tumors. However, postoperative liver insufficiency according to the low future liver remnant(FLR) worsens the outcome. Portal vein embolization(PVE) prior to resection improves the FLR volume. Still its influence on the FLR function is not known. Method Patients undergoing PVE before surgery were included in this prospective study. The PVE was performed using polyvinyl alcohol particles (PVA) only. Total liver volume and FLR volume before embolization and before operation were measured from contrast enhanced CT-scan/MRI scans using Visage®-Software. Success of PVE resulting in an increased FLR volume was determined as the percentual growth of the left liver lobe (LLL). Patients were divided into 3 groups accordingly <15% (poor), 15-55% (moderate), >55% (good) hypertrophy of the initial FLR. Liver function was measured using the LiMAx test and biochemical parameters were analyzed. Results 81 patients were included. 22 and 16 were separated into poor and good according to the hypertrophy of the LLL. The FLR volume increased from 435 to 459ml (22 to 23%, n.s.) in poor group. FLR in group with good hypertrophy improved from 278 to 529ml (16 to 29% p<.001). Patients with small FLR before PVE showed higher growth of the LLL (p<.005). The duration between PVE and surgery differed between the groups: 23±7.7 vs. 34±19.8 days (poor vs. good, p<.02). Also higher CRP level before PVE was associated with poorer outcome. Conclusions Findings suggest that smaller LLL prior PVE is linked to better proliferation of LLL. The duration between PVE and surgery plays a major role. Also elevated CRP level is associated with poor outcome. Factors standing for an increased risk for failing PVE should be optimized before embolization to increase the outcome.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
184

E-AHPBA

Andrea Ruzzenente, Alessandro Valdegamberi, Calogero Iacono, Simone Conci, Fabio Bagante, Tommaso Campagnaro, Marco Costa, Alfredo Guglielmi Department of Surgery, Division of General Surgery A, G.B. Rossi University Hospital, Verona, Italy

Objectives Post-hepatectomy liver failure (PHLF) is the main life-threatening complication after liver resection. Prediction of PHLF is crucial to plan safe liver resection. The aim of this study was to develop a new prognostic model able to predict the risk of PHLF in patients with injured liver. Method From 2009 to 2012 a total of 387 patients were submitted to liver resection for primary or secondary liver tumors at our institution. Sixty patients underwent major hepatectomy with injured liver (cirrhosis, cholestasis and post-chemotherapy steathosis or steatohepatitis) and were included in the study. We prospectively collected future remnant liver volume (FRLV) with CT-volumetry, liver functional test through indocyanine green retention rate at 15 minutes (ICGR15) using pulse dye densitometry (LiMON®) and preoperative biochemical data including aspartate transaminase (AST), prothrombine time (PT-INR) and serum sodium level (Na). International Study Group of Liver Surgery (ISGLS) definition of PHLF was adopted. Results Morbidity and mortality rate were 50.0% and 5.0%, respectively. 28.3% of patients (n=17) developed clinical signs of PHLF. The univariate analysis identified ICGR15 (p=0.01), AST (p=0.03), PT-INR (p=0.02) and Na (p<0.01) as risk factors of PHLF. At multivariate analysis ICGR15 (OR: 1.132; CI: 1.082-1.499), FRLV (OR: 0.975; CI: 0.891-1.007) and Na (OR: 0.185; CI: 0.001-0.592) were associated with PHLF. From multivariate analysis results, we developed a predictive mathematic model that includes ICGR15, FRLV and Na. According to this model we stratified patients in high and low risk in which the rate of PHLF were 68 % and 5%, respectively (p<0.01).  Conclusions The mathematic model including ICGR15, FRLV and Na is strongly related to PHLF and could be proposed as a new predictive model to increase the limits of safe liver resection.

185

Abstracts

25.7 Risk factors of post-hepatectomy liver failure in injured liver: a new predictive mathematic model

Abstracts

25.8 Two-stage hepatectomy combined with portal vein occlusion during first operation for complete resection of initially unresectable colorectal liver metastases

Paúl Ugalde, Ignacio Gonzalez-Pinto, Luis Barneo, Pablo Granero, Belén Porrero, Camilo López, Ester Fernando, José Fernandez, Alberto Miyar, Carmen García-Bernardo Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain Objectives Hepatic resection remains currently the only potentially curative therapy for colorectal liver metastases. However, hepatectomy can be performed in only 25% of these cases. Two-stage hepatectomy with portal vein occlusion may enhance resectability, minimizing the risk of liver failure. We present here a revision of our experience. Method Eight patients with multiple bilobar colorectal liver metastases in whom liver resection would leave a functioning liver volume under 30%, were selected for a two-stage hepatectomy. First stage consisted in complete removal of metastases localized in the future remnant liver, with non-anatomical resections, combined with ligation and ethanol infusion of the contralateral portal vein, corresponding to the liver side most affected by metastases. After evaluation of hypertrophy of the remnant liver with CT scan, a second stage hepatectomy was performed. A right hepatectomy, either anatomical or extended, was the most frequent resection; left hepatectomy was performed in 2 cases. Results Mean age of patients was 57 (41-75) years. Half of the patients had synchronous metastases. The median number of metastases was 4 (3-8). Operative mortality was nil. Morbidity after the first stage occurred in 3 patients (37.5%) and was due to minor complications. Morbidity in the second stage hepatectomy was 50%: 1 patient had severe liver failure, while the rest were due to other complications: 1 pleural effusion; 2 reoperations, one due to biliary peritonitis after T-tube removal and the other for an intra-abdominal migration of a drainage. The 3 and 5 year survival rate was 12.5%. Conclusions Two-stage hepatectomy combined with portal vein occlusion during first operation is a safe and effective approach to enhance the resectability of liver metastases that otherwise would be considered unresectable, decreasing the risk of liver failure.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
186

E-AHPBA

Ksenija Slankamenac1, Erik Schadde1, Christoph Tschuor1, Gregory Sergeant1, Victoria Ardiles2, Janine Baumgart3, Kris Croome4, Roberto Hernandez-Alejandro4, Hauke Lang3, Eduardo de Santibanes2, Pierre-Alain Clavien1 1 Swiss HPB Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland, 2 Department of Surgery, Division of HPB Surgery and Liver Transplant Unit, Italian Hospital, Buenos Aires, Buenos Aires, Argentina, 3Department of Visceral Surgery and Transplantation, University of Mainz, Mainz, Germany, 4 Department of Surgery, Division of HPB Surgery, Western University, London, Ontario, Canada Objectives The overall morbidity of two-stage hepatectomies is difficult to assess. The Clavien-Dindo classification (CDC) often assesses the highest complication on an ordinal scale. Although commonly used, the CDC doesn’t model the overall burden of complications correctly but overemphizes outliers. Complications assessed on an ordinal scale cannot be simply added up. The novel comprehensive complication index (CCI) summarizes all complications and severities in one single number from 0-100 for both stages. This study compares the overall morbidity after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus conventional portal vein ligation (PVL) according to the CDC and novel CCI. Method Patients with liver tumors undergoing  ALPPS and PVL in four liver centers were compared. Primary endpoint was overall morbidity and mortality as assessed by the Clavien-Dindo score and CCI. Risk factors for morbidity modeled by CCI were investigated by a step-wise backward linear regression analysis. Multivariate analysis was performed to adjust for potential confounders. Results After ALPPS stage-one, there appeared an almost threefold increase of severe complications (≥IIIb) (14.9% vs. 6.3%) and a slight increase after ALPPS stage-two (25.5% vs. 19%) compared to PVL-group. There was no difference in CCI after stage-one (p=0.809) or stage-two (p=0.377). The overall morbidity of both stages assessed by the CCI wasn’t different in the median CCI of 47 ALPPS (26.2 (IQR 8.7-44.9)) and 32 PVL patients (22.6 (IQR 12.2-37.1),p=0.189)). Risk factors for overall morbidity after ALPPS were intra-operative biliodigestive anastomosis (p=0.005) and the presence of any liver steatosis (p=0.023). The mortality of patients with hepatocellular carcinoma (HCC) undergoing ALPPS was 2/3. Conclusions The new CCI allows to summarize complications after two stage procedures in a single scale and may serve as a primary endpoint in comparative studies. The ALPPS procedure has similar overall morbidity compared to the conventional PVL. In patients with liver steatosis and need for biliodigestive anastomosis the complication burden after ALPPS is increased.

187

Abstracts

25.9 ALPPS for Extensive Liver Tumors is as Safe as Conventional Two-Stage Procedure with Portal Vein Ligation - Assessment by the Novel Comprehensive Complications Index

26.1 Bilobar liver metastases: toward the end of the two-stage hepatectomy? Abstracts

Diane Goéré, François Faitot, Marc-Antoine Allard, Emile Thibaudeau, Charles Honoré, Frédéric Dumont, Dominique Elias Gustave Roussy, Villejuif, France Objectives Surgical treatment of colorectal bilobar liver metastases (LM) is essentially based on a two-stages hepatectomy strategy. However, technical progress in local ablation could afford to treat all the LM in a single surgery. The aim of this study was to analyze the immediate postoperative course and the long-term outcome of patients operated on for bilobar LM in a one stage-hepatectomy. Method In a prospective database, patients operated on for bilobar LM in a one-stage hepatectomy, were selected. Patients, who underwent a right hepatectomy extended to segment IV, without further action, were excluded from the study. Results From 2000 to 2011, 155 patients underwent a one-stage hepatectomy for bilobar LM, with a median number of 7 [3-42], including 4 [1-35] in the right liver and 2 [1-16] in the left. A major hepatectomy was performed in 63 patients (41%), minor in 31 and multiple limited resections in 55 (35%). At least one radiofrequency ablation (RFA) was associated in 131 patients (85%), with a median number of RFA per patient of 3 [1-16]. Three patients (2%) died and complications occurred in 57%. Overall and recurrence-free survivals at 5 years were 38% and 8%. Conclusions A surgical strategy combining hepatectomy and local ablation in one-stage is feasible, safe and achieves longterm survivals. This one-stage strategy could increase the prognosis of such patients, compared to the twostage hepatectomy, by avoiding tumor liver progression between the two stages, reported in 20 to 30% of the patients.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
188

E-AHPBA

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDIMORO, JOSE L. MOYA-ANDIA, JUAN RODRIGUEZ, JESUS ESARTE-MUNIAIN, CARLOS HÖRNDLER, Alejandro Serrablo Miguel Servet General University Hospital., ZARAGOZA, Spain

Objectives The percentage of elderly patients with colorectal liver metastases (CLM) has increased. Liver resection (LR) remains the only curative therapy; data evaluating the outcome in this age group is limited. This study evaluated short- and long-term outcomes after LR for CLM in patients ≥70 years old. Method  Prospective data from 250 resected patients (81, 33.3% were ≥70 years) for synchronous/metachronous CLM from 2004 were reviewed retrospectively, managed by multidisciplinary team in tertiary hospital. Data were coded: sociodemographics, CRC primary, diagnosis-surgical treatment LM, extrahepatic disease (EHD) and follow-up. Categorical variables were compared by χ2-test and continuous by independent-samples T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by KaplanMeier method and compared by logrank test. Univariate and multivariate-Cox regression models analysis was performed to identify factors significantly related to OS-DFS. 90 days-postoperative morbimortality defined by Clavien-Dindo classification. SPSS™ 15.0, p-value <0.05. Results Median age population 64.8±10.4 years, with 81 patients (33.3%) aged ≥70 years. About comorbidity, relationship between aged ≥70 years and ASA score 3-4 was significantly (p=0.001). Overall 90 dayspostoperative mortality and morbidity were 2.4% vs 2.8% (p=0.599) and 34.6 vs 32.5%, respectively (p=0.823), revealing no age-related differences. 3-5 years OS in patients ≥70 years compared with younger counterparts 53.8% vs 65.6% y 45% vs 58.7%, respectively (p=0.047). 3-5 years DFS rates 28 vs 46.9% and 17.4 vs 35.4%, respectively (p=0.003). In multivariate analysis, age ≥70 years was linked with decreased survival (Hazard Ratio [HR]=1.469; p=0.047), and increased recurrence (HR=1.913; p=0.001). Conclusions Reasonable 5-year OS-DFS was observed to provide evidence that LR of CLM in elderly patients can be performed with similar morbimortality than younger counterparts. Age itself was an independent predictor of reduced OS-DFS but it is still better than with palliative treatment. We suggest LR in elderly patients with CLM whenever possible.

189

Abstracts

26.10 Effect of expanding criteria on short- and long-term outcomes after liver resection for colorectal metastases in elderly patients. is an aggressive approach justified?

Abstracts

Lawrence Lau1,2, Sze Ting Lee1,3, Andrew Scott1,3, Mehrdad Nikfarjam1,2, Michael Fink1,2, Robert Jones1, Graham Starkey1, Christopher Christophi1,2, Vijayaragavan Muralidharan1,2 1 Austin Health, Melbourne, VIC, Australia, 2University of Melbourne, Melbourne, VIC, Australia, 3Ludwig Institute for Cancer Research, Melbourne, VIC, Australia

26.2 Metabolic Response to Preoperative Chemotherapy Predicts Prognosis for Patients Undergoing Surgical Resection of Colorectal Cancer Metastatic to the Liver

Objectives  Biological characteristics of colorectal liver metastases (CRCLM) are major determinants of patient outcome but are not incorporated in preoperative assessment.  This study evaluates the prognostic value of quantified metabolic response to preoperative chemotherapy using 18F-FDG PET for patients undergoing liver resection of CRCLM.   Method  All patients (n=80) who had staging 18F-FDG PET prior to liver resection for CRCLM at Austin Health in Melbourne between 2004-2011 were included.  Thirty-seven patients had 18F-FDG PET imaging before and after preoperative chemotherapy.  Semi-quantitative PET parameters:  maximum standardized uptake variable (SUVmax), metabolic tumour volume (MTV) and total glycolytic volume (TGV) were derived.  Metabolic response was determined by the proportional change in PET parameters (dSUVmax, dMTV,dTGV).  Correlation to recurrence-free (RFS) and overall survival (OS) was assessed using receiver operating characteristic/area under the curve (AUC) and Kaplan Meier survival analysis.  Multivariate analysis was performed using Cox proportional hazards regression analysis.   Results Median follow-up was 39 months with 40% RFS and 66% OS.  Semi-quantitative parameters on staging 18F-FDG PET were not prognostic while all parameters after chemotherapy were prognostic for RFS and OS.  OS was best predicted by metabolic response as quantified by dSUVmax (AUC = 0.84).  Patients with metabolic responsive tumours had an OS of 85% at 39 months vs. 38% with non-responsive or progressive tumours (p=0.003).  Tumour size change on CT did not predict survival.  Multivariate analysis identified dSUVmax as an independent predictor for death and recurrence.  The Memorial Sloan Kettering Clinical Risk Score was independently predictive for death.   Conclusions Tumour metabolic response to preoperative chemotherapy with 18F-FDG PET is quantifiable and predictive of prognosis in patients undergoing resection of CRCLM. Assessing metabolic response provides unique characterization of tumour biology which may allow future optimization of patient and treatment selection.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
190

E-AHPBA

ArpadIvanecz,MarkoSremec,MiroslavPalfy,JasminaGolc,JasnaZakelsek,TomazJagric,MatjazHorvat,StojanPotrc University Medical Center Maribor, Maribor, Slovenia Objectives The host’s inflammatory response to tumor (IRT) has been associated with poorer cancer-specific survival in colorectal liver metastases (CRLM). The aim of the current study was to externally validate the preoperative scoring system developed by group from St. James’s University Hospital, Leeds. Method 406 liver procedures for CRLM in the period from 2000 to 2011 were identified from a prospectively maintained database. A total of 284 patients underwent their primary hepatic resection. The presence of IRT was defined by an elevated C-reactive protein (>10 mg/ml). A proposed preoperative prognostic score was validated: 0 = less than 8 metastases and absence of IRT; 1 = 8 or more metastases or IRT; and 2 = 8 or more metastases and IRT. The endpoints of the study were the overall survival (OS) and the progression-free survival (PFS). Results Postoperative mortality and morbidity were 2.8% and 23.6%, respectively. A median follow-up was 30 months. The 5-year OS of those scoring 0 was 35.4% compared with 16.8% for those scoring 1. None of the patients that scored 2 were alive at 5 years. Patients with the best score 0 had an expected 5-year PFS of 20%. The expected 5-year PFS of those scoring 1 was 7.6%. Patients with the worst score 2 had an expected median PFS of 5.3 months and a 5-year PFS of 0%. None of the patients that scored 2 were progression free at 2 years. Conclusions In our patient cohort, PFS was accurately predicted preoperatively by proposed prognostic score. It has been found to be a simple and useful clinical tool allowing patients to be optimized for their subsequent management and surveillance program.

191

Abstracts

26.3 The preoperative prognostic score based on inflammatory response to tumor for colorectal liver metastases

Abstracts

26.4 HEPATIC RESECTION FOR COLORECTAL LIVER METASTASES IN OVERWEIGHT AND OBESE PATIENTS: IS IT SAFE?

Samuele Vaccari, Mariateresa Mirarchi, Emilio De Raffele, Silvia Palumbo, Roberto Bellusci, Antonino Cavallari, Bruno Cola U.O. di Chirurgia Generale e dUrgenza, Dipartimento di Emergenza/Urgenza, Chirurgia Generale e dei Trapianti. Policlinico S.Orsola-Malpighi. Università degli Studi di Bologna., Bologna, Italy Objectives The current increase in incidence of obesity and colo-rectal liver metastases (CRLM) will soon bring an equal increasing in obese and overweight patients candidates for liver resection (LR). The aim of this study was to clarify the perioperative outcome of hepatectomy in obese (OB) and overweight (OW) patients with CRLM in comparison with normal weight patients (NW). Method Complete perioperative parameters were available in 189 of 244 LR performed for CRLM between October 2000 and December 2012 by one of the authors and were reviewed; 62 were performed in NW, 99 in OW, and 28 in OB. These groups were comparable for age, sex and distribution of minor LR, major LR and synchronous colo-rectal resection and hepatectomy. ANOVA and Student’s t tests were used for statistics; significance was defined as p<0.05. Results Intraoperative blood transfusions were 304.4±487.4 ml [0-2500], 201.6±485.6 ml [0-3300] and 135.2±423.8 ml [0-1800] in NW, OW and OB, respectively (p=0.2327). Duration of surgical procedure was 358±142 min [115-785], 374±164 min [140-820] and 348±139 min [180-705] in NW, OW and OB, respectively (p=0.6717). Postoperative complications were 14.52%, 16.16%  and 21.43%  in NW, OW and OB, respectively (p=0.7114). Postoperative mortality was 1.61%, 0% and 3.57% in NW, OW and OB, respectively (p=0.2311). Postoperative hospital-stay was 10.84±5.15 days [7-33], 10.27±3.66 days [4-29] and 10.00±3.63 days [6-23] in NW, OW and OB, respectively (p=0.6000). Conclusions The favourable perioperative outcomes observed in our experience prove that obesity is not a deterrent for liver resection and also for simultaneous colo-rectal resection and hepatectomy; however these patients should be approached cautiously by specialist surgeons in centers with experience in hepatobiliary and bariatric surgery. Surgery should be the treatment of choice also in obese or overweight patients with CRLM.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
192

E-AHPBA

GLENN BONNEY1, CHRIS COLDHAM1, RENE ADAM2, GERNOT KAISER16, EDUARDO BARROSO3, LORENZO CAPUSSOTTI4, CHRISTOPHE LAURENT5, JNM IJZERMANS6, GENNARO NUZZO7, DOMINIQUE ELIAS8, REAL LAPOINTE9, CATHERINE HUBERT10, SANTIAGO LOPEZBEN11, MAREK KRAWCZYK12, OLEG SKIPENKO13, FRANCISCO CASTRO SOUSA14, ESTEBAN CUGAT15, VALERIE DELVART2, DAVID DELVART2, DARIUS MIRZA1 1 UNIVERSITY HOSPITALS BIRMINGHAM, BIRMINGHAM, UK, 2HOPITAL PAUL BROUSSE-CENTRE HEPATO-BILIAIRE, VILLEJUIF, France, 3HOSPITAL DE CURRY CABRAL, LISBOA, Portugal, 4OSPEDALE MAURIZIANO UMBERTO I, TORINO, Italy, 5HOPITAL SAINT-ANDRE, BORDEAUX, France, 6ERASMUS MEDICAL CENTER, ROTTERDAM, The Netherlands, 7 CATHOLIC UNIVERSITY - SCHOOL OF MEDICINE, ROME, Italy, 8INSTITUT GUSTAVE ROUSSY, CANCER CENTER, VILLEJUIF, France, 9CHUM - HOPITAL ST-LUC, MONTREAL, Canada, 10UCL ST LUC, BRUXELLES, Belgium, 11HOSPITAL JOSEP TRUETA, GIRONA, Spain, 12MEDICAL UNIVERSITY OF WARSAW, WARSAW, Poland, 13NATIONAL RESERCH CENTER OF SURGERY, MOSCOW, Russia, 14SERVICO CIRURGIA III - HUC, COIMBRA, Portugal, 15HOSPITAL MUTUA DE TERRASSA, TERRASSA, Spain, 16ESSEN UNIVERSITY HOSPITAL, ESSEN, Germany Objectives Neo-adjuvant chemotherapy is increasingly used in the treatment of colorectal liver metastasis (CLM). However the use of such strategies in resectable liver metastasis is ill defined. The aim of this study was to evaluate the impact of neo-adjuvant chemotherapy on outcome following liver resection for synchronous CLM. Method  An analysis of 1301 patients of a multi-centric cohort from the LiverMetSurvey International Registry who had undergone curative resections for synchronous CLM without extrahepatic disease, between 2000 -2011 was undertaken. Patients who received at least 3 cycles of oxaliplatin- or irinotecan-based neo-adjuvant chemotherapy prior to surgery (group NAS; n=693) were compared with those who were treated by surgery alone (group SA; n=608). Baseline clinicopathological variables of the two groups were compared. Predictors of overall (OS) and disease free survival (DFS) were subsequently identified. Results Clinicopathological comparison of the groups revealed a greater proportion of solitary metastasis in the SA compared to the NAS group (68% vs 61% respectively; p=0.02); therefore a separate analysis of solitary vs multicentric analysis was performed. N-stage (>N1), number of metastasis (>3), serum CEA (>5ng/ml) and no adjuvant chemotherapy independently predicted poorer OS, while N-stage (>N1), serum CEA (>5ng/ml) and no adjuvant chemotherapy independently predicted poorer DFS. Neo-adjuvant chemotherapy did not independently affect outcome. In solitary vs multicentric disease, there was no survival difference in the NAS and SA groups with better survival in multi-centric tumours receiving adjuvant chemotherapy Conclusions We present an analysis of a large multi-centre series of the role of neo-adjuvant chemotherapy in outcome of resectable CLM without extrahepatic disease and demonstrate no survival advantage of neo-adjuvant chemotherapy in this setting. There was a survival advantage for post-operative chemotherapy in this setting particularly in multi-centric tumours.

193

Abstracts

26.5 An evaluation of neoadjuvant chemotherapy in resectable synchronous colorectal liver metastasis; a european multi-centre data analysis

Abstracts

26.6 Positive Resection Margins (R1) in Colorectal Metastatic Liver Disease does not Necessarily Mean Negative Thinking.

Spyros Delis, Christos Agalianos, Dimitrios Karakaxas, Anastasios Sofianidis, Nikolaos Gouvas, Aristotelis Kechagias, Christos Dervenis Konstantopouleion General Hospital, Athens, Nea Ionia, Greece Objectives The effect of surgical margin status on the treatment of various malignancies has been extensively investigated. Perhaps one reason for this is that the accurate assessment of the surgical margin in hepatic surgery can be difficult. Current techniques of gross evaluation  of the surgical margin may overestimate the true positive margin rate because of the different devices for parenchyma transection and friability of the liver. The aim of our study is to compare long-term outcome of R0 (negative margins) and R1 (positive margins) liver resections for colorectal liver metastases (CLM) in both solitary lesions and marginally resected cases. Method All resected CLM patients (R0 or R1) at our institution between 2002 and 2012 were retro-spectively evaluated. We aimed to resect all IOUS identified metastases with negative margins. However, when safe margins could not be obtained, resection was still performed provided that there was a complete macroscopic tumor removal. Overall survival (OS) and disease-free survival were compared between groups, and prognostic factors were identified. Results Of 440 patients, 290 (66%) underwent R0 resection (margin>1mm), 50 (11,3%) underwent R1a resection with RF ablation signs at the margin and 100 (22,7%) underwent R1 resection without signs of RF ablation at the resection margin.After a mean follow-up of 60 months, 5-year OS was 58%, 54% and 50% for R0, R1a and R1 patients . Five-year disease-free survival was 32% in the R0 group versus 25% and 18% in the R1a and R1 group. In the R1 group, intrahepatic (but not surgical margin) recurrences were more often observed (35% vs. 8%;). Conclusions Despite a higher recurrence rate, the contraindication of R1 resection is not very important compare to biologic aggressiveness of the disease because survival is quite similar to that of R0 resection. Patients with aggressive biologic factors and R1 resection margin should receive adjuvant therapy in an attempt to improve survival in this subset of patients at high risk for recurrence. RF assisted liver resection is helpful in marginally resected cases.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
194

E-AHPBA

Francesco Ardito1, Gennaro Grande1, Vincenzo Arena2, Maria Vellone1, Ilaria Pennacchia2, Francesco Majellaro2, Ivo Giovannini1, Fabio Maria Vecchio2, Felice Giuliante1 1 Hepatobiliary Surgery Unit; Catholic University, Rome, Italy, 2Department of Pathology; Catholic University, Rome, Italy

Objectives YB-1 (Y-box binding protein-1) is a protein involved in the proliferation of cancer cells and is correlated with poor prognosis in various tumors (ovary, breast, prostate and stomach). In this study we evaluated the impact of YB-1 overexpression on liver recurrence-free survival (RFS) after resection for colorectal liver metastases (CRLM). Method YB-1 expression was determined by immunohistochemistry in surgical specimens of 66 patients who underwent liver resection for CRLM between January 2004 and December 2010. Slides were analyzed by two observers who were blinded to the clinical data. Each specimen was scored according to the presence and intensity of staining. YB-1 expression was classified as weak (low expression) and strong (high expression). YB-1 expression was observed in all specimens and it was classified as weak in 17 patients (25.8%) and strong in 49 (74.2%). Overall recurrence rate and specific liver RFS were analyzed according to the YB-1 expression patterns. Results After a median follow-up of 43 months, overall recurrence rate was 83.3% (55 patients) and liver recurrence rate was 47.0% (31 patients). Overall recurrence and liver recurrence rates were significantly higher in the strong expression group than in the weak expression group: 89.8% vs. 64.7% (p=0.026) and 55.1% vs. 23.5%, (p=0.023), respectively. The 5-year specific liver-RFS was significantly higher in the weak expression than in the strong expression group (76.0% vs. 41.5%; p=0.034). These results were confirmed at the multivariate logistic regression analysis, where strong YB-1 expression was the only independent predictor of liver-RFS. Conclusions This is the first study which has shown that YB-1 is a molecular marker which is present in all cancer cells of CRLM and that its overexpression is correlated with significantly shorter liver RFS following liver resection for CRLM.

195

Abstracts

26.7 Impact of YB-1 expression on recurrence-free survival following liver resection for colorectal metastases

Abstracts

Jennie Engstrand1, Henrik Nilsson1, Eduard Jonas2, Jacob Freedman1 1 Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden, 2Clintec, Karolinska Institutet, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden Objectives Liver metastases from colorectal cancer are reported to occur in 35-50%, one third as synchronous and two thirds as metachronous. The aim of this study was to describe the metastatic pattern in a population with the hypothesis that currently reported rates of liver metastases are in fact overestimated. Method All patients diagnosed with colorectal cancer in the Stockholm/Gotland region, Sweden, with a population of nearly 2 million between January 1st and December 31st in 2008 were identified. Treatment and outcome in patients with liver metastases was analysed and CT-scans and MR images of the liver were reviewed. The patients were followed until three years after surgery or to time of death. Results In this population, 1028 patients were diagnosed with colorectal cancer. 51 % had a T3-tumor and 19 % had a T4-tumor. At the time of diagnosis 22 % had metastatic disease. 18 % had synchronous liver metastases and 8% were diagnosed with metachronous liver metastases during the follow-up period. Lung metastases were seen in 15%, 7% synchronously and 8% metachronously. 36% of the patients with liver metastases were evaluated at a hepatobiliary MDT conference, resulting in liver resection in 63 patients (24%) which is equal to 6% of all patients with colorectal cancer. Conclusions Currently reported rates of liver metastases are overestimated. According to the results of this populationbased study 26 % developed liver metastases.

26.8 Metastatic Patterns in Colorectal Cancer - a Population-based Study

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
196

E-AHPBA

26.9 Outcomes of live liver surgery. A 15 years experience.

Objectives Live liver surgery has become increasingly common because of its indisputable educational value. However, performing live hepatectomies creates a unique set of circumstances and pressure that could theoretically affect the patient outocome. We sought to determine the outcomes of patients undergoing hepatectomy as a live broadcasted procedure during surgical meetings Method Since 1998 an annual 3-days meeting of live liver surgery is organized in our Institution. Prospectively collected clinical and pathological data of all patients resected between 1998 and 2012 were reviewed. Live cases were compared to those performed under standard operating procedure (i.e. not broadcasted). Results During the study period 1396 patients (855 male and 541 female, median age 62 years) were resected. Seventysix patients (5.4%) were live cases performed by 32 different surgeons. No major differences were observed in the characteristics of patients compared to those resected during our clinical routine. However more patients in the live group underwent major or extended resections (53% vs 39.4%). The rates of postoperative complications (38.1% vs 38%) and mortality (2.6% vs 1.8%) were similar (P>.05) while the length of hospital stay was longer (17.4 days vs 12.7 days, P<.05). Conclusions With a careful patients and surgeons selection live liver surgery is associated with excellent patient outcomes similar to those observed in cases done under normal operating procedures. Live liver surgery represents an excellent educational tool which may be used without increasing patient morbidity.

197

Abstracts

Dario Ribero, Alessandro Ferrero, Francesco Giraldi, Fabio Forchino, Marco Amisano, Lorenzo Capussotti Ospedale Muriziano “Umberto I”, Torino, Italy

Abstracts

Boris Zaporozhchenko1,2, Peter Muraviov1,2, Anatolij Gorbunov1,2, Igor Sharapov1,2 Odessa National Medical University, Odessa, Ukraine, 2Odessa Regional Center of Liver and Pancreas Surgery, Odessa, Ukraine
1

27.11 Effectiveness evaluating of the “open” and laparoscopic cryoablation in patients with metastatic colorectal cancer

Objectives Among the patients with primarily diagnosed colorectal cancer (CRC), IV stage of the diseaseobtains 25 - 30% and manifests by the liver metastases presence. The aim was to improve the immediate and long-term results of surgical and combined treatment of patients with colorectal carcinoma complicated with metastatic liver disease. Method 120 cases of histories of patients with CRC with metastases in the liver were analyzed. The patients were divided into 2 groups - with the “open” (52 patients) and laparoscopic (68 patients) metastases cryoablation. The volume of liver metastases according to Gennari: I stage- in 47 of patients, IInd – in 65, IIIrd - in 8. From 52 of patients with synchronous metastatic liver damage “ ​​ open” cryoablation was made in 45, laparoscopic- in 7. From 68 of patients with metachronous metastatic liver damage, laparoscopic cryoablation was performed in 47, “open”  in 21 patients – during restoring operations after Hartmann’s procedure. Results In the early postoperative period from 52 of patients with colorectal cancer complicated by intestinal obstruction with synchronous liver damage 12 died: after planed operations - 4, and urgent - 8. From the 68 of patients with metachronous metastatic liver damage 9 patients died. During “open” cryoablation, complications in the early postoperative period were in 13.5% of patients, with laparoscopic cryoablation - in 12.6%, mortality was 2.2% and 2.0% correspondingly. Median life in patients with single synchronous metastases was 49 months, with multiple synchronous metastases was 26 months, metachronous single and multiple was 36 and 19 months correspondingly. Conclusions Method of liver metastases cryoablation, particularly laparoscopic, has undeniable advantages over extended liver resection. It should be used in the complex surgical treatment of colorectal cancer, and with solitary metastases it may become the method of choice with a high degree of radicalism.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
198

E-AHPBA

Jennie Engstrand1, Delphine Ribes2, Matthias Peterhans2, Henrik Nilsson1, Jacob Freedman1 Karolinska Institutet, Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Stockholm, Sweden, 2 ARTORG Center for Biomedical Engineering Research, Bern University, Bern, Switzerland
1

Objectives In patients with multiple liver lesions not suitable for surgical resection or where the tumour is not visible with ultrasound, or in the case of vanishing lesions after chemotherapy, ablative therapy can be performed with the aid of a virtual navigation system with 3D reconstruction of CT or MRI images. Method Between September 2011 and November 2012, 17 patients with primary or secondary liver tumours, where no resection was planned, were scheduled for computer assisted and navigated microwave ablation at Danderyd Hospital, Stockholm, Sweden. 9 patients had colorectal liver metastases, 4 patients had HCC, 4 patients had other primaries. A 3D-reconstruction of preoperative CT or MR-images was performed by MeVis Medical Solutions AG and imported into the CAS-oneTM navigation system (Cascination). Ablation was performed using Acculis’ MTA 2,45 GHz microwave ablation system. Follow-up CT or MRI was performed at day 5-7, and then at 3 and 6 months. Results The median age was 61 (36-85), 7 female, 10 male with a median of n=5 tumours (1-22).  The average volumetric estimation of the tumours were 1,7 ml. These multiple microwave ablations were performed with a median time for surgery of 120 minutes (84-172) for the 13 patients that did not have a simultaneous colon resection. Major surgical complications occurred in one patient with necrosis of the left liver and central biliary stricturing. 13 patients have reached six months follow up, 12 were alive with 6 being regarded as disease-free. Conclusions In patients with a high tumour load, who are unlikely to ever become resectable, or in patients with vanished lesions, computer assisted navigated MWA makes it possible to treat multiple lesions, possibly transferring patients from a palliative to a curative approach.

199

Abstracts

27.12 Computer Assisted Navigation in Open Liver Surgery with Microwave Ablation of Multiple Lesions

Abstracts

27.13 LAPAROSCOPIC RADIOFREQUENCY ABLATION OF UNRESECTABLE HEPATOCELLULAR CARCINOMA: LONG-TERM ANALYSIS OF 392 CASES
RobertoSantambrogio,MatteoBarabino,NicolòMariani,MaraCosta,GiovannaScifo,FedericaRenzi,EnricoOpocher Chirurgia Epato-bilio-pancreatica e Digestiva - Osp San Paolo, Milan, Italy

Objectives The optimal treatment for hepatocellular carcinoma (HCC) is either surgical resection or liver transplantation. However, only a small percentage of patients are operative candidates. Percutaneous radiofrequency ablation RFA) has been performed with promising results in patients with HCC.  Our objective was to assess an operative combination of laparoscopic ultrasound with laparoscopic RFA in the treatment of HCC not amenable to liver resection or percutaneous RFA. Method 392 patients with HCC in liver cirrhosis were submitted to laparoscopic RFA which was indicated in patients not amenable to liver resection that had at least one of the following criteria: a) severe impairment of the coagulation tests; b) large tumors (but < 5 cm) or multiple lesions requiring repeated punctures; c) superficial lesions adjacent to visceral structures; d) deep-sited lesions with a very difficult or impossible percutaneous approach. An operative combination of laparoscopic RFA with a selective intra-hepatic vascular occlusion (SIHVO) has been accomplished in 74 patients and microwave technology (MWA) has been used in 84 patients. Results There was one post-operative death (0.26%) due to cardiac failure. Two hundred and ninety-four patients had no complication (75%): a IIIB grade complication according to Clavien classification occurred in only 5 patients (1.3%). In BCLC stage A group (373 pts), a complete response with a 100% necrosis (at 1-month computed tomography evaluation) was achieved in 338 patients (92%) (91% after MWA and 100% after SIHVO). During the follow-up (32.2 + 30 months), 225 patients (61%) (38% after MWA and 61% after SIHVO) developed new malignant nodules (local recurrences: 26% after overall RFA; 20% after MWA and 19% after SIHVO). Conclusions Laparoscopic RFA of HCC proved to be a safe and effective technique: in fact it permits to successfully treat lesions not treatable with the percutaneous approach with a low morbidity rate. New techniques and technology could further improve these results.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
200

E-AHPBA

Athanasios Petrou1, Evangelos Prassas2, Kyriakos Neofytou1, Evangelos Felekouras3 1 Nicosia Surgical Department/Div. HPB, Nicosia, Cyprus, 2Institute of Liver Studies, King’s College Hospital, School of Medicine, King’s College London, London, UK, 3First Department of Surgery, University of Athens Medical School, LAIKO General Hospital, Athens, Greece

Objectives Although liver transplantation is currently the best treatment for HCC, liver resection is a widely accepted safe treatment. The aim of this study is to evaluate the short term morbidity and mortality and the oncological efficacy (overall and disease free survival) of RFA-assisted liver resection in patients suffering HCC.   Method We report  28 consecutive patients who underwent RFA-assisted hepatectomy for hepatocellular carcinoma in LAIKO General Hospital between May 2004 and January 2007. Patient data were collected prospectively. The median follow up was 27.9 months (4.5-46.4). Data included demographic details, tumor characteristics, type of procedure, intraoperative and postoperative complications,  mortality rate, date and site of recurrence. We evaluated the amount of PRBCs transfused,  the necessity for the Pringle maneuver, the postoperative morbidity and mortality, the disease free survival and the overall survival.   Results Twenty eight patients underwent 32 resections. There were 12 major and 20 minor resections. Thirty-day morbidity and mortality were 42.8% and 0% respectively.  Blood transfusion requirement was 28.5%. We did not perform Pringle maneuver to any of the patients. The one- and three-year overall survival was 92.9% and 65.7% respectively. The one- and three-year disease free survival was 62.3% and 54.6% respectively. No patients developed local recurrence at the margin site, although 3 of the patients had a R1 resection. Twelve patients (42.5%) developed in–the–liver recurrence away from the resection area.   Conclusions RFA-assisted  liver resection is a safe and bloodless technique. The fact that no patients developed local recurrence at the margin site, although 3 of the patients had a R1 resection, support the hypothesis that the coagulated zone left in the resection margin improves the clearance of this margin.  

201

Abstracts

27.14 RFA assisted liver resection for hepatocellular carcinoma: morbidity, mortality and long term survival

Abstracts

27.15 Transfer of Liver Surgery Planning into the Operation Room: Initial Experience with the iPad
1

Andrea Schenk1, Alexander Köhn1, Ryusei Matsuyama2, Itaru Endo2 Fraunhofer MEVIS, Bremen, Germany, 2Yokohama City University, Yokohama, Japan

Objectives Today, planning complex liver surgery can be supported by virtual resections, remnant volume computations, and risk analyses. In most cases, results of these planning procedures are transferred into the OR mentally, on paper, or to a workstation. Mobile devices with specialized software wrapped in sterile sleeves offer novel access to this information. Method An iPad application for visualization and augmented reality in liver surgery was developed. Dedicated software tools offer the possibility to check detailed information in the OR by fingertip and to adapt the surgical plan: Measurements of vessels length, territorial volume computations on demand, and rubber functionality to remove vascular structures from the current view. An augmented reality mode enables an overlay of the camera view of the real liver with the three-dimensional organ, vascular, and resection models determined from preinterventional radiological data. Results Initial experience from five perihilar cholangiocarcinoma resections showed the practicability and usefulness of the new software and device. The touch functionality through the sterile sleeve works well, and multi-touch gestures permit quickly zooming and rotating the 3D model. The augmented reality with overlay of vascular structures (portal vein and hepatic artery) enabled identification of single branches, while the vessel length measurements provided valuable information for vascular anastomoses. Display of hepatic veins over the real liver tissue before resection helped identify single risk vessels and avoid bleeding. Conclusions Applying a mobile device with specialized software in the OR enables quickly comparing virtual planning data and the real situation during liver surgery. Intraoperative demonstration of hepatic venous branches supported the aim of reducing intraoperative blood loss.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
202

E-AHPBA

Achilleas Ntinas1, Dimitrios Kardassis1, Ioannis Konstantinopoulos2, Antonios Manias2, Panagiotis Kottos2, Maria Kyritsi2, Dimitra Zilianaki2, Dionisios Vrochides1 1 Center of Hepato-Pancreato-Biliary Surgery, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 2 Department of Anesthesiology and Intensive Care, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece Objectives Fast track recovery protocols are applied to major surgeries, including hepatectomies. The optimal duration of thoracic epidural catheter is not yet defined. The aim of this study was to determine the ideal time to remove the epidural catheter after major hepatectomy.

Method Forty eight consecutive patients, who underwent major hepatectomy over four years, were studied. Data from laparoscopic hepatectomies were not included. Patients with hepaticojejunostomy were included.  A modified protocol of rapid postoperative recovery was applied. For the first twenty four patients the epidural catheter was maintained for four days (group A), while for the next twenty four patients, the catheter was maintained for two days (group B). The length of hospital stay, the time of functional recovery, and the use of opioids and laxatives were recorded and analyzed. Results No postoperative mortality was recorded. The average length of hospital stay was 6.92 ± 1.79 and 6.09 ± 2.08 days for groups A and B, respectively. The mean functional recovery time was 5.46 ± 0.3 and 5.26 ± 0.91 days for groups A and B, respectively. However, in group B more opioid analgesics (+ 50%) and more laxatives (+ 17%) had to be administered. Conclusions In a fast track postoperative recovery protocol, the decrease in the duration of the epidural catheter application from four to two days, leads to reduction of the length of hospital stay after major hepatectomy.

203

Abstracts

27.16 The decrease in the duration of the thoracic epidural catheter application from four to two days in a fast track recovery protocol leads to a further reduction of the length of hospital stay after major hepatectomy.

27.17 Microwave Ablation of Liver Tumours - A Single-Site Experience Abstracts

Silja Karlgren, Henrik Nilsson, Jacob Freedman Karolinska Institutet, Department of Clinical Sciences Danderyd Hospital, Division of Surgery, Stockholm, Sweden Objectives For patients with primary or secondary liver malignancies not eligible for resection surgery, thermal ablation can be an alternative. Radiofrequency ablation has traditionally been the method of choice, but lately microwave ablation (MWA) has evolved as a promising alternative. From June 2010, all ablations performed at Danderyd Hospital are MWA. Method From June 2010 until July 2012 a total of 220 MWA on 59 patients were performed. Patients with a follow up of at least 6 months were included in this study. Complications were recorded during and after surgery, radiology was performed for treatment control after approximately one week, and after 3 and 6 months to assess local recurrence at the ablation site, as well as evidence of new disease. Results 59 patients (29 HCC, 24 CRLM, 6 NET) met the inclusion criteria (221 ablations (median1; range 1-22)). 9 patients had simultaneous colorectal surgery, and 8 had simultaneous liver resection. No 30-day mortality occurred. Post-operative complications occurred in 12 patients, 5 related to MWA (1 bile duct injury, 1 ascites, 1 portal vein thrombosis, 1 lung embolus, 1 sepsis), and the other related to simultaneous colorectal surgery. At six months follow-up, 4 patients had died due to disease progression, new metastasis occurred in 17 and 10 had local recurrence. 35 patients showed no signs of disease. Conclusions Our experience of MWA shows that the method is feasible, effective and safe in treating primary and secondary liver tumours, resulting in acceptable numbers of local recurrences. MWA can be an alternative in advanced disease with multiple metastases where traditional radiofrequency ablation would be quite time-consuming.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
204

E-AHPBA

Alexandre Zanchenko Fonseca, Marina Epstein, Stephanie Santin, Marcelo Ribeiro Jr Santo Amaro University- Department of General Surgery, São Paulo/SP, Brazil

Objectives The objective of this study is to evaluate the complications of radiofrequency ablation of malignant liver tumors. Method This is a retrospective study of patients with hepatic malignancies treated by radiofrequency ablation. Tumor size and location, numbers of nodules treated, approach and histology were some of the characteristics analyzed to see if there where any significant correlation between these and complications. Results 151 patients with primary and secondary hepatic malignancies were included; 58 had hepatocellular carcinoma (HCC), 68 had metastatic nodules from colorectal cancer and 25 with other types of tumors. Complications occurred in 24,5% of the patients, being the majority of them (58,9%) in patients with HCC. Ascites was the most common one with 39%, followed by wound infection with 15% from overall complications. The only two significant factors associated to complications were the presence of HCC ( p= 0,0087) and treatment of two or more lesions ( p= 0,0323). The mortality rate was 0,69% (one death due to severe skin burns). Conclusions Radiofrequency ablation for malignant liver tumors is a safe technique. Overall complication rate was 24,5%, being ascites and wound infection the most common ones. HCC patients and treatment of multiple lesions are associated to higher complications rates. Besides it low mortality, complications are both expected and multifactorial. Appropriate patient selection, early complication recognition and adequate treatment are essential.

205

Abstracts

27.18 Complications After Radiofrequency Ablation for Malignant Liver Tumors in 151 Patients

Abstracts

27.19 Resection Margin Status and Long-term Outcome using Radiofrequency Energy as a Resection Tool for Colorectal Liver Metastases

Ashish Shrestha, Thalis Christophides, Madhava Pai, Vassilis Constantinides, David Hunter, Jiao Long, Nagy Habib, Duncan Spalding Imperial College NHS Trust, London, UK Objectives Hepatic resection margin involvements in colorectal liver metastases (CRLM) have poorer long-term outcomes. The aim of this study was to evaluate the long-term prognosis of patients with involved hepatic resection margins following resection using radiofrequency energy (RFE) as a liver parenchymal resection tool for CRLM Method Between 2001-2012, 251 patients undergoing RFE assisted hepatic resections for CRLM were identified. Patients were grouped according to their resection margin status (R0, R1 and R2) and their overall survival (OS) and recurrence rates (RR) were reviewed retrospectively. Results There were 130 (51.8%) R0, 89 (35.5%) R1 and 32 (12.7%) R2 resections.  Median follow-up was 26 (1-135) months. Large tumour size and multiple/bilobar metastases were significantly higher in R2 resections. Overall median survival was 34 (0.3-137) months, significantly higher in the R0/R1 groups compared to the R2 group (55.4, 34.6 and 27 months, P <0.005).  Five-year OSs were 48.5%, 34.8% and 12.5% in R0, R1 and R2 groups respectively, with a significantly lower OS in the R2 group (P <0.039). RRs were not significantly different amongst groups with a median time to recurrence of 37.2 (1-137) months. Conclusions R2 resection margin status for CRLM using RFE shows reasonable long-term prognosis compared to R0/R1 resections. The possibility of an R2 resection margin should not lead to the abandonment of a resection.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
206

E-AHPBA

Chady SALLOUM, Claude TAYAR, Alexis LAURENT, Riccardo MEMEO, Philippe COMPAGNON, Daniel AZOULAY Henri Mondor hospital, Creteil, France Objectives  Laparoscopic surgery via a single-incision is an evolving technique that has been applied over the past 4 years to laparoscopic cholecystectomy, nephrectomy, splenectomy and obesity surgery. The ergonomic difficulties of single-incision laparoscopy include a loss of instrument triangulation and operation with camera and instruments in parallel. To the best of our knowledge, there has been few reports on transumbilical singleincision laparoscopic hepatectomy. We have performed 300 cases of laparoscopic hepatectomy since 1996 .We present our initial experience of single-port laparoscopic liver surgery Method From October 2010 to September 2012, 7 patients were selected for single-incision laparoscopic liver surgery. The abdomen was approached through a 20 mm supraumbilical incision. Each procedure was performed through a single Triport. No supplemental ports were required. The liver was transected using a combination of Ligasure, harmonic scalpels and staplers. Results The liver resection procedure was successfully completed for the 7 patients. The procedures consisted of 2 partial resection of segment 3, 2 partial resection of segment 5 and 3 partial resection of segment 6 in addition to concomittant cholecystectomy (n=1) and pulmonary wedge resection (n=1) The mean operative time was 98.3min (range, 60-150 min) and the mean estimated blood loss was 57 ml (range, 25-150 ml) . The postoperative courses were uneventful and the mean hospital stay was 5.1 days (range, 1-13 days). Pathology identified 3 benign and 4 malignant liver tumors with a clear margin. Conclusions This preliminary experience suggests the technical feasibility and safety of liver wedge resection through single port access in terms of intra- and postoperative results respecting oncological principles concerning the width of the resection margin. However, this surgical technique requires relatively advanced laparoscopic skills and extensive surgical experience. Further studies are needed to determine the potential advantages of this technique, apart from the better cosmetic result, compared to the traditional laparoscopic technique

207

Abstracts

28.1 Our early experiences with single-incision laparoscopic liver surgery : the first 7 patients.

28.2 Radical treatment of primary and residual liver hydatid echinococcosis Abstracts

VladimirVishnevsky,MikhailEfanov,RavshanbekIkramov,IvanKozyrin,NinaNazarenko,DmitryIonkin,AlexeyZhao A.V.Vishnevsky Institute of surgery, Moscow, Russia Objectives Incidence of hydatid echinococcosis is constantly increasing. The frequency of residual decease is still high. There is no consensus in surgical strategy including the role of radical modalities and PAIR treatment.  Aim: estimation of advantages and disadvantages of radical treatment in patients with primary and residual liver hydatidosis. Method Results of treatment of 383 patients with liver hydatidosis from 1976 till 2010 were reviewed. Radical and conservative surgical operations were performed in 359 (93,7%) patients. Primary and residual hydatidosis was established in 278 (75.3%) and 105 (24.7%) patients respectively. Radical operations (pericystectomy and liver resection) were the treatment modality of choice. Complete removal of hydatid cysts were performed in 129 (33,7%) patients. Subtotal pericystectomy and combined surgery were done in 176 (46,0%) patients. Residual liver hydatidosis was revealed in 105 (24.7%) patients (98 from other hospitals). Results of radical treatment of 26 patients with residual liver cysts are presented. Results The postoperative abdominal complications took place in 74 (20,6%) patients. Residual cavitis wrer rarely after total and subtotal pericystectomy in comparison with echinococcectomy only. Mortality rate was 1.6%. Intraoperative blood loss was higher in patients with residual liver hydatidosis in comparison with primary hydatid cysts (1586±455 ml and 803±97 ml). The rate of relapse of decease was similar in patients with primary (4,5±2%) and residual (7,6±5%) liver hydatidosis. Total pericystectomy led to higher volume of operative blood loss. Conclusions Relapse of liver hydatid cyst after surgical treatment should be considered as residual echinococcosis in majority of the patients. Radical operations for primary and residual hydatid cysts as a rule led to satisfactory results. Echinococcectomy with total and subtotal pericystectomy are sufficient for safe removal of parasite. Total pericystectomy is justified in patients with wedge hydatid cysts without large tubular structures involved in fibrotic capsule.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
208

E-AHPBA

Cavit Avci, Levent Avtan Istanbul tip fakultesi, istanbul, Turkey

Objectives  Surgical treatement , radical or conservative, is the most commonly used therapeutic choice for hydatid disease among the options of medical treatment and interventional radiology (PAIR). We can do a radical resection when the cyst is simple, small and localized to the periphery of the liver. Otherwise, as it is often the case, conservative surgery is more recommended with a complete removal of the content of the cyst, followed by a good management of the cavity by enroofing, omentoplasty or simple drainage. If precautions are not taken, the contents of the cyst can easily escape into the peritoneal cavity.   Method In addition, during the laparoscopic intervention, the conventional aspirator’s tube can quickly be obstructed by the germinal membrane and scolex, which makes the control of   the spread difficult. This, as well as uncontrolled contamination of the peritoneal cavity are the major causes of several complications and recurrence. To avoid these complications and operate with a maximum safety and efficiency, we have designed and developed a new generation of Perforator-Grinder-Aspirator Apparatus  (PGAA) in our Research Center  (ISTEM) in the surgery department, Faculty of Medicine of Istanbul.   Results  The PGAA consists of four main units including ponction-irrigation needle, perforator-grinder pipe, aspirator canula and   electric motor. The automatically retractable rotary blade on its distal edge, to grind and evacuate all the contents of the cavity including the germinal layer and scolices is one of the most important characteristic of this new PGAA.  Thanks to the retractable rotary blade, intracystic paranchimal damage after the perforation of the outer layer, is avoided.   Conclusions By using PGAA, we have a laparoscopic approach while keeping the necessary pneumoperitoneum pressure to evacuate properly the cyst contents from liver. At the end of the operation, after taking the perforatorgrinder pipe out, the aspiration cannula stays in and we introduce a 10 mm diameter laparoscope which allows visualizing the inner surface of the cystic cavity laparoscopically. We use this device in every patient with liver hydatid cysts placed in different locations, and have positive results and great satisfaction, for the last ten years.    

209

Abstracts

28.3 Secure laparoscopic  treatment  of hydatid cyst with a new “ perforator-grinderaspirator-apparatus” (pgaa)

Abstracts

28.4 Comparative analysis of different techniques and devices efficiency for liver parenchyma transection
Miroslav Stojanovic, Ljiljana Jeremic, Milan Radojkovic, Aleksandar Zlatic, Goran Stanojevic Clinical center Niš, Serbia, Serbia

Objectives Liver resection has been facilitated by improved anesthetic and surgical techniques, as well as by the application of new technologies and devices that minimize hemorrhage and bile leak, and enable the preservation of functional hepatic parenchyma. The aim of this study is to analyze efficiency and determine real value of different techniques and devices used for liver transection.   Method The study was performed by statistical analysis of the prospective conducted database of the 300 liver resection performed at our institution. The patients are divided in 4 groups according to the liver parenchyma transection technique: two groups of selective technique with sceletonisation and identification of the biliovascular structures prior definitive treatment standard- “crush and clamp” /144 pts./, and CUSA technique /60/, and two groups of non-selective techniques -linear radiofrequency device (LRFD) /56 pts./, and bipolar device /40pts/. Duration of the liver ischaemia, liver parenchyma transection time, intraoperative blood loss, significant intraoperative and postoperative complication rate were analyzed. Results Liver ischaemia time was longer after using selective techniques /”crush and clamp” (22 min.) and CUSA (26 min.) compared with non-selective technique (LRFD (9 min.) and bipolar device (7 min.). Transection of the liver parenchyma was slower in the CUSA group,  compared with the LRFD, bipolar device and “crush and clamp” groups (1,5, 2.1, 2,9 and 3,1 cm2/ min. respectively.) Intraoperative bleeding was almost similar in all groups (median 320). Major complications rate was higher after use of the non-selective techniques LRFD /3.57%/, bipolar /4.0%/ compared with 1.66% and 2.08% major complication in the CUSA and crush and clamp technique. Conclusions Liver transection parenchyma using newly developed LRFD and bipolar devices need shorter ischaemia, with no effects to the intraoperative blood loss and slightly higher morbidity. The fastest, safest and cheapest method for liver transection still remains the standard “crush and clamp” technique.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
210

E-AHPBA

Athanasios Petrou1, Kyriakos Neofytou1, Konstantinos Bramis2, Evangelos Felekouras3 1 Nicosia Surgical Department/Div. HPB, Nicosia General Hospital, Nicosia, Cyprus, 2Department of Hepatobiliary Surgery, Surgery and Diagnostics Centre, Churchill Hospital. Headington, Oxford, UK, 3First Department of Surgery, University of Athens Medical School, LAIKO General Hospital, Athens, Greece

Objectives Hepatic resection is the only potential curative treatment for a wide variety of conditions. However, liver surgery is technically demanding and closely associated with a number of serious complications. This retrospective study evaluates the feasibility, efficacy, and safety of RFA-assisted liver resection.   Method We report 145 consecutive patients  who underwent RFA-assisted liver resection to LAIKO General Hospital, in a period of seven years. Patient data were collected retrospectively and included demographic details, histological type and number of tumors, surgical procedure, overall operative time(OOT), parenchymal transection time(PTT), overall amount of intraoperative  blood  loss(IBL), amount of  blood loss during parenchyma transaction(PTBL), intraoperative and postoperative complications and mortality rate. We evaluated the amount of blood loss during operation, the amount of PRBCs transfused,  the necessity for the Pringle maneuver, the length of time needed for parenchymal transection and the postoperative morbidity and mortality.   Results  We performed  95 major  and 50 minor hepatectomies, using Radionics Cooltip RFA System  with a single shaft 15-cm needle electrode with a 2-cm exposure tip. The mean OOT and PTT were 194 minutes(SD 108 minutes) and 51,75  minutes(SD 19,12  minutes) respectively. The mean IBL was 251,1  mL (SD 208,37 mL), and the mean  PTBL was 144,7ml(SD 101,14 ml). The PTT and the PTBL were affected due to the raw liver surface and the presence of cirrhosis(p-value<0,001). Pringle maneuver was necessary in twelve cases(8,27%). Seventeen patients (11,72%) were transfused. There were 47 patients(32%) with postoperative complications. The mortality rate was 0%.   Conclusions  RF-assisted liver resection allows major and minor hepatectomies to be performed with minimal blood loss without the necessity of liver inflow occlusion. This allows the performance of liver resections with minimum requirements for blood transfusions. This technique offers a useful additional method for transection of liver parenchyma for hepatobiliary surgeons.  

211

Abstracts

28.5 Radiofrequency ablation-assisted liver resection. A step toward bloodless liver resection.

28.6 First evidence that intracystic CA72-4 accurately discriminates cystic lesions of the liver Abstracts

David Fuks, Helene Voitot, Hadrien Tranchart, Jacques Belghiti, Valerie Paradis, Olivier Farges Beaujon hospital, Clichy, France Objectives Imaging occasionally fails to differentiate hepatic simple cysts from malignant/premalignant liver cysts, including biliary cystadenomas. Simple hepatic cysts can be treated conservatively whereas malignant/ premalignant cysts require complete resection. We aimed to determine the value of intracystic tumor marker concentrations in differentiating between these entities. Method This retrospective study was performed according to the standards for the reporting of diagnostic accuracy studies. Intracystic concentrations of CEA, CA19-9 and TAG72 were assayed in 120 patients having undergone liver cyst resection. The accuracy of these markers for differentiating (i) atypical hepatic simple cysts (n=34) from biliary cystadenomas (n=24) and (ii) benign cysts (including 39 typical hepatic simple cysts) from those with malignant potential was measured with ROC curves. Immunostaining of the cyst epithelium with antiTAG72 antibodies was performed. Results CEA and CA19-9 failed to accurately differentiate hepatic simple cysts (HSC) from biliary cystadenomas (BCA) or differentiate cysts with malignant potential from those without. In contrast, a TAG72 concentration >25U/ml differentiated (i) BCA from HSC, with sensitivity and specificity values of 79% and 97%, respectively, and (ii) cysts with malignant potential from those without malignant potential, with sensitivity and specificity values of 90% and 92%, respectively. The area under ROC was 0.96 for BCA vs. HSC and 0.98 for malignant vs. nonmalignant lesions. The epithelium lining stained positive for TAG72 in 72% of premalignant cysts and none of the non-malignant cysts. Conclusions Cyst fluid TAG72 levels accurately identify hepatic cysts that require complete resection.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
212

E-AHPBA

Eduard Jonas1, Christoph J Zech2,3, Pornpim Korpraphong4, Alexander Huppertz5, Myeong-Jin Kim6, Ahmed BaSsalamah7 1 Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden, 2Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland, 3Institute of Clinical Radiology, University Hospital Munich–Grosshadern, Munich, Germany, 4Department of Radiology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand, 5Department of Radiology , Charité University Hospital, Berlin, Germany, 6Yonsei University, Severance Hospital, Seoul, Republic of Korea, 7Department of Radiology, Medical University of Vienna, Vienna, Austria Objectives To analyse and compare the impact of imaging strategy using gadoxetic acid-enhanced MRI (Gd-EOB-DTPA-MRI), MRI with extracellular contrast media (ECCM-MRI) or contrast-enhanced multi-detector computed tomography (CE-MDCT) as first-line imaging method in patients with suspected colorectal cancer liver metastases (CRCLM) regarding sensitivity and accuracy and impact on the surgical treatment plan. Method Between October 2008 and September 2010 360 patients with suspected CRCLM were randomised in a multinational prospective trial to one of the three imaging modalities. The primary endpoint was the proportion of patients for whom further imaging after initial imaging was required for a confident diagnosis. Secondary variables included confidence in the therapeutic decision, intra-operative deviations from the initial imagingbased surgical plan due to additional operative findings, and diagnostic efficacy (sensitivity and specificity) of the imaging modalities with the extent of the disease as determined by intra-operative findings (including intraoperative ultrasound) and pathological examination of resected specimens as endpoint. Results After exclusion of screening failures, premature study terminations and major protocol violations, 342 patients (efficacy population) were analyzed, 118, 112, and 112 with Gd-EOB-DTPA-MRI, ECCM-MRI or CE-MDCT as initial imaging procedure respectively. Further imaging was required in 0/118 (0%), 19/112 (17%) and 44/112 (39%) patients, respectively (p<0.0001). Diagnostic confidence was high or very high in 98.3% of cases for Gd-EOBDTPA-MRI, 85.7% for ECCM-MRI and 65.2% for CE-MDCT. Surgical plans were changed intraoperatively in 12.8%, 16.0%, and 29.4% of patients in the respective groups. In patients who underwent surgery (n=112), sensitivity for detection of metastases was 93.8%, 89.4%, and 84.1%, respectively. Conclusions The diagnostic performance of Gd-EOB-DTPA-MRI was better than CE-MDCT and ECCM-MRI as initial imaging modality. No further imaging to assess hepatic resectability was needed in the Gd-EOB-DTPA-MRI group, with implications for work-flow, costs and treatment planning. Comparison of the diagnostic efficacy parameters demonstrates the diagnostic superiority of Gd-EOB-DTPA-MRI.

213

Abstracts

28.7 Gadoxetic acid-enhanced MRI versus conventional MRI or MDCT for staging of liver metastases; The VALUE Study – a randomized multicenter trial

Abstracts

Edgar M. Wong-Lun-Hing1, Baki Topal2, John N. Primrose3, Alexis Laurent4, Ibrahim Dagher7, Bjorn Edwin5, Luca Aldrighetti6, Cornelis H.C. Dejong1, Ronald M. van Dam1 1 Maastricht University Medical Center, Maastricht, The Netherlands, 2University Hospitals Leuven, Leuven, Belgium, 3 University Hospital Southampton NHS, Southampton, UK, 4Henri Mondor Hospital, Paris, France, 5Oslo University Hospital, Oslo, Norway, 6San Raffaele Hospital, Milan, Italy, 7Antoine Beclere Hospital, Paris, France Objectives Recent developments in liver surgery include the introduction of laparoscopic surgery and enhanced recovery programmes. Laparoscopic surgery and enhanced recovery programmes both focus on faster time to recovery and consequently shorter hospital length of stay. The added value of the laparoscopic hemihepatectomy compared to the open hemihepatectomy in an ERAS setting has never been studied in a randomised controlled setting. The multicentre international ORANGE II PLUS - Trial will provide evidence on the merits of laparoscopic compared with open hemihepatectomy. Method Patients eligible for left or right hemihepatectomy will be recruited and randomised at the outpatient clinic. All randomised patients will be operated in the setting of an ERAS® programme. The experimental design produces two randomised arms (open and laparoscopic hemihepatectomy) and a prospective registry. Patients ineligible for randomization can be included in the prospective registry.  We aim at a reduction in time to functional recovery by 2 days after laparoscopic hemihepatectomy. A sample size of 125 patients in each randomisation arm has been calculated to detect a 2-day reduction in hospital length of stay (power 80% and α=0.04 twotailed). Results The primary endpoint of the ORANGE II PLUS trial is time to functional recovery. Secondary endpoints are hospital length of stay, intraoperative blood loss, operation time, resection margin, time to adjuvant chemotherapy initiation, readmission percentage, (liver specific) morbidity, quality of life, body image, reasons for delay of discharge after functional recovery, long term incidence of incisional hernias, hospital and societal costs during one year, overall five-year survival. Conclusions The ORANGE II PLUS trial is a multicentre RCT that will provide evidence on the merits of laparoscopic surgery in patients undergoing hemihepatectomy within an enhanced recovery ERAS® programme.

28.8 The ORANGE II PLUS - Trial:  an international multicentre randomised controlled trial of open versus laparoscopic hemihepatectomy.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
214

E-AHPBA

Laura Llado, Ana Muñoz, Emilio Ramos, Jaume Torras, Joan Fabregat, Juli Busquets, Nuria Pelaez, Lluis Secanella, Antoni Rafecas Hospital U Bellvitge, University of Barcelona, Barcelona, Spain Objectives  “In place” right hepatectomy with hanging maneuver has been advocated to perform right hepatectomy in cases of large right liver tumors. The objective of this study is to evaluate the feasibility and results of “in place”-with hanging maneuver right hepatectomy in case of CRLM. Method  Prospective observational study of all patients who underwent right hepatectomy for CRLM at our institution from 2009 to 2012. Intraoperative and postoperative evolution is evaluated. Results Right hepatectomy for CRLM was performed in 57 cases, being “in place” with hanging maneuver in 44 (77 %). 16 patients had right portal vein embolization previous to surgery, and 36 (81 %) neoadjuvant chemotherapy. Mean surgical duration was 303 ± 54 minutes. No patient had major intraoperative injury technically-related. Mean hospital stay was 12 ± 9 days. No patient had INR lower than 50 % on day 5, but 13 (29 %) had bilirrubin higher than 50 µmol/L. Postoperative morbidity was 32 % , and there was a case mortality (2.3 %). No patient was reoperated. Conclusions “In place” right hepatectomy with hanging maneuver is safe and feasible; probably with a longer learning curve we can increase its applicability. Postoperative morbidity and mortality is low. Future comparison with conventional technique, may stablish this sapproach as the standard in the management of colorectal liver metastasis.

215

Abstracts

28.9 Feasibility and results of “in place” with hanging maneuver right hepatectomy for colorectal liver metastasis

Abstracts

Enrico Vasile0,1, Nelide De Lio1, Mario Antonio Belluomini2, Francesca Costa3, Carla Cappelli0,2, Daniela Campani0,3, Alfredo Falcone0,1, Ugo Boggi4 1 Division of General and Transplant Surgery, University of Pisa, Pisa, Toscany, Italy, 2Division of Oncology, University of Pisa, Pisa, Toscany, Italy, 3Division of Radiology, University of Pisa, Pisa, Toscany, Italy, 4Division of Pathology, University of Pisa, Pisa, Toscany, Italy Objectives We report the results of a phase II clinical trial, coupling high-dose multi-drug neoadjuvant chemotherapy (NACT) with aggressive surgery in patients diagnosed  with  locally advanced pancreatic ductal adenocarcinoma (PDAC) in the absence of distant metastases Method  All patients enrolled in this study were selected by a multidisciplinary workgroup, including surgeons, oncologists and radiologists. Selection criteria included PDAC-stage III locally advanced with suspected arterial involvement (celiac axis (CA), superior mesenteric artery (SMA)), ECOG PS 0-1, age 18-75 years. All patients underwent a phase II NACT protocol, employing a modified FOLFIRINOX regimen. Tumor response was evaluated according to RECIST criteria by comparing pre-treatment contrast-enhanced computed tomography (CT) scan with follow-up imaging obtained at 4-week intervals. The opportunity to add a local treatment, either surgery or radiation therapy, was evaluated by the multidisciplinary team after every CT follow-up. Results Between 11/2010-11/2012 26 patients were enrolled. Mean age was 59 years. 9 had CA involvement, 11 SMA, 6 CA and SMA. 9 had a partial response, 15 had a stable disease (57%). 14/26 were selected for surgery and 11 underwent resection (2 pylorus-preserving-pancreaticoduodenectomy, 9 total pancreatectomy). Overallpostoperative-morbidity was 62%. Mean-hospital-stay was 26 days. All operations were R0. The mean number of resected lymph nodes was 67. 20% of resected venous segments and 33% of resected arterial segments were not involved on histology. Progression-free-survival of the 26 patients was 17.6 months and in resected patients 17.8 months. Median-overall-survival was 24 months. Conclusions  Our interim analysis confirms the activity of modified FOLFIRINOX protocol in PDAC, allowing extended resection in a relevant percentage of PDAC-stage III with results comparable to those achieved in primary resectable patients. New data from further studies and from larger cohorts are needed before any final conclusion may be drawn.

29.11 Resection of locally advanced pancreatic cancer after neoadjuvant chemotherapy with modified FOLFIRINOX: a prospective phase II study.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
216

E-AHPBA

Isabella Frigerio1,2, Alessandro Giardino1,2, Roberto Girelli1, Paolo Regi1, Roberto Salvia2, Claudio Bassi2 1 Pancreatic Surgical Unit, Pederzoli Clinic, Peschiera del Garda, Verona, Italy, 2Department of Surgery B- Pancreas Institute, GB Rossi Hospital, University of Verona, Verona, Italy Objectives  Neo-adjuvant chemotherapy  (CHT) has gained increasing importance in resectable and borderline resectable pancreatic cancer leading to a better performing surgery when we look at negative resection margins and selection of patients with less aggressive disease. We apply this principle to patients with Stage III (LAC) pancreatic cancer undergoing to RFA and try to select patients who may benefit from a local treatment. Method All patients affected by LAC were treated with RFA for a stable disease after a short CHT. Postoperative morbidity and  mortality were evaluated together with overall survival (OS) and disease specific survival (DDS). Kaplan-Meier curves were adopted to estimate the probability of survival rate at each point in time, with the censored cases being those where the expected event did not occur. Results We consecutively treated 57 patients affected by LAC. Median duration of CHT before RFA was 5 months. Postoperative mortality rate was zero. Overall morbidity was 14% with RFA-related morbidity of 3,5%. We had 7 cases (12,3%) of progression within 3 months from the procedure: two hepatic progressions and 5 cases with local progression. The median time to progression (TTP) was 10 months (IQR:7,7 - 13,2). OS and DSS were 19 months and when compared to a similar population who received RFA as up front treatment there was no difference. Conclusions Our results do not support the adoption of a short CHT as a way to identify patients to treat with RFA with the most benefit. Based on this and by knowing the role of immune modulation after RFA and its specific involvement in pancreatic carcinoma, we can propose RFA as upfront treatment.

217

Abstracts

29.12 Short term chemotherapy followed by radiofrequency ablation in stage iii pancreatic cancer: results from a single center.

Abstracts

29.13 Prognostic value of 18 fluorodeoxyglucose PET in patients with pancreatic neuroendocrine tumor
Hipólito Durán, Emilio Vicente, Yolanda Quijano, Benedetto Ielpo, Eduardo Díaz, Isabel Fabra, Ramón Puga, Catalina Oliva, Riccardo Caruso, Valentina Ferri, Sergio Olivares, José Carlos Plaza hospital madrid norte sanchinarro, madrid, Spain

Objectives  PET scan as a prognostic tool in pancreatic adenocarcinoma is established. In   pancreatic neuroendocrine tumors (NET) is still to be defined. To test the role of the PET scan as prognostic factor of NET, comparing the tumoral Standardized Uptake Value with Ki-67 index and tumoral size. Method We retrospectively included 78 consecutive patients that underwent pancreatic surgery form March 2009 to March 2011. 21cases (26.9%) were found to be NET: 11 male and 10 women. Mean age was 58 years (range: 35-73 years). WHO NET classification was: 8 neuroendocrine tumor (38%); 9 well differentiated tumors (42%); 4 poor differentiated tumors (19%). Mean tumoral size was 1.56 cm in neuroendocrine tumor and 5.05 cm for neuroendocrine carcinoma (p < 0.05). The prognostic validation of PET is based upon a bivariant study: positive/negative PET with Ki-67 index and tumoral size. Results  PET scan was positive in 12 cases (mean SUV of 6.34). Patients with positive PET scan has a Ki-67 mean index of 22% and a mean tumoral size of 4.5 cm; while patients with negative PET scan has a Ki-67 mean index of 11.6% and a mean tumoral size of 3.5 cm (p < 0.05). Conclusions Positive PET scan may represent a prognostic factor as it seems to be related with a worse prognosis in NET of pancreas (higher tumoral size and Ki-67 index). Consistent further studies are needed to confirm this result.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
218

E-AHPBA

Hipólito Durán, Emilio Vicente, Yolanda Quijano, Bendetto Ielpo, Eduardo Díaz, Isabel Fabra, Catalina Oliva, Valentina Ferri, Sergio Olivares, Riccardo Caruso, Ramón Puga, José Carlos Plaza Hospital Madrid Norte Sanchinarro, Madrid, Spain Objectives  Reduced absorption of chemotherapy play a role in the poor prognosis of pancreatic cancer, maybe due to the stromal barrier surrounding the tumor. Nab-paclitaxel stablishes a disruption in this stromal barrier. Study the metabolical response, assessed by PET scan, in resectable pancreatic cancer before and after neoadjuvant therapy with Nabpaclitaxel/Gemcitabine Method From Marc 2011, 12 patients where included prospectively. All of them underwent neoadjuvant treatment with two cycles of gemcitabine and nab-paclitaxel prior to surgery. PET scan was performed before and after treatment. All the specimens were evaluated to assess TRR (Ryan score). Results There were two well differentiated neuroendocrine carcinomas and 1 Pan IN-2 that were excluded and 9 adenocarcinomas. Five out of these nine patients underwent biliary stenting prior to chemotherapy. Eight patients presented TRR 0-1 (absence of cancer cells or isolated ones) and the remaining showed TRR 3 (extensive residual cancer) SUV decreased in all patients included with a median of 40.61% SUV (p = 0.004). The four cases with TRR 0-1 and biliary stent presented a decrease of 25.66%; the four cases with TRR 0-1 without biliary stent, 57.20%; and the TRR 3 case with biliary stent, 44.51%. Conclusions The neoadjuvant regimen Nabpaclitaxel/Gemcitabine has shown a 40% average decrease in SUV values ​​in 89% (8/9) of the cases. The smaller decreases in the SUV were due to the placement of an endobiliar stent during neoadiuvancy. However, PET is not predictive of TRR as we have obtained similar decreases in patients with higher (TRR 0-1) and lower (TRR 3) degrees of tumor regression.

219

Abstracts

29.14 Metabolic response assessed by PET scan in resected pancreatic adenocarcinoma after neoadjuvant treatment with Nabpaclitaxel/Gemcitabine

Abstracts

Daniel Galun1,5, Wilfried Tröger2, Marcus Reif3, Agnes Schumann3, Nikola Stankovic4, Miroslav Milicevic1,5 1 Clinic for Digestive surgery, Clinical center of Serbia, Belgrade, Serbia, 2Clinical Research Dr. Tröger, Freiburg, Germany, 3Institute for Clinical Research, Berlin, Germany, 4CLINICOBSS, Nis, Serbia, 5Medical School, Belgrade, Serbia

29.15 Viscum album [L.] extract therapy versus no antineoplastic therapy in patients with locally advanced or metastatic pancreatic cancer: a randomized confirmatory clinical trial (ISRCTN 70760582).

Objectives To compare overall survival (OS) and quality of life (QoL) of patients with locally advanced or metastatic adenocarcinoma of the pancreas receiving Viscum album (L.) (VaL) or no antineoplastic therapy. Method The efficacy of VaL(Iscador®Qu special) was tested by a randomized clinical trial including 220 patients. Primary endpoint was OS observed over 12 month. Secondary efficacy parameters included all15 QoL-dimensions of the EORTC QLQ-C30.Tumour-related symptoms and body weight wererecordedat each visit Results Median OS of VaL versus control was 4.8 vs. 2.7 months (HRadjusted=0.485; p<0.0001).A significant advantage of VaL was observed for13 of the 15 QoL dimensions(p£0.001), with 10 dimensions showing a clinically relevant improvement of≥ 10 units. Analysis of tumour-related symptoms, and change in body weight (posthoc),confirmed the favourable effects on QoL. No VaL-related adverse event (AE) or serious AE were observed. Conclusions VaL therapy led to a relevant increase of OS and quality of lifewithout causingany side-effects.VaL may provide acomprehensive second-line therapy for advanced pancreatic cancer patients.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
220

E-AHPBA

Indika Bandara, Sudip Sanyal, Santhalingam Jegatheeswaran, Aali Sheen, Ajith K Siriwardena Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK Objectives Management of cystic tumours of the pancreas is controversial. International criteria recommend surgical resection of larger cystic tumours as they carry a risk of malignancy. Traditionally, small lesions ≤ 3cm could  be managed non-operatively. However, several recent reports attest to a high risk of malignancy in these small lesions. The objective of this study is to evaluate the natural history of small ≤ 3cm cystic lesions of the pancreas managed in the regional hepato-pancreato-biliary (HPB) service of the Manchester Royal Infirmary (MRI).    Method A prospective database of patients referred to the HPB service at MRI was created in 2008. Data were collected prospectively for new patients and retrospectively for patients who were already in the system. Information was collected on mode of presentation, investigations used to characterise the cysts, management and outcome. Results Ninety-nine patients were included in the cystic tumour database. Forty-five (45%) had lesions that were ≤ 3cm in size. A definitive diagnosis of side branch papillary mucinous cystic tumour (IPMN) was established in 24/45 (53%) by a combination of CT, MRI, and EUS-FNA. Twenty (47%) were other cystic tumours. Resection at the time of presentation was undertaken in 1 side branch IPMN for a final histological diagnosis of high grade dysplasia. During a median (range) period of 32(7-115) months follow up none of the 23 evolved disease characteristics that required surgery.  There were no cancer-related deaths in these patients. Conclusions Accurate categorisation of small cystic tumours of the pancreas is difficult. However, in true side branch IPMN over nearly 3 years follow up the cancer risk is very low. Unanswered questions remain about the longer-term behaviour of these tumours.

221

Abstracts

29.16 Very low cancer risk in small branch duct intraductal papillary mucinous neoplasms (BD-IPMN) managed by an initial non-operative surveillance strategy.

Abstracts

29.17 The 2 layers pancreaticojejunostomy after pancreaticoduodenectomy decreases the rate and gravity of pancreatic fistula  
Béatrice Aussilhou, Safi Dokmak, Fadhel Samir Ftériche, Alain Sauvanet, Jacques Belghiti Beaujon Hospital,Departement of HBP surgery and liver transplantation, Clichy, France

Objectives The best pancreatic anastomosis after pancreaticoduodenectomy (PD) is not well defined. Our aim was to compare one and 2 layers pancreaticojejunostomy (PJ) performed by a single experienced pancreatic surgeon in a referral centre. Method from January 2009 to August 2012, one hundred patients underwent PD, including one group with PJ one layer (A1, n=50) and another group with PJ 2 layers (A2, n=50). There was no pancreatic duct stenting and the 2 groups (A1 vs A2) were similar in terms of age, sex, BMI, underlying pancreatic disease, texture of the pancreas and size of the main pancreatic duct. These two groups were compared in terms of rate of pancreatic fistula (PF), mortality and duration of hospital stay. PF was defined according to ISGPF. Results Comparison of  (A1 vs A2) showed similar mortality (0% vs 2%). PF rate (42% versus 12%, p<0,01), severity (67% vs 35%, p<0,01) and hospital stay (23 versus 15 days, p<0,0001) were significantly lower in the 2 layers group (A2).   Conclusions This study showed that the 2 layers PJ is associated with a lower rate of pancreatic fistula and a shorter hospital stay.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
222

E-AHPBA

Zoran Petrovic, Nebojsa Manojlovic, Dino Tarabar, Radoje Doder Dept. of GI Oncology, Clinic of gastroenterology, Military Medical Academy, Belgrade, Serbia

Objectives Background: Surgical resection is standard of care for patients with liver metastases from colorectal cancer, but only 15% to 30% patients could be underwent to surgery. Therefore most of the patients received systemic chemotherapy. We evaluate the effect of systemic chemotherapy with CapOx in combination with bevacizumab in patients with liver metastases from colorectal cancer.   Method Methods: 56 patients with colorectal cancer liver metastases were analysed in an retrospective study. All patients received Oxaliplatin 130 mg/m2 i.v. D1 and Capecitabine 1000 mg/m2 D1-D14 with Bevacizumab 7,5 mg/kg i.v. D1. The cycles were repeated every 3 weeks. Operability was assessed every four cycles. All patients were analysed for KRAS mutation status.   Results Results: Median follow-up was 28 months. RR was 71%. PFS was 10.6 months. After chemotherapy 14 patients were underwent to surgery. OS was 23 months. G12D and G13D were most common KRAS mutation. The most common toxicity are neuropathy in 25%, hand-foot sy in 14%, and diarrhoea in 12% of patients.   Conclusions Conclusion: The results of the study shows that adding bevacizumab to systemic chemotherapy with CapOx improve response and survival in all KRAS wt and KRAS mt patients with liver metastases from colorectal cancer. The type of KRAS mutation had no effect on response to chemotherapy

223

Abstracts

30.1 Neoadjuvant chemotherapy capox plus bevacizumab in patients with liver metastases from colorectal cancer

Abstracts

30.2 Is it safe and effective to perform repeated hepatectomies in a small-volume center ?
Raffaele Dalla Valle, Bianchi Giorgio, Iaria Maurizio Department of Surgery – Parma University Hospital, Parma, Italy

Objectives Repeated hepatectomies for colorectal liver metastases (CLM) are considered safe but are  mostly carried out in highly specialized hepato-biliary units . Aim of this study was to review the outcomes of re-hepatectomies in the setting of a general surgery Division and to compare them with the data included in  Livermetsurvey. Method We made a retrospective analysis of all comers who underwent liver resection for CLM between January 2002 and December 2011 in our General Surgery Department. Postoperative outcome was analyzed and compared with a control group of single hepatectomies. Three-year survival rates were calculated by Kaplan-Mayer method. The differences in morbidity and mortality between the single-only and the repeated hepatectomies cohort were exhibited through the chi-square test. Our data were compared with the Livermetsurvey Registry. Results 74 patients underwent 101 hepatectomies for CLM. 20(27%) patients received 27 repeated hepatectomies for recurrent metastases, 17 had a second hepatectomy, 2 underwent a third hepatectomy and 1 had a fourth procedure. Postoperative mortality was 1,3% after first hepatectomies and nihil after repeated resections. No difference in terms of mortality was observed between first and second hepatectomies (p=0.79). Postoperative morbidity after the first hepatectomy was 16%, while with repeated resections reached 30%. (p=0.3) The three-year overall survivals after the first and the repeated hepatectomies were respectively 61% and 39%, similar to the data reported by the  Livermetsurvey Registry (61% and 58%). Conclusions Repeated hepatectomies for colorectal liver metastases may be performed safely in a relatively low-volume center with good outcomes. The survival rates are equivalent to those reported by Livermetsurvey.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
224

E-AHPBA

Krstina Doklestic1,2, Aleksandar Karamarkovic1,2, Natasa Milic1,3, Milos Bracanovic2, Sasa Kovacevic2 1 Faculty of Medicine, University of Belgrade, Serbia, Belgrade, Serbia, 2Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade, Serbia, 3Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia Objectives The Glissonean pedicles can be approached intrahepatically or extrahepatically. The aim of this randomized clinical trial was to analyze the safety, efficacy, amount of hemorrhage and  postoperative outcome of two different techniques of liver resection. Method Ninety-two patients with hepatic tumours in non-cirrhotic liver, undergoing hepatectomy were randomly selected for Glissonean approach (GA, n=46) and Hilar dissection (HD, n=46). The classic hilar approach involved the dissection of the appropriate branch of the portal vein, hepatic artery, and the hepatic duct outside the liver. The “glissonean” approach and stapling of pedicle included the dissection of the whole pedicle directly after liver transection. Ultrasonic dissector Cavitron Ultrasonic Surgical Aspirator (CUSA) was used for liver transection. Primary endpoints were surgery duration, transection duration, intraoperative blood loss and blood transfusion. Secondary endpoints included the postoperative morbidity and mortality. Results The groups were equally matched for sex, age,  Child-Pugh score, number of liver tumoral lesions and type of liver resection. The GA was associated with significantly shorter surgery duration (165.08±31.10 vs. 218.32± 46.45) and  transection time (35.64±15.56 vs. 55.32±20.40) ( p<0.001 for all). The amount of blood loss was significantly lower in GA (200.59±139.19 vs. 310.60±155.25; p=0.018). The amount of blood transfusion was significantly lower in GA during surgery (305.86±103.08 vs. 420.76±125.58) as well as postoperatively, than HD (206.67±8.77 vs. 356.67±116.35) ( p=0.038 and p=0.026 respectively). These two techniques produced similar outcome in terms of  postoperative hospital stay, postoperative complications and mortality. Conclusions Liver resection can be performed more easily using the GA than by HD. Glissonean pedicle approach   and transection of pedicles using endo-GIA vascular stapler is safe, associated with lower blood loss and shorter transection time.

225

Abstracts

30.3 “Glissonean” pedicle approach vs classic extrahepatic hilar approach in liver resections.

Abstracts

30.4 Suprahepatic vein or vena cava reconstruction after hepatectomies - always a good decision?
Octav Ginghina, Geert Roeyen, Dirk Ysebaert, Kathleen De Greef, Bart Bracke, Vera Hartman, Stijn Heyman, Thiery Chapelle University Hospital, Antwerpen, Belgium

Objectives  A retrospective study to see if removal and reconstruction of suprahepatic vein or vena cava was always the right decision, when we considered that necesary during hepatectomies.   Method  We reviewed our statistic for the last three years and found 11 cases where we did a hepatectomy with retrohepatic vena cava or suprahepatic vein removal . Our decision was based on preoperatory imaging srudies and intraoperative findings.   Results For most of the patients the anatomo-pathological results supported our decision. We also analyse the relation between the postoperative evolution and the reason for the extended vascular resection. Conclusions As much as vena cava reconstruction has an established place in some oncological settings, suprahepatic vein reconstruction remains an controversial decision in some situations.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
226

E-AHPBA

Wladimir Faber1, Martin Stockmann1, Timm Denecke2, Cosima Schirmer1, Andreas Möllerarnd1, Johannes Kruschke1, Bruno Sinn3, Eckard Schott4, Fritz Klein1, Peter Neuhaus1, Daniel Seehofer1 1 Department of General-, Visceral- and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany, 2Department of Radiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany, 3Department of Pathology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany, 4Department of Gastroenterology and Hepatology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany Objectives Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. It is now well accepted that liver transplantation is the best therapy in case of HCC in cirrhosis. However, this therapy is limited to patients below 65 or 70 years of age. Liver resection is the alternative established treatment with curative intent. However, the long term outcome is limited by a high tumor recurrence rate. Purpose of this study was to define the outcome and potential prognostic factors after hepatic resection in older patients with HCC in liver cirrhosis in comparison with younger patients. Method From January 2000 to September 2010, 141 patients with liver cirrhosis and without extrahepatic metastases underwent curative-intent hepatic resection for HCC.  Patients with fibrolamellar HCC were excluded from the analysis. Results The 1-, 3- and 5-year cumulative survival rates were 78.5%, 56.5% and 47.1 % by patient age below 70, and 59.9%, 40.3% and 6.7% by patient age over 70. In the multivariate analysis, cumulative survival was impaired by patient age, Clavien grade, positive lymph vessels, intubation and BMI. Perioperative mortality was high in old-age patients with cirrhosis (72,7 % overall hospital mortality). In recent years liver function could be judged more reliably. However, the long term outcome of old-age patients is still markedly impaired, since many of the patients died due to non liver specific causes. Conclusions According to our experience and the current literature, liver resection is currently accepted as the best curative treatment today besides liver transplantation. However, the cumulative survival is limited, special by patient age over 70.

227

Abstracts

30.5 Significant impact of patient age on outcome after liver resection for HCC in cirrhosis

30.6 Left hepatic trisectionectomy: Improving results with increasing experience. Abstracts

Alan White, Shahid Farid, N. Khan, Ernest Hidalgo, Giles Toogood, Raj Prasad, JPA Lodge HPB and Transplant, St James’s University Hospital, Leeds, UK Objectives Left hepatic trisectionectomy (LHT) is the most challenging major anatomic hepatectomy with a high complication rate. We report our experience of 111 consecutive patients undergoing LHT for hepatobiliary malignancy. We analyse factors associated with morbidity and mortality and examine changes over time. Method Short and long-term outcomes of 111 patients who underwent LHT from January 1993 to March 2012 were analysed. Of the 111 patients 55, 20 and 14 had colorectal liver metastasis (CRLM), hilar and intrahepatic cholangiocarcinoma respectively. Multivariate analysis was used to identify independent predictors for postoperative morbidity and mortality. Results Median age was 59 years and hospital stay was 13 days. Overall perioperative morbidity was 45%. 90-day mortality was 12%. Hepatic vascular exclusion (HVE) and blood transfusion were identified as positive independent predictors for postoperative morbidity. Blood transfusion was a positive independent predictor for 90-day mortality. Time period analysis revealed a decreasing trend in blood transfusion, morbidity in the last 5 years. Mortality in the last 8 years of the study was 2%. Overall one and five year survival was 69% and 26%. Outcomes were significantly better for LHT for CRLM compared to cholangiocarcinoma. Conclusions This series highlights the association between blood transfusion and HVE with greater morbidity and blood transfusion as an independent prognostic indicator of 90-day mortality. Overall survival and survival according to tumour type was comparable to published data. Our results support LHT as an effective treatment for significant tumour burden.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
228

E-AHPBA

30.7 Macroscopic endobiliary invasion of colorectal metastases: is it really that friendly?

Objectives While colorectal liver metastases (CLM) with macroscopic endobiliary growth remain poorly described, they are thought to be of favorable oncologic prognosis. The objective of the present study was therefore to assess whether the endobiliary nature of these lesions actually influenced both operative results and long-term outcomes following major liver resection.   Method Among 257 patients undergoing major hepatectomy for CLM between 2000 and 2011, 12 (4.7%) displayed macroscopic endobiliary growth (B+). All endobiliary lesions occurred more than 12 months after resection of the primary lesion at a median time of 68.5 (13-144) months. Preoperative characteristics, clinical risk score (CRS) as well as short and long-term outcomes of these patients were therefore compared to that of the 62 other patients without macroscopic endobiliary invasion (B-) undergoing major hepatectomy for metachronous CLM during the same period. Results While both groups shared similar demographic  characteristics, B(+) patients had lower CRS (1 vs.2, p=0.007), displayed more often cholestasis (92%vs.44%, p=0.002) and jaundice (50% vs.3%, p<0.001), underwent more frequently biliary drainage (25% vs.0%, p<0.001) and required more hepaticojejunostomy (75% vs.0%, p<0.001) and portal reconstruction (25%vs.6%, p=0.044) than B(-) patients. Even-though postoperative mortality was similar between both groups (8% vs.3%, p=0.411), the existence of a macroscopic biliary invasion was associated with the occurrence of major complications on multivariate analysis (OR:5.6, p=0.017). One, 3 and 5-year overall survivals were similar (92% vs.97%, 78% vs.69% and 39% vs.39%, p=0.621) between both groups.   Conclusions Despite lower clinical risk score, patients with macroscopic endobiliary invasion of colorectal metastases do not seem to have a better long-term outcome than those with classical non-endobiliary metachronous CLM. Furthermore, the operative risk associated with macroscopic endobiliary invasion jeopardizes the postoperative results and should not be underestimated.

229

Abstracts

François Cauchy, Sebastien Gaujoux, David Fuks, Mathilde Cohen, Valerie Paradis, Safi Dokmak, Olivier Farges, Maxime Ronot, Jacques Belghiti Beaujon Hospital, Clichy, France

Abstracts

30.8 R1 resection by necessity for colorectal liver metastases. Is it still a contraindication to surgery?

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives R0 resection is the gold standard in the surgical treatment of colorectal liver metastases (CLM) but sometimes can only be performed through R1 resection. Chemotherapy may have changed long-term outcome after R1 resection. We compared R0 (negative margins)/R1 (positive margins) liver resections for CLM treated by an aggressive approach. Method Prospective data from 250 resected patients (R0/R1) for synchronous/metachronous CLM from 2004 were retrospectively analyzed, managed by a multidisciplinary team in a tertiary hospital. Exclusion criteria were macroscopic incomplete (R2) resection. Patients were divided according to their surgical margin status into a R0 (≥1 mm.)/R1 group (<1 mm.). Categorical variables were compared by χ2-test and continuous by independent-samples T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by log-rank test between groups. Univariate and multivariate analyses were performed, using log-rank test and Cox-proportional hazard-model, respectively. SPSS™ 15.0, p-value <0.05. Results Of 250 patients, 85.2% underwent R0-resection and 14.8% underwent R1-resection of whom 24.3% intrahepatic, 18.9% extrahepatic and 13.5% intra-extrahepatic recurrence. After a mean follow-up of 27 months, 3-5-years OS were for R1 and R0-patients 57.3 vs 62.3 and 50.2 vs 54.6%, respectively (p=0.806). Three-5-years DFS were for R1 and R0-patients 26.6 vs 43% y 22.2 vs 30.5%, respectively (p=0.051). In multivariate analysis, R1-resection was not independent predictor of poor OS but R1-resection was linked with increased recurrence or decreased DFS (Hazard Ratio [HR]=1.498; p=0.044). Our policy is the same like others groups and we derivate R1-patients for adjuvant chemo. Conclusions Despite a higher recurrence rate, the contraindication of R1-resection should be revised in the current era of effective chemotherapy because survival is similar to that of R0-resection. Long-term outcome after R1 resections should no longer be considered as poor as observed after R2-resections, but closer to R0-resections.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
230

E-AHPBA

Toine M. Lodewick1,3, Mechteld C. de Jong1, Ronald M. van Dam1,3, Ulf P. Neumann2,3, Cornelis H.C. Dejong1,3 1 Department of Surgery, Maastricht University Medical Centre & Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands, 2Department of Surgery, University Hospital Aachen, Division of General, Visceral and Transplantation Surgery, Aachen, Germany, 3Euregional HPB Collaboration Aachen-Maastricht, Aachen, Germany - Maastricht, The Netherlands Objectives The impact of post-operative complications on long-term outcomes after surgery for colorectal liver metastasis (CRLM) remains controversial. During the last decade, advances in surgical as well as non-surgical treatment have increased resectability and altered outcomes. We sought to determine the influence of post-operative morbidity on disease-free and overall survival. Method  Between 2000 and 2012, 266 patients underwent surgery for CRLM at our institution. Therapeutic, operative and outcome data were prospectively collected and subsequently analysed. Post-operative morbidity was classified according to Clavien grade. A Clavien grade ≥3a was considered as a major complication. A liverspecific-composite-endpoint, comprising ascites, postresectional-liver-failure, bile-leakage, intra-abdominal haemorrhage and intra-abdominal abscess, was utilized to assess outcome. Patients who died within 90 days following surgery were excluded from the current study. Relevant clinicopathologic variables associated with disease-free and overall survival were examined using univariate analysis and, where applicable, multivariable Cox proportional hazards regression.   Results Of the 266 patients, 88 patients (33.1%) developed post-operative morbidity, of whom 55 (20.7%) had major complications. Patients who developed complications more often had bilateral metastases, more operative blood loss, longer operative time and were less likely to receive adjuvant chemotherapy (all p<0.05). Overall, the median disease-free and overall (5-year) survival were 17 and 53 months (42.1%). The occurrence of post-operative morbidity or liver-specific-composite-endpoint did not shorten overall (p=0.16;p=0.59) and disease-free survival (p=0.07;p=0.30). However, the presence of positive primary colorectal lymph nodes (HR:1.64;p=0.02), >3 liver metastases (HR:2.01;p<0.01) and concomitant extrahepatic disease (HR:2.26;p<0.01) were found to adversely impact overall survival.   Conclusions While a considerable number of patients develop post-operative morbidity after surgery for CRLM in a modernday cohort, the occurrence of post-operative complications does not seem to influence the long-term outcome adversely.  

231

Abstracts

30.9 Post-operative Morbidity Following Surgery for Colorectal Liver Metastasis: Effects on Long-Term Outcome

Felix M. Watzka1, Christiane Laumen1, Philipp Kaudel1, Arno Schad3, Christian Fottner2, Matthias M. Weber2, Hauke Lang1, Thomas J. Musholt1 1 Clinic of General, Visceral- and Transplantation Surgery; University Medical Center University Mainz, Mainz, Germany, 2Endocrinology and Metabolic Diseases; University Medical Center University Mainz, Mainz, Germany, 3 Institute of Pathology; University Medical Center University Mainz, Mainz, Germany Objectives  Due to their rarity and heterogeneous biological behavior, the optimal treatment of advanced PNENs is still debated. Especially the indication of surgical treatment of hepatic metastasis is often challenging. Helpful prognostic factors and new classification systems exist but their value has to be confirmed in prospective trials. Method  In a retrospective single-center study (1990 to 2012), 127 patients with PNENs were included. 79 patients (62%) were diagnosed with stage I or II, 48 patients (38%) with stage III or IV. 19 of 24 patients (79.2%) with liver metastasis (stage IV) underwent hepatic resection. The appearance of hepatic metastasis, tumor stage, Ki-67 index, hormonal activity and the type of resections of the primary as well of hepatic metastasis were analyzed to evaluate successful treatment strategies.   Results   The Ki-67 index showed a significant influence on the overall survival. Surgical interventions according to the primary site consisted of 50 enucleations, 55 distal resections, 15 partial duodenopancreatectomies and 7 explorations with tumor debulking. In case of hepatic metastasis 11 times a non-anatomic liver resection was performed, a segmental liver resection in 4 patients and in 4 patients a hemihepatectomy was carried out. Patients with an R0 resection (16) of their hepatic metastasis had a 5-year survival of 72.7%. Patients with R1/2 had a 5-year survival of 46.9%. In general patients with hepatic metastasis had a 5-year survival of 62.0%.   Conclusions Surgical intervention can reduce symptoms and improve the survival in patients with hepatic metastasis of PNEN and advanced tumor stage. In our study patients benefit from an R0 resection compared to R1 and R2 resection of liver metastasis, which therefore should be the aim of the surgical procedure chosen.  

31.1 Surgical treatment of hepatic metastasis of neuroendocrine pancreatic tumors

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
232

E-AHPBA

Luca Viganò1, Lorenzo Capussotti1, Real Lapointe2, Eduardo Barroso3, Catherine Hubert4, Felice Giuliante5, Jan Ijzermans6, Darius Mirza7, Dominique Elias8, René Adam9 1 Ospedale Mauriziano Umberto I, Torino, Italy, 2University of Montreal, Montreal, Canada, 3Curry Cabral Hospital, Lisboa, Portugal, 4Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium, 5Università Cattolica del Sacro Cuore, Roma, Italy, 6Erasmus University Medical Center, Rotterdam, The Netherlands, 7Queen Elizabeth Hospital, Birmingham, UK, 8Institute Gustave Roussy, Villejuif, France, 9AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France Objectives After liver resection (LR) for colorectal metastases (CRLM) about 60% of patients develop recurrence. If early recurrence (ER) occurs, the prognosis is uncertain and the patient management is still debated. To clarify ER incidence and risk factors, to assess its impact on prognosis and to identify the best ER management. Method All the patients included in the LiverMetSurvey registry undergoing LR between January 1998 and June 2009 were considered. Exclusion criteria were incomplete resection (R2), two-stage hepatectomy and 90-day mortality. ER was defined as any recurrence occurred within 6 months after LR. 6025 patients were included and analyzed. Results 2734 (45.4%) patients had recurrence, including 639 (10.6%) ERs. Independent risk factors of ER were: T3-4 primary tumor (p=0.0002); synchronous CRLM (p=0.0001); >3 CRLM (p<0.0001); 0-mm margin (p=0.003); associated intraoperative radiofrequency ablation (p=0.0005). Disease control by preoperative chemotherapy (complete/partial response) and postoperative chemotherapy reduced ER risk (p=0.003, p<0.0001). ER worsened prognosis: 5-year survival 27.0% vs. 49.4% if late recurrence (p<0.0001, median follow-up 34.4 months). 234 (36.6%) patients had ER resection. They had survival higher than non-re-resected patients (5-year survival 47.2% vs. 8.9%,p<0.0001), similar to re-resected ones with late recurrence (48.7%). Chemotherapy before ER resection improved later survival (61.5% vs. 43.7%,p=0.028). Conclusions After LR for CRLM, about 10% of patients develop ER (one quarter of recurrences). Aggressive disease and inadequate surgical treatment increase ER risk, while peri-operative chemotherapy reduces it. ER worsens prognosis, but re-resection should be systematically considered. Chemotherapy before ER resection is recommended to select the good candidates.

233

Abstracts

31.2 Early recurrence after liver resection for colorectal metastases: risk factors, prognosis and treatment. A LiverMetSurveybased study over 6025 patients

Abstracts

31.3 Survival Impact of Oxaliplatin-related sinusoidal obstruction syndrome in patients undergoing resection of colorectal liver metastases

Alan White, Gareth Morris-Stiff, Daniel Gomez, Shahid Farid, Ernest Hidalgo, Giles Toogood, Raj Prasad, JPA Lodge HPB and Transplant, St. James University Hospital, Leeds, UK Objectives  Sinusoidal obstructive syndrome (SOS) is a well-recognised side effect of oxaliplatin-based chemotherapy but the literature relating to the clinical significance of SOS is mixed. The aim of this study was to identify factors associated with the development of SOS, and to examine its influence on overall survival (OS).   Method Patients undergoing a first hepatic resection for colorectal liver metastases (CRLM) from January 2000 to December 2010 were identified from a prospectively maintained database and those with SOS identified for further analysis. Data analysed included: use of adjuvant chemotherapy; extent of hepatic resection; presence of co-morbidities; requirement for peri-operative blood transfusion; requirement for intensive care unit management; duration of hospital stay, post-operative morbidity; and mortality.   Results 65 of 978 patients developed SOS. Only chemotherapy was associated with the presence of SOS (p<0.001) with SOS in 65 of 316 (20.6%) patients. All 65 patients had received oxaliplatin-based chemotherapy. Analysis of the chemotherapy patients revealed a reduced overall survival (log rank (mantel-cox) p<0.05) in patients with SOS. A difference in overall survival was present for patients with SOS undergoing a major hepatic resection (≥ 4 hepatic segments) (p<0.001). There was no difference for patients with SOS who underwent minor resections compared with those with no SOS (p = 0.929). SOS had no impact on 90-day mortality.   Conclusions SOS is strongly associated with the use of chemotherapy with all cases of SOS in this subgroup of CRLM patients. The presence of SOS does appear to impact on patient on overall survival but only in those undergoing major hepatic resection.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
234

E-AHPBA

Fadhel Samir Ftériche1, Safi Dokmak1, Béatrice Aussilhou1, Alain Sauvanet1, Olivier Farges1, Olivia Hentic2, Philippe Ruszniewski2, Jacques Belghiti1 1 Beaujon Hospital, Departement of HBP surgery and liver transplantation, Clichy, France, 2Beaujon Hospital, Departement of Gastroenterology and pancreatic diseases, Clichy, France Objectives Evaluate the results of liver resection for neuro-endocrine liver metastases (NELM) in a tertiary centre.  Method Between 2000-2009, 70 patients underwent 115 liver resections for NELM, including 36 women with a mean age of 54 years (17-76). The primary tumour was of pancreatic origin in 53%, small bowel in 36%, indeterminate in 10% and lung in 1%. NELM were bilobar and metachronous in 65% and 24% of cases, respectively. Combined resection was necessary in 34 patients. Repeated hepatectomy was needed in 17 patients. Major hepatectomy was done in 52 patients (45%) and a hypertrophy procedure was necessary in 34 patients (48%). The postoperative mortality was observed in one patient with an overall morbidity rate in 53%.   Results The mean number and size were of 8.4 (1-31) and 3.5 cm (0.3-21), respectively. NELM were well differentiated in 83%, MIB≥ 5% in 37% and R0 in 44%. After a mean follow up period of 33 months (2-149), 39 patients (56%) presented recurrence and 3 died. The mean overall and disease free survival (DFS) were of 55 months (0-149) and 33 months (0-149), respectively. The 5 and 10 year global and DFS were of 93%, 87%, 52% and 17%, respectively. In multivariate analysis,  prognostic factors for recurrence or global survival were a MIB>5% or positive nodes of the primary.   Conclusions Resection of NELM give an excellent long term survival but the recurrence rate still very high justifying in some subgroup of patients at higher risk of recurrence, other therapeutic alternatives including  liver transplantation.

235

Abstracts

31.4 Liver resection for neuroendocrine liver metastases gives excellent long term survival but high recurrence rate.

Abstracts

31.5 Concomitant extrahepatic disease in patients with colorectal liver metastases. when is there a place for surgery? liver resection for metastatic colorectal cancer patients in presence of extrahepatic disease: results from a single-institutional analysis
VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain

Objectives The presence and the impact of the location of extrahepatic disease (EHD) on long-term outcomes are still diversely appreciated. We pretended to determine patient outcome in a consecutive series of patients with colorectal liver metastases (CLM) and synchronous/metachronous EHD treated by an oncosurgical approach, combining repeat surgery and chemotherapy. Method Prospective data from 250 resected patients for CLM from 2004 to 2012 were retrospectively analyzed (89, 36.6% had synchronous/metachronous EHD), managed by a multidisciplinary team in a tertiary hospital. Patients were divided according to the presence of EHD. Sequential surgery was routinely combined with perioperative chemotherapy. Categorical variables were compared by χ2-test and continuous by independent-samples T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by log-rank test between groups. Univariate and multivariate analyses were performed, using log-rank test and Cox-proportional hazard-model, respectively. SPSS™ 15.0, p-value <0.05. Results Patients resected for CLM with EHD (38.2%) experienced lower 5-year-survival than those without EHD (26.8% vs 76.3%, p<0.001). Patients with EHD resected (13.9%) experienced similar 5-year-survival than those without EHD (59% vs 76.3%, p=0.114). In the EHD group, patients with EHD-recurrence experienced better outcomes when resected than those treated by chemotherapy alone (5-year-survival: 59 vs 10.2%; p=0.001). EHD concomitant to CLM (6.6%) wasn’t poor factor OS (p=0.446). Two poor prognostic factors OS were identified at multivariate analysis: EHD-location lung vs peritoneum (5-year-survival: 67% vs 0%; p<0.001), EHD-recurrence less to 30 months from first hepatectomy was poor prognostic factor (p=0.009). Conclusions An aggressive oncosurgical approach for patients with CLM+EHD, yielded a 5-year survival rate of 26.8% for total-patient group. Best candidates are patients with isolated lung-metastases or CRC-recurrence. In case of EHD-recurrence, better survival rates are observed compared with no-resection, and long-term outcome is similar to patients who didn’t develop EHD-recurrence.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
236

E-AHPBA

Vladimir Vishnevsky, Michael Efanov, Ivan Kazakov AV Vishnevsky Institute of Surgery, Moscow, Russia

Objectives Liver resection remains the leading treatment for patients with metastatic colorectal cancer. However, longterm results of liver resections, despite their steady improvement over the past two decades, is estimated differently depending not only on years of research, but also from the clinic, the amount of research, the criteria for inclusion of patients.In this study, we aimed to evaluate long-term results of liver resection in patients with metastatic colorectal cancer, identifying the factors significantly affecting the prognosis and development on the basis of the prognostic score. Method We conducted a retrospective analysis 207 patients with colorectal liver metastases. The main group of patients was 155 (61%) liver resection of various sizes for metastases of colorectal cancer. Control group, 52 patients (21%) with unresectable colorectal liver metastases. The total number of major resection was 65 (47%), of whom 15 (23%) had extended liver resection. All major resections were performed in the anatomical variant. Postoperative complications were noted in 53% of cases, half of them wearing a specific character (biliary fistula, liver failure). Assessed up to 26 different prognostic factors of patients from the reference group Results Overall survival of patients undergoing resection of liver metastases of colorectal cancer (study group) were as follows: 3-year survival was 51%, 5-year survival was 41%, 10- year survival was 19.5%. Median survival - 36.9 months. Using multivariate analysis revealed significant adverse prognostic factors, such as: 1) the regional lymph nodes of the primary tumor 2) the number tumors ≥ 4  3) margin resection < 1 cm. 4) major liver resection. Conclusions Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver, with five-year survival rates up to 41%. However, in the group of patients who had adverse prognostic factor 3-4, the long-term results of surgical treatment did not produce significant benefit in survival, compared to patients receiving only chemotherapy. Thus, the solution of liver resection in these patients, apparently, should be taken after discussing the possibility of other treatments for metastatic colorectal cancer in the liver.  

237

Abstracts

31.6 Long-term results and prognosis of survival after liver resection in metastatic colorectal cancer

Abstracts

Aldrick Ruiz1,2, Edward Casto-Santa4, Carlos Castro-Benitez3,2, René Adam2 1 University Medical Center Utrecht, Utrecht, The Netherlands, 2Centre Hépato Biliair Paul Brousse, Villejuif, France, 3 Hospital México, San José, Costa Rica, 4Hospital Nacional de Niños, San José, Costa Rica Objectives The objective of this study was to analyze the possible benefit of multiple hepatectomies in the treatment of recurrent breast cancer liver metastases after initial hepatectomy. Method All breast cancer liver metastases patients between 1985 and 2012 who underwent liver resection at our center were screened for inclusion. Patients who had recurrent breast cancer liver metastases after first hepatectomy were selected and divided into a re-operated or not re-operated group. Clinicopathological data was prospectively collected and analyzed for survival and possible prognostic factors were investigated. Results Sixty-seven (48 %) out of the 135 operated patients had recurrence after first hepatectomy. Twenty-one (30%) patients underwent rehepatectomies of which 15 had a second recurrence. When comparing systemic treatment vs. rehepatectomies (2-4) together with systemic treatment, we found 32 months vs. 100 months median survival and 25% vs. 84% 5-year survival (log rank < 10-3). Median and 5 year disease free survival after rehepatectomy was 56 months and 32 % respectively. Three patients had a third hepatectomy and a single patient had four hepatectomies. Conclusions This current study shows that rehepatectomy should be considered as a valid strategy in recurrent breast cancer metastasis after initial hepatectomy.

31.7 Is there a place for multiple hepatectomies combined with systemic treatment for recurrent breast cancer liver metastases after first hepatectomy?

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
238

E-AHPBA

Mihajlo Đokić, Blaž Trotovšek, Dragoje Stanisavljević, Miha Petrič, Deja Gnezda, Valentin Sojar University Medical Center, Clinical department for abdominal surgery, Ljubljana, Slovenia Objectives As much as 30% of patients with primary colorectal carcinoma have liver metastasis at the time of presentation.  We present retrospective analysis of simultaneous liver and colorectal resections performed on our institution from 2008 to 2012. Method Between 2008 and 2012 we performed 41 simultaneous liver and colon resection. Operations were performed by 3 highly experienced HPB surgeons. There were 63% of man and 37% of females in the study group, with average age of 60. 22% of the primary tumours were found during the screening test for colorectal cancer, and 78% because of the symptoms. The primary tumours were located in 12 % of cases in the right colon, , in 2,5 % in colon transversum, 35% in the left colon and sigma and in 40% in the rectum. Results Metastatic disease was limited to the right liver in 40% of the cases, to the left liver in 20% and on the both sides in 40%. The metastases were in one segment in 35% of the cases, in two segments in 27.5% and in three or more segments in 37.5%. 30% (12/40) of patients had received neoadjuvant therapy. Average length of hospital stay was 14 days, ranging from 5 to 61 days, 7 patients had prolonged hospital stay of more than 15 days ( stage IIIa and more by Clavien-Dindo classification). No early deaths occurred in our study. Conclusions Simultaneous resection does not increase the risk of postoperative complications; hospital stay is shorter if we compare it to the length of hospital stay of both resection of colon cancer and delayed resection of liver metastases.  

239

Abstracts

31.8 Simultaneous resection metastasis:  our  experience

for

colorectal

carcinoma

and

hepatic

31.9 LAPAROSCOPIC ASSISTED LIVER SURGERY THROUGHT MIDLINE LAPAROTOMY Abstracts

Patricia Sendino, Mikel Gastaca, Jorge Ortiz de Urbina, Mikel Prieto, Andres Valdivieso, Patricia Ruiz, Alberto Ventoso, Ibone Palomares, Alberto Colina Cruces Universitary Hospital, Barakaldo, Basque Country, Spain Objectives BACKGROUND: Liver surgery has evolved substantially over the past three decades as a result of better knowledge and application of liver surgical anatomy and  improved approaches to parenchymal transection. Furthermore, he evolution of laparoscopic surgery has performed during the last two decades. We present a laparoscopic assisted liver surgery by video.   Method We report the case of a 55 years-old woman underwent to right colectomy because of a right colon adenocarcinoma. In the postoperative CT scan there were 4 metastasis located in left lateral segment,  another superficial lesions in segment VI-VII and a central lesion in segment V. After nine chemotherapy cicles there was a parcial response. . It was decided making a laparoscopic assisted approach throught the previous midline laparotomy.   Results  We start doing a medial supraumbilical laparotomy. After that we performed an intraoperatory ultrasound to locate the lesions and the mobilization of the left liver lobe begins. Then, the gel-port is placed in the laparotomy and, two trocar ata right hypochondrium. The mobilization of the right lobe was performed by hand-assisted laparoscopy. Subsequently, the gel port is removed. The 2-3 bisegmentectomy and the metastasectomy of the 6-7 segment lesions were performed throught the laparotomy. Radiofrecuency was done in the 5 segment central lesion. Discharge took place the second postoperative day without complications.   Conclusions The minimally invasive surgery benefits patients in need of liver resection in several ways when compared with open resection The advantage of laparoscopy-assisted (or hybrid technique) liver surgery is that it does not require knowledge of any advanced laparoscopic techniques; thus, liver surgeons can perform it easily. In conclusion, a hybrid technique is safe and feasible and it serves as a bridge between open and totally laparoscopic hepatectomies.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
240

E-AHPBA

Isidoro Di Carlo1, Francesco Loria2, Giuseppe Loria2, Giuseppe Crea2, Salvatore Basile2, Luciano Frosina3, Alì Haghighi4, Paola Rodoni4 1 University of Medicine, Catania/Sicily, Italy, 2ASP 5, Reggio Calabria, Italy, 3University of Medicine, Messina/Sicily, Italy, 4EOC, Mendrisio/Ticino, Switzerland Objectives To compare the enhancement pattern of hilar cholangiocarcinoma on contrast-enhanced ultrasound (CEUS) and on contrast-enhanced computed tomography (CECT). Method 32 consecutive patients with pathologically proven hilar cholangiocarcinoma were evaluated by both low mechanical index CEUS and CECT. The enhancement feature of the tumor, hilar vascular infiltration and lesion conspicuity on them were investgated. Results In the arterial phase , the numbers of the lesions showing Hyperenhancement, isoenhancement and hypoenhancement, were 14(43.8%), 14(43.8%) and 4(12.6%) on CEUS, and 12(37.5%), 9(28.1%) and 11(34.4%) on CECT(p=0.162). In portal phase, the numbers of lesions showing hypoenhancement, isoenhancement and hyperenhancement were 30(93.8%), 1(3.1%) and 1(3.1%) on CEUS and 23(71.9%), 8(25%) and 1(3.1%) on CECT(p=0.46). The detection rates for portal vein infiltration were 84.2%(16/19) for baseline US, 89.5% for CEUS(17/19) and 78.9%(15/19) for CECT. CEUS improved lesion conspicuity in comparison with CECT. CEUS and CECT made correct diagnosis in 30(93.8%) and 25(78.1%) prior to pthological examinations (p=0.125). Conclusions The enhancement pattern of hilar cholangiocarcinoma was similar on CEUS and on CECT in arterial phase, whereas in portal phase hilar cholangiocarcinoma shows hypoenhancement more likely on CEUS. CEUS and CECT lead to similar results in evaluating portal vein infiltration and diagnosis of this entity.

241

Abstracts

P1 Enhancement pattern of hilar cholangiocarcinoma: contrast-enhanced ultrasound versus contrast-enhanced computed tomography

Abstracts

Isidoro Di Carlo1, Francesco Loria2, Giuseppe Loria2, Salvatore Basile2, Giuseppe Crea2, Luciano Frosina3, Alì Haghighi4, Paola Rodoni4 1 Dept. of Surgery Univ. of Catania, Catania/ Sicily, Italy, 2Dept.of Radiology PO Palmi, Palmi/Calabria, Italy, 3School of Medicine, Messina/Sicily, Italy, 4Dept. of Radiology EOC, Mendrisio/Ticino, Switzerland Objectives To investigate the correlation between enhancement patterns of intrahepatic cholangiocarcinoma (ICC) on contrast-enhanced ultrasound (CEUS) and pathological findings. Method The CEUS enhancement patterns of 40 pthologically proven ICCs were retrospectively analysed. Pthologically, the degree of tumor cell and fibrosis distributuion in the lesion was evaluated. Results 4 enhancement patterns were observed in the arterial phase for 32 mass-forming ICCs: peripheral rimlike hyperenhancement (19);heterogeneous hyperenhancement (6);homogenous hyperenhancement (3);heterogeneous hypoenhancement (4). Among the four enhancement patterns, the differences in tumour cell distribution were statistically significant (p<0.05). The hyperenhancing area on CEUS corresponded to more tumour cells for ICC. Heterogeneous hyper (2) and hypoenhancement (2) were observed in the arterial phase for 4 periductal infiltrating ICCs. In this subtype. fibrosis was more commonly found. Heterogeneous (1) and homogeneous (3) hyperenhancement were observed in the arterial phase for 4 intraductal growing ICCs. This subtype tended to have abudant tumour cells. Conclusions The CEUS findings of ICC relate to the degree of carcinoma cells proliferation at pathological examination. Hyperenhancing areas in the tumour always indicated increased density of cancer cells.

P2 Contrast-enhanced ultrasound of intrahepatic cholangiocarcinoma: correlation with pathological examination

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
242

E-AHPBA

Arunkumar Krishnan, Ravi Ramakrishnan, Jayanthi Venkataraman Stanley Medical College, Chennai, Tamilnadu, India

Objectives Different endoscopic modalities are available for the extraction of common bile duct stones. However, there is no clear consensus on the better therapeutic approach. The aim is to analyze the effectiveness of ‘interim’ plastic biliary stent deployment in difficult stones in elderly and high risk patients. Method Patients who had co-morbid illness and elderly patients who are not fit for surgery were included. Endoscopic plastic biliary stenting was performed in 65 patients with large and/or multiple common bile duct stones or those difficult to extract with conventional endoscopic therapy.  Liver function test was done before and after procedure. Bile duct drainage and endoscopic placement of 7 Fr plastic biliary stents were established in all patients. The diameters of the CBD stones were measured on the radiographs before and after stenting.   Results 22 patients has multiple CBD stones (>3) and 46 patients had large stones (>2cms).  Stone retrieval was possible, after a median of 24 days. All patients had reductions in the stone number and/or stone size.  In 18 patients there was spontaneous clearance of the stones. The median number and size of stones per patient was significantly reduced after biliary stenting compared with before {5 (3) vs 2.0 (1.0) [P <0.0001]} and {2.8 (1.5) to 2.0 (1.0) [P< 0.001]} respectively. All the stones were black and amorphous in consistency. Liver function test also showed a significant improvement after stenting p<0.00001.   Conclusions Plastic biliary stenting is safe and effective in the management of difficult stones in elderly and high risk patients. It may fragment common bile duct stones and decrease stone sizes. Unlike the reports for cholesterol stones, shorter period of deployment is sufficient for pigment stones, because these are either black or mixed and are amorphous, unlike the hard cholesterol stones reported for hard cholesterol stones.

243

Abstracts

P3 Management of difficult common bile duct stones using plastic biliary stent in elderly and high risk patients

Abstracts

Olusegun Alatise1, Oladejo Lawal1, Adewale Adisa1, Adeolu Arowolo1, Oluwagbemiga Ayoola2, Augustine Agbakwuru1 1 Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria, 2Department of Radiology, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria Objectives We audit the management and management outcome of gallbladder cancer in our hospital, highlighting peculiarity associated with our setting. Method Consecutive patients managed as cases of gallbladder cancer at Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria between January 1990 and October, 2012 were studied retrospectively. Results 45 cases of gallbladder cancer were diagnosed over the 23 year period and this accounts for about 0.2% of all cancer cases seen in our hospital. The median age of this patient cohort was 58 years. 25 (55.6%) patients were age below 60 year. 11 patients underwent complete resection as they had radical cholecystectomy. The stages of the resected patients were T3 in 8 patients and 3 T2. Overall 1- year and 5-year survival rates for our entire patient cohort were 69% and 20%, respectively. Addition of chemotherapy such as gemcitabine and cisplastin improve survival in stage 4 cases. Conclusions This study showed that good outcome can be obtained when radical surgeries in combination with standard chemotherapy are offered to these few patients within the limitation of resources in few patients with resectable tumor.

P4 Audit of management of gall bladder cancer in a Nigerian tertiary health facility

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
244

E-AHPBA

P5 A Case of Choledochocele Unclaasifiable by Sarris’s Classification Abstracts
Kenji Sasaki Tome Municipal Hospital of Toyosato, Tome, Japan

Objectives Choledochocele is an extremely rare congenital anomaly, engendering sometimes pancreatitis, obstructive jaundice, and rarely intracystic carcinoma.  It is classified according to its anatomical relationships among the common bile duct (CBD), main pancreatic duct (MPD), and papilla of Vater.  This report presents a case of choledochocele not covered by Sarris’s classification. Method A 74-year-old Japanese housewife was incidentally shown to have a large, smooth-surfaced, subpedunculated tumor covered with the normal duodenal mucosa on the medial wall of the mid descending part of the duodenum immediately oral to the papilla of Vater at the location of the oral protrusion by esophagogastroduodenoscopy.  Though suffering from post-hepatitic cirrhosis due to hepatitis C virus (HCV) after given blood transfusion, when she underwent hysterectomy for myoma uteri, she had no history or complaints suggestive of pancreatobiliary diseases.  Laboratory data showed mild liver dysfunction, pancytopenia and high-titered circulating 1b-typed HCV RNA but no hyperamylasemia or hyperbilirubinemia. Results ERCP demonstrated the normal main and accessory pancreatic ducts.  Just after abruptly contracted, the terminal CBD showed a piriform dilatation correspondent to the duodenal tumor, tapering off to drain into the duodenum without forming the common channel but through the same papillary orifice with the MPD.  She was diagnosed with choledochocele unclassifiable by Sarris’s categorization.  As the duodenal wall around and anal to the papilla was swollen by infusion of contrast medium into the CBD, the choledochocele was less expanded in the usual state.  Even fully distended, it did not compress the MPD.  Remaining asymptomatic, the lesion was left untreated. Conclusions The present case was unclassifiable by Sarris’s classification.  Though might cause bile stagnation, this choledochocele would not induce pancreatitis due to obstruction of the MPD or malignancy due to pancreatobiliary reflux through pancreatobiliary malunion.  It is important to scrutinize the anatomical relationships among the structures in predicting development of complications.

245

P6 an unexpected complication of hydatid cyst of liver Abstracts

Ihsan Birol, Omer Vedat Unalp, Alper Uguz, Taylan Sezer, Tayfun Yoldas, E. Murat Sozbilen, Ahmet Coker Ege University Department of General Surgery, Izmir, Turkey Objectives Hydatid cyst disease of the liver can present with many different symptoms. Biliary obstruction and rupture of the cyst to biliary tract are frequent presentations. A patient with an extraordinary course of the disease has been presented. Method We report an unexpected reason for biliary leak as a result of hydatid cyst perforation to the biliary tract in a patient whom admitted with acute abdominal pain. Fifty three years old female patient admitted emergency room with severe abdominal pain and diffuse abdominal tenderness. Results At admition, the patient had elevated hepatic functional tests and bilirubin and leukocytosis, all other laboratory studies were within normal  ranges. Computerized tomography demonstrated a 9x5 cm mass  resembling hydatid cyst in segment 8. There was severe biliary ductal dilation of the right lobe due to compression of the mass and subcapsular fluid collection. No considerable amount of free fluid in the abdomen and extrahepatic biliary ducts appeared to be normal. Surgical exploration revealed rupture of the hydatid cyst to biliary tract and bile leak from a dilated periphery duct adjacent to falciforme ligament. Cystotomy and choledochotomy (t-tube insertion) were performed. Postoperative course was uneventful. Conclusions Improvement in imaging techniques provided surgeons the comfort of preoperative diagnosis and therefore a planned surgery; however, many details can only be manifested during surgical exploration. Awareness of the surgeon to every probability and careful exploration is essential for an adequate surgical management. Biliary leak secondary to obstruction due to hydatid cyst disease is an unexpected course of disease which may lead to inadequate surgery if remains unnoticed during surgery.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
246

E-AHPBA

Kostas Katsaros, John Massalis, Eleni Pagoni, Fyllis Lazaridou, Efi Papadema, Eleonora Avramopoulou, Rosina Chalkia, Despina Kriketou, Panos Gkanas The general hospital of Nafplion, Nafplion Argolis, Greece

Objectives Background: After the initial treatment and resuscitation, patients with billiary pancreatitis can undergo laparoscopic cholecystectomy (LC) upon admission if pancreatitis is mild (three or fewer Ranson’s criteria) and controllable. Objectives: The management and outcome evaluation of early LC in patients with mild billiary pancreatitis.   Method Patients and methods: 98 patients (41 males, 57 females, aged 37-85 years) were admitted between 2003 to 2012 with billiary pancreatitis were studied retrospectively. All the patients suffered from epigastric pain accompanied by  elevated serum amylase (three times above the normal range) and ultrasound findings compatible with acute pancreatitis, gallbladder microlithiasis or sludge. Following the clinical and laboratory impovement and according to the findings, patients were subject to either preoperative ERCP (common bile duct larger than 8 mm) or LC. The surgery was performed 10-15 days after their admission. Results Results: LC was done successfully at 92 patients, while 4 high risk patients underwent percutaneous cholecystostomy and 2 conversion due to active inflammation in the area of  the Calot triangle. 15 patients underwent preoperative ERCP and followed of succesful removal of stones from the common bile duct and 1 single patient referred for postoperative ERCP due to cystic bile leak. There were no systemic complications or other iatrogenic complications related to the extrahepatic bile ducts. Conclusions CONCLUSIONS: Patients suffering from mild gallstone pancreatitis after the initial clinical and laboratory evaluation, stabilization and the classification as mild pancreatitis patients should be assessed by new u/s or ERCP due to the possible presence of calculi in the common bile duct. If there are no findings concerning the common bile duct, the serum amylase comes to normal and abdominal tenderness settles, those patients can safely proceed to LC. Following this procedure leads to high safety, saves resources and prevents a possible relapse of the disease in the future.

247

Abstracts

P7 Mild billiary pancreatitis and early laparoscopic cholecystectomy in our hospital J. Massalis, E. Pagoni, F. Lazaridou, E. Papadema, E. Avramopoulou, K. Katsaros, R Chalkia, D. Kriketou P. Gkanas. Department of Surgery, General Hospital of Nafplion, Greece

P8 Same day surgery for laparoscopic cholecystectomy Abstracts

Alexandra Tsaroucha, Nikos Mpoltsis, George Evaggelou, George Panousis, Nikos Kalochristianakis, Vasilios Mpoursinos, Constantinos Mavrantonis Department of General Surgery, “Henri Dunant” General Hospital, Athens, Greece Objectives We investigate the possibility of one-day surgery in patients undergoing laparoscopic cholecystectomy. Method 2028 patients (age 15 to 82; mean 56 years) underwent laparoscopic cholecystectomy. Four hours after surgery, iv fluids were discontinued and p.o. analgesics were administered based on each patient’s needs. A clear liquid diet was given. Patients were offered the option to leave hospital 9 hours after surgery with a detailed instruction leaflet. Patients with acute cholecystitis, or patients to whom a drain was placed at the end of the operation, were excluded from the study. Results 145 patients (7.15%) with no comorbidity have decided in favor of same day discharge (group 1). The remaining 92.85% were discharged the morning of the following day (group 2). There were no emergency readmissions from the first group. 44% of patients communicated by telephone for further instructions regarding mostly analgesia or nausea treatment. No differences were noted between the two groups, regarding quality of life, long-term outcome, complication rate, and patient satisfaction in one-month follow-up. A 70 to 240 Euro reduction in cost was achieved for the same day release group, which corresponds to approximately 10% of the total cost. Conclusions Same day hospital discharge is feasible and safe. A decrease in cost was achieved in this group of patients. Most patients, however, preferred to remain hospitalized for one day after surgery. The benefit of same day discharge is hospital bed availability, so that priority is given to emergency cases or patients needing longterm treatment.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
248

E-AHPBA

P9 Complex treatment of liver hilar tumor jaundice.

Objectives Primary and metastatic malignant liver and biliary tree tumors, hilar lymph nodules metastasis are caused the obstructive jaundice (OJ). The early elimination of biliary hypertension is a key treatment of OJ. Traditional surgical interventions on the OJ peak are accompanied of high mortality level (15-40%).  Mortality level decreases more than four times after preoperational elimination of jaundice. The study of our purpose was to define and optimize the strategy of minimal invasive surgery (MIS) methods in diagnostics and treatment of OJ in liver hilar tumor (LHT). Method From 2002 to 2012 y-s. complex treatment was performed in 69 adult patients with OJ caused by LHT. The bile ducts cancer was found in 49 patients, gallbladder cancer in 12 patients, metastatic cancer in 8 patients. The majority of patients was elder 60 y-s age, had concomitant pathology. In 60% of patients the OJ time was more than 1 month. In 80% of patients the bilirubin level exceeded 230 mkmol/l. The examination protocol included ultrasound (US), MRI with MRCP, CT, radionuclide scintigraphy of biliary tree, and whole body bones, endoscopy. Cholangiography used to be a stage of treatment procedure. Results Two-stage treatment of OJ used to be in LHT. 1 - biliary tree decompression by antegrade or retrograde method. Then the tumor location and resectability identification. 2 - radical resection or final decompression. Severe cholangitis was indication in only external biliary tree drainage without pass through the tumor in 10% patients. Radical procedure was performed in 20% patients. Post-OP mortality was 7%. The final decompression with MIS was performed in 80% patients with non-resectable tumors: antegrade stenting of bile duct in 43 patients, endoscopic retrograde stenting in 6 patients, endoscopic retrograde stenting into two lobe ducts in 6 patients. Conclusions The two-stage treatment strategy for severe OJ in LHT allows perform radical procedure in 20% patients, palliative stent placement in 80%. The stent placement in complex with chemotherapy improves life quality of patients with non-resectable tumors. So high number of patients with non-resectable tumors caused by admission in late stage of disease. Nevertheless the system and address chemotherapy allows have satisfactory quality of a life from 6 to 11 months.

249

Abstracts

M.S. Khubutiya1, K.N. Lutsyk1, À.N. Lotov1, S.À. Bugaev1, T.P. Pinchuk1, N.R. Chernaya1, Å.J. Pavlikova1, V.A. Sharifullin1, N.E. Kudrjashova1, A.V. Chzhao2 1 Emergency institute n.a. N.V. Sklifosovsky, Moscow, Russia, 2Institute of surgery n.a. A.V. Vishnevsky, Moscow, Russia

P10 SURGERY FOR COMMON BILE DUCT CARCINOMA Abstracts
Antonio Frena, Stefan Patauner Central Hospital of Bolzano, Bolzano, Italy

Objectives Carcinoma of the mid or distal third of the common bile duct is a fairly rare nosological entity in the Western world, accounting for 13-23% of tumours of the extrahepatic bile ducts. The surgical treatment varies in relation to the site: in the case of carcinomas of the distal common bile duct the operation of choice is duodenopancreatectomy, whereas for tumours of the mid common bile duct there is still no unanimous consensus of opinion regarding the type of surgery. The prognosis of these tumours is, on the whole, better than that of carcinomas of the proximal choledochus. Method We retrospectively assessed 37 patients with non-hilar extra-hepatic bile duct tumours observed in our surgery department  from 1990 to 2011. The patient series comprised 21 men and 16 women, with a mean age of 71 years. The presenting symptom was jaundice in 95% of cases. In 23 cases the carcinoma affected the distal common bile duct and in 14 cases the mid common bile duct. Results 15 patients were treated with a radial intent by either duodenopancreatectomy (13 cases) or by resection of the common bile duct (2 cases). Ten patients with local inoperability or liver metastases were treated with a palliative biliodigestive anastomosis. Twelve patients were excluded from surgery and treated endoscopically. Postoperative staging identified 1 patient as stage Ia, 2 patients as stage Ib, 8 patients as stage IIa, 3 patients as stage IIb, and 1 patient as stage III according to the new TNM classification. There was no operative mortality. Survival at 1, 2 and 5 years was 51%, 27% and 14%, respectively. Conclusions Carcinoma of the mid or distal portion of the common bile duct is a tumour that offers fairly good prospects of survival. Surgical radicality is achieved essentially by obtaining ductal and radial margins which are free of microscopic infiltration and by means of a thorough lymphadenectomy. These conditions can be achieved more easily in carcinomas of the distal portion of the duct owing to the extent of the duodeno-pancreatectomy they require. In carcinomas of the mid common bile duct the anatomical contiguity with the portal vein is responsible for a lower resectability rate.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
250

E-AHPBA

P11 Hilar Cholangiocarcinoma (Klatskin-Tumor): Preoperative evaluation and therapy Abstracts
Fabian Bartsch, Philipp Kaudel, Hauke Lang General, Visceral and Transplant Surgery, Johannes Gutenberg-University Hospital of Mainz, Mainz, Germany

Objectives The preoperative evaluation of hilar cholangiocarcinomas (Klatskin-tumors) is very difficult because of its location in the liver hilum with striking distance to the portal vein and the hepatic artery. For a curative therapy the expansion of the tumor and infiltration into the surrounded tissues or organs are the important factors. Method We reviewed the diagnostics and therapy of 49 patients with perihilar cholangiocarcinoma who underwent a surgical therapy approach at the Johannes-Gutenberg-University Hospital of Mainz, Germany in a period of 4 years (2008-2012). This retrospective data was collected in a SPSS 19 database and further analysed with focus on the preoperative evaluation and classification, the surgical approach and the postoperative results. Results Preoperative evaluation through MRCP, ERCP and CT/MRT imaging is difficult. An infiltration of the hilar structures or its degree can only be estimated or not totally excluded in most cases. An ERCP is performed in ca. 75% and a MRCP in ca. 31%, but in most cases the Bismuth-Corlette-Classification is not even stated with certainty. 49 patients with Klatskin-tumors underwent a surgical treatment. 39 patients were resected with a curative intention (R0 n=31; R1 n=7; R2 n=1). 2/39 patients were T4 (both R1) and 2/39 were T3 (both R0). 22/39 Patients were pathological classified as Klatskin Type IV (Bismuth-Corlette). Conclusions Surgical exploration of hilar cholangiocarcinomas and intraoperative evaluation of resectability is superior to preoperative evaluation using endoscopy (ERCP) or CT/MRT imaging (with MRCP), because through mesohepatectomy and vessel-reconstruction for example even extensive tumors (even Klatskin Type IV, Bismuth-Corlette) can be treated curatively.    

251

Abstracts

P12 BILE DUCT TRANSFORMATION. SURGICAL TREATMENT. Vishnevsky V.А., Ionkin D.A., Ikramov R.Z.
Dmitry Ionkin A.V.Vishnevsky Institute of Surgery, Moscow, Russia

Objectives PURPOSE: To determine the optimal diagnostic algorithm and appropriate surgical treatment for cystic transformations of the bile ducts. Method Materials and methods. Recently we have gained experience in treating 61 patients aged 16 to 62 years (mean age - 32.4 years). There were 43 women and 16 men. All patients had symptoms of the disease from childhood. The main clinical manifestations were remitting jaundice and cholangitis. External drainage was performed under ultrasound control as the first treating stage in 25 (42.3%) patients for severe jaundice relief. In cases when direct opacification of biliary tract was not conducted before surgery or MRCP, the intervention began with intraoperative cholangiography. Results Results.  The effectiveness of ultrasound and CT was respectively 79.2 and 85.8%. MRCP -98%. 23 patients were operated initially. Patients underwent the following interventions: cysts excision with BDA formation in 34 patients (with type I - 25, II - 4, III - 5), liver resection with BDA formation  in 19 (type IV - 6, with V - 13). One incurable patient with Caroli’s disease undergone diagnostic laparotomy. Malignancy of cystic-modified bile duct was found in 25.4% (5 - intrahepatic cysts and 10 - extrahepatic). Conclusions  Conclusion. We have identified neoplastic mass in the cystic wall in nearly a quarter of patients which is to be the main motivation to perform radical surgery. Hepaticocholedochus resection within healthy tissue is believed to be radical intervention in the patients with bile duct cysts. Roux-en-Y broad hepaticojejunoanastomosis has to be formed with single-row monofilament suturing using precision technology.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
252

E-AHPBA

P13 A rare complication of calculous cholecystitis: cholecystocutaneous fistula

Objectives Cholecystocutaneous fistula is rare complication of chronic calculous cholecystitis. With the improvement in imaging techniques, antibiotics, operative techniques and perioperative care, such situations are rarely encountered. We report a case of cholecystocutaneous fistula in a woman presented with an abdominal pain and palpable mass on the right upper abdominal quadrant.   Method A 42 year-old-woman presented with a twenty day history of abdominal pain and swelling, induration and redness on the right upper abdominal quadrant. She had no systemic disease and medical history. On abdominal examination we found a 10x10 cm tender, erythematous mass palpable over the right upper quadrant. The laboratory study showed WBC 14 000/mm³. The other haematological, biochemical and coagulation parameters were normal. An abdominal US scan showed that the thickened gallbladder wall was adherent to the anterior wall of the abdomen. Also there were gallstones within the adherent subcutaneous adipose tissue and in the gallbladder.   Results At surgery inflamed gallbladder, full of stones,was found to be adherent to the anterior abdominal wall via a fistulous track. Also there were lots of stones within the subcutaneous adipose tissue. Cholecystectomy was performed and inflamed subcutaneous adipose tissue and fascia were debrided and irrigated thoroughly with a betadine saline solution. Histopathology of the gallbladder revealed chronic inflammation.    Conclusions In this case we favoured open approach because of adhesion of gallbladder to the anterior wall of the abdomen and surrounding organs and high possibility of wound infection. Following control of the acute inflammatory process in the abdominal wall cholecystectomy is advisable in these patients.      

253

Abstracts

ZAFER SABUNCUOGLU1, ISA SÖZEN1, FATIH BENZIN1, OZGUR DANDIN2, RECEP ÇETIN1 1 UNIVERCITY OF ISPARTA SULEYMAN DEMIREL DEPARTMENT OF GENERAL SURGERY, ISPARTA, Turkey, 2BURSA MILITARY HOSPITAL, BURSA, Turkey

Abstracts

P14 Intraluminal radiotherapy as a part of combined treatment of extrahepatic bile duct cancer
Makarov Evgeny, Kukushkin Andrey, Kravchenko Dmitry Blokhin’s Cancer Research Center, Moscow, Russia

Objectives To estimate capabilities of intraluminal radiotherapy (IR) as a part of combined treatment of patients with extrahepatic bile duct cancer. Method 68 patients with malignant strictures of extrahepatic bile ducts complicated with obstructive jaundice underwent a combined treatment that included percutaneous transhepatic draining of bile ducts, IR with the following reconstruction of the biliary system.  Percutaneous transhepatic draining of bile ducts was performed by the standard methodoly guided by radiography. Extrahepatic bile duct IR was performed using a Microselectron HDR at 10 mm from the source center. Total radiation dose was 60 iGr.  The subsequent bile duct reconstruction was realized by 3 ways: bile duct stenting, leaving a transhepatic drainage, forming a cholangiogastrostoma. Results At the first step, all the patients were performed a percutaneous transhepatic cholangiostomy. 43 patients further underwent only IR, 60 iGr. 4 patients underwent IR (42 iGr) plus distant gamma therapy (30-35Gr). 22 patients underwent surgical therapy – hepaticocholedoch resection with the subsequent IR of the lobular duct stump (60iGr). The control group (n=34) included patients who underwent only a palliative drainage of the biliary system. Survival rate in the analytic group (n=68) was  100%, 85%, 66%, 46%, 22% for  3, 6, 9, 12 and 24 months, respectively. Survival rate in the control group was 96%, 67%, 23%, 4%, 0%. Conclusions The technique developed has let reliably increase the life expectancy of patients.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
254

E-AHPBA

Slobodan Arandjelovic Clinic for Surgery, Clinical Center Prishtine Serbia, K.Mitrovica/ KiM, Serbia

Objectives Objectives: A subclassification of Mirrizi syndrome into type -I and II lesions has been proposed. Bassed on this classification a standardized surgical approach is now proposed. Method Patient and method: In a retrospective series of 1 cases with. Empyema vesicae felleae Mirizzi syndrome type I, found among 621 cholecystectomies performed since 2002-2012.   Results Rezults: There were  males with an age of 60 years. Type-I lesions were treated by cholecystectomy, and had concomitant exploration of the common bile duct with suttura defecti d.hepaticocholedochi and T-tube sec. Kehr. There was no postoperative mortality and postoperative morbidity.   Conclusions Conclusion: This management strategy has yielded very satisfactory results  

255

Abstracts

P15 A Standardized Surgical Approach for the Treatment of Mirizzi Syndrome (Sy Mirizzi type I.) - Empyema vesicae felleae A Case for Open Surgery

Abstracts

BATUHAN HAZER1, OZGUR DANDIN2, YAVUZ OZDEMIR3, MEHMET ZAFER SABUNCUOGLU4 1 KASIMPASA MILITARY HOSPITAL, ISTANBUL, Turkey, 2BURSA MILITARY HOSPITAL, ISTANBUL, Turkey, 3GULHANE MILITARY MEDICAL ACADEMY HAYDARPASA TRAINING HOSPITAL, ISTANBUL, Turkey, 4UNIVERCITY OF SULEYMAN DEMIREL, ISPARTA, Turkey Objectives Mirizzi syndrome was reported in 0.3–3% of patients undergoing cholecystectomy. The distortion of anatomy (with dense fibrosis and the cholecystocholedochal fistula) increase the risk of bile duct and duodenum injury. Method  We present three cases with Miriizi type 2 syndrome, aged 24 man (case 1), 26 man ( case 2) and 32 lady (case3). Case 2 and 3 had history of  two or more acute cholesystitis treated conservatively where as case 1 had none. None of them has had abdominal surgery before. Preoperative usg revealed cholelithiasis in all cases.  No abnormality of choledoch, intra and extra hepatic bile ducts was reported. So laparoscopic cholescystectomy is planned. During peroperative exploration, the anatomy of calot is disturbed.   Results We opened the fundus of gall bladder 2 cm proximal of the calot, aspirated all the contents then excised the distal gallbladder into endobag. Then we examined the proximal pouch to understand relationship of the pouch and the choledoch.  After the dissection of calot with this technique, type2 Mirizzi syndrome is diagnosed. The proximal pouch is closed with two layers of sutures and subtotal cholecystectomy is performed by open surgery at case 1 and 2 and by laparoscopic surgery at case 3. All the patients are discharged 3 days postoperatively with no complications.   Conclusions It may be hard to diagnose Mirizzi Syndrome preoperatively. The disturbed calot is an unwilling surprise and many surgeons swear not to operate any patient from there on because of the severe complications. At these cases, our alternative technique is a safe procedure for understanding the calot’s anatomy without complications.      

P16 AN ALTERNATIVE APPROACH FOR DISSECTION OF CALOT’S TRIANGLE IN MIRIZZI SYNDROME

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
256

E-AHPBA

P17 Outcome of surgical resection for gallbladder carcinoma 

Objectives < Background> The gallbladder carcinomas (GBCs) are usually in the advanced stage at the time of diagnosis. Although surgical resection is a golden standard of the treatment, a standard procedure has not yet been established. In this study, we retrospectively reviewed our experiences of resected cases of advanced-GBCs, in term of clinicopathological features and the outcome. Method < Methodology> Between April 2000 and December 2012, a total of 50 surgical resections for GBCs were carried out in our department. Here we focused on the 40 cases of UICC-stage III and IV advanced-GBCs (A-GBC). Results 5-SR of patients with positive and negative for LN metastasis were 9.8 and 60.0 % (P=0.04), respectively, and H-inv were 20.2 and 59.8 % (P=0.04). 25 cases cases were positive for either LN metastasis or H-inv, and the procedure revealed that there were 7 cases of extended cholecystectomy, 4 cases of anatomic resection of liver segment 5 and of the lower part of segment 4(S4S5R), 3 cases of central hepatectomy, 7 cases of ERHL, and 4 cases of HPD. MST of extended cholecystectomy, S4S5R, CH, ERHL, and HPD were 19.0, 130.0, 74.0, 31.0, and 12.5 months (P=0.03), respectively. Conclusions < Conclusions> In this study, the positive LN metastasis and H-inv were the adverse prognostic factor, and S4S5R is effective procedure for these cases.

257

Abstracts

Yukihiro Iso, Keiichi Kubota Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan

Abstracts

Alberto Brolese1, Francesco A. Ciarleglio1, Giovanni Viel0,2, Paolo Valduga1, Stefano Marcucci1, Cristina Prezzi1, Paolo Beltempo1, Giovanni Bellanova1, Paola Bondioli1, Francesco E. D’Amico1 1 APSS Santa Chiara Hospital-II Surgery Unit, Trento, Italy, 2HBP Center and Liver Trasnplantation Unit-University of Padova, Padova, Italy Objectives Evaluation of preliminary results about feasibility, safety, and efficacy of SSC. Method Patient history, indication, operation time, complication rate, conversion rate, robot-related issues, length of hospital stay. Follow up was 1-month. All operations were performed by the same surgeon. Results We have performed 54 Robotic assisted cholecystectomy from Jan 2012 to Jan 2013 - 31 MC (57.4%) and 23 SSC (42.6%). Conversion rate was 1.8%. There were no major complications.  Mean age, BMI, Operation time and hospital stay were 48.4± 16.7 vs 41.7 ± 15.4  y.o., 27.4 ± 5 vs 24.4 ± 3.4, 83.5 ± 32.3 vs 90.1 ± 28.4 min, 2± 1.1 vs 1.3± 0.5 days (p 0.052) for MC vs SSC respectively. Conclusions Da Vinci Intuitive Platform Surgical Device® is a new platform offering a potentially more stable and reliable environment to perform many surgical procedures technical possibilities to overcome the natural limitations of laparoscopy. Learning curve and costs are ongoing open key points.

P18 SINGLE SITE (SSC) VS MULTIPORT (MC) ROBOTIC ASSISTED (Da Vinci Intuitive Platform Surgical Device® ) CHOLECISTECTOMY: PRELIMINARY RESULTS in SINGLE HBP SURGICAL CENTER

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
258

E-AHPBA

Valentina Lisienko, Edvard Mikaelyan Ural State Medical Academy, Ekateriburg, Sverdlovsk region, Russia

Objectives  It  is to  substantiate the possibility of HB presence in bile-excreting ducts,  its role in purulent cholangitis onset, HB migration into pancreas ducts under bile-excreting ducts hypertension condition, to establish eradication therapy need in treatment complex of patients infected with HB and undergoing the cholangitis and pancreatitis surgical operations. Method Cytological examination of biopsy material smears from choledoch was used. Microbial HB duct wall dissemination degree was identified. Its histological examination was conducted. The specific humoral response against Helicobacteriosis antigens was studied (identification of immunoglobulin A, M, G). There was conducted a pathological process comparative clinical investigation in 55 patients with pancreonecrosis receiving anti-HB preparations (n=11) and not receiving this treatment (n=44). With bile-excreting ducts obstruction, BED pressure prevailing and bile reflux the spreading of HB in pancreas is possible with arising complications, lymphogenous and hematogenous way of HB migration. Pancreatic tissue biopsy is risky. Results With Limphoplasmatic infiltration background in choledoch HB was identified in 44 % of patients, in 50 % of high concentration cases. Histological and immunological methods confirmed the presence of HB. In cytological investigation immunoglobulin A level (n=10) in HB infected subjects was higher than in (n=14) not infected subjects. It was twice and more higher than the physiological norm. There was no difference in these groups concerning the indexes of immunoglobulin M and G. Among 44 subjects not receiving preventive antiHB therapy 4  developed purulent pancreatitis. 11 patients treated with anti-HB preparations had no purulent process.   Conclusions  Patients with purulent cholangitis need HB infection test to take a decision about an adequate treatment including anti- HB therapy. To prevent  purulent pancreatitis development it’s necessary to remember about the possibility of HB presence alongside the other micro flora and to administer anti-HB eradication therapy in complex treatment.

259

Abstracts

P19 The possibility of Helicobacter infection presence in the development of purulent cholangitis and  pancreatitis in surgical patients

Abstracts

Aliaksandr Varabei1, Yury Arlouski1, Egi Vizhinis1, Natali Lagodich1 1 Belarussian Medical Academy of Postgraduation Education, Minsk, Belarus, 2Republican Centre of Surgical Gastroenterology, Minsk, Belarus

P20 Role of double balloon enteroscopy in diagnosis and treatment of strictures of hepaticojejunoanastomoses after bile duct injuries

Objectives Development of strictures of hepaticojejunoanastomoses (HJA) is observed in 6-30% of patients and mortality after repeated reconstructive interventions range from 13 to 25%. Double balloon enteroscopy (DBE) is a new method investigation of a small bowel pathology. This technique allows to visualise a zone of Roux-en-Y anastomosis after reconstructive operations on the bile ducts for differentiation between stricture of HJA and recurrent cholangitis. Method The patients with Roux-en-Y HJA and jejunum loop with Brauns bypass anastomosis that underwent DBE with endoscopic retrograde cholangiography (ER-ChG) in our unit between February 2009 and December 2012 were enrolled in this study. A total of 25 procedures were performed during this period. MRI-ChG was carried out to 13 patients. All of them carried out examination of HJA through a jejunum loop by DBE with capture of bile for bacteriology, Roux loop wall for biopsy and miniinvasive procedures. Results MRI-ChG excluded the stricture of HJA only in 9 cases. Two times we revealed candidosis cholangitis. DBE examination excluded stricture in other 5 cases. HJA zone was examined in 16 (64%) patients. In 11 cases stricture of HJA was confirmed: at 6 reoperations were performed, at 5 - minimally invasive procedures (3 laser vaporisations, 1 - lithotripsy, 1 - the first stage stone extraction was carried out, then - laser vaporization). ER-ChG was performed in 13 (52%) patients. The overall diagnostic success with Browns bypass was 100%, after Roux-en-Y reconstruction - 59,1%. Therapeutic success was 20%. Conclusions MRI-ChG in our series frequently (10,3%) shows false-positive result in advantage of HJA strictures. DBE examination of HJA with additional cholangiography is a modern and precise method of detection HJA strictures. Their DBE-ballon dilation and argon-laser vaporization or DBE lithoextraction are a new ways of miniinvasive treatment.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
260

E-AHPBA

Yury Khoronko, Artyem Ermolaev, Eugeniy Khoronko, Artyem Blikyan Rostov State Medical University, Rostov-on-Don, Russia

Objectives The bile duct injuries (BDI) rate after laparoscopic cholecystectomy seems to be higher than in open surgery. Temporary external drainage and followed by biliodigestive (BD) reconstruction can be effective. But even the orthodoxies of surgical manipulations for creation of BD-anastomosis does not allow preventing a reflux. This fact demands using the antireflux technique. Our research is dedicated to this problem. Method Over last 10 years 95 patients were operated on at our clinic by BD-anastomosis, 39 from them with BDI. They all were admitted from outside hospitals 1-98 days after initial operation, 34 cases with the results of nonadequate surgical correction. Each patient underwent from 1 to 3 interventions, including attempts to repair the injury (4 cases), external drainage or unsuccessful BD-reconstruction. In 34 - the isolation injury of bile ducts was diagnosed, in 4 - with combination of hepatic artery damage and in 1 - injury of hepatic duct with right hepatic artery and portal branch, which caused lobe necrosis. Results Primary end-to-end repair with T-tube drainage was performed in 3 patients (follow-up period 6-7-9 years), successful right hemihepatectomy in 1 case, and in 35 - Roux-en-Y hepaticojejunostomy, with 20 among them using our antireflux modification of the anastomosis (Russian Fed Patent N 2470592). Mortality was not registered. There were following criteria for research: wound infection, cholangitis attacks, anastomotic leak, period of time for postoperative blood- and liver function analyses restitution. Estimation of follow-up results showes the advantages of the proposal method. Conclusions The method of choice in surgery of biliary ductal obstruction due to BDI is repair using antireflux Roux-en-Y hepaticojejunostomy. To provide success in the treatment of BDI one should perform the management of these patients by experienced and skillful surgeons in centers specialized in hepatobiliary surgery.

261

Abstracts

P21 Antireflux Roux-en-Y hepaticojejunostomy in treatment of bile duct obstructions due to their injuries

Abstracts

Stojan Sekulic1, Aleksandra Sekulic-Frkovic1, Andrijana Milankov1 1 Surgical Clinic,C.H.C.Pristina-Gracanica,Medical faculty, Gracanica, Serbia, 2Pediatric Clinic,C.H.C.PristinaGracanica,Medical faculty, Gracanica, Serbia, 3Interna Clinic, C.C.Vojvodina, Novi Sad, Serbia Objectives The most frequent cause of primary cancer of gallbladder(70-95%) is calculus with it. The depth of the tumour and lymph node metastasis are important prognostic factors. Method During the five-years long study (2006-2010), there were found 461 cancers of the abdomen’s organs, from which  58, or 12,6% , were cancers of gallbladder. Out of 1407 bilious tractus operations, gallbladder cancer was found in 58 or 4,12%. of patients. Results There were 16 or 27,6% male and 42 or 72,4% female patients. Solitary calculosis occurred in 31 (53,4%). Primary gallbladder cancer was found at 49(84,5%)  patients, that were older than 50 years. In only 19(23,7%) cases gallbladder was diagnosed preoperatively(ultrasound,CT,MR), and in 39(76,3%) cases it was detected by routine histological examination of gallbladder. Adenocarcinom was found histologically in 54(93,1%) patients.   3(5,2%) patients had adenosquamous cell carcinomas and 1(1,8%) had poorly differentiated carcinomas. Radical operation  was performed in 37(63,8%) patients. Paliative operation was performed in 5(8,6%).After surgical and oncologycal treatment 3(5,1%) patients.Mortality rate of all bilious tractus operations was 10(0,7%). Conclusions  We can conclude that gallbladder cancer is a very rare disease. The prognosis of patients with carcinoma of the gallbladder is very bad, as most patients were presented at anadvanced tumor stage.

P22 Diagnosis and surgical treatment-carcionoma of gallbladder

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
262

E-AHPBA

Agustin Dietrich, Nicolas Resio, Martin de Santibañes, Fernando Alvarez, Juan Pekolj, Rodrigo Sanchez Clariá Hospital Italiano de Buenos Aires, Buenos Aires, Argentina Objectives The aim of this study was to analyze the morbidity, mortality and outcomes between patients with biliary lithiasis who underwent LCBDE and biliary stenting versus external biliary drainage.

Method Between January 2007 and May 2012, a series of 48 patients who underwent biliary decompression after laparoscopic common bile duct exploration (LCBDE) due to choledocholithiasis was retrospectively analyzed. The results in those patients with transpapillary stent placement (TS=35) were compared with those who had an external biliary drainage (EBD=13). Results LCBDE and TS placement was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with an external biliary drainage (EBD) presented more surgical related complications (P<0,0001) and also a longer hospital stay (p=0,03). Postoperative ERCP to remove the TS and residual stones, was successful in all cases. Conclusions Laparoscopic TS is a safe method in the treatment of selected patients with CBD stones that can be achieved without the need of a choledochotomy. Due to the lower morbidity and shorter hospital stay compared with EBD, it should be considered as a first approach whenever biliary decompression is needed after LCBDE.

263

Abstracts

P23 Single-stage laparoscopic management of common bile duct stones: transpapillary stenting or external biliary drainage?

Abstracts

Kemal Beksaç1, Nihan Turhan1, Ergun Karaagaoglu2, Osman Abbasoğlu1 1 Hacettepe Univeristy Department of General Surgery, Ankara, Turkey, 2Hacettepe Univeristy Department of Biostatistics, Ankara, Turkey Objectives  Eventhough laparoscopic cholecystectomy is the current standart treatment for cholelithiasis, some cases still require conversion to open cholecystectomy. Since predicting this conversion would allow better surgical planning, we aimed to delevop a predictive statistical model. Method Between August 2006 and January 2011, 1444 cholecystectomies were performed at General Surgery Department of Hacettepe University. Of these 104 cases were started as laparoscopic surgery but converted to open cholecystectomy. Laparoscopicaly completed 104 cases were randomly chosen and compared with the converted cases. Over 30 parameters including demographics, ultrasonographic findings, laboratory values were included in a  logistic regression analyzes to create a  statistical model that predicts conversion to open cholecystectomy. Results Among the 1444 total cholecystectomies performed, 1231 of them was performed laparoscopicaly. Conversion rate from laparoscopic to open cholecystectomy was 7.7 %. Age, gender, acute cholecsytitis, history of choledocolithiasis, history of abdominal surgery, alkaline phosphatase (ALP) levels were found to be significant risk factors. With ROC(Receiver Operating Characteristic) Curve, we found that risk significantly increases after age of 55 years and ALP over 80 IU/L. Conclusions Using four parameters: age, gender, history of abdominal surgery and ALP in our  statistical model, conversion was predicted with 70% sensitivity and 79% specificity.

P24 A Statistical Model for Predicton of Conversion from Laparoscopic to Open Cholecystectomy

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
264

E-AHPBA

David Fuks, Francois Cauchy, Giulia Boarini, Sebastien Gaujoux, Safi Dokmak, Valerie Paradis, Jacques Belghiti Beaujon Hospital, Clichy, France Objectives While liver transplantation (LT) is the treatment of choice for selected patients with cholangiocarcinoma (CC) developed on primary sclerosing cholangitis (PSC), liver resection (LR) has long been considered as a contraindication. We therefore aimed to examine the results of LR in this subset of patients. Method Characteristics and outcomes of 15 (9 males, and median age 62 years (14-74)) patients with PSC undergoing hepatectomy with en-bloc resection of the extra-hepatic bile duct between 1997 and 2012 were retrospectively analyzed. Indication for LR was stenosis of either hilar confluence (n=11) or intrahepatic ducts (n=3) and gallbladder tumor (n=1). Results Major resection was performed in 13 (87%) patients including 2 with associated pancreaticoduodenectomy. One (7%) patient died postoperatively and 14 (93%) patients experienced complications including 8 (53%) major ones (Clavien-Dindo ≥3). Severe (F3-F4) underlying fibrosis was observed in 8 (53%) patients and was significantly associated with both increased rates of major complications (63vs.43%, p=0.03) and longer hospital stay (26vs.12 days, p=0.001). Among the 11 patients resected for hilar stenosis, those displaying CC were all <50 years. Five-year overall survivals were 100% in patients resected for benign disease and 45% in malignant disease (n=8), respectively, including 2 patients undergoing pre-emptive LT.  Conclusions Despite high complication rate, LR should not be discarded in patients with PSC, especially in patients >50 years considering the exceptional risk of malignancy.  

265

Abstracts

P25 Liver resection in patients with primary sclerosing cholangitis: an option that should be considered

Abstracts

David Birnbaum, Luca Viganò, Alessandro Ferrero, Serena Langella, Nadia Russolillo, Lorenzo Capussotti Ospedale Mauriziano Umberto I, Torino, Italy

P26 Resection of locally advanced gallbladder cancers: evolution of the outcome and refinement of the indications into a European center

Objectives Surgery achieves favorable outcomes in early-stage gallbladder cancers (GBC). In T3-4 ones indications are controversial, mainly if extended surgery is required. To assess the outcome of surgery in patients with locally advanced GBC, with special attention paid to those requiring associated resections and to results evolution through the study period. Method 126 patients operated on for GBC between January 1989 and December 2011 were considered. The 79 with T3 or T4 GBC were included in the present study. Thirty-nine (49.4%) patients were operated on before 2003 and 40 (50.6%) later on. One third (n=26) of cases was jaundiced at diagnosis (preoperative biliary drainage in 15). Forty (50.6%) patients required common bile duct (CBD) resection and 11 (13.9%) duodenopancreatectomy. A major hepatectomy was performed in 22 (27.8%). GBC was T4 in 17 (21.5%) patients. Fifty-three (67.1%) had lymph-node metastases (22 N2). Resection was complete (R0) in 66 (83.5%) patients. Results In-hospital mortality rate was 7.6%, 10% before 2003 vs. 5% later on. Overall morbidity rate was 48.1% (Grade 3-4 20.2%), stable during the study period. Duodenopancreatectomy increased neither severe morbidity (0%) nor mortality (9.1%). Five-year overall survival was 16.9%. It improved in patients treated after 2002 (26.9% vs. 8.6%, p=0.04). Outcome was poor in R1 patients (median survival 10.1 vs. 17.4 months, p=0.001). CBD resection/infiltration did not worsen prognosis, while patients requiring duodenopancreatectomy had 0% 2-year survival (p=0.078). Multivariate analysis identified four negative prognostic factors: R1 resection (p=0.026), lymph-node ratio >0.15 (p=0.006), perineural invasion (p=0.009) and surgery before 2003 (p=0.0006). Conclusions Outcome of surgery for T3-4 GBC improved in recent years: operative mortality was halved and 5-year survival reached almost 30%. Resection is indicated only if complete surgery is possible. The need for CBD resection does not contraindicate resection, while benefits from surgery in patients requiring a duodenopancreatectomy are doubtful.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
266

E-AHPBA

Olga Sergeeva, Vadim Panov, Andrei Kukushkin, Boris Dolgushin, Andrei Reshetnickov N.N. Blokhin Cancer Research Center, Moscow, Russia

Objectives Demonstration of early and late intraductal photodynamic therapy (PDT) outcomes in hilar cholangiocarcinoma patients.   Method  Seventy nine PDT procedures (from one to ten per patient) have been performed in twenty three biopsy confirmed hilar cholangiocarcinoma patients (9 female, 14 male, age range 34-75y) with previous percutaneous bile duct drainage since February 2008. All patients had Bismuth IV type tumors and weren’t surgical candidates. The second generation chlorin sensitizers, 0.6-2.0mg/kg, were administrated intravenously two to four hours prior the procedure with consecutive intraductal laser irradiation (662 nm laser LAHTA-MILON) at low fluence rate pulse mode regimens (20-50mW/cm2, up to 1000 J per liver).  The follow-up included clinical examination, lab tests and abdomen MRI every three months.   Results  There was no post-procedural mortality. The only patient developed post-procedural liver abscess requiring percutaneous biliary drainage. The intraductal PDT resulted in bile duct recanalization, cholangitis abatement and improvement of liver function tests. Several MRI findings (post-PDT peritumoral inflammatory infiltration, lymph node reaction etc.) assumed possible immune system activation. The median survival was 13.6 months (min-max 2-41 months) from the first PDT procedure and 25.6 months (min-max 5-59 months) from the diagnosis. One and two-year survival rates were 68.0% and 20.4% from the first PDT procedure.   Conclusions  Intraductal PDT is safe and effective strategy of non-surgical hilar cholangiocarcinoma patient management increasing both survival rate and quality of life.  

267

Abstracts

P27 Five-year experience of photodynamic therapy in hilar cholangiocarcinoma patients

P28 carcinosarcoma of the gallbladder Abstracts

Carmen Ramiro Pérez, Jose Manuel Ramia Angel, Farah Adel Abdulla, Roberto De la Plaza Llamas, Vladimir Arteaga Peralta, Jose Quiñones Sampedro, Pilar Veguillas, Jorge Garcia-Parreño hospital universitario Guadalajara, Guadalajara, Spain Objectives Carcinosarcoma of the gallbladder is an extremely atypical subset of gallbladder malignancies, characterized by the presence of both epithelial and mesenchymal components. Currently, fewer than 100 cases have been reported in the literature. We present a patient with carcinosarcoma of the gallbaldder with unusual presentation as cholecystitis with liver abscess. Method A 76 year-old woman presented with abdominal pain in the upper right quadrant. Blood examination showed mild cholestasis. Abdominal ultrasound and MRI demonstrated a distended gallbladder, lithiasis, small abscess in segment IVa and wall thickening with fundus enhancement. Radiological diagnosis was complicated cholecystitis. The patient had a clinical, analitical and radiological improvement after antibiotic treatment, so she was discharged but 8 days after, the patient presented fever and abdominal pain. CT showed an abscess in segment IVa , with inflammatory changes in the gallbladder. A percutaneous drainage was performed, but evolution was torpid, so we decided the elective surgery. Results The laparotomy demonstrated a gallbladder neoplasm which infiltrated transverse colon, a mass in the gallbladder bed and a nodule of 6 cm in segment IVa-VIII. We performed an intraoperative biopsy of the mass attached to gallbladder which was reported as carcinoma. Given these findings and the age of the patient, surgical resection was dismissed. The final biopsy was reported as carcinosarcoma. The patient was discharged in 8 days but a month after she was admitted with dyspnea and malaise. CT showed multiple hepatic nodules and some abscesses, and peritoneal dissemination. The patient worsened quickly and died a week after admission. Conclusions In most cases of gallbladder carcinosarcoma, surgical exploration demonstrate locally advanced disease.  It is considered that surgical treatment remains the only curative management option, but even with aggressive surgical resection, the prognosis is generally poor: mean survival only a few months. Adjuvant treatments do not increase patient survival. 

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
268

E-AHPBA

Faruch Makhmadov, Karimchon Kurbonov, Bahman Ikromov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan

Objectives  diagnosis and prevention of sub-and postoperative complications of laparoscopic cholecystectomy of a “difficult” gallbladder.   Method For the period 2010 to 2012 in the clinic videolaparoscopy performed in 31 patients with so-called “difficult” gallbladder. There were 22 men and. For the differential diagnosis of vascular-secretory structures of a hepatoduodenal area, we have developed a method suboperation cholangiography during a laparoscopic cholecystectomy. Method of diagnosis: in identifying of atypical location of the gallbladder, an atypical confluence and  inability of differentiation of the cystic duct, through the cystic duct or choledoch puncture by a puncture 0,5cm is introduced with X-ray contrast agent, which allows differentiation of the extrahepatic bile ducts and avoid heavy sub-and post-operative complications.   Results Following the suboperation cholangiography in 4 (12.9%) were inserted the indication for conversion, in the other (n = 27) cases of laparoscopic cholecystectomy performed with the location of the identified pattern of the gallbladder and biliary tract. Duration of operations averaged 76.3 minutes. No cases of intraoperative complications were observed. Postoperative period in all patients was uneventful. Patients discharged in 3-5 days after the procedure. Conclusions  Suboperation laparoscopic cholangiography can be performed in a separate group of patients with so-called “difficult” gallbladder. The method allows for the prevention of heavy sub-and post-operative complications such as iatrogenic injury, the common bile duct ligation (hepaticocholedochus), stricture hepaticocholedochus etc.  

269

Abstracts

P29 The method of differential diagnosis of extra hepatic bile ducts during laparoscopic cholecystectomy of a “difficult” gallbladder

Abstracts

P30 Low-invasive surgical procedures under ultrasound in the treatment of obstructive jaundice

Faruch Makhmadov, Karimkhon Kurbonov, Zokir Nurov, Atoboi Sobirov, Alisher Gulahmadov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan Objectives Improve treatment outcomes in patients with obstructive jaundice by the differential application of different options of low-invasive surgery under ultrasound guidance.   Method  The present study is based on an analysis of clinical findings in 39 patients who were on treatment for jaundice of benign and malignant origin between 2009 and 2012. Among the studied patients were 23 men and 16 women. Senile elderly persons and the age category of 53 to 79 years accounted for 64.1%. Percutaneous transhepatic cholecystostomy under ultrasound was performed using a “free hand”. The contents of the gall bladder was subjected to macroscopic evaluation, bacteriological test, the cavity was washed dekasana bubble. To clarify the origin of obstructive jaundice in 13 (33.3%) were performed cholecystocholangiography.   Results In 13 (33.3%) patients, the cause of jaundice served gallstone disease, in 26 (66.7%) - malignant lesions hepatopancreatobiliary zone, of which 17 (65.4%) cases, there was an advanced stage of cancer. In 16 patients with biliary decompression by percutaneous transhepatic biliary drainage is designed as a stage of preparation of patients for radical surgery, in 6 (15.4%) - palliative. In 17 (43.6%) cases, drainage of bile duct was the final operation. To 7-9 days in the condition of patients stabilized. Died 3 (7.7%) patients in the presence of inoperable cancer. Postoperative complications were observed in 2 (5.1%).   Conclusions Percutaneous transhepatic cholecysto and holedohostomy under ultrasound is less traumatic, highly effective decompression and rehabilitation biliary tract, which extends the treatment of heavy contingent, creating favorable conditions for radical and palliative surgery. Low-invasive intervention is easy to carry seriously ill patients, with the presence of multiple comorbidities.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
270

E-AHPBA

P31 Video : Mesocaval shunt for Portal biliopathy Abstracts
SURYABHAN BHALERAO, APARNA REGE KEM HOSPITAL,PUNE, PUNE, India

Objectives Decompression of Portal pressure is necessary  to decrease bile duct obstruction due to varices or to treat bile duct obstruction with further surgery & cholecystectomy. and sometimes during emergency bleeding following ERCP.   Method A total of 5 patients portal biliopathy  have been managed by shunt surgery to treat billiary tract obstruction in last 2 years. on 3 occaions shunt surgery was done as an emergency operation for bleeding from ampulla during ERCP. In 2 patients it was a planned affair.In two patients gall bladder was removed. In two patients mesocaval shunts were performed and in three splenorenal shunts were done. Results All patient received bile duct stent before shunt surgery & subsequently  liver functions showed improvements. On follow up imaging in all patients showed decrease in varices in around bile duct decrease in collaterals.All patients could be operated successfully for bile duct stones and billiary bypass.   Conclusions Portosystemic shunt is choice of treatment for portal biliopathy. Mesocaval shunt is a viable option when splenoportal veins are thrombosed.

271

Abstracts

OZGUR DANDIN1, DURSUN KARAKAS2, FERHAT CUCE3, AHMET ZIYA BALTA4, DENIZ TIHAN5, BATUHAN HAZER6, UGUR DUMAN5 1 BURSA MILITARY HOSPITAL, BURSA, Turkey, 2AGRI MILITARY HOSPITAL, AGRI, Turkey, 3VAN MILITARY HOSPITAL, VAN, Turkey, 4GATA HAYDARPASA TRAINING HOSPITAL, ISTANBUL, Turkey, 5SEVKET YILMAZ TRAINING HOSPITAL, BURSA, Turkey, 6KASIMPASA MILITARY HOSPITAL, ISTANBUL, Turkey Objectives Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure for diagnosing and treatining of choledocholithiasis. The size of a center and experience of an endoscopist both have an effect on the risk of ERCP complications. Major complications of ERCP are pancreatitis, cholangitis, retroperitoneal perforation and hemorrhage. Method We reported a fourty-eight years old man who has had choleltiasis and choledocolithiasis and performed therapeutic ERCP. Biliary hematoma was reported at computerized tomography (CT) for being in rise the bilirubin levels after ERCP. Results In follow-up of patient we saw blood bilirubin levels decreased and hematoma was disappeared in control CT scan.  Complication rates of ERCP is vary between 0,8% and 45%. Duedonal and hepatic hematoma was reported but no literature about biliary hematoma after ERCP. Conclusions ERCP is most difficult and invasive technique in digestive endoscopy. It should be considered that especially after therapeutic ERCP, biliary hematoma rarely may develop and therefore further examination, especially CT scan and Magnetic Resonance Cholangiopancreatography, may be required by surgeons and endoscopists.  

P32 Biliary Hematoma: An Uncommon Complication of Endoscopic Retrograde Cholangiopancreatography

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
272

E-AHPBA

K Psarras, M Baltatzis, N Symeonidis, ET Pavlidis, M Lalountas, G Papatolios, TE Pavlidis, AK Sakantamis 2nd Propedeutical Department of Surgery, Aristotle University School of Medicine,, Thessaloniki, Greece Objectives Xanthogranulomatous cholecystitis is a rare but severe presentation of cholecystitis characterized by extensive inflammation of the gallbladder wall with characteristic histopathological features. Frequently, the inflammatory mass resembles gallbladder cancer macroscopically, which further complicates therapeutic decisions. Method We report a case of xathogranulomatous cholecystitis with characteristic computed tomography findings. Results The case was managed by percutaneous drainage of the gallbladder, giving the opportunity for a delayed elective cholocystectomy with an excellent postoperative outcome.

Conclusions Recent studies give emphasis on certain criteria for the differential diagnosis of xanthogranulomatous cholecystitis against carcinoma. Characteristic computed tomography features are usually sufficient to establish the diagnosis with safety and decide a nonoperative management of the disease in the acute phase. Percutaneous gallbladder drainage is regarded as a safe and an efficient method for the initial treatment of severe cases.

273

Abstracts

P33 A severe case of xanthogranulomatous cholecystitis along with a review of CT indications for nonoperative management including percutaneous drainage

Abstracts

P34 An extremely rare case of Mirizzi syndrome type Va: coexistence of  three diffierent  fistulae(cholecysto-choledochal, cholecysto-duedonal and cholecystopyloric)

KD Ballas, K Psarras, M Lalountas, N Symeonidis, M Baltatzis, G Papatolios, TE Pavlidis, AK Sakantamis 2nd Propedeutical Department of Surgery, Aristotle University School of Medicine, Thessaloniki, Greece Objectives Mirizzi’s syndrome is a complicated form of prolonged symptomatic cholelithiasis with presence of impacted gallstones into the Hartmann’s pouch, causing chronic extrinsic compression of the common bile duct and other neighboring structures, with possible fistula formation. According to the new Csende’s subclassification, additionally to the most uncommon type IV (4%), another type (Va) with presence of cholecysto-enteric fistulae was described. We present a rare case of a triple cholecysto-enteric fistula in Mirizzi’s syndrome. Method A 77-year-old man was referred to our department  to undergo surgical treatment six months following  recurrent episodes of cholecystitis and cholangitis. Choledocholithiasis was diagnosed on MRCP, and pneumobilia was identified on abdominal CT. Two fistulae orifices (duedonal and pyloric) were noted during ERCP.   Results Laparotomy revealed a large communication of the gallbladder with the pyloric antrum, which was interrupted with a surgical stapler, and another smaller one with the duodenum, which was ligated. Due to the presence of severe inflammation, the attempt of even a partial cholecystectomy was  considered risky, and therefore a T-tube drain was temporarily placed into the common bile duct through the gallbladder. The patient remains asymptomatic postoperatively, awaiting eventual surgery. Conclusions Mirizzi syndrome may be complicated in the form of multiple communications with neighboring structures of the gastrointestinal tract, such as the stomach, the duodenum and the colon (Mirizzi syndrome type Va), whereas type Vb refers to additional ileus due to translacation of the impacted gallstones. The co-existence of three different fistulae (cholecysto-biliary, cholecysto-duodenal and cholecysto-pyloric) is extremely rare, and we haven’t identified any similar case in the medical literature.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
274

E-AHPBA

N. Symeonidis, T.E. Pavlidis, M. Baltatzis, K. Ballas, K. Psarras, O. Ouroumidis, M. Lalountas, A.K. Sakantamis 2nd Propedeutical department of Surgery, Aristotle University School of Medicine, Thessaloniki, Greece

Objectives Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management and short-term outcome of patients with complicated liver echinococcosis. Method A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with non-complicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%) and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications and hospital stay were assessed. Results Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated.   Conclusions Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently, severe clinical manifestations, complexity of the surgical management and increased postoperative complications, characterize complicated liver echinococcal disease.  

275

Abstracts

P35 Complicated liver echinococcosis: 30 years of experience from a University Hospital in Greece

P36 Primary gallbladder lymphoma as a rare post-cholecystectomy finding Abstracts

K. Psarras, M. Baltatzis, N. Symeonidis, G. Papatolios, E.T. Pavlidis, N. Asaloumidis, K. Ballas, T.E. Pavlidis, A.K. Sakantamis 2nd Propedeutical Department of Surgery, Aristotle University School of Medicine, Thessaloniki, Greece Objectives Primary lymphoma of the gallbladder is an extremely rare entity with approximately 50 cases reported so far. In most of these cases the presenting symptoms were mimicking symptomatic gallstone disease and the diagnosis was made postoperatively. Method We report a case of primary lymphoma of the gallbladder in an 85 year - old man with gallstone disease, who was admitted for elective cholecystectomy 2 months after an episode of acute cholecystitis and pancreatitis. Results Histological evaluation of the specimen revealed a small lymphocytic lymphoma of the gallbladder, the type of which has not been previously described for the gallbladder. Thourough long-term investigation of the patient did not reveal any other pathological sites in the patient, therefore the gallbladder site has been considered as primary. Conclusions The most common primary lymphomas of the gallbladder are MALT lymphomas and diffuse large B-cell lymphomas, although a variety of other histological types has been reported. The association of these lesions with chronic inflammation is the most convincing theory for their pathogenesis. For lesions confined to the gallbladder, cholecystectomy is considered to be sufficient, while supplementary chemotherapy significantly improves prognosis in more advanced disease.     

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
276

E-AHPBA

Elizabeth Boonstra, Bas Noordermeer, Robert Porte UMCG, Groningen, The Netherlands

Objectives Some patients, who had surgical intervention for iatrogenic bile duct injuries after cholecystectomy, have persistent health issues after a follow-up period of at least two years while others recover uneventfully. The aim of this study was to identify riskfactors for the development of these persistent health problems. Method We performed a retrospective cohort study of 113 patients referred to the University Medical Centre Groningen in the period 1992-2010. All patient underwent surgical intervention. Univariate analyses were used to identify significant differences between the two groups. Multivariate analysis was used to identify independent risk factors for the development of persisting health problems. Results Five independent variables influencing the chance to remain health issues were found;   age during cholecystectomy (p=0,031), moment of diagnosis of iatrogenic bile duct injury (p=0,001), type of bile duct injury according to Hannover classification (p=0,038), repair with hepticojejunostomy (0=0,003) and ERCP (p=0,001). Conclusions We identified five risk factors in patients who had surgical intervention for iatrogenic bile duct injuries after cholecystectomy influencing the chance to develop persistent health issues after a follow-up of at least two years.  

277

Abstracts

P37 Persisting health problems after cholecystectomy complicated by iatrogenic bile duct injury

Abstracts

Abdul Hakeem1, Gabriele Marangoni1, Stephen Chapman1, Richard Young1, Amit Nair1, Judy Wyatt0,2, Giles Toogood1, Peter Lodge1, Raj Prasad1 1 Department of HPB and Transplant Surgery, St James’s University Hospital NHS Trust, Leeds, UK, 2Department of Histopathology, St James’s University Hospital NHS Trust, Leeds, UK

P38 Does the Extent of Lymphadenectomy, Number of Lymph Nodes, Positive Lymph Node Ratio and Neutrophil-Lymphocyte Ratio Impact on Surgical Outcome of Perihilar Cholangiocarcinoma?

Objectives Lymph node (LN) status is an important predictor of survival following resection for perihilar cholangiocarcinoma (PHCCA). Controversies still exist regarding the optimum extent of lymphadenectomy and the prognostic value of total number of nodes removed, lymph node ratio (LNR) and Neutrophil-Lymphocyte Ratio (NLR) on overall (OS) and disease-free survival (DFS) following PHCCA resection. Method From 1994 to 2010, 84 PHCCAs were resected at our Institution. Seventy-eight patients with available data were included in our analysis. OS and DFS were calculated and stratified according to the extent of lymphadenectomy, number of lymph nodes excised, positive LNR and NLR at different cut-off levels. KaplanMeier survival curves were studied using log-rank statistics to assess which variables affected OS and DFS.  The variables which showed statistical significance (p value <0.05) on Kaplan-Meier univariate analysis, were subjected to multivariate analysis using Cox proportional hazards model and hazard ratio with 95% confidence interval calculated appropriately. Results 3- and 5-year OS for LN+ (n=45) was 18% and 10%, whilst LN- (n=33) OS was 62% and 41% (p<0.001). Similarly, 3- and 5-year DFS was worse in the LN+ (12% and 8%) vs. LN- (44% and 36%, p=0.001). Patients with >20 LNs removed had worse 3- and 5-year OS (22% and 0%) when compared to those with <20 LN (41% and 29%, p=0.047). Moderate/poor tumour differentiation, distant metastasis and LN+ were independent predictors of OS. LNR had no effect on OS. Vascular invasion and LNR >0.37 were independent predictors of DFS. NLR had no effect on OS and DFS. Conclusions Extended lymphadenectomy patients (>20 LN) had worse OS when compared with a more limited (<20 LN) resection. LNR >0.37 is an independent predictor of DFS. Larger, prospective studies are necessary to confirm these results.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
278

E-AHPBA

1

Amit Nair1,2, Eldo Verghese1, Sarah Perry1, Nicola Ingram1, Louise Coletta1, Raj Prasad2 Leeds Institute of Molecular Medicine, Leeds, Yorkshire, UK, 2Department of HPB/Transplant Surgery, St James’ University Hospital, Leeds, Yorkshire, UK Objectives Perihilar Cholangiocarcinoma (PHC) is an aggressive malignancy of major bile ducts with poor rates of resectability.  With no established treatments apart from resection, there is a need to identify strategies to improve diagnosis and develop novel therapeutics. The expression of potential biomarkers identified by previous proteomic analysis is investigated here. Method Formalin-fixed paraffin embedded tissue from 20 patients who underwent resection of PHC from 20058 was obtained for immunohistochemical analysis. Sections were stained with antibodies against 2 potential markers of PHC invasiveness viz. Neutrophil Gelatinase Associated Lipocalin (NGAL) & Matrix Metalloproteinase-9 (MMP9). In addition, antibodies against microvascular endothelium viz. CD31, CD105 and Vascular Endothelial Growth Factor Receptor-2 (VEGFR2) were assessed. All staining intensities were visually scored. Clinicopathological parameters including patient outcomes were collected from corresponding hospital records. Several cholangiocarcinoma (CCA) cell lines were assessed for expression of NGAL and MMP9 using Western Blotting (WB) and ELISA techniques.   Results Median (range) age at diagnosis was 55 (40-75) years. Eight patients (40%) had nodal spread whereas distant metastases occurred in 12 (60%). NGAL expression was classed as moderate in 11 (55%) and high in 9 (45%) patients whereas MMP9 expression was low in 2 (10%), moderate in 13 (65%) and high in 5 (25%) cases. Normal cholangiocytes expressed these proteins at lower intensities. PHC vasculature expressed endothelial markers to varying extents. Disease-free and overall survival at 5 years was 23% and 18%. WB and ELISA showed NGAL to be expressed in cell membrane fractions and secreted into culture supernatants respectively.   Conclusions  This work suggests that NGAL and MMP9 could be used as molecular targets for tumour detection and/or therapy of PHC via endothelial targeting. The application of nanotechnology platforms in this regard could serve to increase the specificity of such approaches whilst minimizing toxicity to surrounding normal tissues.  

279

Abstracts

P39 Neutrophil Gelatinase-Associated Lipocalin, Matrix Metalloproteinase-9 and tumour endothelial markers in Perihilar Cholangiocarcinoma: Identifying biomarkers for targeted therapies

Abstracts

Stefan Hofmeyr, Philip Bornman, Jake Krige University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa

P40 Repair of major laparoscopic bile duct injuries: an analysis of total hospital cost

Objectives A major bile duct injury is an infrequent but potentially life-threatening complication after laparoscopic cholecystectomy. Few data exist about the financial implications of duct repair. This study calculated the actual costs of operative repair in a cohort of patients who underwent bile duct reconstruction after major ductal injury. Method A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital between 2002 and 2012 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2012. Results 39 patients (28 women, 11 men, median age 49 years, range 32–78) with a major bile duct injury were referred for management at a median of 23 days (range 1 – 280) after initial surgery. Patients were admitted to hospital for a median of 15 days (range 6 to 52 days). The mean cost of repair was €15 389 (range €5 581 - 31 772). The contributors to cost were: hospital bed costs (29%), theatre costs (26%), radiology (16%), specialist fees (11%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%). Conclusions The cost of repair of  a major laparoscopic bile duct injury is substantial. These costs are generated by prolonged admission to hospital, complex surgical intervention and intensive imaging requirements.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
280

E-AHPBA

Ibrahim Barut, Selcuk Kaya Suleyman Demirel University Medical School, Isparta, Turkey

Objectives Many experimental studies have verified obstructive jaundice (OJ) causes bacterial translocation (BT).  The aim of this study was to assess to whether CRP can be used to detect biliary obstruction induced bacterial translocation. Method Twenty rats divided into two groups containing 10 rats each: sham-operated controls and obstructive jaundice (OJ) group. After an upper midline incision, the common bile duct (CBD) was identified, mobilized, ligated and divided. Sham-operated animals had a similar incision followed by mobilization of the CBD, without ligation or division. At 10th day, blood samples were collected for culture and serum CRP analysis. Liver, spleen, and mesenteric lymph node (MLN) specimens were taken for microbiological culture to determine the presence of BT. BT was considered positive in case of any bacterial growth in cultures, whereas no bacterial growth indicated a negative BT. Results  The OJ group had significantly higher rates of bacterial translocation than the sham operated group (p=0.002). Mean CRP levels (ng/mL) were 8.7±11.8 and 18.6±17.2 in the sham and OJ groups respectively. There was no significant difference in mean CRP levels between two groups (p=0.257). Mean CRP levels were 4.5±4.3 and 24.9±16.4 in the BT (-) and BT (+) groups, respectively (p=0.003). A marked increase in CRP levels paralleled an increase in BT. Conclusions This study has demonstrated a direct relationship between the BT and CRP levels in an experimental model of OJ.

281

Abstracts

P41 Diagnostic value of C - reactive protein in bacterial translocation of experimental biliary obstruction

Abstracts

Dimitrios Kardassis1, Achilleas Ntinas1, Alexandros Kofokotsios2, Ioannis Konstantinopoulos3, Dionisios Vrochides1 1 Center of Hepato-Pancreato-Biliary Surgery, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 2 Department of Interventional Gastroenterology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 3 Department of Anesthesiology and Intensive Care, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece Objectives Recently, single-incision laparoscopic cholecystectomy (SILC) has been “accused” for potentially increasing the likelihood of iatrogenic biliary tract injury compared with conventional laparoscopic cholecystectomy. The aim of this study was to evaluate relevant data of SILCs performed at our center. Method This was a retrospective study of prospectively recorded data. From 03/2011 to 08/2012 17 consecutive patients (mean age: 59.5 years – mean body mass index: 24.93) underwent SILC by the same surgeon with the use of a flexible laparoscopic port (SILSTM Port, Covidien, Mansfield, MA, USA). Preoperative diagnoses included: symptomatic gallstone disease (n = 11), gallstone pancreatitis (n = 3) and acute cholecystitis (n = 3). Fifteen SILCs were performed electively. Results Four SILCs, three of which were elective procedures, had to be converted to conventional laparoscopic (n = 1) or open (n = 3) cholecystectomy. The reason was unsafe operating conditions due to either acute cholecystitis (n = 3) or extensive postoperative adhesions. The mean converted SILC duration was 175 minutes (unconverted: 150 minutes). No postoperative complications were recorded. Conclusions SILC is a safe option for cholecystectomy. However, to ensure safety during operations facing acute gallbladder inflammation or extensive adhesions, an increased conversion rate seems inevitable. Therefore, under such conditions, SILC should either not be the preferred cholecystectomy method in the first place or be converted rather early in order to avoid iatrogenic biliary tract injury.

P42 Does acute cholecystitis represent a contraindication to single-incision laparoscopic cholecystectomy?

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
282

E-AHPBA

Marco Massani, Bruno Pauletti, Ezio Caratozzolo, Cesare Ruffolo, Tommaso Stecca, Nicolo’ Bassi Regional Hospital, Treviso, Italy Objectives The gold standard procedure for the treatment of cholecisto-coledocholityasis is laparoscopic cholecistectomy (LC), associated with ERCP with endoscopic sphinterectomy. According to some authors endoscopic procedures on bile duct and papillosphintercetomy cause an inflammatory response that may alter normal anatomy increasing difficulty  in performing LC, with longer operating time and higer rate of conversion in laparotomic procedure.   Method We analyzed retrospectively 696 patients, male and female, who underwent LC in elective surgery between genuary 2008 and  december 2011. In 45 patients LC followed ERCP with or without papillosphinterectomy for symptomatic coledocholityasis or acute pancreatitis. Of the 45 patients 4 had more than one ERCP without conversion to open cholecistectomy. The other 631 underwent directly LC. We didn’t consider patients with ERCP done during laparoscopic cholecistectomy (rendez-vous). Primary outcomes: conversion rate, operating time, postoperative complications. Results In our experience preoperative ERCP doesn’t increase difficulty in performing laparoscopic procedure. In our data there is no significant difference between the two groups in terms of conversion rate ( 7% in ERCP group vs 5% in LC only) and operating time (median duration 66 min vs 60 min). Postoperative complication as infections or bile leaks, considering 1 month follow up, are occasional in both groups, with the same incidence. Conclusions Our opinion is that inflammatory process due to endoscopic procedure is not so important to influence the outcome of laparoscopic surgery. Our experience suggests that conversion rate is related to others causes.

283

Abstracts

P43 Laparoscopic cholecistectomy: Pre-operative ERCP doesn’t increase conversion rate

Abstracts

P44 BILIARY CARCINOMA ASSOCIATED TO CONGENITAL BILIARY DILATATION IN ADULT (report of 3 cases)

Benali TABETI, Anisse TIDJANE, Nabil BOUDJENAN SERRADJ, Mohamed Toufik BOUHADIBA, Nabil CHERRAK, Noureddine BENMAAROUF EHUOran/Faculty of medicine, Oran, Algeria Objectives Congenital biliary dilatation(CBD) is a rare disease often discovered at the pediatric age , but 20 to 23% of cases are diagnosed in adulthood.  Risk of biliary malignancy  is then 20 to 30 higher compared to natural control. We report 3 cases of biliary carcinoma associated to CBD in adults.   Method From July 2008 to December 2012 ten adult patients were operated in our department for biliary congenital dilatation. From these patients, three had an associated carcinoma of biliary tract. Results Patient 1: 75 years old man with a CBD type VI of Todani (isolated dilatation of cystic duct) diagnosed by CTM and cholangioMRI, and treated by a simple cholecystectomy. Histology showed an in situ carcinoma of gallblader. Patient 2: 36 years woman with type I  CBD with associated carcinoma of gallbader at moment of diagnosis, treated by resection of the CBD with  bisegmentectomy IV & V, lymphadenectomy and hepaticojejunostomy. Patient 3: 24 years woman with left Caroli’s disease, diagnosed by CTM and MRI, and treated by left hepatic lobectomy. histology diagnosied intrahepatic carcinoma.   Conclusions Incidence of malignant transformation in CBD is higher with advanced age of patients (from 0.7% before 10 years, to 45.5% between 70 and 80 years). Because of this high risk of malignancy,surgical complete treatment of CBD is necessary as soon as they are diagnosed.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
284

E-AHPBA

Vitor Costa Simões, Pedro Nuno Brandão, Cláudia Paiva, Bárbara Costa Leite, Cecília Pinto, Donzília Sousa Silva, José Davide HEBIPA - Hepatobiliopancreatic Unit, Hospital de Santo António, Porto, Portugal

Objectives Reliable risk factors for postoperative complications in patients undergoing laparoscopic cholecystectomy (LC) would be extremely useful to optimize the clinical management. This study aimed to determine risk factors that can be used for predicting postoperative complications. Method Possible risk factors for postoperative complications in patients undergoing LC for acute and chronic cholecystitis were analysed by a stepwise logistic regression model using data prospectively collected from patients undergoing LC at one single surgical university institution. Validity of the models was checked using the Hosmer and Lemeshow Goodness-of-Fit test. A p value < 0.05 was considered statistically significant. Results 4166 patients with mean age of 55.43 ± 15.15 years and a female predominance (73.4%) underwent LC (92.1% elective) between 1991 and 2008. Bile duct injury occurred in 0.2%. Conversion rate was 8.9%. Multivariable analysis showed that age (OR = 1.18), intraoperative complications (OR = 1.63), conversion (OR = 4.60), American Society of Anesthesiologists score (OR = 1.57), duration of surgery (OR = 1.51), and surgeon’s lesser experience (OR = 1.47) were found to be associated with higher incidence of postoperative complications. Age, female gender, obesity and surgeon’s experience were factors implicated in conversion. Conclusions For patients undergoing LC, the risk of possible postoperative complications can be estimated based on patient characteristics (age, body weight, ASA score), and the surgeon’s own clinical practice with LC. These factors predict a “difficult cholecystectomy” so an experienced surgeon should be early involved.

285

Abstracts

P45 Risk factors for complications in patients undergoing laparoscopic cholecystectomy: analysis of a single centre 4166 consecutive cases.

P46 The treatment of hydatid cysts in the breakthrough of the extrahepatic bile ducts Abstracts
Karimhon Kurbonov, Faruch Mahmadov, Alisher Gulahmadov, Atoboi Sobirov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan

Objectives Improving the results of surgical treatment of liver echinococcosis  complicated by obstructive jaundice. Method There were examined and treated 415 patients with liver echinococcosis, operated in the City Clinical Emergency Hospital in Dushanbe for the period from 2000 to 2012. Liver echinococcosis complicated by obstructive jaundice was found in 87 (20.9%) patients. Age of patients ranged from 16 to 76 years. Males were 174 (41.9%), women - 241 (58.1%). When choosing a diagnostic algorithm the preference was given as to endoscopy (EGD, laparoscopy), and to instrumental methods (ultrasonography, ERCP, CT, MRI). Results We divided the patients into three groups. The first group included 43 (49.4%) patients with severe (icteric) form of the disease. To the second group there were classified 26 (29.9%) patients. 18 (20.7%) patients of the third group had mild clinical course. Endoscopic papillosfincterotomy (EPST) was conducted in 27 patients, including the instrumental removal of fragments of chitinous shell (15).  Combined EPST and nazobiliar drainage were used in 7 patients. In 48 (55.2%) patients  there were performed traditional surgery. After performing the above surgeries  (87) there were 5 deaths (5.7%). Postoperative complications were diagnosed in 7 (8.0%) patients. Conclusions Thus, in obstructive jaundice of echinococcosis origin advisable to carry out a watershed treatment. In the first phase the paramount importance has endoscopic intervention, which involves simultaneous decompression of the residual cavity of echinococcosis cyst of common bile duct, lower toxicity and cupping of liver failure. Further traditional surgery.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
286

E-AHPBA

P47 Endoscopic retrograde cholangiopancreatogrphy in octogenarians Abstracts
Laura Smith, Muhammad Ali Karim, Abdulmajid Ali, Aya Musbahi, Stephanos Pericleous University Hospital Ayr, Ayrshire, UK

Objectives  Due to an aging population and increased prevalence of pancreato-biliary disease in the elderly there is an increasing demand for endoscopic retrograde pancreatography (ERCP) in this cohort of patients. This study aims to compare the outcomes of ERCPs in octogenarians and 60-79 year old patients in terms of rates of cannulation, success rates, complication rates and mortality as well as causes of repeat ERCPs.   Method A prospectively maintained database was reviewed to identify all patients over the age of 60 years who underwent ERCP from May 2010 to May 2012. These patients were divided into two cohorts, Group A: 60-79 years (n=66) and Group B: >80 years old (n=48). Data on indications for ERCP, outcome of the procedure, complications and repeat procedures was collected for all patients. Results Over the two-year period 114 patients between the age of 60 and 92 years were identified. In Group A, 89 ERCPs (n=66) and in Group B 69 ERCPs (n=48). Cannulation rates were only marginally lower in Group B (91%) compared to Group A (93%).  The success rate of Group B was higher (88% versus 85.3%) with the overall complication rate being comparable in both groups. Post ERCP pancreatitis was more prevalent in Group A. There were two cases of perforation in Group B and one associated mortality (1.4%) however the findings were statistically insignificant.   Conclusions ERCP in octogenarians is safe and effective however extra caution should be exercised in elderly patients as the risk of perforation is increased.  

287

Abstracts

P48 The method of differential diagnosis of bile duct during laparoscopic cholecystectomy “difficult” gallbladder
Faruch Makhmadov, Karimhon Kurbanov, Bahman Ikromov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan

Objectives diagnosis and prevention of sub-and postoperative complications of laparoscopic cholecystectomy “difficult” gallbladder. Method For the period 2010 to 2012 in the clinic videolaparoscopy performed in 31 patients with so-called “difficult” gallbladder. There were 22 men and women - 9. For the differential diagnosis of vascular-secretory structures hepatoduodenal area, we have developed a method suboperatsionnoy cholangiography during laparoscopic cholecystectomy. Method of diagnosis: the detection of atypical location of the gallbladder, and the inability of atypical confluence differentiation of cystic duct through the cystic duct or choledoch puncture puncture by 0.5 cm is introduced with X-ray contrast agent, which allows differentiation of the extrahepatic bile ducts and avoid heavy sub-and post-operative complications. Results Following the suboperatsionnyh cholangiography in 4 (12.9%) were inserted indication for conversion in the other (n = 27) cases of laparoscopic cholecystectomy performed with the location of the identified pattern of the gallbladder and biliary tract. Duration of operations averaged 76.3 minutes. No cases of intraoperative complications were observed. Postoperative period in all patients was uneventful. Patients discharged in 3-5 days after the procedure. Conclusions Suboperatsionnaya laparoscopic cholangiography can be performed in a separate group of patients with so-called “difficult” gallbladder. The method allows for the prevention of heavy sub-and post-operative complications such as iatrogenic injury, the common bile duct ligation (hepaticocholedochus), stricture hepaticocholedochus etc.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
288

E-AHPBA

LUDMIL MARINOV VELTCHEV1, MANOL ANASTASOV KALNIEV2, DYMO KRASTEV2, NIKOLAY KRASTEV2 1 State Hospital, Surgery department, Biala Slatina , Vratza, Bulgaria, 2Medical University, Sofia, Bulgaria Objectives Cholecystectomy is still the most performed operation in general surgery departments. Introduction of laparoscopic technique dosn’t eliminate traditional open cholecystectomy.  Good knowledge of liver and subhepatal anatomy and its variations my help to avoid biliary complications due to laparotomy, insertion of first troacar and performance of pneumoperitoneum, dissection of Callot triangle and ligation (clipping) of tube structures as cystic duct, cystic artery and gallbladder bed. Uncontroled use of electrical divise may cause depth injuries. Method Statistical analysis of 5 years operative protocols in the two departments helps to determine indications and contraindications for each method , discover and describe the biliary complications that cause postoperative problems.  Good knowledge of liver and subhepatal anatomy and its variations may help to avoid biliary complications due to laparotomy, insertion of first troacar and performance of pneumoperitoneum, dissection of Callot triangle and ligation (clipping) of tube structures as cystic duct, cystic artery and gallbladder bed. Uncontroled use of electrical divise my cause depth injuries.   Results We found that all biliary complications may be organized into the following major groups: 1. Due to dissection of triangle of Callot 2. Due to mobilisation of gallbladder 3. Due to ligation or clipping of cystic duct and cystic artery 4. Due to hemostasis of gallbladder bed and presens of open Lushka bile ducts 5. Due to common bile duct lithiasis   Conclusions Cholecystectomy requires experiensed surgeon. Undiscovered Extrahepatic biliary tree anatomical variation present dificulty in dissection ad porta hepatis. Use of clipps is advantage under visual control. Electrical divises may cause injury of surrounding structures as common hepatic duct, common bile duct,  right hepatic artery.

289

Abstracts

P49 Major injuries of extrahepatic bile duct systhem after cholecystectomy-comparison between open and laparoscopic methods.

Abstracts

P50 Local and systemic content of TNFa and IL-6 in patients  with acute calculous cholecystitis
Jabbar Hajiyev, Elman Tagiyev, Novruz Hajiyev, Elmar Sharifov Azerbaijan Medical University, Baku, Azerbaijan

Objectives  Proceeding from the idea that cytokines play a key role in development of inflammatory process, it is important comparative study of cytokines in the blood and bile in patients with acute calculous cholecystitis. Today, there are only a few works dedicated to assessment of changes of cytokine balance in the blood and bile in acute period of the disease. The aim of this work was a comparative study of the contents of TNFa and IL-6 in serum and bile in patients with acute calculous cholecystitis   Method 30 patients with acute calculous cholecystitis, who examined the contents of TNFa and IL-6 in serum (with catarrhal form - 10, with abscess - 7, gangrenous - 7 and complicated with obstructive jaundice and cholangitis - 6). Local indicators in the bile was identified in 26 patients: in 7 - with catarrhal, 8 - with abscess, 6 - with a gangrenous form of the disease, and in 5 –acute calculous cholecystitis was complicated with obstructive jaundice and cholangitis. The level of TNFa and IL-6 in serum was measured preoperatively, and in bile - at once (first portion).   Results  Thus, the level of TNFa in preoperative serum in patients with catarrhal form by 3.1 times, abscess - 2.7 times, gangrenous - 2.4 times, obstructive jaundice and cholangitis - 2.2 times  more than in healthy individuals. The level of this cytokine in bile in all forms of gallbladder inflammation is less than those in the serum of patients. In patients with acute calculous cholecystitis complicated with obstructive jaundice and cholangitis, the level of TNFa in bile is higher compared with the serum levels.     Conclusions In the catarrhal form of acute calculous cholecystitis the concentration of IL-6 in bile was - 6,59±0,37 pg/ml, in abscess - 8,34±0,34 pg/ml and in gangrenous form - 13,80±0.94 pg/ml. In acute calculous cholecystitis complicated with obstructive jaundice and cholangitis the level of IL-6 in bile was higher than in serum. Thus, a comparative evaluation of the studied cytokines in the serum and bile shows a clear relationship between the forms of the disease and the condition of the cytokine balance. Revealed changes in cytokine regulation in acute calculous cholecystitis confirms disturbances of cytokine balance an organ and organism level.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
290

E-AHPBA

Veselin Stanisic1, Igor Andjelkovic2, Darko Vlaovic1, Igor Babic1, Nikola Kocev3, Bosko Nikolic2, Miroslav Milicevic4,5 1 Surgical Department General hospital Berane, Berane, Montenegro, 2University of Belgrade School of Electrical Egineering, Belgrade, Serbia, 3Institute for Medical Statistics and Informatics Univeritiy of Belgrade, Belgrade, Serbia, 4The First Surgical Clinic, Clinical Center of Belgrade, Belgrade, Serbia, 5University of Belgrade-School of Medicine, Belgrade, Serbia Objectives Predicting technical difficulties in laparoscopic cholecystectomy (LC) in a small regional hospital increases efficacy, cost-benefit and safety of the procedure. The aim of the study was to assess whether it is possible to accurately predict a difficult  laparoscopic cholecystectomy (DLC) in a small regional hospital based only on the routine available clinical work-up parameters (patient history, ultrasound examination and blood chemistry) and their combinations. Method A prospective, cohort, of 369 consecutive patients operated by the same surgeon was analyzed. Conversion rate was 10 (2.7%). DLC was registered in 55 (14.90%). Various data mining techniques were applied and assessed. Results Seven significant predictors of DLC were identified: (1) shrunken (fibrotic) gall bladder, (2) US gallbladder wall thickness > 4mm, (3) > 5 attacks of pain lasting > 5 hours , (4) WBC>10x109 g/L, (5) pericholecystic fluid, (6) urine amylase > 380 IU/L and (7) BMI > 30kg/m2. Bayesian network was selected as the best classifier with accuracy of 94.57, specificity 0.98, sensitivity 0.77, AUC 0.96 and F-measure 0.81. Conclusions It is possible to predict a DLC with high accuracy using data mining techniques, based on routine preoperative clinical parameters and their combinations. Use of sophisticated diagnostic equipment is not necessary.

291

Abstracts

P51 Predicting technical difficulties during laparoscopic cholecystectomy based on routine patient work-up in a small community hospital - data mining technique

P52 Gallbladder carcinoma associated with cystic dilatation of the bile duct Abstracts

Nabil BOUDJENAN SERRADJ, Anisse TIDJANE, Benali TABETI, Toufik BOUHADIBA, Noureddine BENMAAROUF Etablissement hospitalo-universitaire d’Oran, Oran, Algeria Objectives the association between cystic dilatation of the bile duct and bile duct cancer is fairly common. The objective of this presentation is to demonstrate the surgical management of this type of pathology at the service hepatobiliary surgery and liver transplantation in the EHU. Oran in Algeria. Method This is a young woman aged 36 years, complaining of pain in the right hypochondrium, without jaundice or  palpable mass. scanner and an RMN showed the presence of gallbladderl tumor associated with cystic dilatation of the bile duct. Results Surgical exploration include: • A gallbladder with a bud-like malignant tumor at its bottom. • An inflammatory hepatic pedicle completely distorted by the presence of a large choledochal cyst. • Several nodes of the hepatic pedicle which is extemporaneous histological analysis benign. • Absence of liver metastases or carcinomatosis nodules. Is performed: • A puncture of the cyst with intraoperative cholangiography showing a cyst type I Todani saaciforme kind. • peel back duodenopancreatic showing the absence of inter-aortic lymph-cellar. • Resection of choledochal cyst. • Bisegmentectomie IVb-V. • Cleaning hepatic pedicle. • jejunal anastomosis hepaticojejunal. .Conclusions The risk of degeneration of cystic dilatation of the common bile duct, as well as its association with cancer of the gallbladder is still valid, by adopting an attitude of vigilant diagnostic and therapeutic radical against this disease..  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
292

E-AHPBA

P53 Obstructive jaundice caused by large common bile duct stones

Objectives To compare the success rate, complications and hospital stay of patients treated because of large common bile duct stones in our department. Method Five  patients (2 males and 3 females) were admitted to our surgery unit  because of large common bile duct stones ( ≥25 mm in largest diameter). Different examinations such as ultrasound tomography, ERCP, and CT was  used to confirm the diagnosis. Results In three of our five patients the commonest  manifestations were abdominal pain and in all five patients jaundice was the cardinal disquietude for their coming in our department . The laboratory test values of bilirubin was between 75 – 120 μmol/l, AST 15 -110 U/l, ALT 25 – 120/l.  The diameter of the CBD stone determined by the ultrasound ranged from 29  mm to 35 mm in largest diameter. In one patients the level of Ca 19-9 tumors markers was 258 I.U/ml,  meantime the ultrasonography and CT do not distinguishes the presence of the stone inside the common bile duct. Surgical management was done successfully in all five  patients.  Supraduodenal choledochotomy and T-tube drainage was performed in all of them. Complications in the form of wound infection occurred in two patients and  biliary leakage in one of them. Mean hospital stay was 14  days. Post-operative tests showed significant decrease in the mean values of liver functions and enzymes. Ultrasonography was done in all patients (2 – 3  weeks after intervention) and revealed complete clearance of the CBD. Conclusions Surgical management of large CBD stones is usually the only possibility to treat this patients despite the extended hospital stay and sometimes the high level of post operative complications.

293

Abstracts

Kastriot Haxhirexha, Xheladin Elezi, Nehat Baftia, Ferizat Dika-Haxhirexha, Lendita Dika Clinical Hospital, Tetove, Macedonia

P54 Repairing iatrogenic bile duct injury: one single centre experience Abstracts
Vítor Costa Simões, Pedro Nuno Brandão, Donzília Sousa Silva, José Davide HEBIPA - Hepatobiliopancreatic Unit, Hospital de Santo António, Porto, Portugal

Objectives Despite the frequency of iatrogenic bile duct injuries and their complex management, the published literature contains few substantial reports regarding their perioperative management. The aim of this article was to review the management of bile duct injury (BDI) after cholecystectomy at author´s institution. Method A retrospective analysis was performed on all patients with iatrogenic BDI from 2005 to 2012. Details of time between cholecystectomy and recognition of the injury, time from injury to definitive repair, type of injury, use of intraoperative cholangiography, definitive repair and postoperative outcome were recorded. Results Complete follow-up data were available for 33 patients with mean age of 56 years, 69.7% transferred from other hospitals. There was a slight female predominance (51.5%). According to Bismuth classification, BDI was classified as type 1 in 18.2%, 2 in 36.4%, 3 in 24.2% and 4 in 21.2% of cases. Only 15.2% of BDI were recognized during cholecystectomy. When the injury was not immediately recognized, 42.8% of patients became jaundiced and equal proportion developed bile leak/peritonitis. Two patients (6.1%) died from sepsis already present at admission. Twenty-four (72.7%) patients had uncomplicated recovery and there was one late stricture requiring surgical revision. Conclusions Early prediction that BDI during cholecystectomy would decline substantially with increased experience has not been fulfilled. BDI is still little recognized during cholecystectomy. Prevention is the key but, should an injury occur, referral to a specialized hepatobiliary unit is indicated, where successful repair can be achieved.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
294

E-AHPBA

P55 Obstructive jaundice caused by large common bile duct stones

Objectives To compare the success rate, complications and hospital stay of patients treated because of large common bile duct stones in our department. Method Five  patients (2 males and 3 females) were admitted to our surgery unit  because of large common bile duct stones ( ≥25 mm in largest diameter). Different examinations such as ultrasound tomography, ERCP, and CT was  used to confirm the diagnosis.  Results In three of our five patients the commonest  manifestations were abdominal pain and in all five patients jaundice was the cardinal disquietude for their coming in our department . The laboratory test values of bilirubin was between 75 – 120 μmol/l, AST 15 -110 U/l, ALT 25 – 120/l.  The diameter of the CBD stone determined by the ultrasound ranged from 29  mm to 35 mm in largest diameter. In one patients the level of Ca 19-9 tumors markers was 258 I.U/ml,  meantime the ultrasonography and CT do not distinguishes the presence of the stone inside the common bile duct. Surgical management was done successfully in all five  patients.  Supraduodenal choledochotomy and T-tube drainage was performed in all of them. Complications in the form of wound infection occurred in two patients and  biliary leakage in one of them. Mean hospital stay was 14  days. Post-operative tests showed significant decrease in the mean values of liver functions and enzymes. Ultrasonography was done in all patients (2 – 3  weeks after intervention) and revealed complete clearance of the CBD. Conclusions Surgical management of large CBD stones is usually the only possibility to treat this patients despite the extended hospital stay and sometimes the high level of post operative complications. 

295

Abstracts

Kastriot Haxhirexha, Xheladin Elezi, Nehat Baftija, Feriza Dika-Haxhirexha, Lendita Dika Clinical Hospital, Tetove, Macedonia

P56 Obstructive jaundice caused by large common bile duct stones Abstracts

Kastriot Haxhirexha, Xheladin Elezi, Nehat Baftija, Ferizat Dika - Haxhirexha, Lendita Dika Clinical Hospital, Tetove, Macedonia Objectives To compare the success rate, complications and hospital stay of patients treated because of large common bile duct stones in our department. Method Five  patients (2 males and 3 females) were admitted to our surgery unit  because of large common bile duct stones ( ≥25 mm in largest diameter). Different examinations such as ultrasound tomography, ERCP, and CT was  used to confirm the diagnosis. Results In three of our five patients the commonest  manifestations were abdominal pain and in all five patients jaundice was the cardinal disquietude for their coming in our department . The laboratory test values of bilirubin was between 75 – 120 μmol/l, AST 15 -110 U/l, ALT 25 – 120/l.  The diameter of the CBD stone determined by the ultrasound ranged from 29  mm to 35 mm in largest diameter. In one patients the level of Ca 19-9 tumors markers was 258 I.U/ml,  meantime the ultrasonography and CT do not distinguishes the presence of the stone inside the common bile duct. Surgical management was done successfully in all five  patients.  Supraduodenal choledochotomy and T-tube drainage was performed in all of them. Complications in the form of wound infection occurred in two patients and  biliary leakage in one of them. Mean hospital stay was 14  days. Post-operative tests showed significant decrease in the mean values of liver functions and enzymes. Ultrasonography was done in all patients (2 – 3  weeks after intervention) and revealed complete clearance of the CBD. Conclusions Surgical management of large CBD stones is usually the only possibility to treat this patients despite the extended hospital stay and sometimes the high level of post operative complications.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
296

E-AHPBA

P57 Hydatid cyst of the liver ruptured into the bile duct

Objectives The hydatid cyst remains a public health problem in the Maghreb countries. The objective of this paper is to elucidate through a typical one of the most common complications and the most serious is the break in the bile duct Method This is a young woman aged 21 years presenting at our service for acute cholangitis. .Clinical examination revealed: -jaundice generalized mucocutaneous cholestatic type. -pain in the right hypochondrium. - Fever 39 °. .Abdominal CT scan found a cystic formation of liver segment IV. .RMN found a significant dilation of the bile duct with multiple formations, with total obstruction of the latter in its distal portion. Results Medical treatment was introduced, with significant clinical improvement after one week of treatment. .We operated the patient, surgical exploration include: -a hydatid cyst liver segment IV of about 40 mm, its opening is found that the membrane proligerous vacuo. -a bile duct dilated to 30 mm. .Is performed: -sterilization of the cyst puncture segment VI of the liver, resection of the protruding dome. -choledochotomy for extracting multiple hydatid variable volume calculations. -wash the bile duct. -checking the emptiness of it by intraoperative cholangiography. -Biliary drainage with a Kehr drain. The postoperative course was uneventful. Conclusions Hydatid cyst of the liver is a benign course, but its malignant complications especially break in the bile duct

297

Abstracts

Nabil BOUDJENAN SERRADJ, Benali TABETI, Anisse TIDJANE, Toufik BOUHADIBA, Nourredine BENMAAROUF Etablissement hospitalo-universitaire d’Oran, Oran, Algeria

Abstracts

Radoje Colovic1 1 Medical Faculty University Belgrade, Belgrade, Serbia, Serbia, 2Professor Emeritus, Medical Faculty University Belgrade, Serbia

P58 Surgical technique of high bile duct lesions and strictures reconstructions. Can we further improve the technique and results?

Objectives Objective. Bile tree injuries are the most serious complications of cholecystectomy. Benign bile duct strictures as a result of  injuries still represent a serious challenge. Thanks to the improved surgical technique repair of Bismuth’ types I, II and III strictures should be successful in most cases. The repair of type IV strictures is much more difficult and uncertain. In almost all these cases the most difficult challenge is how to improve biliary drainage from the right liver and how to achieve a life long patency of the anastomosis.   Method Material and method. In order to reach  bile ducts in type IV Bismuth’strictures lowering of the hilar plate and   dissection of the  gallbladder bed may be necessary. But, they are not enough in some patients. Also, we found very difficult to perform two or even more anastomosis in such a small room. So, over the years we have been using some additional  maneuvers such as, first, excision of the scar that divide right and left hepatic bile ducts, second, carinoplasty and third, if possible, anastomosis of the divided hepatic bile ducts before performing single anastomosis with Roux-en-Y-jejunal limb Results Results. With the lowering of the hilar plate as well as with these three additional maneuvers whenever possible we achieved to performe a wide and long patent single Roux-en-Y hepaticojejunostomy in a number of cases which will be shown in the presentation.   Conclusions  Conclusion. With standard surgical technique of biliary repair of type IV Bismuth’s strictures as well as with additional maneuvers such as exscision of the scar that devides left and right hepatic bile ducts or anastomosis of the devided ducts prior to Roux-en-Y hepaticojejunostomy whenever possible and indicated the results of repair of these strictures may be further improved.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
298

E-AHPBA

Michael Vozdvizhenskiy, Vyacheslav Solovov Samara Oncology Center, Samara, Russia

Objectives For determination the treatment strategy for hepatic metastases of colorectal cancer, it is important to take into account different kinds of treatment methods. The aim of the study is to show the effectiveness of the combined treatment method. Method Treatment results of 874 patients with colorectal cancer liver metastases were included in the retrospective analysis. Strategy and tactics of treatment were developed due to the interdisciplinary approach of oncosurgery, chemotherapy and intervention radiology. According to the treatment patients were divided into the following groups: 1) 152 (17,4 %) patients underwent liver resection; 2) 145 (16,5 %) patients - radiofrequency ablation; 3) 134 (15,4 %) patients - chemoembolization of hepatic arteries; 4) 321 (36,7 %) patients received only chemotherapeutic treatment; 5) 122 (13,9 %) patients received combination of above-mentioned treatment methods. Results In the first group the median of survival rate after the diagnosis of liver metastases was 25,5 months, in the second group - 18 months, in the third group - 32 months. In the case of unresectable metastases schemes of chemotherapy (FOLFOX, FOLFIRI, and XELOX) were used, the median of survival rate was 12 months. In the group where patients received the combination of treatment methods: resection of liver and radiofrequency ablation or chemoembolization of hepatic artery the median of survival rate was 29 months. Conclusions The multimodal approach in treatment of hepatic colorectal cancer metastases increased the survival rate till 29 months.

299

Abstracts

P59 Multimodality approach in the treatment of patients with hepatic colorectal cancer metastases

Abstracts

P60 Results of surgical treatment of colorectal cancer hepatic metastasis: 5-year experience
Vyacheslav Solovov, Michael Vozdvizhenskiy Samara Oncology Center, Samara, Russia

Objectives Hepatectomy offered the best patient’s prognosis for colorectal cancer hepatic metastasis. Here we analyzed 5-year results of surgical treatment of hepatic colorectal metastases. Method The study included data of 152 patients who underwent resection of liver metastases of colorectal cancer from February 2007 to November 2012. 78 (51.4%) patients were male, 74 (48.6%) were women. The median age was 57,1 ± 10,2 years (range: 45-72). 122 (80,3%) patients underwent anatomic resections (hepatectomy and segmental), in 30 (20,7%) cases – atypical resection. Mean follow-up was 42 (3-68) months. The choice of resection type, anatomical or atypical, were based on preoperative topical diagnosis of metastases (CT, MRI) and intraoperative ultrasound. Results The aim of hepatic resection was to achieve complete resection of all metastases with negative surgical margins while preserving sufficient hepatic parenchyma. Median survival for patients was 25.5 months. 5-year survival rate was 52%. Resection of the liver metastasis associated with a low mortality rate (3.7%) and minor complications (14.9%). Multivariate analysis showed that the number of tumors (<4), tumor size (<4 cm), type of resection and negative resection margins were signicantly correlated with five year survival. Conclusions Surgical resection is the main and effective treatment for patients with hepatic metastases of colorectal cancer, with a median survival 25.5 months. 5-year survival rate was 52%.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
300

E-AHPBA

Mathieu D’Hondt, Dirk Devriendt, Frank Van Rooy, Franky Vansteenkiste Groeninge Hospital, Kortrijk, Belgium

Objectives Liver resection is a safe procedure that should be considered within a multimodal treatment concept of patients with breast cancer liver metastases (BCLM). In patients with colorectal liver metastases it is known that, despite a complete response on imaging, only a minority (<20%) have a complete pathologic response. Method  A patient with 3 synchronous BCLM from breast cancer was referred.There were 2 lesions in the right hemiliver and 1 in the caudate lobe.Neoadjuvant chemotherapy was given. New imaging showed a complete radiologic response.Operative strategy was based on initial imaging.The left part of the caudate lobe was resected along the vena cava.Preparation of the hepatoduodenal ligament was performed and the right hepatic artery was clipped, the right portal vein was transected using a vascular stapler. The right hemiliver was mobilised followed by parenchymal transection. The right hepatic duct and hepatic vein were dissected and transsected intraparenchymally using a vascular stapler. Results Operative time was 270min, blood loss was 200cc. Recovery was uneventful and the patient was discharged on day 7. Pathologic examination showed no microscopic residual disease. Conclusions To date, no reports of BCLM with complete pathologic response were published. This video shows a ‘blind’ laparoscopic major hepatectomy. Operative strategy was based on initial imaging (pre-chemo).

301

Abstracts

P61 ‘Blind’ laparoscopic major hepatectomy for liver metastases from breast cancer: a case of complete pathologic response.

P62 Radical laparoscopic treatment for liver hydatidosis: multicentre study Abstracts

Jose M Ramia, Ignasi Poves, Camilo Castellon, Luis Diez-Valladares, Carmelo Loinaz, Alejandro Serrablo, Miguel Angel Suarez, Andres Valdivieso, Juan L Blas, David Fernandez-Luengas, Santiago Lopez-Ben, Ricardo Robles, Fernando Rotellar, Joan Figueras Hospital Universitario de Guadalajara, Guadalajara, Spain Objectives There is no scientific evidence which surgical technique should be performed in hydatidosis of the liver. Nor is there consensus on whether laparoscopy should be used in hydatidosis due to the risk of dissemination or anaphylaxis. We conducted a multicenter study of laparoscopic radical surgery for hydatidosis of the liver (LRSH). OBJECTIVE: The main objectives of the study were to determine the feasibility and morbidity of LRSH and evaluate the associated recurrence rate. Method A retrospective multicenter study of patients with hydatid disease of the liver treated by LRSH. The study period was from January 2000 to April 2012. Results There were 37 patients (46% male) with 43 cysts.  Median age: 53.1 years. Median cyst size: 5.8 cm. The most common location of the cyst was the left lateral sector (62%). Median number of trocars:  4. Protective scolicide-soaked swabs were used in 57% of patients. We performed 24 total closed cystectomies, 12 left lateral sectionectomies, and four liver resections. Median operating time was 185 minutes and mean blood loss was 184 mL. The conversion rate was 8%. Morbidity was 16% and mortality 0%. Length of hospital stay was 4.8 days. No recurrence was observed after a follow-up of 41.3 months. Conclusions Despite the limitations and biases of a retrospective multicenter study we believe that LRSH is feasible in favorable segments but is technically demanding. The low morbidity and absence of recurrence suggest that LRSH should be performed whenever feasible.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
302

E-AHPBA

Objectives The aim of this study was to analyse our results of operative treatment of the patients with the liver metastases of colorectal carcinoma.   Method This  study included 387 patients. Diagnostic protocol  including functional state of the liveras, spiral computed tomography.   Results Of all the patients 40.6% had metastases in the liver, synhronous 20.15% and metachronous 20.45%. In  21% of them it was performed operation. The average age 60.09 years. Up to 4 metastases had 90.9%  and in 9.09% had up to 5 and more. On average, metastases occupied 2.6 of the liver segments.  There were 60.6% of anatomical liver resections and 39.4% of atypical resections.  An average number of segments where resection had been performed was 2.65  90.9% was of the type R0, 9.09% of the type R1.  Morbidity rate was 15.15% and  mortality 3.03%.   Conclusions Anatomic liver resection   is  efficient and secure method with good surgical results.  

303

Abstracts

Radenko Koprivica1,2, Goran Tosovic0,2, Miljko Pejic2,3 1 1General hospital Murska Sobota, Murska Sobota, Slovenia, 22Health Center Uzice, Uzice, Serbia, 33Sorlandet sykehus Kristiansand, Kristiansand, Norway

P63 Our results of liver resection due to metastases of colorectal carcinoma

Abstracts

P64 Treatment unresectable hepatic metastases of colorectal cancer by transarterial chemoembolization
Sergey Dudko, Michael Vozdvizhenskiy Samara Regional Oncology Center, Samara, Russia

Objectives The purpose of the study was to evalutate the results of trans-arterial chemoembolization (TACE) in patients with unresectable liver metastases from colorectal cancer (CRC). Method 138 patients with hepatic metastases of CRC were treated from 2006 to 2012, 289 treatment cycles of chemoembolization were made (from 1 to 5, average 2.0 per patient) . Characteristics of patients: 33% (n = 46) women, 67% (n = 92) males. All patients underwent from one to six courses of systemic chemotherapy. Chemoembolization was performed with microspheres DC Bead (Terumo) which consisted of 100 mg of irinotecan or 50 - 100 mg of doxorubicin. Results In 11 patients (8%) was observed a partial response, 71 (52%) - stabilization, and in 56 (40%) progression. The median time to progression of CRC hepatic metastases after TACE was 5 months. Median survival time from the start of the chemoembolization was 16 months. 1 -, 3 - and 5-year survival rates were 94%, 56% and 7% respectively. Conclusions TACE is effective treatment to stabilize the development of unresectable liver metastases of CRC. Chemoembolization shows good survival rates, compared with systemic chemotherapy.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
304

E-AHPBA

Anders Jansson1, Jennie Engstrand2, Silja Karlgren2, Henrik Nilsson2, Eduard Jonas1, Jacob Freedman1 1 Karolinska University Hospital, Stockholm, Sweden, 2Danderyd Hospital, Stockholm, Sweden Objectives Local ablative techniques for destruction of liver tumours has evolved from alcohol injection to cryoablation and further to heat destruction with radiofrequency ablation and on to microwave ablation (MWA). MWA has some distinctive advantages; a quicker ablation and more consistent ablative zone with less sensitivity to cooling effects of nearlying vessels. Heat destruction has a further potential benefit of presenting denaturated tumour cell antigens to the patients immune system with a potential antitumoural effect. Method Patients with multiple liver metastases selected for local liver MWA at the central multidisciplinary therapyconference for liver tumours were retrospectically analysed regarding postoperative ablation volumes on follow-up CT or MRI scans. Routine follow-up was planned at 1,3,6 and 12 months. Volumes were calculated by a commercial service provided by MeVis AG, Bremen, Germany. Patients with muliple ablations were included to reduce volume calculation errors of single ablations. Results Six patients were analysed. Patient characteristics are displayed in table 1. One patient had a suspected recurrance in segment 7 after one year and had a subsequent liver resection. No tumour was encoutered in the preparation, the histological appearance of a resected volume can be seen in figure 2. The individual data is shown inset in figure 1. When the data is normalised to an estimated maximal ablation volume, the rate of liver regeneration is surprisingly uniform and similar to rate of regeneration reported after liver resection. Conclusions Microwave ablation treatment can be given with good effect even in the face of widespread colorectal liver metastases. Further studies are warranted.

305

Abstracts

P65 Liver regeneration pattern after multiple microwave abalations of colorectal liver metastases.

Abstracts

P66 Possible curative role for microwave ablations in unresectable livermetastases of colorectal cancer.

Jennie Engstrand1, Silja Karlgren1, Anders Jansson2, Henrik Nilsson1, Eduard Jonas2, Jacob Freedman1 1 Danderyd Hospital, Stockholm, Sweden, 2Karolinska University Hospital, Stockholm, Sweden Objectives Colorectal cancer is the 2:nd or 3:rd most common cancer in Europe depending on gender and country. Liver metastasis occurs in 30-50% of patients. Good results of active resective treatment in operable patients leads to 5-year survival in 30-60%. Operability is decided by comorbidity and ability to perform resections with adequate remaining liver tissue, usually 25-30% of total liver volume. Ablative procedures lika Radiofrequency ablation and Cryoablation have been used as palliative techniques. Microwave ablation (MWA) is a newer method with more consistant ablation zone and quicker application with the potential benefit of immunological activation through denaturated  tumour antigens. Method All patients with a new diagnosis of colorectal cancer in the greater Stockholm area, population 2 miljon, in 2008 were included in a retrospective analysis of metastatic patterns, diagnosis and treatment. Cases were selected from the Swedish Colorectal Cancer Registry and crosschecked with the General Swedish Cancer Registry. Every single case was accounted for. A second group consists of all cases during the last three years, with more than 5 liver metastases. MWA was in these cases applied under general anaestesia with open abdomen and guidance with ultrasound or a computer assisted system(CAS-one). Results Of 1032 new cases of colorectal cancer, 266 had liver metastases (CRLM) before july 2012. 16% synchronous and 10% metachronous. Of these, 93 cases were selected that only had metastases less then 30mm in diameter, not more than 20 in number and no other incurable metastases at time of diagnosis of CRLM. Of these, 38 had a liver resection. These are compared to our experiance with palliative multiple MWAs with regard to survival. There was a significant difference in survival between the palliative and both the treated groups (p<0.05) but not between the two treated groups. Conclusions Microwave ablation treatment can be given with good effect even in the face of widespread colorectal liver metastases. Further studies are warranted.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
306

E-AHPBA

ANTONIO PESCE, TERESA ROSANNA PORTALE, LUCIANO NIGRO, GIOVANNI LI DESTRI, ROBERTO SCILLETTA, STEFANO PULEO A.O.U. Policlinico-Vittorio Emanuele, Catania, Sicily, Italy

Objectives  Cystic Echinococcosis (CE) is a parasitic zoonosis caused by the larvae of the cestode Echinococcus granulosus. Humans are accidental intermediate hosts and can accommodate one or more cysts in different locations, mainly the liver and lungs. The standard treatment for hydatid disease has historically been surgical, including conservative and radical procedures. The purpose of this study was to retrospectively assess epidemiological and clinical characteristics and to compare the  safety of radical and conservative surgical interventions which have taken place over the last forty years for hydatid disease of the liver in an endemic area such as that of Western Sicily.   Method Patients who had undergone surgery for liver hydatid cysts between January 1970 to December 2011 were analyzed retrospectively. We divided the modifications of surgical treatment into three different periods: 19701990, 1991-2000, 2001-2011. Data were collected on patient age, sex, general characteristics of liver cysts, surgical treatment, complications, recurrences and follow-up. Results A total of 312 patients had undergone surgery for liver hydatid cysts between January 1970 to December 2011; of these, 161 were male (51.6%) and 151 were female (48.4%); the median age was 63 (range 7-80 ys). The main clinical presentation was abdominal pain in 260 (83.3%) patients. In the current series, we observed a progressive reduction of conservative surgery as opposed to radical approaches and a considerable decreasing of postoperative complications and recurrences rate.  The mean hospital stay was seven days (range 5-15 days). The median follow-up time was 36 months (range 3-60 months).   Conclusions There was a considerable reduction of conservative surgical approaches as opposed to an increase in radical surgical treatment over the forty-year period analyzed with a substantial reduction of postoperative complications and recurrence rates. We believe that surgical treatment still remains the best therapeutic option in terms of radicality and recurrence rates. Alternative therapies to surgery should be carefully evaluated.  

307

Abstracts

P67 Hepatic echinococcosis: forty years of surgical improvements for a decreasing hypothetic disease in an endemic area. Has surgery become a secondary option?

Abstracts

P68 Could neoadjuvant chemotherapy influence the presentation of postoperative complications in patients with colorectal liver metastases?
Roberto Scilletta, Teresa Rosanna Portale, Antonio Pesce, Salvatore Gruttadauria, Stefano Puleo A.O.U. Policlinico-Vittorio Emanuele, Catania, Italy

Objectives Postoperative infections are frequent complications after liver resection and they have a significant impact on length of hospital stay, morbidity and mortality. Surgical site infections (SSIs) are the most common hospital-acquired infections among surgical patients, with significant impact on patient morbidity and health care costs according to the U.S. Centers for Disease Control and Prevention (CDC) through the National Nosocomial Infections Surveillance (NNIS) program.The aim of this study was to clarify the incidence of surgical site infections and postoperative complications according to the Clavien-Dindo classification after hepatic resection for metastatic colorectal cancer in patients with or without associated neoadjuvant chemotherapy. Method Data were collected on patient age, sex, comorbidity, site of primary tumour, type of hepatic resection, duration of surgery, length of total hospital stay and postoperative stay. Patients were divided in two groups: the first group involved patients who had undergone hepatic resection for metastatic colorectal cancer with associated neoadjuvant chemothapic treatment to liver metastases with a latency time less than eight weeks; the second group included patients who had undergone hepatic resection without associated neoadjuvant chemotherapy. Results The current series enrolled 181 patients. The first group included 129 patients without associated chemotherapic treatment, the second included 52 patients undergone neo-adjuvant chemotherapy. Preoperative characteristics of patients who had neo-adjuvant chemotherapy were not significantly different from the other group. Statistical analyses of two-by-two contingency tables of Exposure (to chemotherapy) vs Outcome (Surgical Site Infection or Clavien-Dindo Classification) did not show significant differences in the proportion of affected cases according to presence of chemotherapy. Neither statistical analyses of various preoperative and intraoperative characteristics vs Outcome showed significant differences in the proportion of affected cases according to presence of chemotherapy. Conclusions The current study did not demonstrated a direct correlation between neoadjuvant chemotherapy and postoperative complications. The presence of factors as length of total hospital stay, length of postoperative hospital stay and duration of liver surgery were identified as independent predictor for SSI and Clavien-Dindo complications in liver surgery.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
308

E-AHPBA

P69 Variant hepatic arterial anatomy on angiography in 3756 patients Abstracts
Pavel Balakhnin, Pavel Tarazov Russian Scientific Center of Radiology and Surgical Technologies, St. Petersburg, Russia

Objectives To study hepatic arterial variants using digital subtraction angiography in a large series of patients. Method Hepatic arteriograms of 3756 patients (1985-2011) were analyzed according to N. Michels (1955) classification. Variants not included in the classification were considered. Results Nine types of arterial anatomy were identified in 90.2% cases. Normal anatomy was found in 64.8% (CHA trifurcation = 11.3%), type 2 = 4.8%, type 3 = 5.2%, type 4 = 1.1%, type 5 = 5.4%, type 6 = 5.1%, type 7 = 1.0%, type 8 = 1.1%, type 9 = 1.7%, type 10 not found. In 368 (9.8%) remaining cases, 89 other variants were found and divided on 5 groups: variants of LHA origin (3.4%), RHA (3.3%), LHA + RHA (1.4%), PHA (0.3%) and variants of CHA (1.4%). Sixty-three variants of the hepatic artery have never been described. Conclusions Typical arterial anatomy of the liver is present in about 1/2 patients while different variants in the remaining 1/2. Knowledge of these variants is important for HPB surgeons and interventional radiologists.

309

P70 Hydatid cyst scolices Abstracts

Alexandros Charalabopoulos1,3, Anna Batistatou2, Anastasios Machairas3 1 Department of General Surgery, Guy’s and St Thomas’ Hospital, London, UK, 2Department of Histopathology, University of Ioannina Medical School, Ioannina, Greece, 33rd Department of General Surgery, University of Athens Medical School, Attikon University Hospital, Athens, Greece Objectives A rare histopathology finding of hydatid cyst scolices is presented. Clinicians who deal with the treatment of liver pathologies should be aware of this clinical and pathological entity, which although vanished today in the Western World , is reappearing. Method The case of a 59-year-old Caucasian woman of Greek origin, with liver hydatidosis and with an extremely interesting finding during microcopic examination, is presented. Results The patient presented with a 2-month history of dull right upper quadrant abdominal pain. Physical examination showed mild abdominal tenderness during liver palpation. Total leukocyte count was 6400 uL-1 with 1% eosinophils and serology for echinococcosis showed a titre of 1:1024; imaging studies (Ultrasound, Computerised Tomography) confirmed liver hydatidosis. Albendazole was given 4 weeks pre-surgery. At laparotomy, the colorless fluid filled viable cyst containing daughter cysts was excised from liver segment VI. Satellite cysts were also present. During histopathology examination, the extraordinary rare scolices with the characteristic hooklets of about 20μm long were observed. Albendazole was prescribed postoperatively according to protocol. Conclusions Echinococcosis of the liver although rare nowadays in the Western World,  is making its appearance once again and an increased prevalence of the disease is noted. An extraordinary microscopic image, of hydatid cyst scolices with the characteristic hooklets is presented. Clinisians and pathologists should be aware of the disease and its characteristics.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
310

E-AHPBA

P71 Robot-assisted laparoscopic hepatectomy : The Henri-Mondor experience.

Objectives  Laparoscopic hepatectomy remains technically challenging. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery in many different surgical specialties in regards to 3-dimensional images and better instrumentations. It offers solutions to the fundamental limitations of conventional laparoscopic liver resection.   Method Between Mars 2011 and November 2012, we performed 14 hepatic resection for benign and malignant lesions by robot-assisted laparoscopic approach . A Da Vinci Robotic Surgical System (Intuitive Surgical, Mountain View, CA, USA) with three arms was used, with two additional laparoscopic ports for the assistant surgeons .No Pringle maneuver was used. The dissection was carried out with the bipolar forceps on the left arm of the surgeon and the Harmonic curved shears on the right arm. For left lateral sectionectomy, we divided the glissonian pedicles for segments 2 and 3 with EndoGIA staplers. Prospectively collected data was analysed retrospectively. Results The operations were  left lateral sectionectomy n=8, atypical resection segment 3 n= 3, atypical resection segment 4 n=1, atypical resection segment 5 n=1, atypical resection segment 6 n=1.Overall mean operative time was 185.6±60.2 minutes (range  :120-290). Overall mean intraoperative blood loss was 167.8±146.2 ml (range  :50-600). One open conversion was needed. One patient (7.1%) had postoperative complication (thrombosis in the right anterior portal branch). There was no mortality and no reoperations. Mean hospital stay was 6±3.6days  (range :2-16). All patients had R0 resection with a mean margin of 13.1± 11.2 mm (range: 0-45 mm).   Conclusions In experienced hands, robot-assisted laparoscopic hepatectomy is feasible and safe. Further evaluation with clinical trials is required to assess for improvement in outcomes and to validate its real benefits. Long-term oncologic outcomes are still pending. Further research on its cost-effectiveness is required.  

311

Abstracts

CHADY SALLOUM, ALEXIS LAURENT, CLAUDE TAYAR, ALEXANDRE MALEK, RICCARDO MEMEO, PHILIPPE COMPAGNON, DANIEL AZOULAY Hôpital Henri Mondor, Créteil, France

Abstracts

P72 Risk factors for long-term outcome following liver resection in patients with colorectal liver metastases

SORIN ALEXANDRESCU, ZENAIDA IONEL, DOINA HREHORET, VLADISLAV BRASOVEANU, IRINEL POPESCU DAN SETLACEC CENTER OF GENERAL SURGERY AND LIVER TRANSPLANTATION, FUNDENI CLINICAL INSTITUTE, BUCHAREST, Romania Objectives The postoperative chemotherapy regimen and follow-up are crucial to improve the survival rates after liver resection in patients with colorectal liver metastases. Because chemotherapy and follow-up should be tailored to each patient according to the risk factors, we investigated the risk factors associated with overall survival in our series. Method Between 1995 and 2012, in “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni, 430 patients underwent liver resection for colorectal liver metastases (378 patients presented liver only metastases, and 52 patients presented hepatic and extrahepatic metastases). Clinical, pathologic and outcome data of these patients were examined, in order to identify the factors that correlate with survival. The parameters assessed in this study were: number of liver metastases, metastases maximum size, interval between the primary tumor and liver metastases development, presence of extrahepatic metastases, T and N categories, and the initial stage of the disease. Results The survival rates were significantly higher in patients presenting with: single liver metastases ( p < 0.001), up to 3 metastases ( p = 0.001 ), no regional lymph node involvement ( p = 0.004), less than 4 metastatic lymph nodes ( p = 0.022), no extrahepatic disease ( p < 0.001) and stage I or II disease at the diagnosis (comparative with patients  diagnosed with stage III disease – p = 0.014). In patients diagnosed in stage III, the survival rates after liver resection following the development of liver metastases were similar to those achieved by hepatectomy in stage IV patients ( p = 0.352). Conclusions Postoperative chemotherapy and follow-up should be tailored according to the number of liver metastases, number of metastatic lymph nodes, initial stage of the disease, and presence of extrahepatic  metastases. The initial stage of the disease seems to be a more accurate predictive factor than the moment of liver metastases development.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
312

E-AHPBA

P73 LAPAROSCOPIC LIVER RESECTION. PERSONAL EXPERIENCE WITH 122 CASES Abstracts
Marcel Autran Machado, Fabio Makdissi, Rodrigo Surjan Sirio Libanes Hospital, Sao Paulo, Brazil

Objectives The aim of this paper is to analyze our personal experience with more than a hundred laparoscopic liver resections over a 5-year period and evaluate recent developments in technique Method Between April 2007 and September 2012, 122 laparoscopic liver resections were performed in 119 patients. Mean age was 53.9 years (range: 17-85). Sixty patients were male and 59 female. All surgical interventions were conducted by the authors. Results Conversion rate was 2.4% or three cases. Morbidity was 14.8% and overall mortality was 1.6%. Two patients died but only one related to the liver resection. Blood transfusions were necessary in 22 patients (18%). The most frequent type of operation was left lateral sectionectomy (33 cases) followed by right hepatectomy (25 cases). Seventy six hepatectomies (62.3%) were performed by Glissonian technique. There was an increase of cases per year along the 5-year period of study. Conclusions The authors conclude that laparoscopic liver resection is a complex operation and even with the advent of new technique and instruments should be performed by surgeons with both expertise in hepato-pancreato-biliary surgery and advanced laparoscopic skills.

313

Abstracts

Robert Öllinger1, Hüseyin Bektas2, Sascha Weiss1, Johann Pratschke1, Ivan Troisi5 1 Medical University Innsbruck, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck, Austria, 2 Department of General, Visceral and Transplant Surgery, Medical School Hannover, Hannover, Germany, 3 Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium, 4Department of General, Visceral and Transplantation Surgery, Heidelberg, Germany, 5Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent, Belgium Objectives Bleeding is a major concern in hepatic surgery, it is associated with morbidity and mortality. The VerisetTM Hemostatic Patch is a novel hemostat comprised of an absorbable backing of oxidized cellulose and self adhesive hydrogel components. VerisetTM is designed to achieve hemostasis quickly, adhere to tissues and be degraded within 28 days. Method This study was a prospective randomized, EU multi-center, single-blind study, performed to compare the VerisetTM Hemostatic Patch (G1) to TachoSil® (G2) for the management of diffuse bleeding after hepatic surgery. A total of 50 subjects at 6 centers were included in the study. Subjects underwent hepatic surgery according to the standard practices of each institution and randomized following confirmation of diffuse bleeding from the hepatic resection surface requiring the use of a topical hemostat. Post application of either device, time to hemostasis was assessed at preset intervals until hemostasis was achieved. Subjects were followed for 30 days post procedure. Results Both groups were similar in comorbidities, use of the Pringle maneuver, type of resection and cutting techniques. Both hemostyptics were successful in bleeding control in most of the cases (G1 93,8%; G2 88,9%). The median time to hemostasis (mTTH) for G1 was 1.0 minute compared to 3.0 minutes for G2 (p=0.0001). This result was independent of both the severity of bleed and area of the bleeding surface. VerisetTM and TachoSil® had similar safety profiles and no statistical differences were observed for adverse and device related events. Conclusions The VerisetTM Hemostatic Patch is as efficient as TachoSil® to achieve local hemostasis in patients undergoing hepatic resection. VerisetTM application results in a significantly faster time to hemostasis, thus its use should be considered for diffuse parenchymal bleedings during hepatic resections.

P74 A prospective, multi-center, randomized, single-blind study to compare an new hemostatic patch made of oxidized cellulose to a fibrin sealant in subjects undergoing hepatic surgery

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
314

E-AHPBA

P75 Technical challenges in treating Recurrent Non Parasitic Hepatic cysts Abstracts
Tarek DEBS, Arianne THOUVENY, Marc JOHANN Hôpital Saint André HPM, Metz, France

Objectives Most series report on the initial surgical management of hepatic cysts. However, studies regarding the management of recurrent cysts are not available. The purpose of this study is to determine the recurrence rate, evaluate the factors that increase the risk of recurrence and find the optimal management of these recurrences. Method From 2000 to 2012, 35 patients with symptomatic or complicated non parasitic hepatic cysts were treated at our institution. One patient was excluded because the pathology report showed a cystadenoma. We present a retrospective review of 34 patients, 33 females and one male who underwent operations for symptomatic or complicated hepatic cysts. From these patients, 27 were polycystic and 7 were simple cysts. Our initial management for most hepatic cysts was to start with a laparoscopic deroofing of the cyst. For 25 out of the 34 patients, laparoscopic deroofing was completed successfully. Results  After the laparoscopic deroofing, 5 of 25 (20%) patients showed symptomatic recurrences. No mortality was identified.  From these patients, we noted 3 factors that increased the risk of recurrence. First, the location of the cyst, with cysts located in the superior parts of segments IV, VII and VIII because of their tendency to adhere to the diaphragm, and reform a cyst. Second, cysts located in the posterior segments, technically difficult to access and deroof laparoscopically. Third, the thickness of the layer of the cyst. Repeating a derrofing for these cysts seems to result in another reccurence.   Conclusions The laparoscopic management of NPHC is a safe and feasible procedure and should be considered the initial surgical strategy. As for recurrent cysts, the approach should be more radical and an enucleation should be considered for cysts located close to the dome of the diaphragm or in the posterior segments.

315

Abstracts

Gregor A. Stavrou1, Carolin Frankenreiter1, Cay-Uwe von Seydewitz2, Axel Stang2, Karl J. Oldhafer1 1 Asklepios Hospital Barmbek, Asklepios Medical School, Department of General and Visceral Surgery, Hamburg, Germany, 2Asklepios Hospital Barmbek, Asklepios Medical School, Department of Oncology, Hamburg, Germany Objectives Preoperative contrast enhanced ultrasound (CE-US) and intraoperative ultrasound (IOUS) are known to influence detection rates and resection strategies for colorectal liver metastasis (CRLM). Combining the methods as intraoperative contrast enhanced ultrasound (CE-IOUS) can possibly augment the rate of detection of lesions and therefore influence operative strategy. Up to now there is very little data about how CEIOUS is realized, especially with dynamic probes. Method From October 2011 to March 2012 we examined 22 patients with resectable CRLM with CE-IOUS using a newly developed ultrasound probe (7,5 MHz, dynamic THI, Hitachi, used with a Hitachi Avius). To optimize the contrast picture we varied the listed parameters: Dose of contrast agent (Sonovue, Bracoo 1.2-4.8ml), beginning of ultrasound scan post injection of contrast (0-60s  p.i.), mechanical index (-1.4 to + 1.0) and gray scale calculation of pixels (linear vs. non-linear). Results An optimized contrast picture was generated using 4.8ml SonoVue as bolus injection, beginning the CE IOUS examination 15s post injection of contrast, a mechanical index of 0.8 and a non-linear gray scale calculation of pixels (gamma curve). With these parameters it was also possible to classify small lesions below 1 cm.  Conclusions Defining the optimal contrast agent dose and timing it´s administration and the start oft he examination is the base for an acceptable analysis of data generated by CEIOUS and to further develop the method. CEIOUS may have an important impact in the detection rate of lesions during surgery and possibly on the survival of patients in the future. It is now necessary to compare detection rates of CT, MRI, CEUS vs IOUS and CE IOUS

P76 Contrast Enhanced Intraoperative Ultrasonography (CE-IOUS). Preliminary experience with developing a new ultrasound probe.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
316

E-AHPBA

Matthew Wiggans1,2, Golnaz Shahtahmassebi0,2, Paul Malcolm1, Francis McCormick1, Somaiah Aroori1, Matthew Bowles1, David Stell1,2 1 Derriford Hospital, Plymouth, UK, 2Plymouth University, Plymouth, UK

Objectives The aim of this study was to analyse the influence of factors reported in the minimum histopathology dataset for colorectal liver metastases (CRLM) and other pre-operative factors compared to additional data relating to the presence of tumour pseudocapsules and necrosis on recurrence one year after resection.   Method  For a period of fourteen months extended histological reporting of CRLM specimens was performed, including the presence of pseudocapsules and necrosis in each tumour. Details of recurrence were obtained from surveillance imaging.   Results In 66 patients there were twenty seven recurrences within one year. Rates were lower for patients with tumour pseudocapsules (8/27) than for patients without (19/36) (p=0.030). Pseudocapsules were associated with younger age (p=0.005), nodal stage of the primary colorectal tumour (p=0.025) and metachronous tumours (p=0.004). In patients with synchronous disease and pseudocapsules the recurrence rate was 2/12 compared to13/23 patients without pseudocapsules (p=0.026).   Conclusions Histological examination of resection specimens can provide significant additional prognostic information for patients after resection of CRLM, compared to clinical and radiological data. Our finding that the absence of a pseudocapsule in patients with synchronous CRLM is associated with dramatically worse outcome may help direct patient-specific adjuvant treatment and care.  

317

Abstracts

P77 Extended pathology reporting of resection specimens of colorectal liver metastases - the significance of a tumour pseudocapsule

P78 Microbial translocation in patients operated on liver echinococcosis Abstracts

Evgeny Khlebnikov, Vladimir Vishnevsky, Ravshan Ikramov, Mikhail Efanov, Yulia Stepanova, Sergey Andreenkov A.V. Vishnevsky Institute of Surgery, Moscow, Russia Objectives The bacterial translocation plays an important role in the development of postoperative infectious complications in patients operated on liver echinococcosis, the aim is to study this phenomenon. Method Microbial translocation has been studied in 30 patients who underwent surgery for hydatid cysts of the liver. Microbiological studies of the samples taken at the beginning of the operation and in the period of maximum surgical aggression (echinococcectomy and periсisteсomy or liver resection) were carried out. Results Lymph node biopsy at the beginning of the operation revealed a growth of microorganisms in 52% of patients (monoculture - 39%, associations - 13%). The blood samples from a peripheral vein showed no microbial growth in 60%. Similar results were obtained in the study of microbial inoculation of the portal vein:  no microbial growth - 65%, growth test was positive in 35%, including 4 patients with monoculture growth, and 4 in association. The second stage of the research revealed microbes in larger quantities in the lymph nodes (96% of cases), the portal vein (70%) and peripheral vein (50%) blood samples. Conclusions The cause of the microorganisms presence in the samples collected at early surgical stage is the pathological process. The quantitative and qualitative changes in the microflora isolated from biological substrates in surgery process shows an increase of microbial translocation, which is the basis for antibiotics perioperative prescription with prophylactic aim.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
318

E-AHPBA

Dimitrios Kardassis1, Achilleas Ntinas1, Alexandros Kofokotsios2, Konstantinos Papazisis3, Ioannis Konstantinopoulos4, Dimosthenis Miliaras5, Anastasios Kelekis6, Dionisios Vrochides1 1 Center of Hepato-Pancreato-Biliary Surgery, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 2 Department of Interventional Gastroenterology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 3 Department of Medical Oncology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 4Department of Anesthesiology and Intensive Care, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 5Department of Pathology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 6Department of Diagnostic and Interventional Radiology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece

Objectives Depending on individual indications, resectable colorectal hepatic metastatic disease is currently being treated with either the classic, combined or reverse approach respectively. The aim of this study was to assess a ‘liver first’ treatment protocol for patients with multiple synchronous colon (not rectal) cancer liver metastases, that cannot be initially resected in one stage. Method This was a retrospective study of prospectively recorded data. Eleven consecutive patients (mean age 65.7 years) were included. They were suffering from colon cancer and synchronous multiple liver metastases (type II or III) and no extrahepatic disease. Patients underwent preoperative staging. In case of an imminent bowel obstruction a stent was placed endoscopically. Following neo-adjuvant chemotherapy and a positive response provided, patients underwent one or two hepatectomies and finally a colectomy. In between, disease re-staging was carried out in order to exclude progression and chemotherapy regimens were administered. Successive operations were performed only if disease recurrence could not be diagnosed. Results The maximum follow up duration was 30.1 months. In four patients all scheduled operations were completed. Their mean survival time was 22.5 months, while the mean disease-free survival time after completing the protocol was 7.7 months. The mean survival time of the other seven patients was 10.5 months. There was no need for a palliative colectomy. Conclusions The reverse therapeutic approach in cases of extensive hepatic metastatic disease in patients with colon cancer under a specific protocol ensures the administration of chemotherapy to all patients and helps avoiding unnecessary surgical procedures. Conclusions concerning possible survival prolongation can only be reached after further patient enrollment and follow-up.  

319

Abstracts

P79 Treatment protocol proposal regarding multiple synchronous colon cancer hepatic metastases that are initially not resectable in one stage

Abstracts

Julian Ananiev1, Galin Ganchev2, Alexander Zdraveski2, Valentin Velev1, Mariana Penkova3, Maya Gulubova0 1 Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria, 2 Department of Surgery, Medical Faculty, Trakia University, Stara Zagora, Bulgaria, 3Department of Internal Medicine, Medical Faculty, Trakia University, Stara Zagora, Bulgaria Objectives Liver failure (LF) is characterized by a deterioration in liver function,  hyperbilirubinemia, hepatic encephalopathy and coagulopathy. The main causes of LF are viral and bacterial infections, drugs and indeterminate causes. Many factors including clinical parameters, constitutional factors and cellular and molecular factors can play a important role in this integrate process. Method Liver specimens from 22 patients who died with LF were examined for the presence of CD31, CD68 and CD83 by immunohistochemistry. The correlation between expression of the markers and patient clinicopathological parameters was evaluated. Results In the livers with temperate acute LF the numbers of CD68 and CD83 were significantly more in sinusoids and portal tracts as compared to strongly damaged patients (χ2=8,45; p=0,033 resp. χ2=5,56; p=0,04).  Also, in patients with previously livers disability DCs and macropfages were less in numbers, especially in the areas of degeneration. There is no significant correlation between endothelial cells distribution and other clinicopathological factors. Conclusions We may state that different liver damages can lead to liver failure followed by inhibition of competent cells – macrophages and dendritic cells development and activation.

P80 ROLE OF MACROPHAGES, ENDOTELIAL AND DENDRITIC CELLS IN DEVELOPMENT OF ACUTE LIVER FAILURE

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
320

E-AHPBA

P81 Echinococcectomy technique “second on first”.

Objectives Liver cystic echinococcus (LCE) unfortunately till is widely spread in endemic areas of Europe, Africa and Aisha. Both traditional surgery and minimal invasive surgery (MIS) perform for treatment. To choose the treatment method we use ultrasonic numerical of H. Gharbi et al. 1981 y., the WHO recommendations 2003 y., the WHO-IWGE expert consensus 2010 y. For MIS are applicable type: 1- CL; 2 - CE1, I; 3 - CE3a, II; 4 - CE4, IV; 5 suppuration of the monovesicular cist; 6 - recurrent and residual monovesicular cist. All other forms require traditional surgery methods. Method 25 years old gentleman (from Uzbekistan) was admitted with complaint of discomfort in RUQ. The ultrasound scanner, MR with MRCP, serological tests and routine methods was performed. The LCE was found - two huge gydatid cists replaced the left liver lobe. The first one 11.2x9.7x9.2 cm and the second one 19.6õ12.9õ7 cm. Type CE3b, III according to WHO-IWGE and Gharbi. For anti-gydatid processing we use 85-87% liquid glycerin solution. We use severe intraoperation gydatid dissemination prophylaxis. The anti-relapse chemotherapy by albendazole we use in complex treatment of LCE. Results In J-laparotomy two cysts were found with thick and dense walls with calcinosis. The first was located more up and medial to the right, the second more down and lateral to the left. Thereby the lateral cyst was located on the medial cyst and had common wall to it and almost didn`t touch the liver parenchyma. A lot of child cysts were evacuated from the first cyst. After opening the cyst was found - to remove the second lateral cyst didn`t require to open it. Thus the second lateral cyst removed on the walls of the first medial cyst. Conclusions The “second on first” technique may be apply without incision and opening of the second cyst if two echinococcus cysts locate together and have common wall without severe liver parenchyma invasion of one of them. By the way the operation time can be shortened. And the risk of abdominal cavity gydatid dissemination can be reduced, if the walls of the second cyst are thick and dense.

321

Abstracts

M.S. Khubutiya, K.N. Lutsyk, S.A. Bugaev, V.A. Sharifullin, N.B. Ioseliany Emergency institute n.a. N.V. Sklifosovsky, Moscow, Russia

P82 Portal hypertension treatment for end-stage liver cirrhosis. Abstracts

S.A. Bugaev1, B.N. Kotiv2, I.I. Dzidzava2, D.P. Kashkin2, A.V. Smorodsky2, K.N. Lutsyk1 1 Emergency institute n.a. N.V. Sklifosovsky, Moscow, Russia, 2Military-medical academy n.a. S.M. Kirov, SaintPetersburg, Russia Objectives The liver replacement is the adequate treatment for end-stage liver disease (ESLD). However donor grafts shortage both in living donor and deceased donor liver transplantation is the severe problem in all LTx programs. Patients with ESLD complications are required severe treatment including invasion treatment for severe portal hypertension. Method From 2006 to 2011 y-s 91 adult patients with liver cirrhosis Child-Pugh C was treated. Indications for surgery treatment were: severe esophageal varices with recurrent bleeding (64% patients); refractory ascites (41% patients); parenchyma liver failure (21%). The endoscopic variceal ligation was the started procedure in all cases. Surgery treatment was performed in 20% patients with ineffective endoscopic ligation and adequate rate ICG test, liver volume more than 1300 cc, POSSUM score rate less than 60%. Distal splenorenal shunt and mesentericocaval H-fistula was performed. TIPSS was performed for 8 patients. Results  There was no post-operation mortality and recurrent variceal bleedings in open surgery cases. 1-, 3-, 5-years survival are 78%, 59%, 35%. 6 patients was shifted into non-active listing after surgical porto-caval shunting procedures due to reduction of bleeding and ascitic syndromes and improving of liver function. LTx was performed for 14 patients. 3 patients had open surgical procedures earlier. Conclusions Patients with ESLD and severe portal hypertension are required in surgical follow up in the view of complications. Different methods for treatment are possible. The minimal invasive methods are preferable. For patients with ineffective minimal invasive methods surgery procedures are applicable.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
322

E-AHPBA

Mariateresa Mirarchi, Samuele Vaccari, Emilio De Raffele, Silvia Palumbo, Ferdinando Lecce, Barbara Dalla Via, Dajana Cuicchi, Bruno Cola U.O. di Chirurgia Generale e dUrgenza, Dipartimento di Emergenza/Urgenza, Chirurgia Generale e dei Trapianti. Policlinico S.Orsola-Malpighi. Università degli Studi di Bologna., Bologna, Italy

Objectives Liver resection (LR) has become the standard treatment for patients with synchronous colorectal cancer liver metastases (SCRLM), even though the optimal timing of LR is still controversial, especially in patients requiring major hepatectomies. Recent reports demonstrate that intraoperative ultrasonography (IOUS) reduces the need for major resections. This study aimed to determine whether simultaneous radical but conservative IOUSguided LR and colorectal resection (CRR) are safe and effective in patients with SCRLM. Method Ninety-nine patients with CRLM had LR between Jul 2005 and Dec 2012. Thirty-four were admitted with colorectal cancer and SCRLM. There were 21 males and 13 females aged 66.28±10.39 years [39-86]. Three (8.82%) received staged resection; 2 (5.88%) received intraoperative radiofrequency thermal ablation without resection; 2 (5.88%) underwent colorectal resection without LR due to the extent of the liver disease; 27 (79.41%) had simultaneous IOUS-guided LR and CRR and were analyzed in detail with respect to their intra and postoperative course. Results Ten patients (37.04%) had simultaneous lower anterior resection of rectal cancer. Fourteen (51.85%) had bilobar SCRLM; due to IOUS guidance, however, only 6 (22.22%) required major hepatectomy; four of them had bilobar SCRLM. The mean±SD operation time was 504±158 minutes [225-820]; 6 patients (22.22%) required blood transfusions. One patient died (3.70%) postoperatively; he was a 83-years old male with coronary disease and obstructive chronic pulmonary disease with pulmonary hypertension, who received a left hemicolectomy and a limited wedge resection. According to the Dindo-Clavien classification, four patients (14.81%) had minor postoperative complications. The mean±SD hospital stay was 12.81±8.05 days [7-50]. Conclusions This study confirms that IOUS guidance is effective in reducing the extension of LR in patients with SCRLM, even in those with biliobar SCRLM. Since major complications are frequent after simultaneous major LR and CRR, reducing the extent of liver parenchyma removal may have a favourable impact on postoperative course. Simultaneous radical but conservative IOUS-guided LR and CRR is safe and effective in patients with SCRLM and could serve as a primary option for selected cases.

323

Abstracts

P83 SIMULTANEOUS ULTRASONOGRAPHY-GUIDED LIVER RESECTION AND COLO-RECTAL RESECTION AS A SAFE APPROACH TO ADVANCED COLO-RECTAL CANCER.

P84 Synchronous and staged resections of colorectal primary and hepatic metastasis Abstracts
Igor Shchepotin, Andrii Lukashenko, Olena Kolesnik, Anton Burlaka National Cancer Institute, Kiev, Ukraine

Objectives Main approaches of surgical treatment for patients with synchronous colorectal cancer and liver metastasis are staged resection of the colorectal primary and hepatic metastases or synchronous operation. The optimal surgical strategy for resectable, synchronous, colorectal liver metastases remains unclear. This study aimed to compare the surgical outcome and survival benefit between synchronous and staged resection of liver metastases from colorectal cancer. Method We analyzed medical records between 2008-2012 years of 98 patients with colorectal cancer and synchronously hepatic metastases which was planed to underwent (40 patients, group A) or staged (58 patients, group B) colonic and hepatic resections. Results No significant differences were observed between groups A and B in type of colon resection (p=0.5) or hepatic resection (p = 0.1), operative duration (390±48 vs 360±55 minutes respectively), blood loss (310±52 vs 250±48 ml respectively). Duration of hospitalization was significantly shorter for synchronous than for staged resection (mean, 23 vs. 12 days; p<0.001).The previous results showed no statistically difference in the 3-year survival rates in both groups: 42% versus 55% in groups A and B respectively (p = 0.001). Patients in the group A had a high incidence of postoperative morbidity 25% (7.5% specific for liver resections) vs 17.8%. Conclusions Staged resection for patients with synchronous colorectal cancer and liver metastasis is more safe. Subsequent research should be directed to the study of optimization of the term of appointment of systemic therapy, the search criteria for the selection of patients in the surgical group.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
324

E-AHPBA

P85 LIVER ADENOMATOSIS OR FLEJOU DISEASE: A SURGICAL APPROACH Abstracts
Antonio Frena Central Hospital of Bolzano, Bolzano, Italy

Objectives Liver adenomatosis (LA) can be defined a rare entity in which numerous (> 10) hepatocellular adenomas occur in patients with a normal hepatic parenchyma without history of steroid use or glycogen storage disease. Method In the last five years we followed the cases of 3 women (37, 43, and 51 yrs.) suffering from LA and treated by liver resection. In all cases an intraprenchymal hemorrhage of the greater lesion was present. According to the original Flejou’s description of the disease, all patients had only a serous increase of alkaline phosphatase and gGT.   Results Up to the present, all patients are alive without signs of recurrence of the disease. Microscopic examination of the specimens revealed that all lesions were composed of benign hepatocytes arranged in irregularly thickened cords, separed by sinusoids. The histologic findings were characteristic of liver cell adenomas; in view of the large number of lesions pre-sent (in all cases > 20), the diagnosis of LA was established.   Conclusions This report confirms the existence of the unusual entity of LA. These lesions can be extremely vascular and prone to hemorrhage: this argues for removing large adenomas even in the presence of LA. The distinction between LA and well-differentiated hepatocellu-lar carcinoma  (Edmonson I) is very difficult on histology alone. A long follow-up is essential to confirm the diagnosis.

325

P86 HOW TO REDUCE THE INCIDENCE OF BILIARY FISTULAS AFTER LIVER SURGERY Abstracts
Antonio Frena, Stefan Patauner, Federico Martin Central Hospital of Bolzano, Bolzano, Italy

Objectives Standardization of hepatic resective treatment has reduced mortality and morbidity rates. Anatomical resection and effective hemostasis have led to a reduction in postoperative complication rate (4-7%). One of the most fearful complications is the onset of a biliary fistula, namely bile leakage following parenchymal transection. Although numerous methods for the intraoperative detection of bile leaks have been developed through practice and chemical substances have been manufactured for fistula Method Our experience began in 1995: we have attempted to improve intraoperative biliostasis to minimize the risk of postoperative fistula development by testing different materials. In the early 2005, we began employing the collagen sponge coated with fibrinogen and thrombin. The resected surface must be cleaned of blood and subsequently the sponge, moistened with saline solution, can be applied, gently pressing for 3-5 minutes. Results In our clinical experience, prior to sponge use, a biliary fistula developed in 3.9% of elective resections (4/103 cases) and 5.1% of surgical procedures to treat bleeding due to hepatic trauma (4/79 cases): conversely, there were no postoperative bile leaks in the 14 patients (11 hepatic resections and 3 traumas) treated with collagen sponge coated with fibrinogen and thrombin and the drain was always removed 3-5 days after surgery. Conclusions Although the limited number of cases do not constitute clinical evidence, of note is the fact that hepatobiliary surgeons can rely on local products for biliostasis, enabling them to safely carry out hepatic resection or posttraumatic liver biliostasis. Absent or reduced biliary fistula incidence has a positive impact on both patients (lower septic complication and re-operation rates) and institutions (shorter mean hospital stay and reduced costs).

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
326

E-AHPBA

P87 LIVER TRAUMA SURGERY

Objectives Liver injuries are the most frequent cause of death in the field of abdominal traumas. The increase in road accidents and sports injuries makes discussion of the treatment modalities increasingly relevant in this area. In recent years we have witnessed an evolution in the therapeutic management of such injuries with the increasingly frequent use of non-operative procedures for the management of non-complex lesions. Method A retrospective study was conducted in 154 cases of liver injuries observed in our department over a 25-year period (1985-2010). The mean age of the patients was 31 years. The most frequent causes were road accidents (48%), followed by sports injuries (23%) and occupational accidents (11%). Results 113 patients (73%) were treated surgically and 41 conservatively. In 79 cases (35 of which treated surgically), the liver injury was isolated, while in the other 75 cases lesions were also present in other abdominal organs. The liver injuries, classified according to the AAST, were grade I in 63 cases, grade II in 38 cases, grade III in 28 cases, grade IV in 13 cases, and grade V in 12 cases. Thirty-five percent of grade I-II lesions were treated conservatively, while 94% of grade III-IV-V lesions received surgical treatment. The overall operative mortality was 12.5%. Conclusions The evolution of the management of liver injuries has witnessed an increase in conservative treatment, particularly for grade I and II lesions. There is no alternative to surgical treatment when the injury involves the major hepatic vessels or substantial amounts of parenchyma. The mortality rate is high compared to that of elective liver surgery, but this is due to the frequent associated lesions in other organs and apparatuses.

327

Abstracts

Antonio Frena, Stefan Patauner, Ivo Kompatscher, Federico Martin Central Hospital of Bolzano, Bolzano, Italy

Abstracts

Farah Adel1, Jose M. Ramia1, Julian del Cerro2, Roberto de la Plaza1, Pilar Veguillas1, Vladimir Arteaga1, Carmen Ramiro1, Jorge Garcia-Parreño0 1 HPB Unit. Dept. of Surgery. Hospital Universitario de Guadalajara, Guadalajara, Spain, 2Dept. of Radiology. Hospital Universitario de Guadalajara, Guadalajara, Spain Objectives The best treatment for active (CE1-CE3) or complicated cases of liver hydatidosis (LH) is surgery. Some groups have advocated PAIR as a good treatment in CE1 and CE3 non-complicated cysts. But it is not an accepted indication for CE2 or complicated cysts. When surgeons faced patients with these clinical scenarios (CE2 or complicated cases) not suitable for surgery, there is no consensus about the best approach to manage them. We present our PAIR experience in these extreme patients. Method Period May2007-December2012. We have evaluated 103 patients suffering LH. We perform PAIR only in three patients. The reason for doing PAIR was: negative for more surgical procedures, ASA IV EF:30%, small liver remanent after left extended hepatectomy previously done for LH. AGE SEX CE TYPE ASA CYST SIZE Number of cysts LOCATION Relapse PREVIOUS SURGERY CLINICAL SYMPTOM 50 Male Disseminated Hydatidosis (CE1 to CE3). II 100 mm Multiple Multiple Yes 4 Severe Pain in Right Flank, 75 Male

P88 PAIR FOR EXTREME CASES OF LIVER HYDATIDOSIS

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
328

E-AHPBA

CE2 IV 80 1 Right Lobe No No Obstructive jaundice 67 Female CE1 II 50 1 Right Lobe No 3 Abdominal Pain Results An ERCP previously to PAIR was done in the patient with obstructive jaundice. No frank intrabiliary rupture was seen. No morbidity associated to PAIR was observed. One patient received 2 PAIR. In follow up, serology is still positive, but no cyst has increased their size and symptoms have disappeared. Number of PAIR performed PAIR Morbidity New size after PAIR % volume Reduction STAY (days) Serology after PAIR Follow up (months) 1 PAIR No 30 mm 70% 4 +

329

Abstracts

36 2 PAIR No 60 mm 30% 2 + 12 1 PAIR No 33 mm 30% 7 + 12 Conclusions PAIR could be a palliative therapeutical procedure in extreme cases where surgical procedures is not a option due to: severe comorbidities of the patients, small liver remanent or disseminated hydatidosis even in CE2 or complicated cases. If relapse is seen in follow up we could repeat PAIR again

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
330

E-AHPBA

Dmitry Panchenkov1,3, Sergey Leonov1, Ruslan Alikhanov2, Yuri Ivanov1,3, Fedor Zabozlaev3, Dmitry Agibalov3, Anastasia Sorokina2,3, Dmitry Astakhov1,3, Vyacheslav Chugunov3 1 A.I. Evdokimov Moscow State University of Medicine and Dentistry, Department of Surgery, Laboratory of Minimally Invasive Surgery, Moscow, Russia, 2M.V. Lomonosov Moscow State University, Department of Surgery, Moscow, Russia, 3Research Institute of Clinical Surgery, Federal Research Clinical Center of Specialized Medical Care and Medical Technologies FMBA, Moscow, Russia

Objectives Aim of the study: estimation of liver parenchyma full electric impedance  before and after major hepatectomy Method The study based on examination of 27 white rats Vistar, which has undergone laparotomy and measurement of  bioelectric impedance of liver parenchyma. The invasive bioimpedancemetry (BIM) performed with bipolar needle electrodes and the original device for measurement of full electric impedance of biological tissues “BIM II” (patent ¹ 2366360). Major hepatectomy performed (about 70% of the liver) and measured bioelectric impedance of residual liver parenchyma. In 72 hours after the procedure was performed relaparotomy and measured liver impedance one more time. After relaparotomy animals were taken out  of the experiment and the fragment of the liver sent to morphological examination. Results Postoperative mortality was 52 % (14 animals). The electric impedance of intact liver was 3,18±0,12 kÎm. Immediately after major hepatic resection  parameters slightly decreased to 3,04±0,17 kÎm (differences are not significant, p>0,05). After 72 hours the electric impedance of the liver significantly increased to 4,00±0,2 kÎm (n=14, p<0,05). The microscopic examination of residual liver in all survived animals showed fatty hepatosis. Conclusions The results of bio impedancemetry reflect the changes of functional activity of liver parenchyma and could be used for the elaboration of new diagnostic and prognostic methods in surgical hepatology.

331

Abstracts

P89 Electric impedance of liver before and after major hepatectomy: experimental study.

P90 Our cyst hydati̇c treatment experience Abstracts

Omer Unalp, Batuhan Demir, Tayfun Yoldas, Alper Uguz, Murat Sozbilen, Ahmet Coker Ege University department of general surgery, Izmir, Turkey Objectives  Hydatid disease is a serious public health problem in endemic areas, and the management is controversial. Operative treatment is generally accepted especially in patients presenting complications. Our policy is to perform radical surgery and, whenever possible, anatomic hepatic resection. The purpose is to report our experience and results in the management of liver hydatid disease.   Method Between January 2008   and December 2012, 108 patients were referred to our department for surgical treatment of hepatic hydatid cyst. Patients data were retrospectively reviewed. Patients were divided into three treatment groups: conservative surgery (CS), total pericystectomy (PC), and hepatic resection (HR). The main outcome measures were the mortality, morbidity, and recurrence rate. Results median patient age was 45 years. (range 18-84). Radical surgery was performed in 57 patients: major HR in 12 patients, minor HR in 6, and total PC in 39. CS was performed in 65 cases. There were no postoperative deaths. Hepatic resection group there were no recurrence. Conservative surgery group recurrence was %20. 8 patient operation was done another center and came for percutaneous treatment. Conclusions The findings of this study suggest that surgical resection is not associated with much more postoperative and cyst cavity-related complications than the other groups. In addition, there was no mortality and a low recurrence rate. The successful outcome of conservative surgery in experienced hands can reach.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
332

E-AHPBA

Constantinos S. Mammas1, George Kottis1, Chryssa Nikolaou2, Nikolaos Arkadopoulos1, Georgia Kostapanagiotou1, Nikolaos Kavantzas3, Tina Tiniakou4, Tom Kotsis1, Vasileios Smyrniotis1 1 Aretaieion University Hospital, Surgical Laboratory ’’Constantine Tountas’’, Athens, Greece, 2National and Kapodistrian University of Athens, Medical School, Aiginiteion University Hospital, Department of Immunology., Athens, Greece, 3National and Kapodistrian University of Athens, Medical School, Department of Histopathology, Athens, Greece, 4National and Kapodistrian University of Athens, Medical School, Department of Histology, Athens, Greece Objectives Angiogenesis is important to the regenerative process, and typically vessels are laid down in conjunction with new extracellular matrix in the remnant liver, after partial hepatectomy. The impact of the Open  (OLPH) and the Laparoscopic  (LLPH) Left Partial Hepatectomy on the angiogenesis process in the remnant liver, of a porcine experimental model, is compared. Method A series of twenty eight liver tissue sections from fourteen  porcine liver biopsy taken after operation (PD0) and on the 7th postoperative day (PD7) from each open (OLPH) or laparoscopic (LLPH) left partial hepatectomy, respectively, were randomly allocated into two groups: the OLPH group (n=8) and the LLPH group(n=6). The liver tissue sections in each group, had been prepared and stained with a VEGF specific stain. An angiogenesis index (LCANGI), was estimated for all anatomic sections microscopically. LCANGI compared on the time points PD0 and on PD7 1:in each group (OLPH) or (LLPH), and 2: between the groups (OLPH vs LLPH). Results By using rank-order statistical methods for small samples, statistical comparisons of the LCANGI, between PD0 and PD7: 1. showed no statistically significant difference, in each group. 2. Statistical comparisons between the two experimental groups showed that LCANGIOLPH was statistically significantly higher than  LCANGILLPH , on PD7 (LCANGIOLPH > LCANGILLPH, .028). Conclusions In the porcine experimental model, angiogenesis in the remnant liver, seems to be significantly increased after OLPH in comparison with LLPH, on PD7.

333

Abstracts

P91 Angiogenesis in the remnant liver, after open and laparoscopic left partial hepatectomy, in the porcine model

Abstracts

P92 Parenchyma sparring of segment 5 in modified left trisectionectomy:  how should we do with the outflow?
Jun Li, Bjoern Nashan Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Objectives Segment 5 and 8 are usually drained by middle hepatic vein (MHV) together. In patients with tumor extension from left hemi-liver to segment 8 but not segment 5, left trisectionectomy is indicated to remove the tumor as well as segment 5 due to otherwise congested parenchyma with detached segment 5 tributaries. Carrying the concept of parenchyma-sparring, the authors would like to find out whether it is possible to keep segment 5 in the remnant liver. Method Patients undergoing extended left hepatectomy from 2010 to 2012 were analysed retrospectively. Hilar cholangiocarcinoma was excluded from the study.  Modified left trisectionectomy was defined as resection of at least segment 2, 3, 4 and 8. Resection of segment 8 was evidenced by expose at lease 3 cm of the intrahepatic right hepatic vein (RHV) with resection of segment 8 vein with its corresponding parenchyma. The segment 5 was kept in the remnant liver when at least 1 cm margin to the tumor could be achieved. The hepatic venous outflow, postoperative complication, tumor residual status were analysed. Results Segment 5 sparring was carried out in five of seven patients who were indicated for a left trisectionectomy. Three patterns of segment 5 venous outflow were identified: 1) drained by RHV with occluded MHV by tumor (n=2); 2) drained by MHV, which was kept in remnant liver to ensure sufficient segment 5 outflow (n=2); 3) drained by MHV, which was resected. However, there was no dramatic congestion of segment 5 even without venous reconstruction (n=1). R0 status was confirmed in all. No posthepatectomy liver failure developed. One patient had Grad IIIb bile leak. No complication was developed in others. Conclusions Segment 5 parenchyma-sparring can be achieved safely in all 5 patient without tumor involvement of segment 5. Compromised outflow is not an excuse to remove this segment.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
334

E-AHPBA

Carlos Soares1,7, Diana Gonçalves1, Mariana Borges1, Emanuela Gomes0, Ana Oliveira2, Nuno Silva3, Joaquim Paquete3, Paulo Morgado3, Pedro Pereira4, Cristina Sarmento5, Joanne Lopes6, Renato Bessa Melo1,7, Luís Graça1, José Costa Maia1,7 1 General Surgery Department, Hepatobiliopancreatic Unit, of Centro Hospitalar São João, Porto, Portugal, 2Nuclear Medicine Department of Centro Hospitalar São João, Porto, Portugal, 3Radiology Department of Centro Hospitalar São João, Porto, Portugal, 4Gastroenterology Department of Centro Hospitalar São João, Porto, Portugal, 5Medical Oncology Department of Centro Hospitalar São João, Porto, Portugal, 6Pathology Department of Centro Hospitalar São João, Porto, Portugal, 7Faculty of Medicine of Porto University, Porto, Portugal

Objectives Resection or transplantation is the treatment of choice for hepatocellular carcinoma (HCC), but most patients are not suitable candidates. During the past decade a variety of treatment modalities have been developed. Multidisciplinary boards are faced with the challenge of adopting these therapies in the management of these patients. The main aim of this study was to evaluate the number of patients submitted to multimodality treatment for HCC at our institution and the clinical results of that treatment. Method We retrospectively evaluated the last 150 patients with the diagnosis of HCC, discussed at the Hepatobiliopancreatic (HPB) Oncological Board. We evaluated multiple variables including therapeutical decision, treatment done, global survival rate and survival rate by specific treatment modality. Results 150 patients with the diagnosis of HCC were included in the study. Thirty patients (20%) were submitted to multimodality therapy. A 21.1 month median survival (2 - 54 meses) was verified in this group of patients. Conclusions Different treatment modalities may be combined in the treatment strategy of HCC or used as a bridge to resection or liver transplantation. Patients should undergo formal multidisciplinary evaluation prior to initiating any such treatment in order to individualize the best available options.

335

Abstracts

P93 Combined Modality Treatment of Hepatocellular Carcinoma - Evaluation of the last 150 patients presented at a Hepatobiliopancreatic Oncological Board

Carlos Soares1,7, Diana Gonçalves1, Mariana Borges1, Emanuela Gomes7, Ana Oliveira2, Nuno Silva3, Joaquim Paquete3, Paulo Morgado3, Pedro Pereira4, Cristina Sarmento5, Joanne Lopes6, Renato Bessa Melo1,7, Luís Graça1, José Costa Maia1,7 1 General Surgery Department, Hepatobiliopancreatic Unit, of Centro Hospitalar São João, Porto, Portugal, 2Nuclear Medicine Department of Centro Hospitalar São João, Porto, Portugal, 3Radiology Department of Centro Hospitalar São João, Porto, Portugal, 4Gastroenterology Department of Centro Hospitalar São João, Porto, Portugal, 5Medical Oncology Department of Centro Hospitalar São João, Porto, Portugal, 6Pathology Department of Centro Hospitalar São João, Porto, Portugal, 7Faculty of Medicine of Porto University, Porto, Portugal Objectives Hepatic metastasis are responsible for significant morbidity and mortality and only a small percentage of patients is indicated for resection with curative intent. Radioembolization with yttrium-90 is an alternative treatment for patients with unresectable primary or secondary liver tumours. The main aim of this study was to evaluate the number of patients submitted to Radioembolization at our institution and the clinical results of that treatment. Method We retrospectively evaluated patients with primary and secondary liver tumors selected for radioembolization at our referral center, from March 2008 to October 2012. Results From March 2008 to October 2012, 26 patients were selected for radioembolization. Of these, 17 efectively did the treatment. Forteen had the diagnosis of hepatocellular carcinoma (HCC); 2, hepatic metastasis of melanoma; and 1, hepatic metastasis of neuroendocrine carcinoma. 5 patients were submitted to 2 sessions of radioembolization. 2 patients received posterior indication for surgical treatment. The median survival of the patients treated with radioembolization was 27.7 months. Conclusions Radioembolization with yttrium-90 is a therapeutical option for the palliative treatment of unresectable ou recurrent HCC without extrahepatic spread. It can also be used as a bridging therapy before liver transplantation or as a tumor downstaging treatment, for posterior curative surgical treatment, in a variety of tumors.

P94 Radioembolization for primary and metastatic hepatic malignancies

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
336

E-AHPBA

Carlos Soares1,7, Diana Gonçalves1, Ana Oliveira2, Joaquim Paquete3, Paulo Morgado3, Pedro Pereira4, Cristina Sarmento5, Joanne Lopes6, Renato Bessa Melo1,7, Luís Graça1, José Costa Maia1,7 1 General Surgery Department, Hepatobiliopancreatic Unit, of Centro Hospitalar São João, Porto, Portugal, 2Nuclear Medicine Department of Centro Hospitalar São João, Porto, Portugal, 3Radiology Department of Centro Hospitalar São João, Porto, Portugal, 4Gastroenterology Department of Centro Hospitalar São João, Porto, Portugal, 5Medical Oncology Department of Centro Hospitalar São João, Porto, Portugal, 6Pathology Department of Centro Hospitalar São João, Porto, Portugal, 7Faculty of Medicine of Porto University, Porto, Portugal Objectives Locorregional transarterial therapies have led to a major breakthrough in the management of unresectable hepatocellular carcinoma (HCC), but the exact role of the various treatment modalities has not yet been established. Method 74 year old male patient, referred to the Hepatobiliopancreatic (HBP) Unit of our institution for HCC. Abdominal imaging showed “... a 17x11x12.2cm diameter tumor of the right hepatic lobe... with contrast enhancement... and a 18mm segment II nodule with contrast enhancement...”. The clinical case was presented at the HBP Oncological Board (OB) and the patient was selected for radioembolization. Angiography with Technetium99m labeled macroaggregated albumin demonstrated an hepato-pulmonary shunt of 25%. The OB indicated fractionated treatment. Results Pre-radioembolization CT scan revealed “... significant reduction of the neoplastic lesion of the right lobe...”. Histological revision of the biopsy sample from the exterior confirmed HCC. Conclusions Intra-arterial treatments of HCC have a palliative effect that can lead to extensive tumour necrosis, but the impact on survival has generated contradictory results. ...sometimes however, during patient selection for a specific treatment modality the unexpected happens and we need to re-establish the therapeutic options.

337

Abstracts

P95 Intention to Treat, An Interesting Response of a Hepatocellular Carcinoma to Angiography

Carlos Soares1,7, Diana Gonçalves1, Ana Oliveira2, Joaquim Paquete3, Paulo Morgado3, Pedro Pereira4, Cristina Sarmento5, Joanne Lopes6, Renato Bessa Melo1,7, Luis Graça1, José Costa Maia1,7 1 General Surgery Department, Hepatobiliopancreatic Unit, of Centro Hospitalar São João, Porto, Portugal, 2Nuclear Medicine Department of Centro Hospitalar São João, Porto, Portugal, 3Radiology Department of Centro Hospitalar São João, Porto, Portugal, 4Gastroenterology Department of Centro Hospitalar São João, Porto, Portugal, 5Medical Oncology Department of Centro Hospitalar São João, Porto, Portugal, 6Pathology Department of Centro Hospitalar São João, Porto, Portugal, 7Faculty of Medicine of Porto University, Porto, Portugal Objectives Transarterial locoregional therapies, such as chemoembolization and radioembolization, have been widely investigated for the treatment of hepatocellular carcinoma (HCC) and have generated encouraging outcomes in term of survival, response, and quality of life. Radioembolization with yttrium-90 is an option of palliative therapy for large or multifocal HCC without extrahepatic spread. Method 58 year old female patient, with a history of arterial hipertension, diabetes and HBV infection. Imagiological diagnosis of HCC of the left hepatic lobe with portal vein invasion.  The hepatobiliary and pancreatic (HBP) oncological board proposed treatment with entecavir and radioembolization. (90)Y embebed microspheres were selectively delivered to the left branch of the hepatic artery. Results Post-radioembolization imaging showed a significant response of the tumor to the procedure. The patient was subsequently submitted to a laparoscopic left hepatectomy. The pathological specimen showed necrotic areas with no residual tumor.  Conclusions Radioembolization with yttrium-90 is a treatment option in the palliative treatment of unressectable and recurrent HCC. This treatment modality has also been used as a bridge to hepatic transplantion and to downsize hepatic tumors for potentially curative treatments.

P96 Optimal response to radioembolization

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
338

E-AHPBA

Emanuela Gomes1, Carlos Soares1,2, Diana Gonçalves2, Ana Oliveira3, Joaquim Paquete4, Paulo Morgado4, Pedro Pereira5, Cristina Sarmento6, Joanne Lopes7, Renato Bessa Melo1,2, Luís Graça2, José Costa Maia0 1 Faculty of Medicine of Porto University, Porto, Portugal, 2General Surgery Department, Hepatobiliopancreatic Unit, of Centro Hospitalar São João, Porto, Portugal, 3Nuclear Medicine Department of Centro Hospitalar São João, Porto, Portugal, 4Radiology Department of Centro Hospitalar São João, Porto, Portugal, 5Gastroenterology Department of Centro Hospitalar São João, Porto, Portugal, 6Medical Oncology Department of Centro Hospitalar São João, Porto, Portugal, 7Pathology Department of Centro Hospitalar São João, Porto, Portugal Objectives The main aim of the treatment of patients with hepatocellular carcinoma (HCC) has been cure rate, survival rate, and survival time. Recently, evaluation of patients´ quality of life (QoL) has been emphasized. FACT-Hep (Functional Assessment of Cancer Therapy Hepatobiliary) questionnaire is a valid instrument for assessing QoL in patients with HCC. It´s a 45-item self-report instrument designed to measure health-related (HR) QoL in patients with hepatobiliary cancers. The main aim of this preliminary study was to evaluate the QoL of patients with HCC submitted to multiple treatment modalities. Method 16 patients with HCC, treated and followed at our University Hospital, were randomly selected from the last 150 patients discussed at the Hepatobiliary and Pancreatic Oncological Board and invited to fill the FACT-Hep questionnaire. The FACT-Hep consists of the 27-item FACT-G, which assesses generic HRQoL concerns, and a 18-item Hepatobiliary Subscale (HS), which assesses disease-specific issues. Results Of the 16 randomly selected patients, 2 patients were submitted to multiple treatment modalities; 2 - hepatic resection; 1 - radiofrequency ablation; 6 - transarterial chemoembolization; 3 - radioembolization and 1 - best supportive care. QoL of the patients studied was good, with a mean of 147 in a maximum of 180 points in the FACT-Hep questionnaire . Conclusions QoL must be considered as important as survival in the selection/ evaluation of treatment of patients with HCC. However, some factors unrelated to treatment can deteriorate patients´ QoL, namely tumor progression and/ or hepatic function deterioration.

339

Abstracts

P97 Quality of life of patients with Hepatocellular Carcinoma submitted to multiple treatment modalities

Abstracts

Erik Brecelj1, Eldar M Gadzijev1, Ibrahim Edhemovic1, Maja Music1, Gorana Gasljevic1, Maja Cemazar1, Damijan Miklavcic2, Gregor Sersa1 1 Institute of Oncology, Ljubljana, Slovenia, 2Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia

P98 ELECTROCHEMOTHERAPY (ECT) OF RECURRENT HEPATOCELLULAR CARCINOMA (HCC).  A CASE REPORT

Objectives Electrochemotherapy is a novel local treatment, successfully used in a treatment of cutaneous tumors but with only few clinical data in treatment of deep-seated tumors. According to our encouraging results in the treatment of colorectal liver metastases with ECT, we tested effectiveness of ECT in the treatment of recurrent HCC.   Method A 60-years-old female, who underwent right hemihepatectomy for multifocal hepatocellular carcinoma and after 14 months hepatoduodenal lymphadenectomy for metastatic disease. After a 18 months disease free period MRI confirmed a new lesion in Sg4b of the liver. First, numerical treatment planning for ECT was performed based on MRI images. During open surgery, under the ultrasound guidance 4 long needle electrodes were inserted around and one in the center of the tumor. Electrodes were connected to electric pulse generator (Cliniporator VITAE ) and electric pulses were delivered  according to ESOPE protocol 8 minutes after systemic injection of bleomycin (15, 000 U/m2).   Results  During and after surgery there were no adverse effects. No major cardiac arrhythmia during and after ECT treatment were identified. All pulses were delivered outside the vulnerable period of the ECG cycle because the triggering of pulses was synchronized with ECG signals. Despite the fact that electrodes were positioned near and even through the left portal vein, no bleeding or vessel damage were recorded. The patient was discharged from the hospital 7 days after procedure. During follow-up contrast-enhanced MRI one month after therapy showed partial and after 3 and 6 months complete response with no viable tissue in the tumor.   Conclusions ECT is feasible, safe, and effective procedure. It is very useful in treatment of tumors located near large hepatic vessels where RFA is not suitable because of the heat sink effect and in a difficult to reach locations. Further studies are required to assess clinical importance of ECT in HCC.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
340

E-AHPBA

Felix M. Watzka1, Christiane Laumen1, Christina Schwarz1, Arno Schad3, Matthias Miederer4, Christian Fottner2, Matthias M. Weber2, Hauke Lang1, Thomas J. Musholt1 1 Clinic of General, Visceral- and Transplantation Surgery; University Medical Center University Mainz, Mainz, Germany, 2Endocrinology and Metabolic Diseases; University Medical Center University Mainz, Mainz, Germany, 3 Institute of Pathology; University Medical Center University Mainz, Mainz, Germany, 4Department of Nuclear Medicine; University Medical Center University Mainz, Mainz, Germany

Objectives Neuroendocrine Neoplasms of the small intestine are noticed more frequently over the past 35 years. At time of diagnosis hepatic metastasis exist in 60 to 80%. In our study, we aimed to evaluate the surgical indication, for resection of liver metastases and / or the primary NEN. Neuroendocrine Neoplasms of the small intestine are noticed more frequently over the past 35 years. At time of diagnosis hepatic metastasis exist in 60 to 80%. In our study, we aimed to evaluate the surgical indication, for resection of liver metastases and / or the primary NEN.   Method In a retrospective study data about 83 surgically treated patients with neuroendocrine neoplasms of the small intestine (48 males and 35 females) with a median age of 62 years (range 25-86 years) were analyzed. In 58 patients (69.9%) hepatic metastasis were present at time of diagnosis. 37 were subjected to various forms of liver resection. According to the overall survival the influence of several prognostic factors like the Ki-67, stage and resection status was evaluated. In a retrospective study data about 83 surgically treated patients with neuroendocrine neoplasms of the small intestine (48 males and 35 females) with a median age of 62 years (range 25-86 years) were analyzed. In 58 patients (69.9%) hepatic metastasis were present at time of diagnosis. 37 were subjected to various forms of liver resection. According to the overall survival the influence of several prognostic factors like the Ki-67, stage and resection status was evaluated.   Results Hepatic resections consisted of solitary atypical resection (16), multiple atypical liver resections (7), segmentectomies or larger wedge resections (7), hemihepatectomy (4), one two-step hemihepatectomy, one laparoscopic liver resection and one intraoperative radio frequency ablation (RFA). Patients who underwent an R0 or R1 resection of the hepatic metastasis had a better 5-year survival rate (88.5%) than patients who had a R2 resection (69.1%). NEN with low-grade (Ki‑67 ≤ 2%, 92.9%) and intermediate-grade (Ki-67 3-20%, 84.5%) had a better 5-year survival than high-grade NEN (Ki‑67 > 20%, 30.7%). The overall 3-, 5- and 10-year survival rates were 88.2%, 80.3%, and 71.0%, respectively. Hepatic resections consisted of solitary atypical resection (16), multiple atypical liver resections (7), segmentectomies or larger wedge resections (7), hemihepatectomy (4), one two-step hemihepatectomy, one

341

Abstracts

P99 Neuroendocrine neoplasm of the small intestine with hepatic metastasis: a retrospective analysis of surgical intervention

laparoscopic liver resection and one intraoperative radio frequency ablation (RFA). Patients who underwent an R0 or R1 resection of the hepatic metastasis had a better 5-year survival rate (88.5%) than patients who had a R2 resection (69.1%). NEN with low-grade (Ki‑67 ≤ 2%, 92.9%) and intermediate-grade (Ki-67 3-20%, 84.5%) had a better 5-year survival than high-grade NEN (Ki‑67 > 20%, 30.7%). The overall 3-, 5- and 10-year survival rates were 88.2%, 80.3%, and 71.0%, respectively.   Conclusions The Ki-67 index has proven its value as prognostic factor. Resection of hepatic metastases improves the overall survival and supports symptom palliation. A R0 / R1 situation should be the aim of the liver resection. The resection of the primary site should include a systematic lymphadenectomy.  

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
342

E-AHPBA

Matthew Wiggans1,2, Tim Starkie1, Golnaz Shahtahmassebi0,2, Tom Woolley1, Paul Erasmus1, David Birt1, Ian Anderson1, Matthew Bowles1, Somaiah Aroori1, David Stell1,2 1 Derriford Hospital, Plymouth, UK, 2Plymouth University, Plymouth, UK

Objectives The aim of this study was to determine if arterial lactate concentration following hepatic resection is associated with mortality, length of hospital stay, morbidity and renal or hepatic dysfunction and to determine which factors are independently associated with lactate concentration.    Method Serum lactate concentration was recorded at the end of resection in a consecutive series over seven years. Liver function, coagulation and electrolyte tests were performed post-operatively. Renal dysfunction was defined as a creatinine rise of >1.5x the preoperative value. Statistical analysis comprised generalised linear models or logistic regression    Results In 488 patients the median lactate was 2.8mmol/L (0.6-16mmol/L). The lactate concentration was elevated (>1.6mmol/L) in 80% of patients. Lactate was associated with peak post-operative bilirubin, prothrombin time, renal dysfunction, length of stay and 90-day mortality (P<0.001). The 90-day mortality in patients with a post-operative lactate ≥6mmol/L was 28% compared to zero in those with lactate ≤1.6mmol/L. Pre-operative diabetes, number of segments resected, surgeon’s assessment of liver parenchyma, blood loss and transfusion were independently associated with lactate concentration.   Conclusions Initial post-operative lactate concentration is a good predictor of outcome following hepatic resection. This finding could be used to stratify patients to different levels of monitoring and care following liver resection.    

343

Abstracts

P100 Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection

Abstracts

P101 RADIOFREQUENCY ABLATION OF   LIVER COLORECTAL METASTASES. LONG-TERM RESULTS. Ionkin D.A., Vishnevsky V.А., Zhavoronkova O.I.,Melechina O.V., Shurakova A.B., Zhao A.V.
Dmitry Ionkin A.V.Vishnevsky Institute of Surgery,, Moscow, Russia

Objectives Aim: patients with liver colorectal metastases treatment improvement Method Technique, materials and methods: A total of 112 patients with liver colorectal metastases including 414 males and 68 females; main age - 51.6 years/ Since 2002 underwent ultrasound-guided radiofrequency Ablation. All patients but three undergone primary tumor removal as the first stage and they had adjuvant therapy.  198 RFA was performed in total, among them 172 percutaneous RFA (PcRFA) and 26 RFA with laparotomy. Mean session time  (PcRFA) was 2.2+1.7 (from 1 tо 8). Efficiency control was performed with US, MRI from first 24 hours after procedure, from 3,5 days (US) and then from1,3,6 (MRI), 12 (MRI),18,24 (MRI) months. Results  Results: An overall complication rate was 11.6% (20/172) after PcRFA and 15.4% (4/26) after RFA by open approach. Pleural effusion was the most frequent complication (42.5%). 2 patients died (1.078%) within the first two months after the procedure. In spite of chemotherapy and   repeated RFA sessions 61% developed new foci during first 6 months, among them 26% intrahepatic, 34% extrahepatic and 45.8% intra- and extrahepatic. Post-RFA 1-, 2-, 3-, 4- and 5-years survival rates were 84.2%; 62.7%; 51.7%;  32.7% and 26.3% relatively. Mediana survival  - 30 months. Conclusions  Conclusions: Patients with liver colorectal metastases treated with RFA, as well as operatively develop different results, depending on the following prognostic factors: metastases identification period, localization, tumor nodes number and size. US and CT are less informative in RFA efficiency control comparing with MRI. Partial destruction is more frequent than progressive tumor growth. PcRFA can be performed whenever necessary. RFA, especially PcRFA, as a minimally invasive local treatment, has become an effective and relatively safe alternative for the patients with liver colorectal metastases.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
344

E-AHPBA

Dmitry Ionkin A.V.Vishnevsky Institute of Surgery, Moscow, Russia

Objectives   Aim: patients with primary liver cancer treatment improvement. RFA indications: Residual/recurrent tumor after RFA or operation;General contraindications for liver resection (heavy somatic condition, coagulopathy etc.);Liver malfunctioningB (liver cirrhosis “B” and “C” (by Child-Pugh), chemotherapy effects, liver steatosis etc.). Method Technique, materials and methods: A total of 24 patients with primary liver cancer underwent ultrasoundguided RFA. There were 16 males and 8 females;  main age - 52.8 years. Of them, 6 patients (25%) were in stage II (UICC Systems) and 18 (75%) in stages III-IV. 16 patients (66.7%) had Child-Pugh class B and 8 (33.3%)-class C, respectively.  31 RFA were performed in total, among them 30 percutaneous RFAand 8 RFA with laparotomy. Mean session number (PcRFA) was 1.4 (from 1 tо 4). Efficiency control was performed with US, MRI from first 24 hours Results   Results: The ablation success rate after the first RFA based on the MRI were 89.5(34/38). Local tumor recurrence was found in 7(18.4%) patients. 3 patients died (12.5%) within first month after the procedure due to liver failure followed by multi-organ failure. The occurrence rate of major complications was 10.5% (4/38. Post-RFA 1-, 2-, 3-, 4- and 5-years survival rates were 73.7%; 47.4%; 36.8%;  26.3% и 10.5% relatively. Mediana survival  - 26 months. Conclusions  Conclusions: Patients with primary liver cancer treated with RFA, as well as operatively develop different results, depending on the following prognostic factors: metastases identification period, localization, liver malfunctioning,  tumor nodes number and size. Partial destruction is more frequent than progressive tumor growth. Patients are to by dynamically monitored (US, CT, MRI and cancer-specific markers level determination). RFA, especially PcRFA, as a minimally invasive local treatment, has become an effective and relatively safe alternative for the patients with primary liver cancer.

345

Abstracts

P102 RADIOFREQUENCY ABLATION OF   HEPATOCELLULAR CARCINOMA. LONG-TERM RESULTS Ionkin D.A., Vishnevsky V.А., Zhavoronkova O.I., Melechina O.V., Shurakova A.B., Zhao A.V.

Abstracts

P103 СRYOSURGERY WITH LIVER RESECTION FOR LIVER ALVEOCOCCOSIS.Zhao A.V.,1 Ionkin D.A.1, Zhavoronkova O.I., Vetsheva N.N.,1 Shurakova A.B., 1 Kungurtsev C.V. 2
Dmitry Ionkin 1 Vishnevsky Institute of Surgery, 2 Innovative company BIOMEDSTANDART, Moscow, Russia

Objectives Relevance: The only radical treatment in liver alveococcosis is surgery. However, alveococcosis often diagnosed at later stages, when the progression of the disease precludes the implementation of radical surgery.Aim: to improve treatment outcomes in patients with liver alveococcosis, especially after repeated operations Method  Materials and methods: We have an experience of surgical treatment of 82 patients with liver alveococcosis. Almost all patients undergone repeated liver resection. Since 2012 we have begun to use cryoablation on the remainder of the parasitic tissue using Russian apparatus. This surgical intervention was performed in 8 patients. Mean age - 34.3±3 years (24-49 years). The procedure of cryoablation lasted from 2 to 5 minutes of freezing at T ° C from -175 to -186 ° C. All patients subsequently undergone appropriate worming chemotherapy. Results  Results. Liver resection was performed in 5 patients, with additional nephrectomy - in 1, additional resection of the portal vein in 1 as well. In all cases cryoablation of adjacent affected tissues infected was performed on the remaining part of the parasite on the right dome of the diaphragm (1), in the gate of the liver (2), the remaining parenchyma of the left lobe after right lobe resection (2), in the para-aortic tissue (1), in the course of the right urether ( 1). Conclusions   Conclusion: Using a combination of hepatic resection and removal of the affected adjacent organs and tissues with cryoablation, especially after repeated surgical procedures can be considered a radical treatment for liver alveococcosis. The risk of liver failure in the immediate postoperative period is not a reason to reject the radical treatment. No signs of recurrence of the parasitic lesions may be the indication for a given volume of operations in a alveococcosis, especially with repeated interventions.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
346

E-AHPBA

Milan Radojkovic1,2, Miroslav Stojanovic1,2, Aleksandar Zlatic1, Ljiljana Jeremic1,2 1 Clinical Center, Surgery, Nis, Serbia, 2Medical faculty, Surgery, Nis, Serbia

Objectives The aim of our study was to examine and compare protective effects of ischemic preconditioning, adenosine and prostaglandin E1 on hepatic ischemia/reperfusion injury in an experimental model. Method Forty chinchilla rabbits were divided into four groups: group I - 10 rabbits that underwent ischemic preconditioning (3 minutes ischemia, 5 minutes reperfusion) followed by 45 minutes inflow hepatic occlusion; group II - 10 rabbits that underwent intraportal adenosine administration followed by 45 minutes inflow hepatic occlusion; group III - 10 rabbits that underwent intraportal prostaglandin E1 administration followed by 45 minutes inflow hepatic occlusion; and Control group - 10 rabbits that underwent 45 minutes inflow hepatic occlusion. Lab serum analysis and pathohistological examination of liver specimens were performed on 2nd postoperative day in all animals and compared. Results All three examined methods demonstrated protective effects on liver ischemia/reperfusion injury. However, protective action od ischemic preconditioning and adenosine are more prominent and enhanced in comparison to prostaglandin E1. Also, further analysis revealed slightly better liver protection when ischemic preconditioning was used compared to adenosine. Conclusions Ischemic preconditioning is safe and effective method for prevention of liver ischemia/reperfusion injury. Our study results demonstrated its superior protective effects over adenosine and prostaglandin E1.

347

Abstracts

P104 Ischemic preconditioning vs. adenosine vs. prostaglandin E1 in liver ischemia/ reperfusion injury prevention.

P105 Surgery for complicated abdominal echinococcosis Abstracts
Rossen Madjov, Todor Ivanov, Plamen Arnaudov, Ilko Plachkov Medical University, Varna, Bulgaria

Objectives Human echinococcosis is still endemic in some areas of the world including countries from Balkan peninsula and the liver is the most frequently infected organ. There is no effective medical therapy and surgical procedures remain the principal mode of treatment.  Method Retrospective study of 548 patients. 324 female and 224 male. Aged between 14 and 78 years. The main location of the hydatid cysts was in the liver – 526 pts. Other rare locations: spleen – 21, pancreas – 6, abdominal cavity - 23, retroperitomeal - 2, anterior abdominal wall - 1, right inguinal region – 1. Complications found in 259 (47,26%). Most common was infected cyst – 117 ; with severe, septic character – 34. Bile duct communication - 71 (12,9% of all). Obstructive jaundice – 53 (9,67%). More than one complication - 41 pts. Recurrent hydatid cysts – 43.   Results Main signs and symptoms were: heaviness in right upper abdominal quadrant – 57,98%; upper abdominal pain – 23%; dyspepsia – 46%; high temperature – 26%. Asymptomatic - almost 17%. Greatest significance for exact diagnosis had US and CT scan. ERCP and MRI were useful in Obsctructive jaundice. All of the patients underwent operative interventions. Distribution according to operative procedures: Echinococcectomy – 391 (71,3%); Echinococcectomy + Cholecystectomy + BD exploration – 87 (15,8%); Pericystectomy – 38; Liver resection – 43; Splenectomy – 21; External drainage of abscess cavity – 14. Postoperative morbidity – 7,6%. Postoperative mortality – 0,5% (3 pts).   Conclusions Surgery is the only way for radical management of  hydatid disease. The choice of the operative procedure should be ruled by: location, size, number of the cysts and complication. Complete surgical resection (lever resection and pericystectomies) should be performed whenever possible, preferably in specialized HPB centers.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
348

E-AHPBA

Dmitry Panchenkov1,2, Sergey Leonov1, Yury Ivanov1,2, Ruslan Alikhanov3, Yulia Stepanova4, Nikolai Soloviev1,2, Aleksey Nechunaev1,2, Dmitry Agibalov2 1 A.I. Evdokimov Moscow State University of Medicine and Dentistry, Department of Surgery, Laboratory of Minimally Invasive Surgery, Moscow, Russia, 2Research Institute of Clinical Surgery, Federal Research Clinical Center of Specialized Medical Care and Medical Technologies FMBA, Moscow, Russia, 3M.V. Lomonosov Moscow State University, Department of Surgery, Moscow, Russia, 4I.M. Sechenov First Moscow State Medical University, Moscow, Russia Objectives  Measurement of electric impedance could be an informative diagnostic method, permitting to clarify the functional reserve of the liver in patients who are scheduled to undergone liver resection. The aim of the present study was to work out the methodology of laparoscopic bioimpedancemetry of the liver.     Method Laparoscopic biompedancemetry (LBIM) performed to 42 patients during planned cholecystectomy (n=23), liver cyst fenestration (n=3), liver resection combined with radiofrequent ablation of colorectal metastases (n=3), nephrectomy (n=4), diagnostic laparoscopy (n=9). Bioimpedancemetry (BIM) performed with bipolar needle electrodes and the original device for measurement of full electric impedance of biological tissues “BIM II” (patent of Russian Federation № 2366360). The value of electric impedance determined in one zone of the electrode injection in series on three frequencies - 2 kHz, 10 kHz, 20 kHz. Results When analyzing the results of the study valid differences were noticed between the electric impedance of intact liver and the liver with cirrhotic and metastatic changes. Conclusions LBIM of the liver is available, safe and informative diagnostic method, which permits to clarify the functional condition of the liver. The results of LBIM could be useful in planning of major liver resections and prediction of outcome of surgical treatment of patients with    liver pathology.

P106 Laparoscopic measurement of the electric impedance of the liver.

349

Abstracts

P107 EFFECT OF IRINOTECAN ON LIVER REGENERATION, EXPERIMENTAL STUDY ON RATS  Abstracts
Erdinc CETINKAYA1, Samir ABDULLAZADE2, Osman ABBASOGLU1 1 Hacettepe University General Surgery, Ankara, Turkey, 2Hacettepe University Pathology, Ankara, Turkey

Objectives  Irinotecan is one of the most frequently used drug in the treatment of metastatic colorectal cancer. The aim of this study was to determine the histopathological changes caused by irinotecan and show the effect of these changes on liver regeneration. Method  96 Winstar-Albino  breed female rats were used. Rats were divided into two groups; 40 mg/kg dose of irinotecan was given intraperitoneally one time per week for four weeks to the first group, during the same period same amount of salin solution was given instead of irinotecan to the second group. One week after the last injection all animals had undergone %70 hepatectomy. Liver regeneration was determined immunohistochemically using PCNA activity index on the tissue samples obtained at 0., 24., 48., 72., 96. and 120. hours.  Specimens  were evaluated for steatohepatitis with Hemotoxylen-Eosin staining. Results Hepatic steatosis was significiantly more in the irinotecan group. Although lobuler inflammation and celluler swelling were more prominent in the irinotacan group, these values were not statistically significiant. In both groups, regeneration reached to peak at 48th hour and returned to baseline at 120th hour. Liver regeneration indices were not different between the groups. Conclusions In this study, it was shown that irinotecan caused steatohepatitis on %70 hepatectomy model on rats however it didn’t affect the liver regeneration adversly. In order to show the effects of irinotecan on liver regeration in humans further clinical studies are needed.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
350

E-AHPBA

P108 Rupture of the hydatid diseasess of the liver into the biliary tracts Abstracts
Slobodan Arandjelovic Clinic for Surgery, Clinical Center Prishtine Serbia, KiM, Seychelles

Objectives  Objectives: To analize the diagnosis and the surgical treatment of intrabiliary ruptured hydatid disease of the liver.   Method Mathods: Between 2002 and 2012, 1 patients with hydatid cysts of the liver underwent surgery in a university hospital. One patients with Echinococus hepatis lobi sin multilocularis. Icterus e obstructione. Cholangitis suppurativa and intrabiliary rupture of hepatic hydatid cyst were retrospectively reviewed. Results Results: A 20-year-old men underwent a procedure for a diagnosis was principally made using ultrasonography and computed tomography scanning and was confirmed by the findings of other tests. Cholecystectomy and perycystectomy echinococcici with drainage and omentoplasty was performed in patients. The common bile duct was explored and it was drained by a T-tube. The postoperative hospoitalization time was 8  days in patients treated with T-tube drainage respectively. Complications not were seen in  with intrabiliary ruptured hydatid cyst.   Conclusions   Conclusion: This study indicates that T-tube drainage in intrabiliary ruptured hydatid cysts are effective procedures with low morbidity and mortality rates.  

351

P109 Acute Budd Chiari due to a simple liver cyst – good cyst gone bad? Abstracts

Jennifer Long, Hannah Vaughan-Williams, Joshua Moorhouse, Harsheet Sethi, Naggapan Kumar University Hospital Wales, Cardiff, UK Objectives Simple liver cysts are common, rarely causing significant morbidity or mortality. Budd Chiari syndrome (BCS), caused by obstruction of hepatic venous outflow, is the leading cause of post-sinusoidal liver failure. We present a rare case of BCS caused by a simple hepatic cyst. Method A 16 x16 cm liver cyst was found on computed tomography of a 66 year old woman presenting with abdominal pain and nausea. Cyst exerted mass effect on portal vein bifurcation and almost complete compression of the IVC. Shortly after admission patient developed acute liver failure, with deranged clotting and hepatic encephalopathy.  She developed multiorgan dysfunction requiring inotropic, ventilatory and renal support on the intensive care unit (ICU).  Cardiac output studies showed a cardiac index of 1.4 (normal 2.5 - 4.0 L/min/m2). Results An emergency laparotomy with fenestration of cyst and drainage of two litres of purulent material lead to a full recovery. Cystic fluid aspirates taken intra-operatively later confirmed no evidence of echinococus on parasitology studies and cultured mixed coliforms. The fibrous cyst wall contained inflammatory cells and foci of hepatocytes with no evidence of malignancy, confirming a simple liver cyst. Liver biopsies showed severe, confluent, bridging necrosis in a predominantly centrilobular distribution, with no evidence of parenchymal liver disease. Conclusions Acute BCS due to rapid compression of all major hepatic veins leading to fulminant hepatic failure is rare. Our case highlights a rare but clinically significant complication of a simple liver cyst that clinicians should be aware of when managing these “innocent” lesions.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
352

E-AHPBA

P110 LIVER LESIONS: NOT ONLY MALIGNANT CASES.

Objectives Usually HPB Units evaluate and operate on more patients with malignant disease (primary HCC and liver metastasis) than patients with benign diseases. Benign solid and cystic tumors are common but their management remains controversial. Most accepted surgical indications for these tumors are: symptomatic/ complicated cases (rupture, hemohrrage or pain), adenoma>5cm. or uncertain diagnosis. The laparoscopic approach should not extend these indications. HPB surgeon must know how to deal with these patients. We evaluated our experience in last five years. Method : Period 2007-2012. Prospective data base. Patients referred to Outpatient HPB Clinic. We have evaluated 155 patients with 215 lesions. Solid tumors (38 patients and 73 lesions): hemangioma (20 patients/45 lesions), Focal Nodular Hyperplasia (6p/9), Adenomas (7p/14) (1 adenomatosis), other (5p/5). Cystic tumors (15 patients and 13 lesions in cysts type I and uncountable in type II): Gigot Type I: 7 patients/13 lesions and Type II: 8 patients. Liver hydatidosis (102 patients and 129 lesions). Results We operated on 75 patients (46%) (solid (11), cystic (5) and hydatidosis (59)). Indications were: solid tumors (3 rupture, 3 accepted indications, 5 uncertain diagnosis); cystic tumors (3 symptomatic, 2 complicated), hydatidosis (active cysts (32) or symptomatic/complicated cases (27)).  Mortality was 0%.   Patients Symptomatic Surgical Cases Operated Patients/% Scheduled /Emergency Laparoscopic procedures Morbidity Hospital Stay SOLID TUMORS 38

353

Abstracts

JoseMRamia,CarmenRamiro,RobertoDelaPlaza,FarahAdel,VladimirArteaga,PilarVeguillas,JorgeGarcia-Parreño HPB Unit. Department of Surgery, Hospital de Guadalajara, Guadalajara, Spain

3/11 (29%) 11(29%) 8/3 2/11 (18%) 0% 5 CYSTIC TUMORS 15 5/5 (100%) 5 (33%) 4/1 4/5 (80%) 0% 2 HYDATIDOSIS 102 27/59 (46%) 59 (58%) 57/2 3/59 (5%) 23% 11 TOTAL 155 35/75 (46%) 75 (48%) 69(92%) 6(8%) 9/75 (12%) 19%   Conclusions Benign liver lesions are a heterogeneous group of diseases. The percentage of surgical cases is about 40%, usually operated as scheduled procedure with low morbidity and without mortality. Operated cystic lesions are symptomatic and usually performed by laparoscopic approach. Solid tumors can rupture (10%) and we have to operate on as an emergency procedure.  40% of hydatidosis are complicated cases and morbidity is higher in those patients. HPB surgeon should know how to manage (surgery/follow-up) not only HPB malignant diseases but also the benign cases.

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
354

E-AHPBA

P111 Advance techniques for difficult bi or monosegmentectomies in hepatic surgery.

Objectives Liver resection remains the gold standard treatment of both primary and secondary tumors of the liver. Major hepatectomies have specific indications and considered anatomic preservation of liver parenchyma should always be attempted in order to prevent liver failure and increase the chances of re-operation in cases of recurrence. Method Intrahepatic Glissonian approach is a recent popularized technique of identification and dissection of right and left segmental pedicles and their ramifications. Results Although intrahepatic Glissonian approach is helpful in most cases of both major and minor hepatectomies, it seems to be more complicated in cases of anatomic posterior segmental liver resections. In such cases a thorough identification of the anatomic landmarks using ultrasound devices and precise intrahepatic ligation of the inflow and outflow pedicles is of paramount importance. The description of both techniques is of special interest in daily surgical practice, as they facilitate a rapid and bloodless anatomic hepatectomy  in demanding segmentectomies. Conclusions These techniques allow complete ischemic demarcation of all liver segments and facilitate anatomic bi or monosegmentectomies.

355

Abstracts

Spyros Delis, Dimitrios Karakaxas, Christos Agalianos, Andreas Bakoyiannis, Nikolaos Gouvas, Christos Dervenis Konstantopouleion General Hospital, Athens, Nea Ionia, Greece

Abstracts

P112 Docosahexaenoic acid (DHA) induces apoptosis inhuman hepatocellular carcinoma cells
sinan sun, jiansheng li Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, hefei,anhui, China

Objectives The docosahexaenoic (DHA), a ω-3 fatty acid, could play a beneficial inhibition of the incidence and progress of a series of human diseases including cancer. It has been report that DHA is involved in cell apoptosis. Method Recent studies show that the signal transduction pathway links with bcl-2, bax, caspase-3 and MMP-9 molecules. Therefore, we tested the relationship between DHA and cell apoptosis in human hepatocellular carcinoma cells (Bel-7402 cells). We show here that DHA induces Bel-7402 cells apoptosis after pre-treating cells with DHA. Results DHA down-regulates the protein expression of Bcl-2 and Bim mRNA level, and up-regulates caspase-3 activity and Bax expression level. We also found that DHA inhibits Bel-7402 cells migration. Conclusions Basic on our studies, DHA may play a role in tumor invasion and survival.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
356

E-AHPBA

P113 Defining indications to ALPPS procedure. Technical aspects and open issues

Objectives A limit to the chance of surgical treatment for patients with hepatic tumors is represented by the inadequate volume of residual hepatic parenchyma (FLR - Future Liver Remnant) and the resulting high risk of postoperative liver failure. Portal vein embolization (PVE) and ligation (PVL) are standardized techniques to increase FLR while a new two stage technique has been developed with the acronym ALPPS (Associating Liver Partitioning and Portal Vein Ligation for Staged hepatectomy) to obtain a rapid and effective increase in FLR, thus reducing the rate of patients excluded from surgery after PVE/PVL for disease progression or inadequate FLR growth. Method Between January and December 2012, 6 patients were candidates to ALPPS at the Hepatobiliary Surgery Unit of San Raffaele Hospital, Milan. The first three patients (Series 1) underwent right trisectionectomy and were affected by hilar cholangiocarcinoma, while the following three (Series 2) underwent right hepatectomy for colorectal liver metastases. Intra- and postoperative outcome was evaluated with the aim of defining indications to ALPPS. Results All patients reached an adequate FLR (median volume increase 78%) after a median of 7 days from the first procedure (rate of program completion 100%). In Series 1 two patients developed septic complications: right liver abscess in one case and segment IV necrosis in one case. Both patients underwent urgent resection, but one patient died for multiple organ failure. In Series 2 postoperative course was uneventful in all patients, and in particular no patient showed disease progression between the two procedures or signs of postoperative liver failure. Conclusions ALPPS approach was initially considered suitable for patients affected by Klatskin tumors who required extended hepatectomies (right trisectionectomy) associated with surgery of the biliary tract: the analysis of this first series of patients has led to a re-evaluation of the indication to this strategy, as a consequence of encountered criticisms. Patients affected by colorectal liver metastases and candidates to right hepatectomy may be good candidates to ALPPS, whenever indicated (i.e. small FLR, presence of CALI, need for surgery for other reasons).

357

Abstracts

Francesca Ratti, Federica Cipriani, Annalisa Gagliano, Marco Catena, Michele Paganelli, Luca Aldrighetti San Raffaele Hospital, Milano, Italy

Abstracts

P114 Liver failure in patients treated with chemotherapy for colorectal liver metastases: role of chronic disease scores in  patients undergoing major liver surgery. A CaseMatched Analysis
Francesca Ratti, Federica Cipriani, Annalisa Gagliano, Michele Paganelli, Marco Catena, Luca Aldrighetti San Raffaele Hospital, Milano, Italy

Objectives  An accurate and non-invasive tool to predict preoperatively histopathologic chemotherapy induced liver injury still lacks. Objective of this study was to evaluate the role of chronic liver disease scores as Postoperative Liver Failure (PLF) predictors in Colorectal Liver Metastases (CLM) surgery for patients treated with Oxaliplatinbased chemotherapy and undergoing major liver resection. Method  Data regarding 8 patients who developed PLF after major hepatectomy (Group B) were compared to those of 24 patients who did not develop PLF (Group A) in a case-matched analysis (1:3) for baseline and disease characteristics and liver resection extension. Pearson coefficient was calculated to assess chronic liver disease scores association with biochemical data. ROC curves analysis was performed too. Results  In Group A median number of CT cycles was lower, interval between treatment and surgery was longer and bevacizumab was more frequently administered. In Group B the median APRI score was 0,53 (range: 0,86 4,26) whereas in Group A was 0,30 (range: 0,06 - 2,21), (p <0,05). Median FIB-4 score was 2.46 (range: 0,8613,65) in Group B and 1.58 (range: 0,27-7,68) in Group A (p <0,001). Multivariate analysis showed correlation between APRI and the onset of PLF. A good accuracy of APRI score was evident in ROC curves with an area under the curve of 0,72 (p 0,003). Conclusions  APRI score is calculated considering both liver damage and platelet count, it is costless and easy available. This study demonstrates that it has in a good accuracy in PLF prediction and consequently in CT induced liver damage evaluation.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
358

E-AHPBA

Luca Aldrighetti, Saverio Di Palo, Francesca Ratti, Federica Cipriani, Marco Catena, Michele Paganelli, Carlo Staudacher, Gianfranco Ferla San Raffaele Hospital, Milano, Italy

Objectives 30% of patients with colorectal cancer presents with liver metastases at diagnosis. Long-term survival is influenced by obtaining a complete removal (R0) of the primary tumor and liver metastases. Aim of this study was to assess the short-term outcome of combined resection of left colon or rectum cancer and liver metastases, comparing the results of the primary tumor resection performed laparoscopically or by laparotomy. Method From January 2004 to December 2012, 106 patients underwent combined resection of colorectal cancer and synchronous liver metastases. 69 patients underwent laparoscopic colorectal resection (LPS Group), and were compared with 37 patients undergoing colorectal resection by laparotomy (LPT Group). Right colonic resections were excluded from the analysis. A further analysis was performed, including only the colonic resection. Results The two groups resulted comparable in terms of patients and disease characteristics, extent of liver resection, lymphadenectomy and length of surgery. Patients in the LPS Group had a significatively lower blood loss (400 mL vs 650 mL, p<0,001) and rate of intraoperative transfusions (19.3% vs 47.2%, p=0.04). LPS Group was associated with a lower postoperative morbidity (24.6% vs 44.4%, p=0.039), and a shorter postoperative median hospital stay (9 vs. 13 days, p<0.001). Blood loss, morbidity and length of postoperative stay were not correlated to liver resection extent. The analysis of the subgroup of patients undergoing colon resection confirmed these outcomes. Conclusions Laparoscopic resection of colorectal cancer in patients undergoing simultaneous resection of liver metastases by laparotomy is associated with a reduction of blood loss, morbidity and postoperative hospital stay, without affecting the oncologic radicality. In simultaneous resections of colorectal cancer and liver metastases, postoperative morbidity and hospital stay are mainly conditioned by the type of approach to intestinal surgery (laparoscopic or open), rather than the extent of liver resection.

359

Abstracts

P115 Synchronous surgery for colorectal cancer and liver metastases: laparoscopic colorectal resection improves short term outcome. A comparative study

Abstracts

P116 Transjugular portosystemic shunt in combination with left gastric vein embolization in treatment of patients with esophageal bleeding
Yury Khoronko, Arair Sarkisov, Andrey Dmitriev, Vitaliy Mikryukov, Konsta Glebov Rostov State Medical University, Rostov-on-Don, Russia

Objectives Esophageal hemorrhage is the most dangerous complication of portal hypertension. Endoscopic ligation in complex with transjugular intrahepatic portosystemic shunt (TIPS) is an effective line of treatment. Left gastric vein (LGV) embolization as addition to TIPS placement using created intrahepatic channel allows prevention of rebleeding in cases of shunt dysfunction. Method 134 TIPS were performed at our clinic from 2007 to present time in patients with portal hypertension due to liver cirrhosis with mean age of 49,2+/-4,6 (range, 14-83 y). In 102 cases the control of variceal bleeding or prevention of rebleeding were an indication for intervention. 58 cases among them were accompanied with selective LGV embolization using Gianturco coils (1-5 per procedure depending of vessel diameter and features of portal branching). We explain disability to make this procedure in other cases by individual angioarchitectonics of portal branches and insufficient surgical experience in initial period of using the method. Results Among 102 patients, who have undergone a TIPS procedure, shunt dysfunction was in 15 (14,7%). During the follow-up period from 1 month to 1 year, the rebleeding episodes, by which the TIPS occlusion has manifested, were registered in 8 cases. At the same time in other 7 patients operated by TIPS placement in combination with LGV embolization, the shunt trombosis was asymptomatic and revealed occasionally during ultrasonography monitoring. In all 8 cases of thrombosis-associated hemorrhage, it was successfully controlled by pharmacotherapy and then a re-TIPS procedure was performed. 30-days mortality - 1,96% (2 patients). Conclusions In summary, the rebleeding rate in cases of the shunt dysfunction was significantly reduced in patients treated by TIPS combined with LGV embolization in comparison with the TIPS procedure alone. This fact significantly influenced survival of such a difficult category of patients with variceal hemorrhage due to liver cirrhosis.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
360

E-AHPBA

Tamara Gall, Mohamed Basyouny, Adam Frampton, Long Jiao Hammersmith Hospital, London, UK

Objectives To review the outcomes of patients with synchronous rectal liver metastases at our centre. At initial diagnosis, a quarter of patients with rectal cancer have synchronous liver metastases, a predictor of poor outcome.  There are no standardised guidelines for treatment.  We offer a primary-first approach with neo-adjuvant chemotherapy. Method All patients who underwent surgical resection for synchronous rectal liver mestastases from 2004 to 2011 were identified retrospectively from a prospective MDT database.  Patients underwent chemotherapy or chemoradiotherapy before resection of the primary tumour followed by hepatic resection and finally post-operative chemotherapy. Results 36 rectal cancer patients with 94 synchronous liver lesions were identified.  Following systemic therapy, 5 patients had complete response in liver disease, 28 partial response and 3 stable disease.  All patients had resection of their primary tumour, 34 had surgical treatment of their liver.  After a median follow-up of 48.1 months (range: 17.1-107.6) 20 patients (56%) were alive, 10 with disease, and 16 (44%) had died.  Overall survival was 59% at 3 years and 39% at 5 years.  Survival was similar in patients with no recurrence and those with hepatic recurrence only but worse in those with extra-hepatic recurrence. Conclusions Rectal resection before hepatic resection combined with pre-operative and post-operative chemotherapy gives good survival rates.  It allows down-staging of liver metastases and the removal of the primary tumour before the development of further micrometastases.  Further, patients who do not respond to chemotherapy are identified and may avoid major surgery.

361

Abstracts

P117 Neo-adjuvant chemotherapy and primary-first approach for rectal cancer with synchronous liver metastases

Abstracts

P118 CYSTO-GASTRIC AND CYSTO-DUODENAL FISTULA SECONDARY TO HEPATIC HYDATID DISEASE. De la Plaza R, Ramia JM, Arteaga V, Adel F, Kühnhardt  AW, Gonzales JD, Valenzuela JC, Veguillas P, Ramiro C, García-Parreño J.
Roberto De la Plaza, Jose M. Ramia, Vladimir Arteaga, Farah Adel, Andree Kuhnhardt, Jhonny Gonzales, Jose Valenzuela, Pilar Veguillas, Carmen Ramiro, Jorge Garcia-Parreño Hospital de Guadalajara, Guadalajara, Spain

Objectives The presence of a hydatid cyst (HC) perforation to gastric/duodenal cavity is exceptional. In our review of PubMed until December 2012, including articles in all languages have been published only 15 cases of cystogastric and 9 of cysto-duodenal fistulas. We report two new cases which presented as abdominal sepsis. Method 77 year-old woman with hypertension, diabetes and renal failure. She suffered an accidental fall 15 days before. She is transferred to the emergency room presenting septic shock. Physical exam: fever, hematoma on right flank and abdomen, abdominal pain and peritonism. CT showed a broken HC with involvement of gallbladder, biliary tract and abdominal wall. - 82 year- old male with moderate degenerative cognitive impairment and a known 8.5cm HC not surgically treated. He went to emergency room for dehydration, abdominal pain and fever. CT showed a 7cm HC open to peritoneal cavity, gallbladder and bile duct with gas inside. Results Case 1: In laparotomy, HC perforated to the abdominal wall and stomach was seen. Total cystectomy, cholecystectomy, suture of biliary fistulas and gastric wall was performed. In the postoperative period developed. septic shock, fungemia, Stenotrophomona pneumonia and multiple organ failure dying at 32º postoperative day. Case 2:  A HC located in segments VI-VII-V and perforated to duodenum and retroperitoneum was seen. Near total cystectomy, cholecystectomy, suture of duodenal and biliary fistulas was performed. Morbidity: abscess solved with percutaneous drainage and biliary fistula due accidental removal of T-tube solved with ERCP + stent. He was discharged on the 63th postoperative day. Conclusions The communication between HC and the stomach or duodenum has been exceptionally reported. These fistulas have a high morbidity and mortality. The debut of hydatid disease as cysto-gastric fistula coexisting with perforation to the abdominal wall and septic shock has not been previously reported in the literature.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
362

E-AHPBA

Maciej Malinowski1, Bernhard Gebauer2, Victoria Heller1, Timm Denecke2, Lina Demirell1, Daniel Seehofer1, Gero Puhl1, Peter Neuhaus1, Martin Stockmann1 1 Department of General, Viseral, and Transplantation Surgery, Charité, Berlin, Germany, 2Department of Radiology, Charité, Berlin, Germany

Objectives An extended right hemihepatectomy is often the only curative option in patients with liver tumors. However, postoperative liver insufficiency according to the low future liver remnant(FLR) worsens the outcome. Portal vein embolization(PVE) prior to resection improves the FLR volume. In this study a new PVE Method using vascular plug was analyzed. Method Patients undergoing PVE using AmplatzerTM vascular Plug before surgery (PLUG) were included in this prospective analysis. Those patients were compared to the retrospective group embolized using polyvinyl alcohol particles (PVA) only. Total liver volume and FLR volume before embolization and before operation were measured from contrast enhanced CT-scan/MRI scans using Visage®-Software. Success of PVE resulting in an increased FLR volume was determined as the percentual growth of the left lateral liver lobe (LLL). Standard biochemical and clinical parameters were analyzed as well. Results 38 and 81 patients were analyzed in the PLUG and PVA groups respectively. The time between PVE and operation was 27±15 days. The low left lateral liver lobe volume before PVE (p=.002), as well as PLUG (p<.001 vs. PVA) had a significant positive influence on the LLL. In the PLUG group the low left lateral liver lobe volume before PVE was the only factor positively influencing the LLL (p=.008). Also if the time from PVE to operation was restricted (28±4 days, 26 and 28 patients PLUG and PVA), the same influence factors were identified. Conclusions Our findings suggest that PVE using vascular plug improves proliferation rate of the left lateral liver lobe and thus might significantly improve the extended hepatectomy rates. Also a low left lateral liver lobe volume before PVE is a positive prognostic factor influencing the LLL.

363

Abstracts

P119 Portal vein embolization using vascular plug improves growth of the left lateral liver lobe significantly

Abstracts

P120 PORTAL THROMBECTOMY DURING HEPATECTOMY FOR HEPATOCELLULAR CARCINOMA: A SINGLE CENTER EXPERIENCE.
Federica Cipriani, Annalisa Gagliano, Francesca Ratti, Marco Catena, Michele Paganelli, Luca Aldrighetti San Raffaele Hospital, Milan, Italy

Objectives HCC may cause portal invasion, being a negative prognostic factor. Clinical practice lacks of standard indications in case of portal thrombosis. The value of hepatic resection in presence of portal thrombosis remains controversial. This study evaluates the results of a series of liver resection for HCC with portal thrombectomy.   Method  Eighteen liver resections with portal thrombectomy in patients with HCC conditioning vascular invasion were performed at our institution, with portal resection and reconstruction being associated in some cases. This series was included in the statistical analysis of short (intraoperative and perioperative) and long term outcome.   Results  The series was composed of 7 right hepatectomies, 3 extended right hepatectomies, 5 left hepatectomies, 2 extended left hepatectomies, 1 right posterior sectoriectomy. Liver resections were associated with thrombectomy of the portal trunk main and / or its first order branches. There were no intraoperative deaths. The rate of postoperative complications was 44.4%. There were no reoperation for major complications and there were no acute portal thrombosis. Postoperative mortality at 30 days was zero and the average length of hospital stay was 20 days. On average, the disease-free survival was of 6.7 months, with an overall survival of 8.2 months.   Conclusions  In case of HCC conditioning portal invasion, the association of hepatic resection with portal thrombectomy appears feasible and a safe therapeutic option, with possible favorable impact on patient outcome.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
364

E-AHPBA

Serge Evrard1,2, Veronique Brouste1, Pippa McKelvie-Sebileau1, Grégoire Desolneux1 1 Institut Bergonie, Bordeaux, France, 2Université de Bordeaux, Bordeaux, France

Objectives Liver metastases (LM) in close contact to suprahepatic veins (SHV) is a frequent cause of unresectability.  Radical approach involving hepatic vein resection have been published using demanding grafting techniques for reconstruction. Otherwise experimental data have shown high resistance of SHV to heat. Intraoperative radiofrequency ablation (IRFA) with vascular exclusion (VE) may be a useful approach.   Method Out of 358 patients operated for LM, 22 with LM close to a SHV treated by IRFA under VE with at least one year of follow-up were included in this retrospective study. Complications and outcomes are reported. Results Median number of metastases was 4.5 [range: 1-12]. They were bilateral for 17 patients. Median size of ablated lesions was 2 cm [range: 1-5.5]. Seven complications occurred (4 Grade IVa), and no mortality. At 4 months, no recurrence of ablated lesions was detected. Median overall survival for colorectal patients was 40 months 95%CI[17.5-not reached].The OS at 2 years was 72.2%, 95%CI [45.6-87.4].   Conclusions IRFA plus VE for LM in close contact to a SHV is a safe and effective technique which can extend the applications of liver metastases surgery.  

365

Abstracts

P121 Liver metastases in close contact to supra-hepatic veins ablated under vascular exclusion

P122 BILIARY CYSTADENOCARCINOMA Abstracts

Jose M Ramia, Roberto De la Plaza, Vladimir Arteaga, Belen Perez-Mies, Farah Adel, Luis Gijon, Nicolas Mohedano, Carmen Ramiro, Santiago Pinto, Jorge Garcia-Parreño Hospital Universitario de Guadalajara, Guadalajara, Spain Objectives Biliary cystadenocarcinoma (BCAC) is an exceedingly rare tumor. First time described by Willes in 1943, only 150 cases have been published in medical literature. Preoperative correct diagnosis is unfrequent and differentiating from benign biliary cystadenoma is a hazardous work. Method : Male, 75 year-old, past medical history: hypertension, prostatic cancer (Gleason 6) treated with radiotherapy and hormonotherapy. No toxic habits. No abdominal symptoms. In abdominal ultrasound made in follow-up of prostatic cancer, a complex liver cyst was seen. Blood analyses were normal but CA19-9 was 53 UI/l. Hydatidosis serology: negative. Abdominal CT and MRI: cyst of 65x55x45 mm with hyperintense intracystic mural nodules, mild dilatation of intrahepatic left biliary tree and contact/infiltration of left portal branch. Cyst was mainly located in segment IV but segments V and VIII were involved Results We performed a left extended hepatectomy. Performing transection of liver parenchyma, we observed that right intrahepatic biliary tree was infiltrated by tumor, so we decided to resect bile duct and performing a hepaticojejunostomy. Postoperative course was uneventful. Macroscopically: white cystic tumor with necrotic areas of 6,4 x 5,3 cm. Microscopically: cystic lesion with intracystic papillary nodules and infiltration of liver parenchyma (G1). No perineural or vascular invasion. Tumor was CK7 positive and CK20 negative. Final diagnosis: Biliary Cystadenocarcinoma pT1pN0M0, stage I (TNM 7ª ed). Chemotherapy:  oral capecitabine plus radiotherapy. Six months later no relapsed has been detected. Conclusions BCAC occurs without gender predominance. Two subtypes of CABC have been postulated. Correct radiological diagnosis is difficult. Differential diagnosis includes: biliary cystadenoma, biliary IPMT and complex liver hydatid cysts. Surgery with free margin is best treatment option. There is no clear consensus about chemotherapy treatment. Data about survival are confusing

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
366

E-AHPBA

Sanjay Pandanaboyana, Savita Brito-Mutunayagam, Francesca th’ng, Steven Wigmore Royal Infirmary Edinburgh, Edinburgh, UK

Objectives Fibrin sealants are frequently used in liver surgery to achieve intraoperative haemostasis and reduce postoperative haemorrhage and bile leak. This metaanalysis aimed to review the haemostatic and biliostatic capacity of fibrin sealants in elective liver surgery Method  An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches to identify all articles published that related to this topic. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. Results Ten randomised controlled trials encompassing 1225 patients were analysed to achieve a summated outcome. Pooled data analysis showed the use of fibrin sealants resulted in reduced time to haemostasis (mean difference -3.45 mins [-3.78, -3.13] (P < 0.00001)) and increased numbers of patients with complete haemostasis (risk ratio (RR) 1.56, 95% confidence interval (c.i) 1.04 to 2.34, p = 0.03) when compared controls. The use of fibrin sealants did not influence perioperative blood transfusion requirements, bile leak rates, postoperative haemorrhage, intraabdominal collections and overall morbidity and mortality compared with controls. Conclusions There is no solid evidence that the routine use of fibrin sealants reduces the incidence of postoperative haemorrhage or bile leak compared with other treatments. The use of fibrin sealants may reduce the time to haemostasis, but this does not translate to improved perioperative outcomes.

367

Abstracts

P123 Systematic review and metaanalysis of haemostatic and biliostatic efficacy of fibrin sealants in elective liver surgery

Abstracts

P124 Metaanalysis of intermittent Pringle Manoeuvre versus No Pringle Manoeuvre in elective liver surgery
Sanjay Pandanaboyana, Savita Brito-Mutunayagam, Francesca th’ng, Steven Wigmore Royal Infirmary Edinburgh, Edinburgh, UK

Objectives Intermittent pringle manoeuvre (IPM) is frequently used during liver surgery. This metaanalysis aimed to review the impact on blood loss, operating time and morbidity and mortality with and without use of IPM. Method An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches to identify all articles published that related to this topic. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. Results Four randomised controlled trials encompassing 392 patients were analysed to achieve a summated outcome. Pooled data analysis showed the use of IPM resulted in reduced transection time/cm2 (mean difference (MD) -0.53 [-0.88, -0.18] min/cm2 (P=0.003) but with comparable blood loss (ml/cm2) (MD -1.67 [-4.41, 1.08] ml/ cm2, p=0.23, overall blood loss (MD -20.42 [-89.42, 48.58] ml, blood transfusion requirements (RR 0.78 [0.40, 1.52, p=0.47] and morbidity and mortality compared to NPM (No Pringle manoeuvre).  In addition there was no significant difference in the postoperative hospital stay (MD 0.37 [-0.60, 1.34] days Conclusions There is no evidence that the routine use of IPM improves perioperative and postoperative outcomes compared to NPM and its routine may not be recommended.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
368

E-AHPBA

Emmanuel Melloul1,2, Andrea Vuck1, Dimitri A. Raptis1, Rolf Graf1, Pierre-Alain Clavien1, Mickael Lesurtel1 1 University Hospital Zurich, Zurich, Switzerland, 2University Hospital Lausanne, Lausanne, Switzerland Objectives To assess the efficacy of temporary portal vein embolization (PVE) compared to permanent occlusion of the portal vein with embospheres or ligation (PVL) on hypertrophy of the non-embolized liver lobes, and to observe the impact of temporary PVE, permanent PVE and PVL on embolized liver lobes. Method One hundred fifty-five BL6/male mice underwent 70% portal vein occlusion using powdered absorbable agent (temporary PVE), embospheres (permanent PVE), or ligation (PVL). Repeated portography and MRI angiography were carried out in each group to confirm portal vein occlusion and to assess recanalization time course after temporary PVE. Liver regeneration was assessed by immunohistochemistry (Ki-67, Phosphorylated-histone 3 staining). Liver lobe volumes were determined by small animal MRI volumetry. Results Proximal and complete recanalization occurred 10 and 20 days after temporary PVE, respectively. The hypertrophy ratio of non-embolized lobes at day 30 was 136 ± 52% after PVL, 103± 17% after permanent PVE, and 107± 37% after temporary PVE (p=0.09).  The atrophy ratio of embolized lobes at day 30 was 69±4% after temporary PVE, 75±8% after PVL, and 83±4% after permanent PVE (p=0.04). There was a complete remodelling of liver parenchyma architecture at day 7 after temporary PVE and PVL. Temporary, permanent PVE and PVL induced significant hepatocyte proliferation in the non-embolized lobes at day 2. Conclusions Although PVL seems superior to induce liver hypertrophy, temporary PVE is as efficient as permanent PVE to induce liver regeneration and hypertrophy in the non-embolized lobes. The lower atrophy of embolized lobe and complete parenchyma remodelling after temporary PVE needs further investigation to assess the functional recovery of this lobe.

369

Abstracts

P125 Permanent versus Temporary portal vein occlusion to induce liver hypertrophy: A comparative study

Abstracts

R.B. Alikhanov1, D.N. Panchenkov2,3, F.G. Zabozlaev3, A.V. Sorokina1,3, D.A. Astakhov3, D.Y. Petrov1, O.V. Moroz1 1 Department of Surgery, M.V. Lomonosov Moscow State University, Moscow, Russia, 2Department of Surgery, Laboratory of Minimally Invasive Surgery, A.I. Evdokimov Moscow State Universi, Moscow, Russia, 3Institute of Clinical Surgery, Federal Research Clinical Center of Specialized Medical Care and Medical Technologies FMBA, Moscow, Russia Objectives The protective effect of octreotide and prednisolone infusion before the major  hepatic resection is  controversial. Morphologic assessment of the liver tissue response to the preoperative infusion of octreotide and prednisolon after the major hepatic resection was studied in rats. Method 25 male Wistar rats weighing 230-280 g were used. All rats underwent 70-80% hepatectomy. The rats were divided into three groups according to the infusions received 1 hour before hepatectomy: group A (N=7) – received octreotide, group B (N=8) - prednisolone, group C (N=10) - 0.9% saline solution as the control. The dose of infusions was titrated according to weight of the rats. Histologic features of the remnant liver were evaluated in the sacrificied rats after 72 hours post-hepatectomy. Results In the group A we observed much less significant subcapsular albuminous degeneration of hepatocytes, the rapid decrease of edema and the sufficient amount of the newly formed blood vessels in comparison with the groups B and C. In the octreotide infusion group (group A) we observed the tendency to the regeneration process which was established in the obvious separation of sphacelous hepatocytes from the relatively unchanged tissue within the resection area. This tendency is marked by significant lymphocyte and granulocyte response with the following granulation tissue formation. Conclusions Short time octreotide infusion before the major hepatic resection may have protective effect on  hepatocytes and it doesn’t suppress  regeneration in the remnant liver

P126 Octreotide and prednisolone protective effect on hepatocytes before the major hepatic resection in experimental study on rats.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
370

E-AHPBA

P127 Surgical resection of hepatocellular carcinoma. Review of our experience

Objectives Liver resection (LR) is the treatment of choise for certain hepatocellular carcinoma (HCC), especially in noncirrhotic patients. The aim of this work was to compare the outcomes of this surgery in cirrhotic (CP) and noncirrhotic patients (NCP) in our hospital Method Between February 2002 and October 2010, 56 patients with HCC underwent liver resection (LR). Thirty-four patients were cirrhotic (61%). We have reviewed clinical, diagnostic and surgical data about morbidity and mortality of these patients. Follow up data were listed until April 2011. We compared overal survival (OS) and disease free survival (DFS) at the end of the follow up of CP and NCP after LR. Results  No clinical and epidemiological differences were found between groups. The vast majority of patients (95%) was a stage A according the Barcelona Clinic Liver Cancer (BCLC). Anatomical resection was used in most patients (75%). No differences were observed in the complication rate after surgery. Median OS of CP was 47 months. Median OS of NCP was 69 months. Median DFS of CP and NCP was 25 months (DS6,1; IC95% 12,9-37) and 42 months (DS16,6; IC95% 9,4-74,5) respectively. In multivariate analysis two factors (complications after surgery and microvascular tumor invasion) were stadistic significant in OS and DFE.   Conclusions Liver resection is an option to take into account for patients with HCC. This technique shows an acceptable morbidity and mortality figures. In cirrhotic patients, it is necessary to use appropriate selection criteria and combine this surgical treament with the liver transplantation.

371

Abstracts

Lorena Solar García, Alberto Miyar de León, Lino Vázquez Velasco, Carmen García Bernardo, Jose Carlos Fernández Fernández, Luis Barneo Serra, Ignacio González-Pinto Arrillaga University Hospital of Asturias, Oviedo, Spain

Abstracts

Orlando Torres1, Cassio Oliveira2, Cristiano Lima3, Eduardo Fernandes4, Fabio Waechter5, Marcel A Machado6, Marcelo Linhares7, Paulo Herman8, Rinaldo Pinto9, Jose Maria Moraes-Junior1 1 Department of Surgery: Federal University of Maranhao, Sao Luiz/Maranhao, Brazil, 2Federal University of Paraíba, Joao Pessoa/Paraiba, Brazil, 3Federal University of Minas Gerais, Belo Horizonte/Minas Gerais, Brazil, 4Hospital Silvestre Rio de Janeiro, Rio de Janeiro, Brazil, 5Santa Casa from Porto Alegre, Porto Alegre/Rio Grande do Sul, Brazil, 6 Hospital Sírio Libanês São Paolo, Sao Paolo, Brazil, 7Federal University of São Paolo, Sao Paolo, Brazil, 8University of São Paulo Medical School (USP), Sao Paolo, Brazil, 9Hospital Santa Catarina Blumenau, Blumenau/Santa Catarina, Brazil

P128 Associating liver partition and portal vein ligation for staged hepatectomy (alpps): the brazilian experience

Objectives  The aim of this study is to present the Brazilian experience with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for the treatment of patients with initially unresectable primary and metastatic liver tumors. Method Were analyzed 39 patients who underwent hepatic resection using ALPPS approach in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation (PVL) and in situ splitting (ISS). In the second operation the right hepatic artery, right bile duct and the right hepatic vein were then isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years). Results The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three patients (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver had increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients). Conclusions The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
372

E-AHPBA

Harsheet Sethi, Abdul Hakeem, Gabriele Marangoni, Ernest Hidalgo, Giles Toogood, Raj Prasad, Peter Lodge St James’s University Hospital, Leeds, UK Objectives Surgical resection of colorectal liver metastases (CRLM) remains the only hope for cure, with median survival of 20 months after palliative chemotherapy. Resectability is precluded by radiological evidence of extra-hepatic nodal disease. This study evaluates the impact of hepatic pedicle lymph node (HPLN) enlargement on overall (OS) and disease-free-survival (DFS). Method Between November 1993 and 2010, 65 consecutive patients with suspected HPLN metastases (radiological or intraoperative findings of enlarged HPLN) were identified from a prospectively maintained database. Staging with PET-CT was available only in the second half. A total of 1102 patients underwent liver resection for CRLM, of which 65 (5.9%) had excision of enlarged HPLN. Interestingly, only 38 patients (58.5%) had histologically proven HPLN metastases (LN+). The prevalence of HPLN involvement was 2.45%. Nodal involvement was local (pericholedochal, periportal, common hepatic and coeliac) in 36 (94.7%) and distant (para-aortic) in 2 patients (5.3%). The median follow-up was 42.3 months. Results R0 resection was achieved in 41 patients (63.1%) with enlarged HPLN and 27 patients (41.5%) did not have HPLN metastases (LN-). The 3- and 5-year OS was 50% and 38% and 3 and 5-year DFS was 43% and 32% for patients with CRLM and enlarged HPLN. The 3- and 5-year OS for LN+ group was 32% and 21%, which was significantly worse when compared to LN- group (67% and 50% respectively) (Log-rank p=0.005). Similarly the 3- and 5-year DFS for LN+ was 30% and 18%, which was significantly worse when compared to LN- group (58% and 46% respectively) (Log-rank p=0.040).   Conclusions These results indicate that curative intent liver resection with HPLN excision is safe and offers potential cure for patients with CRLM and HPLN enlargement. Surgery should be offered to patients with suspicious HPLN involvement as pre-operative staging often overestimates LN involvement. The impact of extensive lymphadenectomy must be evaluated in prospective trials.

373

Abstracts

P129 Impact of hepatic pedicle lymph node enlargement in patients with colorectal liver metastases

Abstracts

P130 Ultrasound imaging of colorectal liver metastasis:   still relevant or already outdated?
Chalat Al Ali, Mike Liem, Robert Bosker, Rob Dijk Deventer Hospital, Deventer, The Netherlands

Objectives Surgical resection is the mainstay of treatment for colorectal liver metastasis (CLM). Also, a commonly applied curative treatment modality is radiofrequency ablation (RFA). Diagnostic imaging is mainly performed by Computed Tomography (CT). There may be a considerable interval between CT  and operation. Therefore we have employed one day preoperative ultrasound (POUS)  in addition to intraoperative ultrasound (IOUS) by the same investigator. However the usefulness of US is debated considering the widespread improvements in other imaging modalities. This study was designed to investigate the additional use of POUS and IOUS by evaluating their impact on patient management. Method In a secondary and tertiary  referral centre  for CLM we included 125 cases of patients with CLM that underwent surgery in a 6 year period. Patients were retrieved from a prospective database and information was retrieved from individual electronic patient files. Impact on management was defined as dismissal of planned surgery or change in number or range of resection or RFA. Descriptive statistics were used. Data are given in means and percentages. Results Patients were aged between 41 and 84 years. 76 were male (60.8%) and 49 were female (39.2%). POUS had impact on management in 3/114 cases (2.6%). In one case planned RFA was dismissed. In 2 cases it led to more extensive resection. IOUS had impact on management in 38/116 cases (32.8%). In 7/116 cases (6.0%) surgery was averted. In 9/116 cases (7.8%) resection or RFA was reduced in number and/or size. In 22/116 cases (19%) resection or RFA were increased in number and/or size. In 5/116 cases (4.3%) additional histopathology study was performed, but it did not change surgery plan. Conclusions IOUS should be continued to be performed in surgery of CLM, as it has substantial impact on surgical treatment. Unnecessary surgery can even be prevented, This is further encouraged by US being a low cost and radiation free examination. POUS is of limited additional value if evaluated by means of change in management. However, the evaluation by the same investigator of  POUS and IOUS may have conttributed to more accurate management during surgery.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
374

E-AHPBA

P131 The role of FDG PET-CT in the preoperative work up of colorectal liver metastasis. Abstracts
Chalat Al Ali, Mike Liem, F Smit, J Manders Deventer Hospital, Deventer, The Netherlands

Objectives Preoperative imaging and staging for colorectal liver metastasis  is mainly performed using Computed Tomography (CT). With the addition of the tracer 18- fluorodeoxyglucose (FDG) to Positron Emission Tomography (PET), tumours are identified by the accumulation of metabolized glucose in tumour cells. FDG PET-CT is a software fusion of PET data with CT images, which makes precise tumour localisation possible. Current literature is inconclusive on the proper role of PET-CT in the diagnosis and management of CLM. The aim of this study was to investigate whether PET-CT is of added value in the preoperative work up for CLM. Method In a secondary and tertiary  referral centre for CLM in a 6 year period we included 79 cases of patients with CLM, that underwent both CT and PET-CT. Patients were retrieved from a prospective database and information was retrieved from electronic patient files. Radiology reports of CT and PET-CT were evaluated for differences in outcome. Also, patient management after CT and after PET-CT were compared. Outcome of histopathology studies of suspected metastatic lesions were used to calculate sensitivity and specificity of CT and PET-CT imaging on a lesion by lesion basis. Descriptive statistics were used. Results The average age at the time of undergoing PET-CT was 65.2 years. Metastasis outside the liver was detected by PET-CT in 17/79 (21.5%) of cases. PET-CT results changed patient management in 13/79 cases (16.5%): it gave definitive certainty on CLM presence (N=5), colorectal carcinoma recurrence was detected (N=1) which were then resected, metastasis outside the liver was detected which called for histopathology study (N=5), and the outcome changed surgery plan (N=2). Sensitivity and specificity of CT were 90.8% and 35.3% respectively and for PET-CT 62.2% and 82.6% respectively. Conclusions FDG PET-CT can be properly used in the preoperative work up of patients with colorectal liver metastasis as it changes patient management substantially. Whether this is cost-effective when performed routinely, considering the increasing burden of health care costs, is open for debate.

375

P132 Does primary tumour location affect the distribution of colorectal liver metastases? Abstracts

Samir Pathak1, Ebrahim Palkhi2, Rajiv Dave1, Alan White1, Ernest Hidalgo1, Raj Prasad1, JPA Lodge1, Giles Toogood0 1 HPB and Transplant. St’ James’s University Hospital, Leeds, UK, 2University of Leeds, Leeds, UK Objectives There is conflicting evidence regarding whether streamlining of blood flow within the portal vein influences the anatomical distribution of colorectal liver metastases (CRLM). This study aimed to assess the relationship between primary tumour location and metastases development.   Method  Patients were identified using a prospectively maintained database, and those with known site of primary colonic disease included.  Site of metastases and segments affected was confirmed via review of the radiology reports; metastases noted to involve multiple segments were documented as such. The location of primary colonic tumour was confirmed via review of clinical correspondence letters. Chi-square analysis was performed to determine statistical significance.   Results A total of 623 metastases were identified, of which 271 were bilateral. 252 were in the right lobe and 100 in the left lobe. In CRLM arising from the right colon, the ratio of metastases in the right lobe vs the left lobe was 2.7:1 (p<0.05), and the majority of metastases involved segments 6 (48%) and 7 (50%). In CRLM arising from the left colon, the ratio of right lobe vs left lobe was 2.5:1, with marginally fewer metastases in segments 6 (45%) and 7 (46%) and marginally more in segments 2, 3 and 4.   Conclusions  Right-sided CRLM is more likely regardless of the primary location. Portal streaming may have an effect, though the natural anatomical “angulation,” particularly of the left portal vein branch is more likely to play a role. This may favour anatomical resection of right-sided CRLM and non-anatomical resection of left-sided CRLM.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
376

E-AHPBA

Objectives The use of videolaparoscopy in patients with hepatic echinococcus   Method Videolaparoscopic procedures were performed 69 (27.9%) patients with echinococcus, which are presented in the form of three technologies: laparoscopic echinococcectomy (17 patients), endovideoskopic residual cavity in traditional Echinococcectomy (49) and endoskopy fistula residual cavity of the liver (3). Aparazitic operations provided by using multiple tissue, isolating the cyst from the abdominal cavity. Antiparasitic treatment was carried out 0.5% alcoholic solution of fenbendazole. Endoskopy fistula residual cavity of the liver used in the treatment of 3 patients with a functioning drainage of residual cavity of the liver at different times after surgical treatment of hepatic echinococcus.   Results In 6 cases of 23 laparoscopic procedures undertaken the transition to laparotomy due to a total intrahepatic location of the cyst (4), and the localization of the reach segment (2). Through careful examination of the inner wall of the cyst removed in 7 cases unnoticed during the open phase of the operation the germinal elements of the parasite. In 4 cases intraoperatively identified and closed cystbiliary small fistula. Endoskopy fistula residual cavity in 1 patient revealed tsistobiliarny fistula that was coagulated. Chresfistulnaya endovideoskopiya residual cavity of the liver used in 3 patients with a functioning drainage of residual cavity.   Conclusions Application of new technology in the form videolaparoscopy, diagnosis and treatment of liver endovideoscopy residual cavity in the intra - and postoperative periods have improved outcomes in patients with hepatic echinococcus.  

377

Abstracts

Faruch Makhmadov, Karimkhon Kurbonov, Atoboi Sobirov, Alisher Gulahmadov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan

P133 The use of videolaparoscopy in patients with hepatic echinococcus

Abstracts

P134 Can sorafenib be discontinued in patients with hepatocellular carcinoma and a complete response to treatment?
Yiqun Yan, Jing Li, Liang Huang Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China

Objectives Sorafenib has demonstrated clinical efficacy in patients with hepatocellular carcinoma (HCC), more and more studies are underway to assess optimal combinations with sorafenib such as transarterial chemoembolization (TACE) or radiofrequency ablation as well as sequencing of treatment modalities to maximize patient outcome, and thus more and more complete remission (CR) cases were reported. For patients who have achieved complete remission, whether sorafenib can be discontinued remains unknown. This study aims to provide information that whether sorafenib discontinuation can be regarded as safe. Method We presented a case that a HCC patient has achieved CR after sorafenib in combination with TACE therapy, and reviewed the reported literatures concerning sorafenib therapy in patients with HCC and a complete response to treatment. Results Up to December 31, 2012, our patient had maintained the tumor status of CR for 30 months. However, the drugrelated diarrhea made him very discomfortable in everyday life. To the best of our knowledge, there are several case reports concerning this issue (Table 1), and it seems that relapse of tumor hardly happens in patients who have achieved CR after sorafenib monotherapy, irrespective of drug discontinuation or not. Conclusions For patients who have achieved complete remission, we propose that sorafenib may be discontinued. Evaluation of the current hypothesis and investigation with a larger cohort of cases, may provide information that such an approach can be regarded as safe , and thereby improve quality of life and reduce treatment costs for patients in which a CR is achieved.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
378

E-AHPBA

Alessandro Valdegamberi, Andrea Ruzzenente, Calogero Iacono, Tommaso Campagnaro, Simone Conci, Francesca Bertuzzo, Fabio Bagante, Alfredo Guglielmi Department of Surgery, Division of General Surgery A, G.B. Rossi University Hospital, Verona, Italy

Objectives The prognosis of peri-hilar cholangiocarcinoma (PCC) is dismal. In recent years, some improvements in longterm survival due to advances in peri-operative and surgical management have been advocated. The aim is to compare the results of surgical treatment after and before 2005 in patients with PCC in a tertiary Italian center. Method A retrospective review of the medical data of 76 patients affected by peri-hilar cholangiocarcinoma submitted to surgery from 1990 to 2009. Of whom, 34 (44.7%) underwent surgery before 2005 and 42 (55.3%) after 2005.  Results After 2005, patients were older (90.5% of patients older than 60 years vs. 61.7% before 2005, p=0.005). Associated hepatectomies were more frequent after 2005 than before (78.6% vs. 67.6%, p<0.05), as well as major hepatectomies (73.8% vs. 64.7%, p<0.05) and caudate lobe resections (71.4% vs. 58.8%, p<0.05). Mortality was similar. The mean number of lymph-nodes harvested was higher after 2005 than before 2005 (6.17 vs. 2.49, p=0.001). R0 resection rate was 61.9% after 2005 and 55.9% before 2005 (p=0.07). The 5-year overall survival increased after 2005 (39.4% vs. 12.5%, p=0.01), likewise the 3-year disease-free survival (49.6% vs. 26.3%, p=0.01). Conclusions Advanced surgical techniques, such as major hepatectomy, caudate lobe resection and extended lymphadenectomy, allow a significant improvement of long-term outcomes in patients with  peri-hilar cholangiocarcinoma. 

379

Abstracts

P135 Does advanced surgical techniques allow an improvement of long term outcome in patients with  peri-hilar cholangiocarcinoma?

Abstracts

P136 Results of the surgical treatment of huge hepatocellular carcinomas in the Western world.
Umberto Maggi1,2, Gerard Pascal1, Chady Salloum1, Philippe Compagnon1, Alexis Laurent1, Daniel Azoulay1 1 Department of Digestive and Hepatobiliary Surgery, AP-HP, UFR Universitè de Paris XII, Creteil, France, 2UO Chirurgia Gen e Trapianti Fegato - IRCCS Fondazione OM Policlinico, Milano, Italy

Objectives  In western countries, huge (>10 cm) hepatocellular carcinomas (hHCC) are often excluded from surgical resection due to different reasons including the criteria of BCLC staging system. So for untreated patients 5 years survival is poor. The aim of this study is to verify results of their surgical treatment in a tertiary hepato-biliary center.   Method Between 1/2000 and 12/2012, 71 consecutive patients were resected for a hHCC in our centre and entered in a prospective database. An aggressive postoperative treatment of recurrencies was adopted, including reresections and liver transplantations. Demographics, peri-operative, and pathologic data were collected. Postoperative 30, 60, 90 days mortality and long term survival, were calculated. Factors possibly related with early mortality and late survival were analyzed. Fifty three patients (75%) were males with a mean age of 55 years. Seventeen patients (25.4%) had livers with metavir fibrosis score F 3-4. Nine (13%) had cirrhosis with metavir score 4.   Results 13 patients (18%) had no intraoperative  transfusion. Nine (13%) underwent a second procedure. Histopathology demonstrated a mean size of lesions of 153 mm. and macro/ microvascular invasion in 33% and 80% of cases, respectively. 30, 60, 90 days mortality was 6%, 9%, 11%. Age and cardiorespiratory conditions were correlated with 30 and 60 days mortality. At multivariate analysis only intra-operative blood transfusions were significant at 90 days. One, 3, 5 yrs overall survival was 70%, 55%, 38%. No pathologic data was correlated with survival in the multivariate analysis. 5-year survival of patients with hHCC and Metavir 3-4 livers was 16%.   Conclusions In a tertiary western center, complex resections and an aggressive treatment strategy of recurrences can offer an acceptable  long term survival to patients with hHCC. An accurate preoperative assessment may help to enhance post-resection results. Pathologic preoperative results are probably not useful in the selection of patients affected by hHCC to address to surgery.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
380

E-AHPBA

P137 Primary non-hodgkin lymphoma of liver

Objectives The most common malignancy of the liver is metastasis of the other organ cancers Hepatocellular carcinoma is the most common primary malignancy of the liver. Primary non-Hodgkin lymphoma of liver is a very rare malignancy. Primary tumors of   liver are difficult to character­ ize and are frequently associated with poor prognosis.   Method A 63-year-old man was referred to our clinic with  abdominal pain and a palpable mass in the right upper quadrant of the abdomen. Computerize tomography scan and ultrasound showed multiple solid lesions in the liver. The other primary organ metastasis was considered as the primary focus of the liver mass. Upper and lower gastrointestinal endoscopy and the other tests were planned to patient.   Results Another organ primary lesion could not be determined and ultrasonography-guided liver tru-cut biopsy was performed to the patient. Histopathologically primary non-Hodgkin’s lymphoma of the liver was detected. The patient was referred to oncology clinic  and was planned chemotherapy.   Conclusions Among masses detected in the liver; primary non-Hodgkin’s lymphoma is a rare pathology, but should keep in mind by clinicians. If the clinical picture is suspicious for primary non-Hodgkin’s lymphoma, a liver biopsy should be obtained. The disease is treatable and the primary treatment should be chemotherapy.  

381

Abstracts

OZGUR DANDIN1, DENIZ TIHAN2, MURAT CAYCI2, EVREN DILEKTASLI2, UGUR DUMAN2, FATIH EROL2, AHMED TAHA2, HASAN ÇANTAY2 1 BURSA MILITARY HOSPITAL GENERAL SURGERY SERVICE, BURSA, Turkey, 2BURSA SEVKET YILMAZ TRAINING HOSPITAL GENERAL SURGERY SERVICE, BURSA, Turkey

Abstracts

Christoph Tschuor1, Kris P. Croome3, Gregory Sergeant1, Ksenija Slankamenac1, Erik Schadde1, Victoria Ardiles2, Virginia Cano2, Rodrigo Sanchez Claria2, Eduardo de Santibanes2, Roberto Hernandez-Alejandro3, Pierre-Alain Clavien1 1 Swiss HPB Center University Hospital Zurich, Zurich, Switzerland, 2Department of Surgery, Division of HPB Surgery, Italian Hospital, Buenos Aires, Argentina, 3Department of Surgery, Division of HPB Surgery, Western University Medical Center, London, Ontario, Canada

P138 Salvage Parenchymal Liver Transection (SPLiT) for patients with insufficient volume increase after Portal Vein occlusion - An extension of the ALPPS approach -

Objectives Portal vein occlusion using ligation (PVL) or embolization (PVE) is a standard approach to induce liver hypertrophy prior to hepatectomy in primarily non resectable liver tumors. However, in 30% of patients this approach fails, because of tumor progression or insufficient volume increase of the standardized future liver remnant (sFLR). The new “ALPPS” approach combines PVL with parenchymal transection to induce rapid hypertrophy .This study explores whether Salvage Parenchymal Liver Transection (SPLiT) alone boosts liver hypertrophy in all scenarios of prior portal occlusion that failed. Method Three patients with liver tumors not resectable in a single surgical procedure who underwent portal vein occlusion and experienced insufficient volume gain were identified in three centers in Switzerland, Argentina and Canada. All patients underwent SPLiT. Volume increase, patient characteristics, complications and outcomes are reported. Results The first patient had a starting sFLR of 30% after failed PVL and increased in 7 days to 47%. The second patient had a sFLR of 25% after failed PVL and PVE of segment IV and increased in 7 days to 41%. The third had a starting sFLR of 19% after failed PVE and increased in six days to 37%. All patients were resected successfully and are free of liver recurrence. Conclusions This is the first study exemplifying in three cases from 3 centers that salvage parenchymal liver transection alone (SPLiT) induces profound hypertrophy after all currently used types of portal vein occlusion. SPLiT may be a better salvage strategy than additional segment 4 embolization, hepatic vein embolization, or sequential arterial embolization.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
382

E-AHPBA

P139 Surgically treated hepatoblastoma in children. Our experience from 1993-2012 Abstracts
Joze Maucec, Dragan Stanisavljevic University Medical Centre Ljubljana, Ljubljana, Slovenia

Objectives Hepatoblastoma is the most common primary liver tumor in children. Nevertheless it has a very low incidence and occurs in approximately 0.5 - 1.5 cases per million children (0-15 years old) per year and is mostly diagnosed by 2 years of age. Current treatment of choice consists of surgical removal of the tumor with pre- and postoperative chemotherapy. In patients with an unresectable tumor preoperative chemotherapy can achieve down staging and resectability. Our objective was to review our experience with hepatoblastoma in last 20 years. Method Retrospectively collected data on patients with surgically removed hepatoblastoma was analysed for a period of 20 years (1993-2012). Results In the last 20 years we have treated 4 children with hepatoblastoma. That amounts to an annual incidence of 0,63 per million children. Average age at the time of operation was 15,4 ± 7,8 months. The youngest was treated at 6 months of age. Two of the children received preoperative chemotherapy that achieved down staging of the tumor. In all four cases a curative resection was performed and after surgery all children were treated with postoperative chemotherapy. At the present day all 4 patients are without sings of a recurrence of disease. Conclusions Our review has shown that the incidence and survival rate of hepatoblastoma in Slovenia is comparable to other countries in the world. Pre- and postoperative chemotherapy in combination with radical resection is the current treatment of choice.

383

P140 Primary non-Hodgkin’s lymphoma (MALT) of the liver Abstracts

Andrea Police, Andrea Palmieri, Andrea Sagnotta, Andrea Scarinci, Daniele Crocetti, Simona Di Filippo, Pasquale Perri, Gian Luca Grazi Department of HBP Surgery, “Regina Elena” National Cancer Institute, Rome, Italy Objectives Primary hepatic lymphoma (PHL) is a rare primary liver tumor. It’s confined to the liver with no evidence of lymphomatous involvement in the other lymphoid structures. We report a case of PLH in a patient affected by other hematologic disorder which was submitted to hepatic resection.   Method A 50 years old man, nonsmoker, affected by Essential Thrombocythemia (ET) from 1992, with no history of hepatitis, was referred to our attention for the presence of a focal liver lesion revealed at an abdominal ultrasonography during follow up for the hematologic disease . The patient did not show any other symptoms or blood test alterations. The presence of the lesion was confirmed at CEUS, CT scan and MR. The radiologic findings suggest a benign liver lesion consistent with adenoma.   Results A caudate lobe resection was performed. Postoperative period was complicated by moderate biliary leakage that was treated conservatively. Histologic findings was an hepatic MALT. Patient was treated with adjuvant chemotherapy with CHOP schedule twenty-one cycles and after three months he is alive with no evidence of recurrence.   Conclusions PHL is a rare entity that can be often misdiagnosed. In our report the patient did not present any risk factors or any preoperative imagine suspicious for PHL. It should be considered in the differential diagnosis of focal liver lesions. Prognosis is variable with good response to surgery combined with postoperative chemotherapy.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
384

E-AHPBA

Olga Sergeeva, Eduard Virshke, Igor Trofimov, Andrei Kukushkin, Vadim Panov, Boris Dolgushin, Yuri Patyutko N.N.Blokhin Cancer Research Center, Moscow, Russia Objectives Transcatheter arterial chemoembolisation (TACE) is a well-established procedure alleviating the hormonerelated symptoms in hepatic metastatic neuroendocrine tumor patients. The survival prolongation along with the symptomatic response is the subject of the presentation.   Method  Since 1994 37 patients have undergone 110 TACE procedures (median 2.0 procedures per patient, range 1-13) in N.N. Blokhin Cancer Research Center for neuroendocrine tumor hepatic metastases using iodized oil or drug eluting beads with varying chemotherapeutic agents. Ten out of 37 patients demonstrated carcinoid syndrome. TACE were performed in the non-surgical candidates. TACE technique included selective or superselective hepatic arteriography followed by insertion of chemoembolization compound. The additional TACE procedures were performed only while the intrahepatic progression had been revealed. Post-procedural monitoring consisted of clinical examination, laboratory tests and visualization procedures (CT and MRI).   Results There was no post-procedural mortality. The post-TACE syndrome (pain, fever, nausea or vomiting, carcinoid syndrome aggravation) considered being transient. Two liver abscesses requiring percutaneous drainage (1- in the treated tumor, 1- ischemic one in the normal liver) occurred in two patient (morbidity rate 5,4 % per patient and 1,8 % per procedure). The only patient undergoing 13 TACE procedures during 101 months developed liver cirrhosis. All but one patient (9/10) showed carcinoid syndrome alleviation. The median survival was 50.9 months (min-max 9-161 months) from the first TACE procedure. One-, three- and five-year survival rates were 80.4%, 55.2% and 48.2%.   Conclusions TACE is an effective modality providing both hormone-related symptom control and survival prolongation. “On demand” TACE regimen (i.e, symptomatic and radiologic stabilization is enough, no additional intervention intending tumor regression) is safe for durable management of hepatic metastatic neuroendocrine tumor patients.  

385

Abstracts

P141 Long-term outcomes of liver chemoembolisation for non-resectable metastatic neuroendocrine tumors

Abstracts

P142 Impact of expanding criteria for resectability of colorectal liver metastases on short- and long-term outcomes after hepatic resection. Our 8 years´ experience
VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDIMORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, TERESA GIMÉNEZ, Alejandro Serrablo Miguel Servet General University Hospital., ZARAGOZA, Spain

Objectives  An expansion of resectability criteria of colorectal liver metastases (CLM) is justified providing “acceptable” short-term and long-term outcomes. For this reason, we want to show our 8 years´ experience in evaluating what perioperative prognosis factors have influenced and to ascertain this paradigm in an era of modern liver surgery. Method Prospective data from 250 patients (292 liver resections) for synchronous/metachronous CLM from 2004 were reviewed retrospectively, managed by a multidisciplinary team in a tertiary hospital. Data were coded: sociodemographics, CRC primary, diagnosis-surgical treatment LM, extrahepatic disease (EHD) and followup. Categorical variables were compared by χ2-test and continuous by independent-samples T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by logrank test. Univariate and multivariate analysis were performed to identify factors significantly related to 90 days-postoperative morbimortality from first hepatectomy defined by ClavienDindo classification. SPSS™ 15.0, p-value <0.05. Results  1-3-5 years OS-DFS rates 95.5%, 61.7%, 54.1% and 85.7%, 40.6%, 29.5% respectively. Resectability rate was 96%. Mortality 2.8%, morbidity 32.5% (16.8% grades I-II, 15.6% grades III-IV). 33% elderly patients (≥70 years), 26.3% ASA score 3-4, 84.4% stage-CRC III-IV, 49.8% synchronous, 42.8% bilobar, 13.6% resectable EHD. Our morbidity is explained by reference centre, complex patients are transferred to us, more aggressive multidisciplinar approach after neoadjuvant chemo (45.6%), immediate postoperative period was 90 days and Clavien-Dindo classification is retrospective. Prognostic factors of mortality (grade V): grades III-IV (p=0.001), ASA score 3-4 (p=0.009); of survival: grades III-IV (p=0.006) and recurrence: grades III-IV (p=0.021). Conclusions After an aggressive multidisciplinary treatment of CLM, acceptable overall morbimortality rates were observed. Perioperative mortality rates didn’t differ according to literature. However, more recently operated patients experienced more postoperative complications. These favourable short-term outcomes, without worsening of long-term outcomes, justify an expansion of the criteria for resectability.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
386

E-AHPBA

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives In era of modern chemotherapy criteria for resectability of colorectal liver metastases (CLM) have been revised and expanded over last decade. Clinicopathologic factors should no longer be used to exclude patients for surgical resection so we designed this study to investigate long-term outcome after curative resection of CLM in patients with expanded indications. Method Prospective data from 250 resected patients (292 liver resections) for synchronous/metachronous CLM from 2004 were reviewed retrospectively, managed by a multidisciplinary team in a tertiary hospital. Data were coded: sociodemographics, CRC primary, diagnosis-surgical treatment LM, extrahepatic disease (EHD) and follow-up. Categorical variables were compared by χ2-test and continuous by independent-samples T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by KaplanMeier method and compared by logrank test. Univariate and multivariate-Cox regression models analysis were performed to identify factors significantly related to OS-DFS. 90 days-postoperative morbimortality defined by Clavien-Dindo classification. SPSS™ 15.0, p-value <0.05. Results 1-3-5 years OS-DFS rates 95.5%, 61.7%, 54.1% and 85.7%, 40.6%, 29.5% respectively. Resectability rate was 96%. Mortality 2.8%, morbidity 32.5% (16.8% grades I-II, 15.6% grades III-IV). 33% elderly patients (≥70 years old), 26.3% ASA score 3-4, 84.4% stage-CRC III-IV, 49.8% synchronous, 42.8% bilobar, more aggressive multidisciplinar approach after neoadjuvant chemo (45.6%), repeat hepatectomy (13.9%) or EHD-resection (13.9%). Univariate and multivariate-Cox regression models analysis OS-poor prognostic factors: ≥70 years (Hazard Ratio [HR]=1.469; p=0.047), CRC-colon (HR=2.026; p=0.033)., CRC-N2 (HR=1.508; p=0.040). DFSpoor prognostic factors: ≥70 years (HR=1.913; p=0.001), preoperatory CEA levels ≥200 ng/ml (HR=4.551; p=0.001), neoadjuvant chemo (HR=1.472; p=0.033) and R1-resection (HR=1.498; p=0.044). Conclusions This study suggested that liver resection should be indicated in patients with expanded indications, take into account the ability to obtain an R0-resection of all known disease with the ability to preserve an adequate remnant. Multidisciplinary approach is required to select and treat this complex group of patients.

387

Abstracts

P143 Expanding criteria for resectability of colorectal liver metastases and long-term outcomes after hepatic resection: a single-center experience with 250 patients

Abstracts

P144 Provide ours single-centre results on 266 patients to an international registry of patients operated for colorectal liver metastasis-livermetsurvey®. The necesity of multi-institutional and international registries

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives To provide our single-centre results, 8 years´ experience, 266 patients (302 liver resections) to LiverMetSurvey, an international registry of patients operated for colorectal liver metastasis (CLM). To compare our singlecentre results, with a multi-institutional/multi-centre basis the most significant data concerning the history, the treatment and the outcome of operated patients. Method Prospective data from 266 resected patients for synchronous/metachronous CLM from 2004 (302 liver resections) were reviewed retrospectively, managed by multidisciplinary team in tertiary hospital. Data were coded: sociodemographics, CRC primary (perioperative-chemo included), diagnosis-surgical treatment LM, extrahepatic disease (EHD), follow-up and histological data. Similar method that LiverMetSurvey®International-Registry-CLM coordinated from Paul Brousse Hospital, France. https://www.livermetsurvey. org/. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by logrank test. Univariate/multivariate-Cox regression models analysis were performed to identify factors significantly related to OS-DFS and 90 days-postoperative morbimortality defined by Clavien-Dindo classification. SPSS™ 15.0, p-value <0.05. Results We´re second Spanish´s hospital to provide LiverMet´s patients. In comparison with LiverMet 5 years OS-DFS: 54.1% and 29.5% (p=NS). Resectability 96%. Mortality 2.8%, morbidity 32.5%. 33% elderly, 26.3% ASA 3-4, 84.4% stage-CRC III-IV, 49.8% synchronous, 42.8% bilobar, neoadjuvant chemo 45.6%, rehepatectomy 13.9% and EHD-resection 13.9%. Spanish´s centres provides 15% LiverMet´s patients, similar to France-Italy, superior than GreatBritain-Germany. Our patient´s number is limitated comparated to LiverMetSurvey® (386 centres, 17544 patients). Univariate/multivariate-Cox OS-poor prognostic factors: ≥70 years (Hazard Ratio [HR]=1.469; p=0.047), CRC-colon (HR=2.026; p=0.033)., CRC-N2 (HR=1.508; p=0.040). DFS: ≥70 years (HR=1.913; p=0.001), preoperatory CEA-levels ≥200 ng/ml (HR=4.551; p=0.001) and R1-resection (HR=1.498; p=0.044). Conclusions Providing single-centre results to LiverMetSurvey we contributed to define guidelines of optimal treatmentstrategy every centre can compare their outcomes of operated patients with CLM. It is open to all centres across world regardless their experience or size. Nevertheless, it doesn´t include neither comorbidity (like ASA score) nor neoadjuvant chemo data.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
388

E-AHPBA

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives Pathological response to neoadjuvant chemotherapy (NAC) has emerged as an important prognostic marker in resected colorectal liver metastases (CLM). The aim of this study was to correlate longterm-clinical outcomes with three components of pathologic response (necrosis, fibrosis, viable tumor cells) after resection of CLM, with and without NAC. Method Pathology slides from 150 patients who underwent CLM-resection (irrespective of NAC-status), multidisciplinary team-tertiary hospital, were reviewed retrospectively by a blinded pathologist. The PRG system (pathological response grade) was recorded as the summation of percentage necrosis-fibrosis-viable tumour cells. Associations between pathological response, its components, NAC, overall survival (OS) and disease-free survival (DFS) were analyzed. Categorical variables were compared by χ2-test and continuous by T-test. OS and DFS at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method. Univariate and multivariate-Cox regression models analysis were performed to identify factors significantly related to OS-DFS and PRG. SPSS™ 15.0, p-value <0.05. Results NAC-group (n=74) vs not NAC-group (n=76), shown major percentage areas of fibrosis ≥40% (p=0.046) and minor viable-tumor cells (p=0.047). In NAC-group: Necrosis ≥50% (5-year-OS: 80 vs 38.7%, p=0.004; 5-yearDFS: 51.1 vs 23.9%, p=0.025); viable-tumor cells <10% (5-year-OS: 76.9 vs 47.2%, p=0.041; 5-year-DFS: 48.5 vs 28.3%, p=0.044). In the opposite, fibrosis ≥40% did not behave as a prognostic survival factor (27.8 vs 56.6%, p=0.142) and recurrence (25 vs 33.2%, p=0.239). Low number of patients in our series has precluded a multivariate analysis. Conclusions This preliminary study shows necrosis ≥50% and PRG (<10% viable-tumor-cells) to NAC are predictors of survival and recurrence. Prospective-randomized trials with broader population are required to confirm these findings. PRG could be used as objective biological measure of NAC-effectiveness and allows patientsidentification in whom an aggressive multidisciplinary strategy was performed.

389

Abstracts

P145 Pathological response grade of colorectal liver metastases treated with neoadjuvant chemotherapy: a single-center experience with 150 patients

Abstracts

P146 Tumor thickness at the tumor-normal interface: a new prognostic factor for survival and recurrence outcome but not pathologic indicator of chemotherapy response in colorectal liver metastases. Our 150 patient´s experience

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives The pathologic features of chemotherapy response are increasingly recognized clinical importance in resected colorectal liver metastases (CLM). A majority of residual tumor cells are seen at the CLM’tumor-normal interface (TNI). We hypothesized that TNI correlates with pathologic response, overall (OS) and disease-free-survival (DFS) in resected patients after neoadjuvant chemotherapy (NAC). Method Clinical-Histological data from 150 resected patients with (74, 49.3%) or without-NAC (76, 50.7%) for synchronous/metachronous CLM were reviewed retrospectively. Tumor thickness at the TNI, measured as maximum thickness was measured perpendicular to the TNI in millimeters of the uninterrupted tumor cells after reviewing multiple sections (4-mm-thick HE-stained formalin-fixed paraffin-embedded). Categorical variables were compared by χ2-test and continuous by T-test to detect any  difference between two groups. OS and DFS at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by logrank test. Univariate analysis were performed to identify factors significantly related to OS-DFS. SPSS™ 15.0, p-value <0.05.   Results 88.2% of patients TNI were ≥0.5 mm (84.7% NAC-group vs 91.7% not NAC-group) and  11.2% was <0.5 (15.3% NAC-group vs 8.3% not NAC-group) (p=0.197). This finding may reflect a delayed effect of systemic chemotherapy in undetectable tumors because a significant portion (72.4%) of the ‘‘no chemotherapy’’ group completed adjuvant chemotherapy after resection of primary tumor. 5 years OS-DFS rates of TNI ≥0.5 group (84.7% NAC- patients) and TNI <0.5 group (15.3% NAC-patients) were 81.8 vs 47.1% (p=0.036), 58.4 vs 25.3% (p=0.014). Median follow-up OS/DFS were 43.8/35.6 months. Low number of patients in our series has precluded a multivariate analysis.   Conclusions Tumor thickness measured at the TNI is potentially a new prognostic factor for survival and recurrence outcome in patients with resected-CLM but not for chemotherapy-response. Provides a reproducible method for pathologists to measure treatment-response. The pathologists were blinded to radiologic findings and clinical outcome, which added strength of study findings.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
390

E-AHPBA

Floor Huisman1, Lisette T. Hoekstra1, Krijn P. van Lienden2, Joanne Verheij3, Thomas M. van Gulik1 1 Dept of Surgery, Academic Medical Center, Amsterdam, The Netherlands, 2Dept of Radiology, Academic Medical Center, Amsterdam, The Netherlands, 3Dept of Pathology, Academic Medical Center, Amsterdam, The Netherlands

Objectives Unilateral portal vein embolization (PVE) is used to increase future remnant liver volume in patients requiring extended resections. Reversible PVE is of interest when generating sufficient hypertrophy while preserving the embolized liver lobe. We aimed to evaluate the hypertrophy response following PVE using three absorbable embolization materials in rabbits. Method PVE of 80% of total liver volume was performed in rabbits using gelatin sponge (GS,n=5) or fibrin glue with aprotinin (FG+aprot,n=4) or without aprotinin (FG-aprot,n=5). Aprotinin inhibits fribrinolysis and thereby delays absorption of FG. The rabbits were sacrified after 7days. CT volumetry of non-embolized lobe (NELVol), liver damage parameters, liver-to-body weight ratio of NELVol, hepatocellular proliferation rate and histology were evaluated. Data were compared with a previous series using a permanent embolization material, i.e. polyvinyl alcohol (PVAc). Results Post-PVE portography showed complete occlusion of the embolized portal vein branch in all rabbits. GS and FG-aprot were absorbed within 7 days and resulted in significantly lesser hypertrophy response compared to PVAc (p=0.002). The increase rates of NELVol in GS, FG+aprot, FG-aprot and PVAc groups were -7,9±8,9%, 60,21±,65,99%, 8,56 ± 28,40% and 79.8 ± 18,76%, respectively. Hypertrophy response in FG+aprot was greater compared to FG-aprot (p=0,05). Significantly more proliferating hepatocytes were found in the hypertrophic lobe of FG+aprot and GS groups compared to the atrophic lobe. At sacrifice, the embolized portal vein branches in FG+aprot were still occluded. Conclusions PVE using gelatin sponge resulted in significantly less hypertrophy response compared to PVAc. FG+aprot resulted in significantly greater hypertrophy response than FG-aprot, comparable to PVAc. Aprotinin might be useful in regulating the absorption time of embolization material. Longer observation times are required to assess absorption of FG+aprot.

391

Abstracts

P147 ‘Efficacy of absorbable embolization materials for portal vein embolization to induce liver regeneration in a rabbit model’

Abstracts

P148 Oestrogen Receptors in Focal Nodular Hyperplasia – Evidence of a Hormonal Disease

Manju Chandrasegaram1,2, Ali Shah2, Ravish Raju1, Andrew Ruszkiewicz2, David Astill1, Eu Ling Neo2, Paul Dolan2, Chuan Ping Tan2, Mark Brooke-Smith1,2, John Chen1,2, Rob Padbury1, Christopher Worthley2 1 Flinders Medical Centre, Adelaide, Australia, 2Royal Adelaide Hospital, Adelaide, Australia Objectives Hormone receptor status has been assessed in hepatic adenomas and hepatocellular carcinomas, but less so with focal nodular hyperplasia (FNH). The predominance of this tumour in females, suggest a hormonal pathophysiological process, however, this has not been clearly proven. Method The aim of the study was to evaluate oestrogen (ER) and progresterone receptor (PR) expression in resected or biopsied FNH. The ethics committees of both centres approved the study. Tumours were evaluated by two independent pathologists. Tumours were stained immunohistochemically for hormone receptor status. Receptor expression was graded by proportion score (PS) and intensity score (IS). Proportion score (PS) is defined as the percentage nuclei staining for ER and PR by 6 categories: 0, < 1%,1-10%, 11-33%, 34-66%, >67%. Intensity score (IS) is the receptor staining intensity by 4 categories: none, weak, intermediate, strong.   Results Twelve patients with FNH were enrolled in the study. The median age was 39, and the F:M was 5:1. There was one patient with Turner’s syndrome, and another with polycystic ovarian disease amongst the patients with FNH. Oestrogen Receptor Expression In FNH, the median oestrogen receptor PS was 11-33%, and the median oestrogen IS was intermediate. Progesterone Receptor Expression Ten of the FNH patients had no PR expression and 2 had < 1% PR expression. Conclusions There is intermediate ER staining in FNH, and moderate percentage (11-33%) ER nuclei staining which suggests a hormonal contribution to this condition.    

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
392

E-AHPBA

Matteo Fusaglia1, Nicolas Buchs2, François Pugin2, Matthias Peterhans1, Philippe Morel2, Stefan Weber1, Francesco Volonté2 1 ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland, 2Clinic for Visceral and Transplantation Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland

Objectives Robotic systems for minimally invasive approaches ensure a 3D-high-resolution view of the surgical situs. However, the spatial identification of lesions below the surface, in solid organs, remains challenging. To address this deficit, we combined an image-guidance system providing an augmented reality view of anatomical structures within the da Vinci console and evaluated its clinical applicability during two laparoscopic liver resections. Method CAS-One liver navigation system (CAScination AG, Switzerland) was adapted to augmented reality (AR) robotic laparoscopic interventions: retro-reflective spheres were attached to the calibrated endoscope and to one arm of the robot (figure 1). Superimposition of the pre-operative 3D organ models to the intra-operative laparoscopic images was done via a landmark-based registration. Additionally, the distance from the tracked instrument to the targeted structures (e.g. tumours) was displayed in real-time (figure 2). The benefits of the AR robotic system were evaluated during the surgery of two patients presenting superficial tumour on the anterior segments of the liver. Results The navigation system setup required less than 5 minutes. Setup of the robot system and initialization of the augmented reality view required approximately 25 minutes. The navigation system was capable of tracking the robots arms without relevant line of sight issues between the markers attached to the instruments and the optical tracking system. The AR visualisation within the da Vinci console allowed the surgeons to precisely visualize the tumors, and subsequently resect them. Ultimately, we believe, that the use of a stereotactic image-guidance system helped to obtain reliable resection margins. Conclusions We reported for the first time the combination of an image-guidance system with a robotic telemanipulation system. We believe that despite the actual complexity and the setup time, this new technology is safe and applicable in a clinical setting. Our preliminary work indicates that safety margins can be detected more precisely. However, further clinical investigation are required.

393

Abstracts

P149 Case report: Integration of a stereotactic image guidance system for laparoscopic robotic liver resection

Abstracts

P150 Efficacy of neoadjuvant chemoradiation therapy for hilar cholangiocarcinoma Type IV.
Hipólito Durán, Emilio Vicente, Yolanda Quijano, Benedetto Ielpo, Isabel Fabra, Eduardo Díaz, Catalina Oliva, Sergio Olivares, Valentina Ferri, Riccardo Caruso, Ramón Puga, José Carlos Plaza hospital madrid norte sanchinarro, madrid, Spain

Objectives Cholangiocarcinoma is a tumor with poor prognosis, often unresectable at the time of diagnosis. Surgical treatment is the best chance for cure, however it is challenging and sometimes with border not free from disease, especially for Type IV. New neoadjuvant therapy may improve the survival of patients with potentially resectable cholangiocarcinoma. We present the results of patients with cholangiocarcinoma Type IV that underwent neoadyuvant chemoradiation treatment prior to surgery. Method From July 2008 until April 2012, 8 patients have been included. Preoperative work up consists of abdominal ultrasonography, CT and PET scan, RMN and percutaneous trans-hepatic drainage. Portal embolization was performed in 3 patients. Neoadjuvant treatment consist in combination of stereotactic tumor radiotherapy (to a target introduced before) and oral capecitabine. Results No toxicity was found. Surgical treatment was extended right (2) and left (5) and central hepatectomy (1) with extended lymphadenectomy. Portal vein resection was required in 3 cases. Specimen finally exam was well (5), moderate (2) and poorly (1) differentiated adenocarcinoma, all of them free of disease (R0). Tumor regression rate (TRR) (Rodell) was: TRR 3(5 patients), TRR 4 (1 patient) and TRR 2 (2 patients). Mortality before 90 days after surgery occurred in 4 patients. Survival rate was 24, 30 (2 patients) and 34 months in the remaining cases. Conclusions Neoadjuvant chemoradiation for cholangiocarcinoma Type IV may control cancer progression (high TRR), thereby improving oncological surgical resection (all patients had R0 resection) in this study. However postoperative mortality still has an important impact on survival.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
394

E-AHPBA

Antonio Sa Cunha1, Magali Rouyer2, Pernelle Noize2,3, Jeremy Jove2, Emmanuelle Bignon2, Alise Le Monies de Sagazan2, Emmanuel Mitry4, Eric François5, Annie Fourrier-Réglat2,3, Denis Smith6 1 Hôpital P. Brousse, Villejuif, France, 2CIC-P 0005 CHU Bordeaux, Bordeaux, France, 3Inserm U 657, Université Bordeaux Segalen, Bordeaux, France, 4Institut Curie, Saint Cloud, France, 5Centre Lacassagne, Nice, France, 6Hôpital Saint André, CHU Bordeaux, Bordeaux, France Objectives EREBUS aims to describe in real life the resection rates and survival outcomes according to metastases site in patients initiating cetuximab as 1rst line treatment of mCRC.

Method EREBUS is a French multicentre (n=65) cohort that included 389 patients with unresectable mCRC and wt KRAS initiating 1rst line CTX in 2009 and 2010, and followed 12 months. An expert committee reviewed baseline resectability and resection results. Resection rates and survival outcomes were described according to metastases site: liver-only, liver-not exclusively, other sites (i.e. not liver). Factors associated with progression and death were identified using multivariate Cox analysis.   Results Characteristics: 37.8% liver-only metastases, 38.3% liver-not exclusively, 23.9% other sites. 97 patients (24.9%) had metastases resection; liver-only: 36.7%, liver-not exclusively: 20.8%, other sites: 12.9%. Among them, 51.5% radical resection with R0+/-radiofrequency (liver-only: 61.1% and liver-not exclusively: 32.3%), 11.3% R1+/-radiofrequency (liver-only: 16.7%, liver-not exclusively: 3.2%) and 9.4% missing metastases. 52.6% had operative complications (20.6% infectious, 9.3% thromboembolic, 8.2% cardiovascular, 3.1% death). Overall median PFS was 9.5 months (8.6-10.1) and more likely in liver-not exclusively: HR=1.41 (1.03-1.94), other sites: HR=1.85 (1.32-2.61). The 1-year OS was 71.3% (66.4-75.6). Death was less likely in responders with or without resection: HR=0.26 (0.08-0.90) and HR=0.37 (0.21-0.63). Conclusions This cohort shows that 1rst  line CTX in wt KRAS mCRC allows a high proportion of metastases resection, particularly in liver-only. It also provides data on rarely studied mCRC patients (liver-not exclusively and other metastases).

395

Abstracts

P151 Surgical resection of liver metastases and survival outcomes in patients with metastatic colorectal cancer (mCRC) treated with cetuximab (CTX) in real-life: the EREBUS cohort

Abstracts

P152 Hemodynamic effects of extended liver radiofrequency ablation. An experimental study
Petros Ypsilantis, Vassilios Didilis, Savas Eleftheriadis, Nikolaos Varsamis, Anastasios Karayiannakis, Constantinos Simopoulos Laboratory of Experimental Surgery and Surgical Research, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece

Objectives Experimental studies have shown that extended liver radiofrequency ablation (RFA) results to oxidative stress and increased apoptosis of intestinal mucosa leading to gut barrier disruption and bacterial translocation. In terms of investigating the pathogenetic mechanism of this phenomenon, we sought to assess systemic and intestinal hemodynamics following liver RFA. Method In 4 pigs catheterized with a Swan-Ganz catheter, cardiac output and systemic vascular resistance (SvR) were measured continuously before and for 90 min following RFA of 30% of liver parenchyma. In another set of experiments, superior mesenteric artery (SMA) flow rate was continuously monitored in 10 rabbits before and for 90 min following either sham operation (n=5) or 30% liver parenchyma RFA (n=5). Results Systemic vascular resistance increased significantly but cardiac output remained unchanged after RFA in the pigs. SMA flow rate decreased significantly after RFA of 30% rabbit liver parenchyma. Conclusions Extended liver RFA causes hemodynamic disturbances consisted of increased SvR and decreased SMA flow rate.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
396

E-AHPBA

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain

Objectives Progress in the treatment of resected colorectal liver metastases (CLM) demands pathologic indicators of neoadjuvant chemotherapy (NAC) response but the problem is that are only known after resction. We pretend establish these factors by immunohistochemical study (p53, Ki-67, and stem cell markers CD44-CD133-CD166) based on the tissue microarray technique (TMA).   Method Prospective Clinical-Immunohistochemical data from 100 consecutive patients (127 liver resections) for CLM managed by a multidisciplinary team in tertiary hospital were reviewed retrospectively by a blinded pathologist. Immunohistochemical study was done (p53-Protein-Clone DO-7 and Ki-67-Antigen-Clone-MIB-1 Dako®-Autostainer-Instruments and stem cell markers EpCAMhigh-CD44+, CD133-SC-130127(32AT1672), CD166 EpCAMhigh-CD166+). Categorical variables were compared by χ2 test and continuous by T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after hepatic resection were calculated by Kaplan-Meier method using logrank test in all population and between groups (NAC/not NAC). Univariate and multivariate analyses were performed, using log-rank test and Cox-proportional hazard-model. SPSS™ 15.0, p value <0.05. Results In all population, 53 patients were p53+, 74 Ki-67+, CD44+ were 47, 23 CD133+ and  22 CD166+. Univariate and multivariate analyses found inmunohistochemical maker-stem cell-CD44+ as a good prognostic factor associated to 5-year-survival (50% vs 18.2%, p=0.024; HR=1.992, p=0.025) and 5-year-recurrence (37.5 vs 4.5%, p=0.014; HR=1.806, p=0.021) in NAC-group but not for the others markers: p53+ (5-year-OS 35.7 vs 37.5%, p=0.906; 5-year-DFS 14.3 vs 31.3%, p=0.375); Ki-67 (5-year-OS 39.5 vs 25%, p=0.441; 5-year-DFS 26.3 vs 0%, p=0.125); CD133+ (5-year-OS 57.1% vs 28.1%, p=0.061; 5-year-DFS 42.9% vs 12.5%, p=0.068) and  CD166+ (5-year-OS 58.3 vs 28.1%, p=0.064;  5-year-DFS 25 vs 18.8%, p=0.647). Conclusions Prospective-randomized trials with broader population are required to confirm these findings. By TMA, immunohistochemical maker-stem cell-CD44+ could be used as objective biological measure of NACeffectiveness and longterm outcome in this group and allows patients-identification in whom an aggressive multidisciplinary strategy was performed. The role of preoperative-biopsy it could be interesting.

397

Abstracts

P153 Inmunohistochemical analysis based on tissue microarrays after neoadjuvant chemotherapy in resected colorectal liver metastases. Cd44-stem cell marker (epcamhigh-cd44+) is a novel pathologic indicator of chemotherapy response and independent prognostic factor of long-term outcome

Abstracts

P154 Influence of resection margin on survival and liver recurrence following resection for colorectal liver metastases.
Raffaele Dalla Valle1, Giorgio Bianchi1, Elisa Fontana2 1 Department of Surgery -Parma University Hospital, Parma, Italy, 2Department of Oncology - Parma University Hospital, Parma, Italy

Objectives Recent studies have questioned the role of a positive resection margin (R1) as prognostic factor in hepatic resections of colorectal liver metastasis (CLM). The aim of this study was to evaluate the pattern of relapse and the impact of R1 resections on survival. Method We retrospectively collected clinicopathological and follow-up data from 89 consecutive patients submitted to liver resection for CLM. R0 was defined by the absence of microscopic tumor’s invasion of the resection margin. In patients with multiple metastasis the closest margin was taken as representative. Relapse free survival (RFS) and overall survival (OS) were calculated from the time of liver resection, respectively, to the first relapse and to the last follow-up or death. Survival and recurrence according to R1 and R0 resection were analysed with Kaplan-Meier and compared with Log-rank test. Results At a median follow-up of 30.0 months recurrence occurred in 70.8% of patients. Liver recurrence was present in 50% of cases. The median RFS was 16.10 months (CI= 9.24-22.96) and OS was 45.3 months (CI=25.51-65.15). The R1 resection margin rate was 21.3% (n=19). Five years OS rate was significantly lower in R1 resection (LogRank Test=0.0125). R1 resection was not significantly correlated with liver recurrence (p=0.547) and time of recurrence (Log-Rank Test=0.09). Metastasis size major than 30 mm was associated with lower incidence of R1 resections (p=0.04). Conclusions With the limits of a retrospective analysis and a relatively small number of patients in our study R1 resections seems to influence Overall Survival but does not correlate with liver recurrence and Relapse Free Survival.   

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
398

E-AHPBA

Jiri Pudil1, Frantisek Belina1, Kristyna Hlavova2 1 Surgery department, 2. Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic, 2Department of Internal Medicine, 2. Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic

Objectives The hepatocellular carcinoma (HCC) is the most common primary tumour of the liver. Radical resection or transplantation remains the sole curable method. The authors present an unusual case report of HCC metastasis. Method 60-year-old man with chronic hepatitis C was indicated for liver resection due to a solitary HCC tumour. Significant elevations of AFP were observed four months after the operation, with the check-up CT showing metastatic process in both adrenals. We performed bilateral adrenalectomy. Histological findings confirmed HCC metastasis. Results The adrenal is the usual place of haematogenous HCC metastasis; however, it is rarely observed in clinical practice. Bilateral adrenalectomy for adrenal metastases is only described as case reports in Asian literature. The method of choice in both unilateral and bilateral adrenalectomies is the mini-invasive approach. Conclusions HCC is a disease that has been showing increasing incidence; nevertheless, bilateral adrenalectomy for HCC metastases is quite rarely used as a procedure. This case report shows clearly the key role of careful dispensary, launched early after the operation.

399

Abstracts

P155 Surgical treatment of adrenal metastases from hepatocellular carcinoma – case report

Toine L. Lodewick1,3, Anjali A.J. Roeth1, Patrick H. Alizai1, Ronald M. van Dam2,3, Simon A.W.G. Dello2, Steven W.M. Olde Damink2,3, Maximilian Schmeding1,3, Cornelis H.C. Dejong2,3, Ulf P. Neumann1,3 1 Department of Surgery, University Hospital Aachen, Division of General, Visceral and Transplantation Surgery, Aachen, Germany, 2Department of Surgery, Maastricht University Medical Center & Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands, 3Surgical HPB collaboration Aachen-Maastricht, Aachen, Germany - Maastricht, The Netherlands Objectives Sarcopenia/muscle-wasting has been linked to impaired outcome after liver surgery. Preoperative liver function of sarcopenic patients might be impaired compared to patients without sarcopenia possibly leading to more postoperative morbidity. The aim of this study was to explore whether liver function was influenced by sarcopenia in patients undergoing liver resection. Method From 2011 to 2012 all consecutive patients undergoing a liver function methacetin breath test (LiMAx) in the Aachen University Hospital prior to partial liver resection, were included. Liver volumetry and muscle mass analysis were performed using preoperative CT-scans and Osirix® software. Muscle mass was calculated as the L3 muscle index (L3MI) by normalizing muscle areas at the third lumbar vertebral level for height. Sarcopenia was defined as a L3MI <55.4 cm2/m2 in men and <38.9 cm2/m2 in women. Also, body fat mass, body mass index and body surface area were calculated. Postoperative pathologic assessment gave insight in background liver disease.   Results A total number of 39 patients were included in the present study. 59% of the included patients were sarcopenic. Sarcopenic patients had a median non-tumor total liver volume (ntTLV) of 1607 [1052-2550]mL, while patients without sarcopenia had a median ntTLV of 1648 [1094-2708]mL (p>0.05). No differences in liver function were observed between patients with or without sarcopenia (330 [188-490]μg/kg/h vs. 316 [195-460]μg/kg/h, p=0.34). Body mass index (r=-0.46;p<0.01) and fat mass (r=-0.39;p=0.01) were the only body composition parameters to negatively correlate with the LiMAx-test. This was partly confirmed in 23 patients without background liver disease (r=-0.43;p=0.02 and r=-0.31;p=0.12 respectively).   Conclusions Unlike the level of sarcopenia, body mass index is significantly correlated with liver function. The influence of obesity and steatosis on postoperative morbidity should therefore gain more attention in the prevention of postresectional liver failure.  

P156 Sarcopenia, liver function and volume in patients undergoing liver resection

Abstracts

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
400

E-AHPBA

Mihajlo Đokić, Miha Petrič, Blaž Trotovšek, Robert Juvan, Valentin Sojar University Medical Center, Clinical department for abdominal surgery, Ljubljana, Slovenia

Objectives Laparoscopy is accepted both for resection of colorectal cancer as well as for liver resection. A couple of studies showed that combined rectal and hepatic resection of colorectal metastasis is safe. Laparoscopic combined procedures of colorectal cancer and hepatic metastasis have rarely been performed.   Method We report the case of 59 year old man with rectosigmoid junction cancer and synchroneous metastasis in Sg2 and Sg3 as well as in Sg.6 and Sg.7; stage IVa, colon cancer was detected in a screening test . Prior to the operation his case was  presented to the oncologist. Joint decision was to perform laparoscopy- assisted left lateral sectionectomy and  LAR first; so that we could assess the biology of tumor ,and then to send the patient to the oncologist for chemotherapy and to make restaging of the disease ones chemotherapy (XELOX + Cetuximab) was completed.   Results We made laparoscopy-assisted left lateral sectionectomy and LAR. Specimens were extracted by a small median laparotomy.  We achieved negative margins for both specimens. Operative time was 230 minutes,  estimated blood loss was about 100ml and hospital stay was 5 days. After the operation he got adjuvant chemotherapy and was again operated after the completion of chemotherapy. He has been disease free in relatively short follow up of 24months to date.   Conclusions Our report confirm that simultaneous laparoscopic resection of CRC with limited liver resection is feasible and safe procedure. There is a question weather such a combined procedure should be done by one experienced surgeon or by two surgeons, each one highly experienced in his field.    

401

Abstracts

P157 Simultaneous laparoscopic resection of colorectal cancer and liver metastasis Case report and question: who should do it?

Abstracts

P158 Influence of blood transfusions on perioperative and long-term outcome in 250 patients following hepatic resections for colorectal metastases after 8 years´ experience

VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, GABRIEL INARAJA-PÉREZ, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives Several studies have demonstrated that haemorrhage and need of transfusion-blood-products (packed red cell, whole blood, FFP, or platelets) during the operation or during hospital-stay after operation and the number-units given not only adversely affect perioperative outcome but also long-term prognosis of patients undergoing a hepatectomy for colorectal liver metastases (CLM).   Method Prospective data from 250 patients (292 liver resections) for synchronous/metachronous CLM  from 2004 were reviewed retrospectively, multidisciplinary team, tertiary hospital. Data were coded: sociodemographics, CRC primary, diagnosis-surgical treatment LM, extrahepatic disease (EHD) and follow-up. Categorical variables were compared by χ2-test and continuous by independent-samples T-test. Overall (OS) and disease-free survival (DFS) at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by logrank test. Univariate and multivariate analysis were performed to identify factors significantly related to 90 days-postoperative morbimortality from first hepatectomy defined by Clavien-Dindo classification (includding transfusion’s-tax). SPSS™ 15.0, p-value <0.05. Results Mortality 2.8%, morbidity 32.5% (16.8% grades-I-II, 15.6% grades-III-IV). 33% elderly patients (≥70 years), 26.3% ASA score 3-4, 49.8% synchronous, 42.8% bilobar. Transfusion’s-tax 53.6% based on guidelineshospital-blood-bank; transfusion of red blood cell products (or whole blood) was held until hemoglobin level < 8.0 g/dL or the patient was symptomatic from anemia, and fresh frozen plasma (FFP) was held until INR >1.8. Univariate/multivariate relationship between transfusion’s-tax and major-hepatectomies (≥3 segments, 55.6%) (p=0.015), extended-hepatectomies (≥5 segments, 11.2%) (p=0.001), Neoadjuvant-chemotherapy (NAC, 45.6%) (p=0.009), >6 cicles (p=0.001), development Clavien-Dindo-complications (p=0.040) and tendence to high-risk postoperative-mortality (p=0.084). Transfusion’s-tax didn´t affect to survival (p=0.214) and recurrence (p=0.634). Conclusions Consistent with our previous-reports, the extent-resection and complexity-surgery were associated with more morbidity, which resulted in prolonged length-hospital-stay and more frequent use of blood product transfusion. Also, several preoperative variables including patient-age and transfusion’s-tax were found to be associated with postoperative morbidity but not with mortality, survival and recurrence.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
402

E-AHPBA

Dionisios Vrochides1,2, Dimitrios Kardassis2, Achilleas Ntinas2, Dimosthenis Miliaras3, Apostolos Papalois4, Evangelos Magnissalis5, Peter Metrakos1 1 Hepato-Pancreato-Biliary & Transplant Division, Department of Surgery, McGill University, Montreal, QC, Canada, 2 Center of Hepato-Pancreato-Biliary Surgery, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 3 Department of Pathology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 4ExperimentalResearch Center, Elpen Pharmaceuticals, Pikermi, Athens, Greece, 5BioHexagon Ltd, Biomedical Engineering Company, Athens, Greece

Objectives Technological advances led to the development of many devices used in liver resections. However, no single transection tool is uniformly accepted to be better than the others. This study aimed to develop an effective, safe, fast and cost-efficient technique of hepatic parenchymal transection. Method A new liver parenchyma compression device in the form of a locking straight rigid tie (LoStRiT) was developed from scratch. Twelve pigs formed two groups. The control group (n = 6) comprised of animals that underwent hepatectomy using the standard Kelly-clysis technique. The study group (n = 6) comprised of animals that underwent hepatectomy using sequential LoStRiT mechanisms. Transection speed, blood loss and formation of bilomas were recorded. Results The mean parenchymal transection speed was 1.27 ± 0.27 cm2/min for the control group and 2.39 ± 0.56 cm2/ min for the LoStRiT group (p = 0.003). The mean blood loss per kilogram of body weight was 9.8 ± 5.2 mL/ kg for the control group and 3.9 ± 0.9 mL/kg for the LoStRiT group (p = 0.040). No bilomas were identified. Conclusions LoStRiT hepatectomy appears to be effective, safe, fast and reproducible in a porcine model of liver resection. Further development of this novel and potentially cost-efficient technique includes construction of the device with absorbable materials.

403

Abstracts

P159 A novel liver parenchyma transection technique by the use of locking straight rigid ties – Experimental study on pigs

Abstracts

P160 Reflections on 250 interventions for colorectal liver metastases to the liver in a tertiary hospital. Importance of asa-score (american society of anesthesiologists) on short and long-term outcomes after hepatic resection
VICENTE BORREGO-ESTELLA, IRENE MOLINOS-ARRUEBO, ISSA TALAL-EL ABUR, SEF SAUDI-MORO, JOSE L. MOYA-ANDIA, GABRIEL INARAJA-PÉREZ, CARLOS HÖRNDLER, JESUS ESARTE-MUNIAIN, ALEJANDRO SERRABLO Miguel Servet General University Hospital., ZARAGOZA, Spain Objectives To analyze comorbidity based on the ASA (American Society of Anesthesiologists) physical status classification system in patients undergoing resection for colorectal liver metastases (CLM) and determine the relationship between the degree ASA-score with postoperative morbidity, mortality, age, prolonged length-hospital-stay, perioperative transfusion’s-tax and overall-survival (OS), disease-free survival (DFS). Method Prospective data from 250 patients (292 liver resections) for synchronous/metachronous CLM from 2004 were reviewed retrospectively, managed by a multidisciplinary team in a tertiary hospital. Data were coded: sociodemographics, comorbidity based on the ASA-score, CRC primary, diagnosis-surgical treatment LM, extrahepatic disease (EHD) and follow-up. Categorical variables were compared by χ2-test and continuous by independent-samples T-test. OS and DFS at 1-3-5 years after first hepatectomy were calculated by KaplanMeier method and compared by logrank test. Univariate and multivariate analysis were performed to identify factors significantly related to 90 days-postoperative morbimortality from first hepatectomy defined by Clavien-Dindo classification. SPSS™ 15.0, p-value <0.05. Results All patients had any kind of comorbidity according to ASA-score (ASA 2: 181 patients, 72.4% and ASA 3: 69 patients, 27.6%). In the univariate and multivariate analysis ASA-score 3-4 wasn’t associated with increased postoperative-morbidity (p=0.160) but with higher postoperative-mortality (grade V) (p=0.009): 71.4% of deaths occurred in patients ASA-score 3-4. An ASA-score 3-4 wasn’t poor OS-prognostic factor (p=0.221) or DFS- prognostic factor (p=0.546). Patients-aged ≥70 years (30.7% elderly patients) were significantly associated with increased surgical risk score-ASA 3-4 (p=0.001). ASA-score 3-4 risk wasn’t associated with an average stay of ≥15 days (p=0.100) and a higher rate of transfusion intra/postoperative (p=0.773). Conclusions ASA-classification involves any degree of subjectivity. We didn’t considered ASA-1-patients because “healthy patient”-definition shouldn’t be applied to a patient with disseminated cancer independently of systemic pathology associated with/without functional limitation. Absence of ASA grade relationship with prolonged length-hospital-stay and postoperative morbidity but with postoperative mortality, elderly patients is agreeing with others authors.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
404

E-AHPBA

Dionisios Vrochides1, Achilleas Ntinas1, Dimitrios Kardassis1, Dimitrios Tsikaras2, Panagiota Panagiotopoulou2, Konstantinos Tsinoglou2, Anastasios Kelekis2 1 Center of Hepato-Pancreato-Biliary Surgery, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 2Department of Diagnostic and Interventional Radiology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece

Objectives MeVis LiverAnalyzer & MeVis Liver Viewer (MeVis) is a software application that, among other things, allows functional volume calculation of the liver segments, based on data that derives from MDCT. It frequently leads to type or extent alteration of a planned hepatectomy. Method Twenty one patients that were planned to undergo major hepatectomy were included. Retrospective analysis of financial data was performed. All patients met one or more of the five criteria, according to our center’s algorithm, for routine MeVis utilization. Estimated (before MeVis analysis) and true (after MeVis analysis) costs were studied. Results Out of 21 patients, six (29%) had a change in the operative plan after MeVis analysis. Routine MeVis utilization for patients that need major hepatectomy led to a cost reduction by 24% for all changed procedures (n = 6) and by 13% for all intended to change procedures (n = 21). MeVis analysis was responsible for only 4% of the cost of each separate procedure. Conclusions Routine use of MeVis analysis leads to cost reduction of major hepatectomies.

405

Abstracts

P161 Routine use of MeVis LiverAnalyzer & Mevis LiverViewer leads to cost reduction of major hepatectomies.

Abstracts

P162 Liver transplantation from brain dead donors > 70 years old into patients with MELD score > 20

Riccardo Memeo, Chady Salloum, Nicola de’ Angelis, Philippe Compagnon, Alexis Laurent, Daniel Azoulay Hepato-Biliary and Liver Transplant Unit, Henri Mondor Hospital, Creteil, France Objectives Liver grafts from older donors, considered as marginal, are increasingly used due to changing epidemiology of brain death and organ shortage. Subsequently to attribution of liver grafts according to MELD score, these marginal grafts are increasingly transplanted to high risk patients i.e. with high MELD scores. The impact of this situation was never reported and was the aim of the present study in terms of operative mortality, morbidity, patient and graft survival rates Method Since the MELD implementation, 89 consecutive liver grafts from a donor > 70yr old were transplanted. Recipients of these grafts with MELD >= (n=29) were compared to those with MELD<20 (n=60). Pre-, intra-, and post-operative data were analysed Results The 2 groups of donor were similar for all consensual items. For the recipients M>=20 compared those of the M<20: patients were younger (51.4±7.0vs58.2±6.6yrs, p=0.0001), higher MELD (24.5±5.9vs10.6±3.9, p=0.0001) and with an indication for cirrhosis without cancer (65%vs18%, p=0.0001). Bilirubin (203±197vs34±37 mmol/L, p=0.0001) INR(2.3±0.6 vs 1.4±0.4, p=0.0001), AST(161±121vs63±44 IU/mL, p=0.001) and ALT(79±53vs45±25 IU/mL, p=0.02) were significantly higher in M>=20. All intra operative data were similar. Postoperative mortality occurred in 3/29 cases of M>=20 compared to 4/60 cases of M<20 (p=0.3). Postoperative morbidity according to Clavien was higher in the M>=20 (p =0.03).1 and 3 yrs graft and patient survival rates Conclusions Despite a significantly higher morbidity, the transplantation of liver grafts from older donors (>70yrs) to patients with a high MELD score is safe and does not impact on the operative mortality, graft and patient survival rates

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
406

E-AHPBA

Megan Reiniers, Rowan van Golen, Thomas van Gulik, Michal Heger Academic Medical Center, Amsterdam, The Netherlands

Objectives Oxidative/nitrosative stress (ONS) is a cardinal feature and a therapeutic target of hepatic ischemiareperfusion injury. 2’,7’-dichlorodihydrofluorescein diacetate (DCFH2-DA), which is oxidized into the fluorescent 2’,7’-dichlorofluorescein (DCF), is widely used to detect ONS. The intracellular behavior of DCFH2-DA and DCF was analyzed in a hepatocellular carcinoma cell line (HepG2). Method The stability (i.e., auto-oxidation into DCF) of DCFH2-DA in cell media (DMEM, WE, and RPMI with/without serum) and PBS was assessed at 20°C/37°C. Cellular uptake of DCFH2-DA (0-100mM) and DCF (0-50mM) was monitored over time (0-2hr). Next, the effects of both substances on cellular viability were determined via a colorimetric (WST-1) assay. The intracellular localization of DCF was assayed by confocal microscopy.  Results Auto-oxidation of DCFH2-DA was most profound in 37°C serum-free DMEM, while marginal in 20°C PBS. The addition of serum to DMEM or WE was found to enhance DCFH2-DA stability, while in RPMI the opposite was observed. Serum quenched DCF fluorescence. The cellular uptake of DCFH2-DA and DCF was found to be timeand concentration-dependent, and did not significantly affect cellular viability. Notably, uptake of DCF was minor compared to that of DCFH2-DA. DCF localized diffusely throughout the cytosol.  Conclusions DCFH2-DA and DCF are non-toxic to HepG2 cells at concentrations of up to 100mM (DCFH2-DA) and 50µM (DCF). Cellular uptake of both substances is time- and concentration dependent, but that of DCF, which localizes cytosolically, is minimal compared to DCFH2-DA. 

407

Abstracts

P163 Cellular kinetics of the oxidation-specific fluorogenic probe 2’,7’-dichlorodihydrofluorescein diacetate and its fluorescent derivate 2’,7’-dichlorofluorescein in HepG2 cells.

Abstracts

Alfonso Recordare1, Fazli Shala2, Naim Loxha2, Hanumsha Kingij3, Sadushe Loxha4 1 IV Division of Surgery, Treviso General Hospital, Treviso, Italy, 2Division of Surgery, Regional Hospital, Peja/Pec, Serbia, 3Department of Anestaesia and Intensive Care, Regional Hospital, Peja/Pec, Serbia, 4Institute of Pathology, University of Pristina, Pristina, Serbia Objectives Primary Neuroendocrine tumors (NETs) of the liver are very rare neoplasms. Surgery is considered the best therapeutic option. Diagnosis is made if other primary neoplasms are ruled out from imaging and endoscopic investigations. The reported 5 years survival is 78% but the 5-years recurrence free survival is only 19%. Method A 52 years old woman was admitted in hospital for abdominal pain and jaundice. A CT scan revealed a hypodence mass between Couinaud segments 5 and 4 in a healthy liver, with an infiltration of the right bile duct and a dilatation of peripherical bile ducts in both sides. CA19-9 was normal. Colonscopy and upper endoscopy didn’t reveal neoplasms. No other investigations were available to better clarify the diagnosis and a presuntive diagnosis of intrahepatic cholangiocarcinoma was made. Surgery was indicated. Results An enlarged right hepatectomy was performed under intermittent hepatic pedicle clamping, and with the hanging manouver. The right bile duct was transected at the confluence of the bile ducts, and a biliary thrombus was removed from the confluence. The procedure was completed with lymphadenectomy until the common hepatic artery. The postoperative course was uneventuful and the patient was discharged 9 days after surgery. Pathology revealed a NET (Chromogranin A+, Neuron Specific Enolase+, Cytokeratin -) without nodal metastases. She didn’t receive any adjuvant treatment and at 5 years follow up she is alive and well without any sign of recurrence. Conclusions Surgery remains the main therapy for NETs, and actually there is no evidence for a role of adjuvant therapy, but looking at the rate of long-term recurrence, further investigations are needed to better clarify what are the prognostic indicators and how to select patients for eventual adjuvant therapy.

P164 Long term survival after extended liver resection for neuroendocrine tumor

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
408

E-AHPBA

Dionisios Vrochides1, Achilleas Ntinas1, Dimitrios Kardassis1, Konstantinos Tsinoglou2, Panagiota Panagiotopoulou2, Dimitrios Tsikaras2, Anastasios Kelekis2 1 Center of Hepato-Pancreato-Biliary Surgery, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece, 2Department of Diagnostic and Interventional Radiology, ‘Euromedica Geniki Kliniki’ General Hospital, Thessaloniki, Greece

Objectives Studies that compare liver regeneration among the steps of staged hepatectomy in patients who received chemotherapy are lacking. The aim of this study is to investigate the volumetric changes after staged major liver resection in patients with colorectal metastases. Method Four patients with multiple liver metastases of colorectal origin, initially unresectable (resectional category II), underwent staged liver resection (first stage: right hemihepatectomy, second stage: left lateral bisegmentectomy). All patients received FOLFOX based neoadjuvant and adjuvant chemotherapy. Liver volume was measured by MDCT. Results Preoperatively, 10 weeks post-first stage and 10 weeks post-second stage resection, mean measured liver volumes were 1588 ± 235 mL, 1264 ± 208 mL and 1294 ± 222 mL respectively. Development of the oxaliplatin related sinusoidal obstruction syndrome (n = 2) did not have a statistically significant impact on volumetric measurements. Conclusions In patients who underwent staged hepatectomy while on FOLFOX based chemotherapy for multiple colorectal metastases, liver regeneration is completed at approximately 80% of the preoperative measurement after the first stage resection and returns practically the same volume after the second stage.

409

Abstracts

P165 Liver regeneration is less than predicted after the first but not after the second resection in patients who received chemotherapy and underwent staged hepatectomy for metastatic colorectal cancer.

Abstracts

P166 Preoperative assessment of future remnant liver: comparison of volumetric methods and future remnant liver/body weight ratio

Kasia P. Cieslak1, Krijn P. van Lienden2, Roel J. Bennink3, Olivier R.C. Busch1, Dirk J. Gouma1, Thomas M. van Gulik1 1 Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands, 2Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands, 3Department of Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands Objectives Accurate assessment of future remnant liver (FRL) before major liver resection is essential. Various methods of FRL-assessment claim a high accuracy in estimating FRL-volume. We aim to evaluate the value of two additional methods for preoperative estimation of sufficient FRL-volume. Method We analysed 47 patients who underwent computed tomography (CT) volumetry as routine preoperative assessment for a (extended) right hemihepatectomy in patients suspected of small FRL (< 30%) between 2007 and 2012. Decision to perform preoperative portal vein embolization (PVE) and resection based on CTvolumetry was compared with two methods of preoperative FRL-assessment: the standardized liver volumetry based on body surface area and body weight as described by Vauthey and the remnant liver volume to body weight ration ≥ 0,5% method (RLV-BWR). Primary outcomes were decision to perform PVE and prediction of postoperative morbidity and mortality. Results 24/47 patients underwent preoperative PVE while 23/47 patients underwent resection without PVE. According to the Vauthey method, 46/47 patients had a smaller FRL-volume than measured with regular CTvolumetry. 21/23 patients should have undergone preoperative PVE if the decision was based on these findings. The RLV-BWR method predicted a small FRL in only 9/47 patients. 7/9 patients underwent PVE. There were no differences in postoperative morbidity and mortality between patients with PVE vs. without PVE. When incorporated in the decision making process, none of the methods increased the accuracy of predicting in-hospital mortality and the occurrence of complications (Clavien-Dindo grade ≥3a). Conclusions In patients suspected of small FRL who were scheduled for major liver resection, the Vauthey and RLV-BWR methods of FRL-assessment had no value in deciding on preoperative PVE. Moreover, both methods did not increase the accuracy of predicting postoperative outcome.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
410

E-AHPBA

Lasse Pedersen1, Pragya Katoch3, Victor Vishwanath Iyer2, Mogens Sall1, Mogens Vyberg3, Anders Christian Larsen1 1 Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark, 2Department of Nuclear Medicine, Aalborg Universty Hospital, Aalborg, Denmark, 3Institute of Pathology, Aalborg University Hospital, Aalborg, Denmark Objectives  Cyst-adenoma rarely occurs in the liver and can clinically be difficult to distinguish from other liver tumors. Method A 55-year-old woman, gastric bypass surgery 35 years ago, otherwise healthy, was admitted because of pain in the right upper quadrant and back.  Ultrasound revealed hepatomegaly and steatosis and a tumor with mixed density in the right liver lobe. Plasma level of carbohydrate antigen 19-9 was normal. Results Positron emission tomography computer tomography (PET-CT) showed an expansive tumor in the sixth lobe of the liver with normal standard volume uptake (SUV) of 2-deoxy-2-(18F)fluoro-D-glucose (18F-FDG). Histopathological examination showed a mucinous cystadenoma characterized by a multilocular cystic space lined by cuboidal to columnar epithelial cells showing features of low grade dysplasia(nuclear stratification and papillary structures), surrounded by an ovarian-type subepithelial stroma with estrogen receptor positive cells. Conclusions Intra hepatic cyst-adenoma is a rare condition and often a definitive diagnosis needs total resection of the tumor.  Normal 18F-FDG SUV of PET-CT is one of the characteristics of this benign tumor

411

Abstracts

P167 Normal 18F-FDG PET-CT in Intra-hepatic biliary cyst-adenoma is a characteristic of a resectable tumor - a case story

P168 HEPATICPORTAL OCCLUSION,RESECTABILITY,POSTOPERATIVE LIVER FUNCTION Abstracts
Peter K. Kupcsulik, Attila Zsirka, Peter Pajor, Ibolyka Dudas, Oszkar Hahn Semmelweis University, Budapest, Hungary

Objectives  Portal occlusion results in growth of postoperative functional liver remnant (FLR).Concomittant chemotherapy or liver cirrhosis may interfere with volume expansion.Factors influencing regenaration and liver function were investigated   Method  1110 patients  underwent  liver resection at 1st Dept. of Surgery of Semmelweis University between 2001-12. 161 from them were unsuitable for primary extended resection because of small FLR .  To achieve appropriate FLR transhepatic portal vein embolisation (PVE) was applied in 64 cases, operative portal vein ligation (PVL) in 87 cases respectively. In PVL group 32 pts received additional hepatic arterial port implatation. (HAP). Resectability and tumor progression was assessed. ICG excretion was measured in 46 PVE pts before and after PVE, and before resection and on 1st,3rd and 7th postoperative day.   Results Tumor progression  after PVO was less frequent  in chemotherapy treated than in untreated group. (26/75=35% vs. 24/54=44%) PVL+ HAP group showed the best result. (5/32=16%) Growth of FLR  was lower after chemotherapy.Regeneration of cirrhotic liver lags behind of normal but might be promoted by HAE. ICG excretion and laboratory parameters worsened after PVO. Normal values were achieved  at 6-8 weeks.Liver resection resulted in the same tendency. Normalization occured at 7th postoperative day. Cirrhotic patients showed better liver function compared to preoperative values. 120 patients underwent   liver resection.Tumor removal was impeded by   insufficient regeneration (4pts), metastases  (11 pts),  tumor progression (26pts).   Conclusions Preoperative portal occlusion results in marked liver regeneration,permitting extended hepatic resection if adequate FLR was achieved. Regenerated  parenchyma in cirrhotic liver results in stabil postoperative hepatic function.   n HCC      CLM-M   CLM-S   CCC   Other     Resection PVE             64     16             26        11          7        4         42(65,6%) PVL             65     14             19        18          9        5         49(75,3%) PVL+HAP     32       6             14          5         4        3          29(90,6%)  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
412

E-AHPBA

Ricardo Robles, Asunción López Conesa, Roberto Brusadin, Israel Abellan, Pascual Parrilla Virgen de la Arrixaca University Hospital, Murcia, Spain

Objectives We present a new and original method for achieving functional liver volume (FLV) hypertrophy through liver surgery in two-stage liver resection: after right portal vein ligation, we occlude the intrahepatic collateral pathways positioning a tourniquet at the parenchyma section in preparation for major liver resection in the second intervention. Method We performed a two-stage liver resection in 22 patients using the following innovative surgical technique: after right portal vein ligation, we positioned a tourniquet in the parenchyma section line (through the extra-Glissonian hepatic hilum). In 7 cases the tourniquet was positioned in the falciform ligament to achieve hypertrophy in segments II-III and in 15 cases in the Cantlie line after resecting  the left hepatic lobe tumours. In the second operation a right trisectorectomy was performed in 7 cases (3 of these involved resections of the inferior vena cava and goretex grafting) and in 15 cases right hepatectomy was performed. Results On the 7th postoperative day, the baseline volumes of the left lobe increased from a mean of 410 ml (27% FLV) to 700 ml (38% FLV), with an increase of 290 ml (Increase of 71% in the FLV). The second operation was 11 days later (range 8-21 days). The parenchyma division time was 30 min. The  blood losses were 200 ml and 5 patients (23%) required a transfusion. Morbidity was 62% (14 patients), with biliary fistula (8 cases) being the most common complication. Two patients died (9%) due to sepsis with perihepatic collections, progressive cholestasis and multi-organ failure. Conclusions Our innovative technique using right portal vein ligation and the application of a tourniquet at the line of the parenchyma section is a simple and efficient method in both interventions. The first intervention is able to achieve sufficient hypertrophy paving the way for the second operation 7 days later.

413

Abstracts

P169 Right portal vein ligation and liver parenchyma tourniquet: an innovative technique for early liver regeneration in two-stage liver resections

Abstracts

Richard Young1, Michael Drodz1, Wanda McDonald2, Abdul Hakeem1, Amit Nair1, Giles Toogood1, Peter Lodge1, Raj Prasad1 1 Department of Transplant and HPB Surgery, St James’s University Hospital, Leeds, UK, 2Clinical Physiology Department, Leeds General Infirmary, Leeds, UK Objectives Cardio-pulmonary exercise testing (CPET) is used to predict peri-operative risk for a range of surgical procedures. Hepatic resections are being increasingly undertaken, often in high risk patients. Methods to predict operative risk and inform treatment decisions are needed. The utility of CPET in this setting was explored at our centre. Method Retrospective review of a prospective database of patients referred for CPET prior to hepatic resection at St. James’s University Hospital, Leeds, UK. Staging assessment compromised MRI scan of the liver and CT and/or PET scanning for extra-hepatic disease. Patients were referred for CPET based on their operative risk as assessed by the treating surgeon. Standardised CPET protocols were utilised. A cohort of patients proceeding to resection without CPET was used for comparisons. Peri-operative mortality and morbidity were the primary outcomes of interest and CPET parameters were correlated with treatment decisions and outcomes.   Results CPET patients (n=68) were older (65  vs. 73, P<0.001) and more required major resection (54.3% vs. 73.47%, P=0.013). Adoption of proposed referral criteria would increase the CPET referrals (20.12% of resections vs. 65.68%, P<0.001). 17 patients (25.00%) did not proceed to resection after referral, due to disease progression (9, 13.24%) or high risk CPET (8, 15.00%). Resected patients had higher VO2 at AT than non-resected patients (11.02 vs. 9.96 mL O2 kg-1 min-1, P=0.048), although CPET parameters were unable to predict operative outcomes. Morbidity and mortality were equivalent (Morbidity CPET 20.40% vs. No CPET 17.30%, mortality 4.08% vs. 1.38%, P>0.05). Conclusions Older patients undergoing major hepatectomy who pass CPET assessment had similar peri-operative morbidity and mortality as lower risk non-tested patients. Adoption of strict referral criteria will significantly increase referrals for CPET testing and better understanding of the predictive utility in resectional HPB surgery and the cost-benefit implications are necessary.

P170 Utility of Cardiopulmonary Exercise Testing (CPET) prior to hepatic resection

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
414

E-AHPBA

Matthanja Bieze, Heinz-Joseph Klumpen, Joanne Verheij, Ulrich Beuers, Saffire Phoa, Thomas van Gulik, Roel Bennink Academic Medical Center Amsterdam, Amsterdam, The Netherlands

Objectives Diagnosis of hepatocellular carcinoma (HCC) primarily involves imaging. The aim of this study was to assess the advantage of 18F-fluorocholine (18F-FCH) PET for detection of HCC and evaluation of extent of disease.   Method Thirty patients, median age 63 (range 18 – 84 years) with HCC>1cm were included between 2009 and July 2011, follow-up closed February 2013. Fifteen minutes after IV injection of 18F-FCH a whole-body PET and low dose CT imaging was performed. All patients underwent PET/CT-baseline, 7 underwent PET/CT-posttreatment, and 2 patients underwent a third PET/CT after 3-6 months follow-up. Standard of reference was imaging (MR, CT, or ultrasound) if histopathology was not obtained. The standardized uptake value (SUV) of the lesion and surrounding tissue were assessed, and SUV-ratios calculated. 18F-FCH PET scan was considered positive if the SUV-ratio exceeded 1.10. Results  Standard work-up revealed 54 hepatic HCC in 30 patients. In 48/54 lesions 18F-FCH PET was positive (SUV-ratio 1.95 ± 0.65; sensitivity 0.89, specificity 1.0). PET/CT showed uptake in 18 extrahepatic lesions and no uptake in 3 target lesions, all lesions were confirmed with additional investigation (sensitivity and specificity 1.0). In 17/30 patients additional lesions were found on PET/CT imaging, with implications for treatment in 15 patients. Post-treatment PET/CT showed identical results as post-treatment imaging, 1 exception with Sorafenib use and advanced disease showing decrease in SUVratio on follow-up PET/CT imaging.   Conclusions  This study shows additional value of 18F-FCH PET/CT for assessment of extrahepatic disease in patients with HCC. The 18F-FCH PET/CT has no additional value for primary diagnosis of hepatic HCC, however the 18F-FCH PET/CT has implications for staging, management and treatment evaluation because of accurate assessment of extrahepatic disease.  

415

Abstracts

P171 PET/CT using 18F-fluoromethylcholine to detect hepatocellular carcinoma and assess extent of the disease.

P172 Laparoscopic Liver Resection for Hepatocellular Adenoma : a 34 cases series. Abstracts

Nicola de’ Angelis, Riccardo Memeo, Chady Salloum, Gerard Pascal, Philippe Compagnon, Daniel Cherqui, Alexis Laurent, Daniel Azoulay Hepato-Biliary and Liver Transplant Unit, Henri Mondor Hospital, Creteil, France Objectives Hepatocellular Adenoma (HA) has a potential for malignant change or spontaneous hemorrhage. Surgical resection is the recommended treatment. The study aimed to investigate the safety and efficacy of laparoscopy in the HA surgery. Method We reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA between January 2000 and January 2013. Resection was performed for lesions measuring more than 50 mm or for an uncertain diagnosis. Post-operative course (< 2 months) was analyzed Results A total of 34 patients (33 females; mean age 35.7 years) underwent elective laparoscopic resection for a single HA. A major hepatectomy was done in 9 patients. The other anatomical resections were 9 left-lateralsectionectomies and 2 bi-segmentectomies. Wedge resections were done in the remaining 14 patients (41%). The mean size on the specimen was 67 mm (range 35-180). The median hospital stay was 6.2 days (range 2-27). A conversion in laparotomy was needed in 3 patients. There was no need of transfusion. The mean operative time was 199 min (range 90-390). The mortality was nil. Only one complication (3%) occurred. Conclusions Laparoscopic surgery of HA is a safe procedure that can be considered as the gold standard for the treatment of this benign tumor

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
416

E-AHPBA

P173 Risk factors for bleeding in hepatocellular adenoma.

Objectives Hepatocellular adenoma (HCA) is a benign hepatic lesion known with sometimes severe bleeding complications, but the risk for bleeding is still ill defined. We aimed to assess risk factors for bleeding in patients diagnosed with HCA and during follow-up. Method Patients with HCA were prospectively included from January2008 until July2012. Case characteristics were noted including body-mass-index (BMI) and oral contraceptive use. All patients underwent dynamic MR and/or CT imaging at presentation and during follow-up. Lesion characteristics on (follow-up) imaging were noted, and bleeding was graded as intratumoral (Grade I), intrahepatic (Grade II), and extrahepatic (Grade III). Standard of reference for diagnosis was histopathology, or dynamic MR and/or CT imaging. Results In 45 patients included (median 39 years; female/male 44:1), a total of 195 lesions were evaluated (median size 24mm (10-250mm)). Bleeding was seen in 29/45 patients and in 42 (22%) lesions. Patients with BMI>25 showed increased risk for Grade II&III bleeding (12/31 and 1/11; P=0.010). Lesions >35mm showed 36/64 bleeding, lesions <35mm 7/172 (P<0.001). Exophytic lesions showed 16/24 bleeding, intrahepatic 9/82, and subcapsular 17/89 (P<0.001). Lesions in segment 2-3 showed 11/32 bleeding, lesions in the right liver 31/163 (P=0.049). Lesions with peripheral or central arteries were likely to show bleeding (10/13; P<0.001). Conclusions Risk factors for bleeding of HCA include size >35mm, BMI (>25), presence of lesional arteries, location in the left liver, and exophytic growth.

417

Abstracts

Matthanja Bieze, Saffire Phoa, Joanne Verheij, Krijn van Lienden, Thomas van Gulik Academic Medical Center Amsterdam, Amsterdam, The Netherlands

Abstracts

Oszkár Hahn1, Ibolyka Dudás2, Tamás Györke3, Éva Török1, Stephan Bennemann1, Anna Bozó1, Gábor Gyömörei1, László Harsányi1, Péter K. Kupcsulik1 1 1st Department of Surgery, Semmelweis University, Budapest, Hungary, 2Department of Diagnostic Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary, 3Department of Nuclear Medicine, Semmelweis University, Budapest, Hungary

P174 ALPPS (Associated Liver Partition and portal vein Ligation for Staged Hepatectomy) - FASTER AND MORE SIGNIFICANT LIVER HYPERTROPHY

Objectives To define the indication of ALPPS and to evaluate the problems with its use.   Future liver remnant (FLR) hypertrophy after portal vein occlusion techniques is often not enough to provide appropriate liver function. In about 20% of the patients tumor progression may occur in the 4-6 weeks of the hypertrophy. ALPPS may reduce this period and can result in more significant hypertrophy Method Patients with very small FLR, or with very fast tumor progression before surgery were treated with ALPPS. FLR volume -measured with CT volumetry- was considered to be “very small”, if its volume was less than 20% of the whole liver volume. To measure FLR function 99m Mebrofenin SPECT/CT was also performed, both imaging techniques before stage 1 (portal vein ligation-PVL + in situ split of the liver parenchyma) and before the extended liver resection (stage 2). To prevent intraabdominal adhesions antiadhesion membrane was used in all patients. Mortality and morbidity parameters were measured (overall morbidity,liver and kidney failure and bile fistula rates). Results Between July 2012 and February 2013 5 patients (hepatocellular carcinoma: n=1, colorectal metastasis n=3, liposarcoma metastasis n=1) underwent ALPPS. Median FLR volume before stage 1 was 260cm3 (range: 177311 cm3), median FLR function: 21% (range: 20-26%). Median waiting period between the stages was 11 days (range: 10-26 days). After hypertrophy period median FLR volume and FLR function was 505 ml (range: 430566 cm3) and 40% (range: 32-45%).  All patients became resectable. Overall postoperative morbidity was 62%, the ratio of bile fistulas was 60%. Most of the postoperative complications were grade II and III according to Dindo-Clavien classification. Mortality of these patients was 0%. Conclusions ALPPS is a suitable method to increase the rate of respectability. Although the advantage of rapid and more significant FLR hypertrophy is obvious, more precise indication and patient selection is needed because of the high morbidity rates.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
418

E-AHPBA

P175 The addition of Peliosis Hepatis in the differential diagnosis of liver mass

Objectives Peliosis Hepatis is a rare pathological condition characterized by multiple, small cystic blood-filled cavities within parenchymatous organs. It is very uncommon and most of the published cases described the rupture of the lesion with consequent haemoperitoneum. Method This is the case of a 29-year-old woman with recurrent abdominal pain irradiated to the back that persisted after an uneventful laparoscopic cholecystectomy performed in 2006. Contrast-enhanced CT and MRI showed an hepatic nodule with a peripheral enhancing that progressed centripetally with a persistent central hypoattenuation; pooling of contrast medium in the late phase resembled the presence of an hemangioma. Persistent hypoattenuating necrotic areas required differentiation from abscess, hematoma, and other malignancies of the liver. Results Because of the persistent pain, indication for surgery was placed with the presumed diagnosis of segmental Caroli’s disease. Uneventful S7 wedge resection was performed. Histopatological examination showed the presence of cystic blood-filled spaces in the liver parenchyma ranging in size from less than one to several millimetres in diameter. The interface of cavity and parenchyma showed absence of a fibrous wall. No tumour cells were noted. The diagnosis of focal Peliosis Hepatis was established. Conclusions  Peliosis Hepatis should be considered in the differential diagnosis of “difficult” liver mass. Timely recognition and early referral to a liver center are essential for adequate treatment, in consideration of the life threatening complications reported in the literature. Histological examination is mandatory to establish the diagnosis of Peliosis Hepatis.

419

Abstracts

Daniele Crocetti, Andrea Police, Andrea Palmieri, Simona Di Filippo, Andrea Sagnotta, Andrea Scarinci, Paolo Visca, Maurizio Cosimelli, Gian Luca Grazi Regina Elena National Cancer Institute, Rome, Italy

Abstracts

P176 The value of PET-CT after conventional CT  imaging, when clearing extrahepatic disease in colorectal liver metastases
Anders Christian Larsen1, Pernille Halberg Homann1, Kaare Gotschalck Sunesen1, Rune Vincents Fisker2, Mogens Sall1, Victor Vishwanath Iyer2, Ole Thorlacius-Ussing1 1 Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark, 2Department of Nuclear Medicine, aalborg University Hospital, Aalborg, Denmark

Objectives To assess whether PET / CT adds additional information to the diagnostic investigation of extrahepatic disease in patients with colorectal liver metastases after conventional CT has been performed Method Retrospective chart review clinical data and reevaluation of conventional computer tomograhy (CT) images and positron emission tomography CT (PET-CT).   Results In patients with histopathological proven colorectal liver metastasis and conventional thoracic-abdominal CT without extra hepatic disease, an additional PET-CT found 14 of 49 patients (29%) with extrahepatic disease and six(43%) of these were true positive. It failed to find three of nine (33%) with extrahepatic disease. In 18 patients were conventional thoracic-abdominal CT found extrahepatic disease, an additional PET-CT ruled out extrahepatic disease in four of which two were true positive. On 11 with extrahepatic disease on conventional imaging, an additional PET-CT confirmed no extrahaptic disease in two (18%). Conclusions PET-CT is of greatest value  after a  negative  conventional imaging, but will not  find all lesions, that conventional CT scan ignores

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
420

E-AHPBA

SOUMIL VYAS, CHARLES IMBER, ANAMARIA SCHIPOR, GRANT LEE, DINESH SHARMA, GUISEPPE FUSAI, BRIAN DAVIDSON, MASSIMO MALAGO Royal Free Hospital, London, UK

Objectives  Conventionally, Portal Vein Embolization either independently or as a part of of 2 stage hepatectomy has been used to achieve volume enhancement of the Future Remnant Liver ( FRL ) to expand  the possibility of offering a curative resection to patients with borderline liver volume and/or bilobar liver disease. ALPPS has been described as a procedure of great potential and promise to induce a rapid and marked increase in the volume of the FRL and hence enhance the possibility of performing a R0 resection. We present herewith our experience with this technique. Method  17 patients  underwent an ALPPS procedure. The mean age was 58.7 years (33-78). The disease distribution was as follows : Colorectal Liver Mets = 11, Neuroendocrine liver mets = 2 , Cholangiocarcinoma  = 2 ,HCC=2 . Patients had either bilobar metastatic disease or insufficient FRL volume to permit major liver resection . The mean pre-ALPPS  volume of  FRL was 28.69% ( 17-44% ) . ALPPS was carried out in each of these patients as an alternative to 2 stage hepatectomy or to facilitate liver hypertrophy in the background of underlying liver disease in patients with adequate volume (HCC ). Results All 17 patients underwent an ALPPS procedure combined with resection of disease from left lobe (n= 13) (FRL) or purely to enhance liver volumes. The FRL increment was a mean of 30.9% ( 0.14-57.38% , SD =32.44 , 416 mls - 1161 mls , Mean = 718.9 mls ) .Mean time to FRL increase was 10.92 days ( 7-19 days ). 2 patients with CRC metastases had colorectal resections combined with the ALPPS procedure. Mortality was 1/17 = 5.88%. Significant morbidity requiring interventions was noted in 4/17 patients (23.52%).R0 resection was achieved in 16/17 patients (94.11%). Conclusions ALPPS can be performed with an acceptable morbidity and mortality in patients with borderline disease or those with borderline liver volumes. It can be performed in the same hospital admission and is achieves quicker hypertrophy and with greater efficacy as compared to PVE. Complete clearance of liver disease is possible in quick time within the same hospital admission. This has significant impact on costs as well as may influence survival due to lesser time to initiation of adjuvant chemotherapy where indicated. ALPPS should be offered wherever possible and should be considered as a viable substitute for PVE.

421

Abstracts

P177 Associating liver partition and portal vein ligation for staged hepatectomy (alpps) - single centre experience

P178 Enhanced recovery after liver resection in a newly established hpb surgery Abstracts

Andrea Scarinci, Simona Di Filippo, Andrea Palmieri, Andrea Police, Pasquale Perri, Maria Elena Marcelli, Gian Luca Grazi Regina Elena National Cancer Institute, Rome, Italy, Italy Objectives We reviewed the postoperative management of patients submitted to liver resections (LRs) in anewly established surgical programme devoted to HBP surgery, focusing on the aspects related to Enhanced Recovery After Surgery(ERAS). This multimodal strategy couldimprove the restoration of functional capacity after LR. Method 105 consecutive patients from Jun 2010 to Feb 2012 were enrolled in thisretrospective study. There were 63 (60%) males. Cirrhosis was present in 25 (23.8%). 22 (21%) patients received major hepatectomy. Over time, wedeveloped a system whichincluded the early removal/omission ofthe nasogastric tube and abdominal drains, early mobilization and earlier postoperative feeding. Primary outcomes were the parameters which defined the functional recovery of the patients after the surgical procedure. Results In 57 (54.3%) patients the NG tube was avoided. In 23 (21.9%) surgical drains were not placed. As a total, 18 (17.1%) had no drain nor NGT. In these 18 pts, we achieved a shorter time of IV liquid infusion (1.2±.8vs 2.3±1.6 days, p<0.05), a shorter period of bowel movement recovery (3.6±1.1 vs 5.2±2.3 days, p<0.05), a shorter time for returning to normal diet intake (2.3±0.9 vs 3.7±1.7 days, p<0.05) and a shorter post-operative stay (4.3±1.5 vs 9,1±5.7 days, p<0.05). Time to mobilization was also shorter (1.2±0.5 vs 1.8±1.5 days) but did not reach significance. Conclusions In a new HBP surgical center established in an already existent cancer center, enhanced recovery after liver resection can be achieved and pursed as the preferred management system for these patients. The improvement in the postoperative recovery indexes is evident for those patients which could be enrolled in the program

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
422

E-AHPBA

P179 Factors related to early recover to a normal diet after liver resection

Objectives Early return to a normal oral intake is a key factor for a better functional recover after major abdominal surgical procedures. We started a new hepatobiliary program with the aim to progressively increase the number of patients able to quickly restart on a normal oral diet after liver resection (LR).   Method In the period Jun 2010 to Feb 2012 70 LRs, out of the total 105 hepatic procedures performed, were uniformly performed within 3½ hours. There were 39 (55.7%) males. Mean age was 62.4 ± 14.5. Diagnosis were metastases in 37 (52.9%), HCCs in 19 (27.1%), benign tumors in 7 (10%) and others in the remaining. Cirrhosis was present in 16 (22.9%). Nine (12.8%) received a major hepatectomy. Staying in ICU was required in 26 (37.1%). An NGT was placed in 25 (35.7%). Analysis was performed to reveal which factors were related to the early return to a regular oral intake. Results Mean operative time was 150.8±37.4 minutes. Patients returned to a normal diet in 2.9±1.2 days. Thirty (42.9%) patients resumed normal diet in < 3 days. Factors related to the return to an early (<3 days) oral intake were: i) diagnosis of benign disease (100% vs 37.7%); ii) age < 64 yrs (60.6% vs 28.6%); iii) not placing NGT after surgery (55.8% vs 24.0%); iv) not having abdominal drains (66.7% vs 34.0%); v) spending fewer nights in ICU (0.23 ± 0.56 vs 0.68 ± 0.82 days); vi) eraly mobilization (1.1±0.4 vs 1.6±1.1 days) (p<0.05 for all the variables) Conclusions Early return to a regular oral intake is possible and safe after liver resections. Barely half of the patients receiving surgery lasting a limited time are able to resume a normal oral intake within 3 days after surgery. Effort should be placed to further increase an early recover after hepatectomy

423

Abstracts

AndreaScarinci,SimonaDiFilippo,AndreaPalmieri,AndreaPolice,AndreaOddi,MariaElenaMarcelli,GianLucaGrazi Regina Elena National Cancer Institute, Rome, Italy, Italy

P180 Repeated resection for recurrent intrahepatic cholangiocarcinoma Abstracts

Alfonso Recordare1, Naim Loxha2, Fazli Shala2, Sadri Berisha2, Hanumsha Kingji3, Besim Kastrati3 1 IV Division of Surgery, Treviso Regional Hospital, Treviso, Italy, 2Division of Surgery, Regional Hospital, Peja/Pec, Serbia, 3Department of anaestesia and Intensive Care, Regional Hospital, Peja/Pec, Serbia Objectives Management of patient with recurrent intrahepatic cholangiocarcinoma (ICC) is not jet standardized. Surgical resection of recurrence is rarely indicated, but better results are reported in comparison with other available therapies. Method A 52 years old woman was admitted in hospital complaining epigastric pain, nausea and weight loss. CT scan and NMR revealed a central mass of the liver involving also the left lobe and compressing the hepatic hylum and the caval vein. The patient underwent enlarged left hepatectomy with ligation of the anterior right portal pedicle, and regional lymphadenectomy. One year after surgery a recurrence on the remnant liver was evident on CT scan and confirmed at NMR. Five nodules were between the segment 7 and the small remnant of couinaud segment 8, and 1 nodule was located on segment 6. Results Repeated resection was considered because of the technical feasibility, the age and the good conditions of the patient. An atypical resection was performed on the remnant liver involving 4 nodules, and a double wedge resection to separately remove 2 nodules. Postoperative course was uneventuful and the patient followed 6 cicles of adjuvant therapy. Seven months after surgery the patient is alive and well without biochemical and radiological signs of recurrence. Conclusions An aggressive surgical approach is warranted in patients with ICC because resection offer the only hope for prolongation of patient survival.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
424

E-AHPBA

Mohammed Abu Hilal, Francesco Di Fabio, Paolo Di Gioia, Rosemary Godeseth, Joseph Davids, Neil Pearce Hepatobiliary and pancreatic surgery, University Hospital Southampton, Southampton, UK Objectives The 2008-Louisville-Statement suggested laparoscopic hemihepatectomy, trisectionectomy, and resection of segments 7,8,4a to be referred to as major hepatectomy. The complexity of the latter is mainly related to the laparoscopic approach. We critically re-analyzed the Louisville Statement investigating differences in outcomes between laparoscopic resection of segments 7,8,4a and “traditional” major liver resections (hemihepatectomy, tri-sectionectomy).   Method We reviewed a prospectively collected single-centre database of 361 patients undergoing pure laparoscopic liver resections between 2003 and 2012 in a tertiary University referral hospital. A total of 148 consecutive patients who underwent laparoscopic major hepatectomy were selected (male/female: 78/70; median age 65, range 23-84 years). The group was divided into two sub-categories: laparoscopic “size-based” major hepatectomy (LSMH), including hemi-hepatectomy and tri-sectionectomy, and laparoscopic “location-based” major hepatectomy (LLMH), including resection of difficult posterior segments 7,8,4a. LSMH and LLMH subgroups were compared with respect of demographics, intraoperative variables and postoperative outcome. Results LSMH was performed in 113 patients(76%) and LLMH in 35(24%). Indication for surgery was benign disease in 22% and malignant in 78%. Operation time was a median of 330min for LSMH and 210min for LLMH (p<0.0001). Blood loss was a median of 550ml for LSMH and 335ml for LLMH (p=0.048). Conversion rate was 9% for LSMH and 3% for LLMH (p=0.460). Twenty-nine patients (26%) developed postoperative complications after LSMH and 7(20%) after LLMH (p=0.495). Mortality was 1.8% after LSMH and 2.9% after LLMH (p=0.558). Hospital stay was a median of 5 days after LSMH and 4.5 days after LLMH (p=0.329). Conclusions Our data confirms that LLMH is a complex procedure correctly classified as laparoscopic major hepatectomy. Although intra-operative variables were significantly in favour of LLMH, the post-operative outcome of LSMH and LLMH were similar. The creation of two sub-categories (LSMH and LLMH) seems appropriate to more precisely reflect the operative differences.

425

Abstracts

P181 Classification of laparoscopic major hepatectomies: location and size of resection matter

Abstracts

P182 Rationale for early CT surveillance; surgery can improve survival in patients with early (<6 months) recurrences following liver resection for colorectal liver metastases (CRLM)
Alan White, Samir Pathak, Rajiv Dave, Zaed Hamady, Ernest Hidalgo, Raj Prasad, JPA Lodge, Giles Toogood HPB and Transplant Department, St. James’s University Hospital, Leeds, UK

Objectives The majority of recurrence following colorectal liver metastases (CLRM) resection occurs within the first year. However, the optimal frequency of computerised tomography (CT) surveillance is controversial.  The study objective was to rationalise our current surveillance programme in patients treated in the ‘modern era’ of radiological diagnosis and surgical techniques.   Method  We investigated patients with disease recurrence following first liver resection for CRLM between January 2007 and January 2012 and 490 patients were included. CT scans were performed at 3, 6, 12, 18 and 24-months postoperatively, and yearly thereafter. In patients that recurred, we aimed to investigate the patterns of recurrence and compare survival differences in patients managed surgically and palliatively. Statistical analyses were performed using chi-square and log-rank test.   Results 52% (n=254/490) of patients had recurrence, with 62% (n=158/254) within the first year; 10% (n=26/254), 22% (n=56/254), and 30% (n=76/254) recurring at 3, 6 and 12 months respectively. 35% had liver recurrence only. There was a significant increase in survival following curative recurrent surgery vs palliative chemotherapy in those patients with recurrence between 3-6 months (14.9 vs 38.7 months, p=0.002, 19/56 treated surgically) and at 6-12 months (22.1 vs 32.9 months, p=0.0005, 30/76 treated surgically). In recurrences within 3 months, only 4/26 were treated surgically, improving median survival, which did not achieve significance (13.9 vs 33.5 months, p=0.286).   Conclusions The 3-month scan only identified a few resectable patients, however, in this small cohort, resection did infer a survival benefit. The 3-month scan may benefit some patients, but the debate continues as to whether the 3-month scan is justified and can significantly impact on clinical outcome.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
426

E-AHPBA

Amit Nair1,2, Jenifer Barrie1,2, Eldo Verghese1, Abdul Hakeem2, Richard Young2, Giles Toogood2, Peter Lodge2, Raj Prasad2 1 Leeds Institute of Molecular Medicine, Leeds, Yorkshire, UK, 2Department of HPB/Transplant Surgery, St James’ University Hospital, Leeds, Yorkshire, UK

Objectives Patients with colorectal liver metastases (CRLM) detected around the time of diagnosis of primary colorectal cancer (synchronous metastases; SLM) are thought to have differing tumour biology compared to those who present with metachronous liver metastases (MLM), with potential implications on outcomes. We sought to confirm the presence of any such effects.   Method A retrospective analysis was performed of patients undergoing resection for CRLM from 1990-2010 whose primaries were also resected at our centre. Thirty patients were excluded for incomplete data. Patient, clinical and tumour characteristics including recurrence and survival data were compared between SLM and MLM groups. Continuous variables were analysed using the Mann-Whitney U test whereas categorical factors were assessed using Χ2 statistics. Disease-free (DFS) and overall survivals (OS) were evaluated using Cox Regression analysis.   Results A total of 210 patients met eligibility criteria. Following exclusions, 180 patients (109 SLM, 71 MLM) were analysed. SLM were more associated with T4 primaries (p=0.04), primary site in colon (P=0.03) and multiple (p= 0.001) or bilobar (p=0.009) liver metastases. MLM presented with larger diameter liver deposits (p=0.001). Median time to MLM diagnosis was 512 days. SLM and MLM groups proved comparable for patient age, chemotherapy, primary tumour size, nodal status, resection margins (colon and liver), and site-specific recurrences. DFS and OS did not differ significantly between groups. Ten-year OS rates for SLM and MLM were 45% and 35% respectively.   Conclusions Though tumour characteristics differ between SLM and MLM groups, our data highlights that there is ultimately no significant difference in outcomes between them. However more intensive surveillance protocols may be warranted for earlier detection of MLM.  

427

Abstracts

P183 Patterns of Tumour Biology and their Impact on the Outcomes of Resection for Synchronous and Metachronous Colorectal Liver Metastases

Abstracts

P184 Outcome of treatment for simultaneous hepatic and pulmonary colorectal metastasis

Alan White, Samir Pathak, Rajiv Dave, Zaed Hamady, Ernest Hidalgo, Raj Prasad, JPA Lodge, Giles Toogood HPB and Transplant, St James’s University Hospital, Leeds, UK Objectives Aggressive multi-modal therapies are increasingly utilised to increase survival in patients with metastatic colorectal cancer. Few studies with low numbers report outcome after resection of both hepatic and pulmonary metastases. The outcomes of patients in our institution with simultaneous hepatic and pulmonary metastases following surgery for colorectal cancer were examined.   Method  Between January 2001 and January 2012, 1020 patients had liver resection for first presentation of colorectal liver metastasis, out of which 61 patients presented with simultaneous hepatic and pulmonary metastases, of which some were synchronous (colon, liver and lung). All patients underwent hepatic resection and had operable pulmonary disease at presentation. Baseline demographics, operative details and survival figures were identified from a prospectively maintained database. We aimed to retrospectively analyse the outcome of this group of patients presenting with aggressive disease. Survival analysis was performed using KaplanMeier analysis (log rank for survival).   Results Thirty-three patients (54%) had synchronous disease, and had a median survival of 57 (35-79) months, versus 95 (65-124) months for patients with metacronous disease (p=0.059). Following liver surgery, 24 patients (39%, 8/28 metachronous and 16/33 synchronous) did not proceed to pulmonary surgery due to disease progression. Median survival for these unresectable patients was 79 months versus 114 months in those that underwent subsequent lung surgery (p=0.01). Following pulmonary intervention, 24 patients (76%) developed recurrence, mostly in the lung (n=17/24, 71%). Of those recurrences, 15/24 patients (63%) underwent subsequent resections, which did not lead to a significant improvement in survival (p=0.932).   Conclusions Simultaneous hepatic and pulmonary extra-colonic disease is aggressive, and a number of patients may not progress to a thoracic intervention due to disease progression during the surgical convalescence period. However, in selected patients aggressive surgical management of metastases can significantly improve overall survival, up to an extent.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
428

E-AHPBA

Satvinder Mudan1, Athanasios Petrou2, Kyriakos Neofytou2, Alexandros Giakoustidis4, Ferdinando Cananzi1, Christos Petrides2, Andreas Andreou3, Charalambos Andreou1, Evangelos Felekuras5 1 Department of Academic Surgery, Royal Marsden Hospital, London, UK, 2Nicosia Surgical Department/Div. HPB, Nicosia General Hospital, Nicosia, Cyprus, 3Department of General Surgery, Campus Benjamin Franklin, CharitéUniversitätsmedizin, Berlin, Germany, 4London Clinic, London, UK, 5First Department of Surgery, University of Athens Medical School, Laikon Teaching Hospital., Athens, Greece Objectives  Hemorrhage is undoubtedly one of the main factors of morbidity and mortality in liver resections. Vascular occlusion techniques are effective to control intraoperative bleeding, but they cause liver damage due to ischemia. We analyze our experience with using a combined technique for hepatic parenchymal transection without liver inflow occlusion.   Method We retrospective analyzed  313 consecutive patients  who underwent liver resection to 4 Hepato-PancreatoBiliary (HPB) units in a period of six years. Hepatic parenchymal transection was carried out using a combined technique of saline-linked radiofrequency precoagulation and ultrasonic aspiration without liver inflow occlusion. We evaluated overall amount of intraoperative  blood  loss(IBL), amount of  blood loss during parenchyma transection (PTBL), parenchymal transection time (PTT), the amount of PRBCs transfused and the postoperative morbidity and 30-day mortality.   Results During the study period  114 minor and 199 major hepatic resections were performed. The mean IBL was 376.77ml( SD 334.92ml) and the blood transfusion rate was 10.54%. Excluding patients who underwent re-do liver resection or concomitant procedures the mean IBL was reduced to 335.52mL (SD 289.67 ml) and the blood transfusion rate to 6.69%. The median PTBL and PTT were 221.63ml (SD 223.66, range 40-2100 and 61 minutes (range 12 – 150 min ) respectively. There were two post-operative deaths (0.63%). Complications occurred in 84 patients (26.83%) and most complications were minor.   Conclusions Combined technique of saline-link radiofrequency ablation and ultrasonic aspiration appears to be comparable to other techniques and should be considered as an alternative. At the same time, this combined technique eliminates the need for liver inflow occlusion during parenchyma transaction  

429

Abstracts

P185 Combined ultrasonic aspiration and saline-linked radiofrequency precoagulation. A step toward bloodless liver resection without the need of liver inflow occlusion.

Abstracts

P186 The Liver first approach to synchronous colorectal liver metastasis: outcomes in a tertiary centre
Chris Liossis, Senthil Kumar, Mustafa Mourad, Chris Coldham, Bridget Gunson, Ravi Marudanayagam, John Isaac, Darius Mirza, Paolo Muiesan, Robert Sutcliffe, Simon bramhall Queen Elizabeth hospital, Birmingham, UK

Objectives To evaluate the surgical and oncological outcomes of a liver first approach (LF) as compared to the conventional bowel first approach (BF) in patients with synchronous liver metastasis from colorectal cancer. Method A retrospective review of a database of 640 liver resections for metastatic colorectal cancer, in a tertiary centre, (2007-2012), identified 39 patients who had LF. The surgical and oncological outcomes were compared with a cohort of 39 patients who had BF. The LF cohort was matched for age, location of primary, stage of the primary (T and N stage) and the extent of liver resection, to a BF cohort, by an investigator blinded to the outcomes. Many patients in the LF group, with rectal cancer, had their liver surgery in the time hiatus after completion of long course chemoradiotherapy. Results There were no significant differences in the median age (62 years); gender distribution; proportion of rectal cancers (BF-77%; LF-79%); major hepatectomy rates (77% in each) or proportion receiving adjuvant treatment between the two groups.  The median follow up was 18 months(LF) and 23 months(BF). There were no significant differences between the groups in 30 day mortality(0 LF and 1 BF); median overall survival (LF29months; BF-31months; p=0.78log-rank); median recurrence free survival(LF-26.2months; BF-28.4months; p=0.83log-rank); 1, 2 and 3 year survival(LF-83%, 65% and 40% versus BF-81%, 72% and 42% respectively) or overall morbidity (33% LF; 38% BF). Conclusions For synchronous colorectal liver metastasis, the liver first approach is safe and has comparable perioperative and medium term oncological outcomes to the conventional bowel first approach.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
430

E-AHPBA

George Tzimas1, Dimitrios Moraitis1, Kostandinos Stratoulias2, Haralambos Kostas1, Helias Athanasiades2 1 Hygeia Hospital, Athens, Greece, 2Mitera Hospital, Athens, Greece Objectives A fast-track clinical pathway is designed to streamline patient care, to minimize length of stay (LOS) and potentially maximize cost effectiveness. Nevertheless, data on clinical pathways after liver surgery are sparse. Herein, we describe the experience from a comprehensive care package for patients undergoing hepatectomy or liver - related procedures. Method Data from patients undergoing  liver related procedures in our Unit, and who were managed by a fast track clinical pathway over the last 4 years were collected. The clinical pathway included intensive preoperative patient and family training, specific anesthetic and intraoperative techniques, early withdraw of intravenous fluid therapy as well as early dietary intake. All procedures were performed by a senior hepatobiliary surgeon. For further analysis, operations were categorized as simple hepatectomies, or complex procedures i.e. procedures that included biliary reconstructions or complex synchronous intraabdominal procedures. Results During the last 4 years we performed 100 liver - related procedures, 76 hepatectomies and 24 complex  cases. The majority of procedures were performed for metastases.  10% of cases were performed for HCC. R0 resection was achieved in 92% of patients. Mortality rate was 1%. Complication rate was 11% in the simple hepatectomy group and 41% in the complexgroup .  Average LOS was 6.8 days (± 4.6). In the simple hepatectomy group the average length of stay was 5.7 ± 1.8 days, while in the complex procedure group the average length of stay was 10.6 ± 7.9 days (p=0.006). Conclusions Despite the retrospective nature of the study, our data suggest that in patients undergoing hepatectomy, implementation of a fast track clinical pathway leads to shorter length of stay. Prospective validation of these data is warranted.

431

Abstracts

P187 Implementation of a fast track protocol reduces length of stay following hepatectomy or liver related surgery.

Abstracts

P188 Liver resection for hepatic metastases from colorectal adenocarcinoma: a single center experience.
George Tzimas1, Haralambos Kostas1, Dimitrios Moraitis1, Adamandia Nikolaidi2, Helias Athanasiades2 1 Hygeia Hospital, Athens, Greece, 2Mitera Hospital, Athens, Greece Objectives Growing experience in liver resections combined with novel therapies for metastatic adenocarcinoma of colorectal origin, have rendered more patients to be considered eligible for hepatectomy. We herein describe our experience for liver metastases of colorectal origin in a single Institution. Method Data from a prospectively collected database were included for analysis, for patients treated in our Institution between 2008 and 2012.  Results 40 patients were treated and 42 hepatectomies were performed.  The majority of patients (92%) received 1st line chemotherapy with irinotecan or oxaliplatin-based regimen. 23 patients had synchronous liver metastases. 17 patients had major hepatectomies. In addition to hepatectomy 15 patients underwent intraoperative  RFA and 12 patients MWA. 10 patients presented postoperative complications, none required reoperation. There were no perioperative deaths. R0 resection was achieved in 37 patients. Disease recurred in the liver in 15 patients while extrahepatic recurrence was noted in 21 patients. Presently, 34 patients are alive while 16 patients have no evidence of disease on regular follow up. Conclusions In accordance with the literature, our Institutional experience confirms the efficacy of the multidisciplinary and multimodality approach for these patients.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
432

E-AHPBA

Andrea Monaco, Pavlos Lykoudis, Dimitris Zosimas, Charles Imber, Giuseppe Fusai, Massimo Malago Royal Free Hospital, London, UK Objectives The aim of our case - control study is to compare the upper midline incision with the conventional  L inverted incision for  major liver resections. Method all patients undergoing major liver resection between February 2010 and December 2012 were retrospectively studied. Eleven patients had an upper midline incision (case group-A) and  22 patients had a conventional L inverted incision (control group-B). The two groups were well matched with respect to demographic parameters (age, gender, BMI, operation); 3 patients in group A underwent ALPPS procedure. Operative time, blood transfusions, post operative recovery pain score, type of analgesia, length of hospital stay were  analysed. Postoperative mortality and morbidity were also reported (wound complications, overall complications). Statistical analysis carried out using Fisher’s exact test and Pearson Chi-Square test. Results The mean operative time for group A was significantly longer than group B (418.18 vs 371.67 minutes), while the blood transfusion requirement was 0.27 U for group A and 1.27 U for group B. A shorter hospital stay was noted in group A (10 vs 20.19 days). Two patients (18.2%) experienced wound complications in group A, versus 7 (31.8%) patients in group B. Five patients in group A and 11 patients pain group B experienced pain scored > 0. We recorded two deaths in group B and none in group A. No statistical significant difference was found. Conclusions  The upper midline incision for major liver resections, is technically feasible, safe and overall well tolerated. It can achieve the same standards of liver resection and surgical field accessibility, as the conventional L inverted incision, while enhancing postoperative recovery and reducing  postoperative complications. 

433

Abstracts

P189 Upper midline incision: a feasible, safe and effective access for major liver resections

P190 Outcome of laparoscopic trisectionectomy. A single centre experience. Abstracts

Daniel PIETRASZ1, Daren SUBAR1,2, Brice GAYET1 1 Institut Mutualiste Montsouris, Paris, France, 2Royal Blackburn Hospital, Blackburn, Lancashire, UK Objectives Laparoscopic minor and major liver hepatectomies are widely practised with published outcomes comparable to open hepatectomies. However, laparoscopic trisectionectomies is still in its infancy. The aim of this study was to describe indications and outcomes of the largest series of laparoscopic trisectionectomy of the liver. Method This is a retrospective single institution study of patients from a prospective database who had trisectionectomy of the liver between November 2000 and September 2012. The indications for surgery, intraoperative and postoperative course along with complications, resection margin status, morbidity and mortality are reported. Results 22 patients (16 males, 6 females) had laparoscopic trisectionectomy for malignant disease including 50% for colorectal metastases. The mean age was 61.6 years (range 26.3-85 years). 12 patients had preoperative portal vein embolization or ligation. 17 patients had right trisectionectomy and 5 left. There were 3 conversions to laparotomy. The mean operating time was 376.7 minutes (range 180-540 mins) and mean blood loss was 626.1 mls (range 100-1500 mls). 35% of patients had a major complication. Ninety-day mortality rate was 9.1%. Mean ITU and hospital stay was 1.4 days and 20.4 days respectively. Resection margin status was R0 in 86.3%. Conclusions Laparoscopic trisectionectomy is technically demanding. It demonstrates postoperative outcomes and resection margin status comparable to what is published for open trisectionectomy. In a select group of patients and in experienced laparosocopic hands this type of surgery is feasible, with acceptable and comparable outcomes to open surgery.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
434

E-AHPBA

Marina Sekacheva, Lilia Polishchuk, Nikolay Bagmet, Arcady Bedzhanyan, Tatyana Skipenko, Oleg Skipenko Petrovsky National Reasearch Centre of Surgery, Moscow, Russia Objectives Panitumumab has been shown to increase progression free and overall survival in patients with metastatic colorectal cancer. Preoperative panitumumab is not commonly used yet in patients undergoing liver resection. Our purpose was to evaluate whether panitumumab is effective and safe in   potentially resectable colorectal liver metastases (CRLM).   Method Consecutive analysis of data from 11 patients (K-RAS wild) receiving oxaliplatin-based chemotherapy and panitumumab as converse preoperative treatment for potentially resectable CRLM. At the moment of presentation R0-liver resection was not possible due to technical reasons (small remnant volume, liver vessel involvement and etc.). We compared objective response rate, surgical characteristics, skin toxicity profile, and perioperative course of “panitumumab group” with data from patients undergoing liver resection in our hospital in the same period (n=40).   Results After median 6courses of treatment, metastatic liver tumors were reduced considerably (PR) in 9 pts(82%). R0liver resection was done in 5 patients(45%). Two pts underwent the first stage of planned two-stage surgery (1–portal vein embolization and 1–portal vein ligation). Despite of impressive response according to RECIST resection was not done in two cases due to persistent vessel involvement. Two patients progressed on chemotherapy(18%).  There was no correlation between skin toxicity and response. Median blood loss was 200ml compared to 300ml in control. Preoperative administration of panitumumab was associated with significantly higher risk of postoperative infection complication compared to controls (57.1%vs.17.3%;p<0.05).   Conclusions  To the best of our knowledge (Pubmed, ASCO database search)  this is the first report about using panitumumab as a conversion therapy in potentially resectable colorectal liver metastases. The panitumumab and oxaliplatinbased regimen may increase the resection rate of liver metastases. It is reasonable to focus on postoperative infection complications.  

435

Abstracts

P191 Panitumumab and oxaliplatin-based chemotherapy as a “conversion treatment” in potentially resectable colorectal liver metastases

Abstracts

Faruch Mahmadov, Karimhon Kurbonov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan Objectives Seeking opportunities to improve results of surgical treatment of complicated liver echinococcosis. Method This study is based on analysis of 359 clinical observations of patients who were receiving treatment for complicated liver echinococcosis based on surgical department of City Clinical Emergency Hospital in Dushanbe from 2004 to 2012. Analysis of the nature of complications suggests that festering cyst of the liver is one of the most frequent complications of echinococcosis, which amounted to 72.4%. Calcification of echinococcosis cysts of the liver was observed in 279 (77.7%) patients, a breakthrough in the free abdominal cavity - in 3 (0.8%), and a breakthrough in the bile duct with cholangitis clinic were seen in 53 (14.7%). Results “Ideal echinococcectomy “ was executed by us in 23 (6.4%) cases, and echinococcectomy with a preliminary autopsy cyst - in 226 (62.9%) cases. Atypical resection of the liver is made by us in 24 (6.7%) patients with peripheral location of a small cyst. Subtotal pericistektomy was performed in 57 (15.9%), and total pericistektomy - in 47 (13.1%) patients. Open echinococcectomy we performed in 85 (23.7%) patients. Combined surgery was performed in 56 (15.6%) patients. In 54 patients (15.0%) there were performed hepatectomy with a parasitic cyst. Mortality in these patients was 1.7%. 8 (14.3%) patients had complications. Conclusions Thus, the surgical approach in the complicated echinococcosis of the liver should be build on the location, size and number of cysts, their relationship with the biliary structures, as well as the degree of destruction of the parenchyma.

P192 Surgical treatment of complicated hepatic echinococcosis

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
436

E-AHPBA

STOJAN POTRC, ARPAD IVANECZ, BOJAN ILJEVEC, MATJAZ HORVAT, TOMAZ JAGRIC, BOJAN KREBS UMC MARIBOR, MARIBOR, Slovenia

Objectives  The aim of the study was to present the multimodal treatment and to reveal the results of such treatment of patients with colorectal liver metastases (CRLM). Method  A retrospective review of a prospectively maintained database was conducted. Between January 1st 2000 and December  31st 2011 377 procedures for CRLM were performed in 281 patients (178 male, 103 female; mean age 63,3 years; range 27-85 years). Data from the follow-up were obtained by our own outpatient follow-up and by the National cancer register of Slovenia and by outpatient follow-up. Results Of altogether 377 surgical procedures for CRLM 324 were resections and 53 were radio frequent ablations. 145 patients had unilobar and 136 bilobar metastases. The average number and diameter of metastases was 2,9 and 4,3cm per patient. 131 patients received preoperative chemotherapy. Portal embolization or ligature of the right portal branch was done in 26 patients. Simultaneous liver and large bowel resection was done in 41 patients. 72 patients had reintervention for recurrence in the liver. The overall morbidity was 25,5%, and 30 days mortality 1,9%. The 5 year survival for R0 resected patients was 38,3% (median: 43 months). Conclusions Liver resection are safe (morbidity: 25,5%; 30-day mortality: 1,9%) and concerning expected survival offer the most effective treatment for patients with colorectal cancer liver metastases. The multidisciplinary approach and multimodal treatment has a paramount role in treatment strategy of these patients.

437

Abstracts

P193 THE RESULTS OF SURGICAL TREATMENT OF RESECTABLE COLORECTAL LIVER METASTASES IN UMC MARIBOR

Abstracts

P194 Pringle maneuvre increases the risk for anastomotic dehiscence after colon resection in rats
Boris Jansen-Winkeln, Evangelos Tagkaloa, Hauke Lang, Stefan Heinrich University Hospital, Mainz, Germany

Objectives Synchronous liver metastases are found in 30-50% of patients with colorectal cancer. While some groups report excellent results from synchronous resections of the primary tumor and liver metastases, others report an increased incidence of anastomotic dehiscence after synchronous resections. We therefore evaluated the influence of the Pringle`s maneuver on the healing of colonic anastomoses in rats.   Method Male wistar rats underwent a median laparotomy under inhalation anaesthsia   with isoflurane. After a sigmoid resection with end-to-end anastomosis by single stitches (6-0 prolene) rats received either a 25 minutes Pringle´s maneuver (PM) using a mirovascular clamp or were kept under anesthesia for the same period. The anastomotic burst pressure was measured ex-vivo on days 3, 6 and 9 after surgery. Also, the tissue hydroxyproline content was assessed as second parameter for anastomotic healing. Results were compared using the Mann-Whitney U-test, p<0.05 was considered significant. Results All animals lost body weight within the first 3 days of the experiment (95.7% vs. 85.1%, p=0.043). While rats gained weight after sigmoid resection, body weight further decreased after sigmoid resection+PM on days 6 (118.7% vs. 93.9%, p=0.002) and 9 (111.8% vs. 97.2%, p=0.093). The anastomotic burst pressure was lower after sigmoid resection+PM on day 3 (104mmHg vs 196mmHg, p=0.017) and day 6 (204mmHg vs 211mmHg, p=0.67).  While only one rat died after sigmoid resection, 7 rats (30%) died after sigmoid resection+PM (p=0.042). Conclusions The combination of a 25 minutes PM and sigmoid resection increases the morbidity and mortality in rats. Therefore, simultaneous resections of liver and colon should be avoided, if a Pringle` maneuvre is necessary for liver resection.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
438

E-AHPBA

P195 Two-Stage Hepatectomy for Colorectal Liver Metastases in Elderly Adults

Objectives Two-stage hepatectomy is a surgical strategy developed for cases of bilobar multinodular liver metastases. It is performed when all lesions cannot be removed in a single procedure due to a too small remnant liver volume. The main principle in this approach is a consecutive resection in two stages. It relies on the liver regeneration between the two interventions, allowing the second hepatectomy to be performed with a lower risk of complications. Method Subjects are patients with colorectal cancer liver metastases who undergo surgery at the surgical departments of Military Medical Academy – Plovdiv and Eurohospital – Plovdiv, Bulgaria. For the reviewed period 2009 – 2012 - 76 radical resections (45 metachronous and 31 synchronous). 48 of them are patients over 65 years of age. We performed 7 two-stage hepatectomies, 4 of these patients are over 65. Results Blood loss and blood transfusion were without significant differences between these two age groups. Complications rate into the postoperative period and the length of hospital stay were comparable, despite the higher level of comorbidity in the group over 65. Conclusions  Two-stage liver resections are a good opportunity for a small group of patients with bilobar metastases. The indications for this procedure can be successfully applied for elderly patients with appropriate perioperative management concerning the high co-morbidity in this group.

439

Abstracts

Nikolay Belev1, Mihail Slavchev1, Petar Rusev2, Krasimira Staneva2, Ivan Petleshkov2, Neno Shopov2, Boiko Atanasov2 1 Military Medical Academy, Plovdiv, Bulgaria, 2Eurohospital, Plovdiv, Bulgaria

Abstracts

P196 Chromogranin A level as prognostic factor in patients with hepatocellular carcinoma
Marco Massani, Andrea Bunicci, Cesare Ruffolo, Luca Fabris, Luca Bonariol, Nicolo’ Bassai IV Dpt of Suregery, Treviso, Italy

Objectives Background: high serum levels of chromogranin A (CgA) have been demostrated not only in patients with neuroendocrine tumors but also in patients with others tumors at advanced stages (prostate carcinoma above all). Between 43-83% of hepatocellular carcinomas (HCC) show high serum levels of CgA. However the use of CgA as diagnostic marker for HCC is limited by the low specificity. More interesting is the possible role as prognostic indicator. Aim: we have searched an association between serum levels of CgA and prognosis in a group of patients with HCC. Method Materials and methods: serum CgA levels has been valuated in 99 consecutive patients  October 2009 and October 2011. The study was conducted retrospectively; of the initial 99 patients 51 had a diagnosis of HCC, previous or simultaneus with the dosage of CgA. The counfonding factors we have considered were concomitant use of proton pump inhibitors (PPI), hearth failure, kidney failure, active tumors in other locations, chronic atrophic gastritis type A, autoimmune disease active or under steroid treatment; 21 patients were taken PPI. The out-come variables  were: survival, tumor stage, histological grade, presence/absence of angioinvasion and presence/absence of portal thrombosis. Results Results: no statistically significant result was obtained (p < 0,05). Any considerations can be made only on the basis of the values of the means and medians. At the cut-off of 60 ng/ml overall survival was greater in patients with CgA > 60 ng/ml (24,7 months) than in patients with CgA < 60 ng/ml (17,9 months), Δ = 6,8 months (p = 0,123). Higher CgA median values seem observable in case of HCC multifocal, better differentiated, without angioinvasion and without portal thrombosis. Conclusions Conclusions: even with the limitations in statistical significance already stressed

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
440

E-AHPBA

441

Abstracts

seems that moderately elevated CgA values, although more often associated with multifocal HCC, show a weak positive correlation with the other variables considered, especially with the overall survival. Further studies are necessary to better define the association CgA-prognosis in HCC patients.

P197 Anterior approach and Hanging maneuvre for large tumor of the right liver Abstracts
Stefan Heinrich, Hauke Lang University Hospital, Mainz, Germany

Objectives The standard approach for the resection of tumors in the right hemiliver is the transsection along the Cantile`s line after full mobilization of the right liver with transsection of the small hepatic veins and preparation of the right hepatic vein. However, extensive mobilization is suspected to increase tumor dissemination and may be very difficult in large tumors with contact to the vena cava. Method After ligation of the right portal vein and hepatic artery, the right hepatic vein is prepared and a cotton band is advanced between the middle and right hepatic veins down to the liver hilum (hanging maneuvre). The resection is then carried out along the Cantile`s line with the cotton band protecting the vena cava. After transsection of the right hepatic vein the liver is mobilized from the retroperitoneum. Results In this video we present the technique of the anterior approach for right hemihepatectomy using the hanging maneuvre. The resection was carried out uneventfully with complete tumor resection. Final histology revealed an pT2 N0 L0 V0 G2 R0 cancer. Conclusions The hanging maneuvre and anterior approach are very useful for liver resections if the right lobe of the liver should not be mobilized in order to avoid tumor dissemination.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
442

E-AHPBA

Objectives Patients with tumor should be discussed in Multidisciplinary Team (MDT), however not all best type of treatments could be offered from all centers. Aim of this study was to evaluate results of a group of patients with hepatocellular carcinoma (HCC) managed from a MDT with support of external network (EN). Method Retrospective analysis of type of treatments, survival, recurrence and treatments of recurrences of a group of 109 patients with HCC in different BCLC stage managed by a MDT from September 2004 to June 2012. Experts in HCC from different hospitals formed external network; EN confirmed treatments proposed and supported the MDT performing some type of treatments: liver transplatation (OLT), percutaneous treatment (PT) (percutaneous ethanol injection or radiofrequency ablation), Yttrium-90 micropsheres. Results Primary treatments were one OLT, 20 resections, 34 PT, 24 TACE and 9 Sorafenib. Treatment was radical in 52 cases. Six PT or TACE were bridge to OLT. Disease recurrence occurred in 25 patients after median time of 9 months (range 3-61). Treatments of recurrence or residual disease were one resection, 10 PT, 14 TACE, 7 Sorafenib, one Yttrium-90. Seventy (55%) treatments were performed in MDT center and 57 (45%) in EN centers. After a median follow up of 26 months (range 7-84) 24 patients were still free from disease. Overall survival was 37 months (range 31-43). Conclusions Multidisciplinary Teams are necessary to discuss best treatment options for patients with tumors. In our center MDT with an external network of experts could offered different type of treatment for patients with HCC and could reach good results in term of overall survival.

443

Abstracts

Tommaso Campagnaro1, Francesco Di Lecce1, Paolo Costa2, Giorgio Perboni2, Carla Rabbi3, Rita Cengarle3, Alberto Tagliani4, Coriolano Pulica1 1 General Surgery, Mantova, Italy, 2Infectious Disease, Mantova, Italy, 3Oncology, Mantova, Italy, 4Radiology, Mantova, Italy

P198 Multidisciplinary team for hepatocellular carcinoma, is it enough?

Abstracts

Valerio Lucidi1, Carine Boven1, Nathalia Ciobanu1, Georgios Katsanos1, Brigitte Ickx2, Raphaël Maréchal3, Pieter Demetter5, Maria Antonietta Bali4, Vincent Donckier1 1 Department of abdominal Surgery, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium, 2 Department of Anesthesiology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium, 3Department of Gastroenterology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium, 4Department of Radiology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium, 5Department of Pathology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium

P199 Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) compared to percutaneous and surgical portal vein embolization for resection of initially unresectable colorectal liver metastases

Objectives Surgical resection is the only potentially curative treatment in patients with colorectal liver metastasis (CRLM). Insufficient remnant liver volume (RLV) is a major cause of unresectability. Portal vein embolization, either percutaneously (PPVE) or surgically (SPVE) may promote RLV hypertrophy and allow further resection. Recently a two-step technique Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has been described, providing a potentially advantage of reducing time between the 2 interventions. We report our initial experience with ALPPS and compare with classical approaches, including liver resection after PPVE and 2-step hepatectomy associated with SPVE. Method Thirty patients with CRLM considered as initially unresectable due to insufficient RLV were analyzed, consisting in 5 patients with ALPPS, 9 with PPVE and 16 with SPVE. Evolution of liver volumes and clinical outcomes were reviewed and compared in the 3 groups. Results The 3 groups were comparable in terms of demographic characteristics as well as for number and size of metastases. All patients had neoadjuvant chemotherapy. Evolution of RLV/Total Liver Volume and RLV/body weight ratios before PVE and second step hepatectomy were respectively of 29% to 40% and 0.6% to 0.9% in ALPPS, 33% to 45% and 0.5% to 0.85% in PPVE; 28% to 35.5% and 0.6% to 0.7% in SPVE. Time between PVE and hepatectomy was 11 days for ALPPS, 48 days for PPVE and 45 days for SPVE. Major morbidity was observed in 40%, 37.5% and 31% of patients respectively. Conclusions Our initial experience shows that ALPPS is a feasible approach to allow resection in patients with initially unresectable CRLM due to insufficient FRL. ALPPS induced similar FLR hypertrophy as compared with classical PPVE or SPVE but in a shorter period. Further results are needed to evaluate the potential oncological benefit of this technique.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
444

E-AHPBA

P200 Surgical resection for non-colorectal, non-neuroendocrine liver metastases Abstracts
Ana Beatriz Almeida, Renato Bessa-de-Melo, Luis Graça, José Costa-Maia Department of Surgery, Centro Hospitalar S. João, Porto, Portugal

Objectives  The aim of this study was to analyze outcomes after partial hepatectomy for NCRNNE metastases and to identify prognostic factors associated with survival.   Method  Patient demographics, tumor characteristics, treatment and outcome of 30 consecutive patients who underwent hepatic resection of NCRNNE metastases from January 1995 to June 2012 were analyzed. The Kaplan-Meier method was used to analyze survival and Cox regression models were applied to identify independent prognostic variables.   Results NCRNNE tumors included stomach (n=13),breast (n=5),pancreas (n=3),choroid melanoma (n=2),unknown primary (n=1) and others (n=6).Liver metastases were solitary in 56.7% and unilateral in 76.7% of cases.A R0 resection was achieved in 86.7% of the patients.Thirty-day mortality rate was 3.3%, morbidity rate was 23.3%. After a median follow-up of 16months,tumor recurred in 72.4% of the patients.Following hepatectomy,median overall (OS) and disease-free survival (DFS) were 24 and 12months,respectively.In univariate analysis,longer disease-free interval (p=0.04) was associated with better OS.Histology of the primary tumor (p=0.003) and extrahepatic disease (p=0.04) were associated with worse DFS.Cox regression analysis identified histology as an independent prognostic factor considering DFS (p=0.013).   Conclusions In selected patients, resection of NCRNNE liver metastases appears associated with prolonged survival and can be performed in a specialized environment with acceptable morbidity and mortality. Patients with a longer disease-free interval, specific primary location and histology and absence of extrahepatic disease seem to benefit the most from this approach.  

445

P201 Surgical resection for synchronous liver metastases from colorectal cancer Abstracts

Ana Beatriz Almeida, Renato Bessa-de-Melo, Marinho Almeida, Ana Fareleiro, Luis Graça, José Costa-Maia Department of Surgery, Centro Hospitalar S. João, Porto, Portugal Objectives Despite increasing research, the optimal surgical approach for patients with synchronous hepatic metastases from colorectal cancer (smCRC) remains an unfinished issue. The aim of this study was to analyze the outcome of patients operated on smCRC and to compare a staged to a simultaneous surgical approach. Method Patients with smCRC operated between January 2006 and December 2012 were identified from a prospective database and retrospectively reviewed. Patient, tumor and operative parameters were analyzed for their influence on overall (OS) and disease-free survival (DFS). Results 61 patients underwent surgery for smCRC,either synchronous (n=15,24.6%) or staged resection (n=46,75.4%). Staged resections were more frequently performed in patients with multiple (p=0.01),bilateral (p=0.06) or initially unresectable lesions (p=0.01).Thirty-day mortality rate was 0% and overall cumulative morbidity rate was 23.0%,with no significant differences between groups.Median overall and disease-free survival were 39.6 and 15.6months,respectively,with no significant differences between groups.After a median follow-up of 23.2 months, 41 patients (67.2%) developed recurrence:25 in the primary-first,12 in the synchronous and 4 in the liver-first group (p=NS).T status of the primary, number and maximum diameter of metastases and extrahepatic disease were independent prognostic factors for DFS. Conclusions The three surgical strategies considering smCRC seem to be associated with a similar outcome. A staged approach appears more appropriate in patients with multiple, bilateral and initially unresectable lesions.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
446

E-AHPBA

P202 Lessons learned from surgical management of liver hydatidosis Abstracts
Vitor Costa Simões, Pedro Nuno Brandão, Donzília Sousa Silva, José Davide HEBIPA - Hepatobiliopancreatic Unit, Hospital de Santo António, Porto, Portugal

Objectives Cystic hydatid disease is a zoonotic infection of humans caused by Echinococcus granulosus. Liver is the organ most frequently affected and present work focuses on liver hydatid cysts. Surgery remains the most powerful weapon on disease eradication. The authors describe their personal experience with surgical management of hepatic hydatidosis (HH). Method A total of 105 patients operated on between 1989 and 2012 were reviewed retrospectively. The patients’ demographic data, location, number and size of cysts, type of surgical procedure performed, morbidity, recurrences and duration of hospital stay were recorded. Surgery comprised conservative methods [CM] (marsupialization and partial cystopericystectomy) and radical methods [RM] (total pericystectomy and liver resection). Scolicidal agent employed was iodopovidone. Comparison of categorical data was performed with Fisher’s exact test (p < 0.05 was considered statistically significant). Results There were 74 female and 31 male patients with mean age of 50 years. They came mostly from endemic areas of the country and in 32 patients diagnosis was incidental. Surgical management was conservative in 34 and radical in 71 patients. All patients underwent albendazole therapy 2 months before and 1 month after surgery. Intraoperative rupture of the cyst in 13 patients (2 relapsed). No relation between cyst rupture and recurrence was found. Long term follow up showed 5 recurrences, 4 submitted to CM (p = 0.013). Morbidity showed no significant difference between two surgical methods. There was no mortality. Conclusions Surgery combined with medical treatment is effective in eradicating HH and preventing local recurrence. RM seems to be the treatment of choice, but effective surgical management does not necessarily mean radical excision since there are poor candidates to surgery or dangerous disease locations in which CM are the remaining option.

447

Abstracts

Faruch Makhmadov, Karimhon Kurbanov, Atoboi Sobirov, Alisher Gulahmadov Tajik State Medical University named after Abu Ali ibn Sina, Dushanbe, Tajikistan

P203 Application videolaparoscopy patients liver echinococcosis

Objectives To study the validity and effectiveness of the new technology in patients with hepatic echinococcosis. Method Videolaparoscopic procedures were performed 69 (27.9%) patients with echinococcosis, which are presented in the form of three technologies: echinococcectomy laparoscopic (17 patients), endovideoskopiya residual cavity in conventional Echinococcectomy liver (49) and chresfistulnaya endovideoskopiya residual cavity of the liver (3). Aparazitarnost operations provided by using multiple tissue, isolating the cyst from the abdominal cavity. Antiparasitic treatment was carried out 0.5% alcoholic solution of fenbendazole. Chresfistulnaya endovideoskopiya residual cavity of the liver used in the treatment of 3 patients with a functioning drainage of residual cavity of the liver at different times after surgical treatment of liver hydatidosis. Results In 6 cases of 23 laparoscopic procedures undertaken the transition to laparotomy due to a total intrahepatic location of the cyst (4), and the localization of the reach segment (2). Through careful examination of the inner wall of the cyst removed in 7 cases unnoticed during the open phase of the operation the germinal elements of the parasite. In 4 cases intraoperatively identified and closed tsistobiliarnye small fistula. Chresfistulnaya endovideoskopiya residual cavity in 1 patient revealed tsistobiliarny fistula that was coagulated. Chresfistulnaya endovideoskopiya residual cavity of the liver used in 3 patients with a functioning drainage of residual cavity. Conclusions Application of new technology in the form videolaparoscopy, diagnosis and treatment of liver endovideoskopii residual cavity in the intra - and postoperative periods have improved outcomes in patients with hepatic echinococcosis.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
448

E-AHPBA

Fernando Rotellar, Manuel Belver, Alberto Benito, Pablo Martí-Cruchaga, Gabriel Zozaya, Jorge Arredondo, Patricia Mtnez-Ortega, Fernando Pardo HPB and Liver Trasplant Unit. Clinica Universidad de Navarra. University of Navarra., Pamplona, Spain Objectives To present a method to resect lesions located in the depth of the hepatic parenchyma.

Method In this video whe present the case of a metastasis of colorectal cancer located in the depth of the segment VII. Results Under ultrasound contol, we identify the lesion and mark the limits of the resection. During the transection the ultrasound will guide and monitor the resection, so that it is safley performed. Conclusions Ultrasonography sould be used in any liver resection, but it is extremely helpful to guide the resection of lesions located in the depth of the parenchyma.

449

Abstracts

P204 Laparoscopic limited resection of lesions located in the depth of the hepatic parenchyma.  Role of ultrasonography to guide resection.

P205 Liver abscesses by Chromobacterium violaceum: a case report of a rare disease Abstracts

Adriana Orsetti1, Paola Markiewicz1, Marina Epstein1, Orlando Conceição2, Giuseppe D’Ippolito2, Marcelo Ribeiro Jr1 1 Department of Surgery, University of Santo Amaro, São Paulo/ SP, Brazil, 2São Luiz Hospital, São Paulo/ SP, Brazil Objectives This paper reports a rare case of C. violaceum in Brazil that caused multiple abscesses in the liver and was treated with antibiotic therapy and interventional radiology.    Method A 51-year-old man was admitted to the emergency unit of São Luiz Hospital in São Paulo, on Jan 3, 2010, with a fever. He complained of intense sweating for 20 days and weight loss over one month. In addition, hemoglobin concentration dropped from 11.0 to 8.8 g/dL in 15 days for no apparent reason. The patient reported visiting the city of Porto Trombetas, Pará, Brazil, for one week in Nov 2009, and while there cut his foot on a wooden stick. The lesion healed after 2-3 days without complications. Results Tomography of the abdomen and pelvis (Figure 1) performed at admission showed a liver of abnormal size with multiloculated fluid collections in the right lobe that measured up to 10.0 cm in wide axial diameter and a simple cyst in the left lobe  that measured about 2.0 cm. After that, an ultrasound-guided puncture using a 16-gauge needle resulted in collection of about 80 mL of a purulent material from the lower right lobe. The patient was treated with ciprofloxacin and metronidazole; after three days when C. violaceum was diagnosed, treatment was changed to only ciprofloxacin IV 400 mg. Conclusions In conclusion, liver abscesses caused by C. violaceum are associated with high mortality (60 to 80% of cases) if not adequately treated. Therefore, early diagnosis to isolate the agent through adequate drainage by minimally invasive methods, followed by appropriate antibiotic therapy, seems to be the best initial management against this rare infection. This study showed an approach of diagnostic interventional radiology coupled with longterm antibiotic therapy for efficacious management of liver abscesses caused by C. violaceum.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
450

E-AHPBA

Nikolai Popravko1,2, Alexander Vlakhov1,2 1 Crimea State Medical University, Simferopol, Crimea, Ukraine, 2City Clinical Hospital № 6, Simferopol, Crimea, Ukraine

Objectives The objectives of work was improvement of treatment results of non-parasitic cysts of liver by mini-invasive operations under ultrasound control.   Method All patients were carried out all clinical investigations, color Doppler ultrasound mapping mode, CT-imaging. We determined type, localization, cysts size, complications, co-placement with vascular and tubular structures. Punctures were carried out three-compound needles 16-19 G of own design (the Patent of Ukraine No. 12064) under local anesthesia. Aspiration fluid was delivered for laboratory researches. After incomplete aspiration of liquid into a cyst cavity we introduced 96% ethyl alcohol (1/3 to residual liquid) with exposition to 10 minutes that allowed to reach aseptic destruction of internal cyst envelope, denaturation of proteins.    Results The analysis of  treatment 26 patients aged from 21 to 77 years was carried out. Men:women = 6:20. Solitary cysts were found in 23 patients (the right lobe 13 patients, left lobe - 10), polycystic affection - 3. Diameter varied from 4 to 19 cm, capacity of aspirate - from 30 to 2500 ml. In 9 cases the puncture was single made. In 9 cases 2-4 punctures were required. In 8 patients the cavity of cysts was drained. Our method was effective at 88,5% patients. “Difficult” cysts for differentiation and diagnosis were the indication for opened surgery at 3 patients. Conclusions Puncture-draining aspiration with destruction of epithelium and sclerosing under ultrasound control is a radical method of treatment in 85,5% of cases. This method allows to minimize number of open operations, to reduce terms of disability, to avoid characteristic complications for traditional operations, to provide good quality of life of patients.

451

Abstracts

P206 Results of mini-invasive surgical treatment of non-parasitic cysts of liver under ultrasound control.

P207 Feasibility of laparoscopic liver resection for bilobar liver disease. Abstracts

Kursat Serin, Hani Al-Saati, Paolo Di Gioia, Neil Pearce, Mohammad Abu Hilal Southampton University Hospitals NHS Trust Southapton General Hospital General Surgery HPB Department, Southampton, UK Objectives Bilobar disease can represent a challenge in laparoscopic liver resection. Duplicated additional ports, change of patients position is thought to be needed making the laparoscopic approach less appealing .  We aimed to evaluate efficacy and feasibility of laparoscopic liver resection in bilobar disease . Method Twenty eight patients underwent bilobar liver resection.  Eighteen had CRLM, 6 NET metastasis, 3 HCC and 1 liver cysts. On the right; nine right hemihepatectomies, 4 post-sectionectomies, 8 segment6 and 1 segment7 resections , 4 metastesectomies from segment8 and 2 from segment5, resection were performed. On the left 7 left lateral sectionectomies, one left hemihepatectomy, 20 metastesectomies from segment3, 4 and 2 were performed. Median lesion number was 3, median diameter of largest lesion is 25 mm.  All procedures were performed with patients in supine position with operative table tilted to the right or left as needed. Results Median operation time was 220 minutes (180-480). Median blood loss was 400 mL (30-2100), with one patient needing intraopertative blood transfusion. Twenty-three of 28 patients tumors were removed with negative surgical margins (median3.5 mm, ranges1-35), remaining four had multiple NET metastasis (cytoreductive surgery was performed) and one had multiple CRLM.  No major complications or mortality related to liver resection was seen in any patient. Postoperative median high dependency unit stay was 1 day (ranges 0-2) and median hospital stay was 4 days (ranges 1-12). Conclusions  Laparoscopic bilobar liver resections are feasible and safe with no need for additional ports or change in patient’s position. Minimal tilt to the operative table and one additional contro lateral may help in the accomplishment of a safe resection. Special attention should be paid to resection margins.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
452

E-AHPBA

P208 Management of segment 7 lesions, is the laparoscopic approach justified? Abstracts
Kursat Serin, Hani Al Saati, Paolo Di Gioia, Neil Pearce, Mohammad Abu Hilal Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, UK

Objectives  The feasibility and safety of  laparoscopic management of lesions involving segment7 is often questioned, based on presumed technical difficulties, risk of proximity to vasculature and finally the potential difficulty in performing a parenchymal sparing resection. We here assess the options, feasibility and outcomes of laparoscopic management of such lesions. Method We reviewed characteristics and outcomes of 16 patients who had tumors involving segment 7. Five lesions (median diameter 10 mm , range 5-15)  were managed with  segment 7 resection and 11(median diameter 25 mm, range 15-50) were treated with a right posterior sectionectomy (RPS). Results  Median operation time and blood loss were  240min, 200mls and 210 min,500mls  for segment 7, RPS respectively. Median Pringle’s time was higher in R post-sectionectomy (35 vs 30 min ) . R0 resection was achieved in all resections except for one NET metastasis.  All procedures were completed laparoscopically.  One patient with lung fibrosis and poor pulmonary function, had a R posterior sectionectomy died on day 30 of chest infection . Conclusions  Laparoscopic resections for lesions involving seg 7 are difficult and complex. A segmental resection can be performed for small lesions limited to seg 7 or a RPS  is performed for larger lesion or those involving segment 6.   Our experience confirms the feasibility and safety of the technique but also recognize the technical challenge  and the significant potential operative risks based on long operative time, need for Pringles maneuver and associated morbidity and mortality.

453

Abstracts

P209 Laparoscopic hepatectomy versus open surgery: comparative study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data
Elias Elias, walid faraj, Zeina Nasser, Deborah Mukherji, Sally Tamraz, Abdallah Abou Niaj, Mohamad Eloubeidy, Ali Haydar, Faek Jamali, Ali Shamseddine, Mohamed Khalife American University of Beirut, Beirut, Lebanon

Objectives  The aim of this study is to compare the outcome between laparotomy or open hepatectomy (OH) versus the use of laparoscopic hepatectomy (LH), in terms of intraoperative findings, post operative complications and morbidity outcome.   Method  Using the National Surgical Quality Improvement Program (NSQIP) participant using files for 2008 and 2009, we tracked the subjects who underwent hepatectomy. We divided the data into a comparative manner between laparoscopic versus open hepatectomy.   Results  3425 underwent open, while 505 had laparoscopic surgery. Preoperative analysis revealed no difference between the two groups. The disparity attests when comparing intraoperative and postoperative findings. Operative time p<0.01 and intraoperative transfusion p <0.01 were variables that highlighted the difference between techniques. Postoperative complications such as surgical infection and pneumonia were statistically prognostic variables .The estimated probability of morbidity was found lower in patient with LH versus OH (LH 0.07±0.0025 versus OH 0.3±0.002; P value < 0.001). The estimated probability of mortality was found lower in patient with LH versus OH (LH 0.0095±0.001 versus OH 0.025±0.0007; P value < 0.001).   Conclusions  laparoscopic hepatectomy is essential for patient’s quality of life and helps decrease the co-morbidities seen with the practice of open procedures. It should be the modality of treatment for all subjects undergoing hepatectomy, given that it significantly improves and reduces patient’s intra and post operative morbidities and outcomes.  

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
454

E-AHPBA

P210 Repeated Liver Resections for Colorectal Cancer Metastases Abstracts
Vladimir Visokai, Miroslav Levy, Ludmila Lipska, Marek Mracek, Jaromir Simsa Thomayer Hospital, Charles University, Prague, Czech Republic

Objectives Liver metastases will appear approximately in 40% of patients with colorectal carcinoma, synchronous metastases are present at time of diagnosis of CRC in 15% -20 % of patients, in another 20% of patients will develop metachronous metastases (most often within 2 years) after resection of primary CRC. Surgery remains the only option for curative radical treatment for liver metastases for colorectal carcinoma. Method The aim of the study was to evaluate results of repeated liver resections for colorectal cancer metastases. There were 150 patiens operand for CRLM between 1996 and 2012 at our surgery. Of these, 24 patients were operated repeatedly,  19 two times, 3 three times, 2 patients four times together 31 repeated operations were performed. Limited resections were prefered ( 15 times, together 39 nonanatomical resections), segmentectomy was performed in 10 cases, bisegmentectomy in 3 cases and right hepatectomy in 3 cases. Results Morbidity was in all patients 25% in group repeatedly operated was 28,6% (p=0,66), mortality 2,6% vers. 0% , mean blood loos was 6632 ml vers. 835 ml (p=0,14). Median follow up is 3,5 year. Relapse of cancer was in 60 % of all cases, in the group of repeatedly operated in 61% cases. Survival in both groups was simmilar (5-year survival is 40%,) ( p=0,856). Conclusions Our results confirmed that morbidity, mortality, DFI and survival is simmilar in patients who underwent repeated liver resections compared with those with one resection. Indication for repeated liver resection are the same as for first resection. Patient should be well aware of probability of repeated liver resection at the time of first hepatectomy. Liver preserving resection should be prefered. Supported by grants: GAAV IAA500200917, IGA NT13424-4/2012

455

Abstracts

P211 Comparison of simultaneous or delayed liver surgery for synchronous colorectal metastases ¿is there a defined selection criteria?
VICENTE-MANUEL BORREGO-ESTELLA, Irene Molinos-Arruebo, Rafael Fernández-Atuan, Paolo BragagniniRodríguez, Issa Talal-El Abur, Gabriel Inaraja-Pérez, Sef Saudí-Moro, Jose-Luis Moya-Andía, Alejandro Serrablo Hepatopancreatic biliary Surgical Unit. General Surgery Department. Miguel Servet General University Hospital., ZARAGOZA, Spain

Objectives The optimal surgical strategy for patients with synchronous colorectal liver metastases (SCLM) is still unclear. The aim of this study was to compare simultaneous colorectal and hepatic resection with a delayed strategy focused on short- and long-term outcomes in a single-tertiary-institution cohort as well as in highly comparable case-matched subgroups. Method Prospective-data from 250 patients (292 liver resections) for synchronous-metachronous CLM from 2004 were reviewed retrospectively, managed by a multidisciplinary team in a tertiary hospital. Data were coded: sociodemographics, CRC-primary, diagnosis-surgical-treatment LM, extrahepatic-disease (EHD) and followup. Categorical variables were compared by χ2-test, continuous by independent-samples-T-test. Overall (OS)/ disease-free-survival (DFS) at 1-3-5 years after first hepatectomy were calculated by Kaplan-Meier method and compared by logrank test. Separate analyses were performed for the total-study-population and for the casematched-subgroups. Univariate and multivariate-Cox-regression-model analysis were performed to identify factors significantly related short- (90 days-postoperative-morbimortality-Clavien-Dindo classification) and long-term outcomes (OS-DFS) in both subgroups. SPSS™ 15.0, p-value <0.05. Results Of 125 patients undergoing hepatectomy for synchronous-CLMs, 21 (16.8%) had a simultaneous colorectal resection and 95 (75.9%) had delayed hepatectomy. Mortality rate following hepatectomy was similar in twogroups (0 versus 2.6% respectively; p=0.157); cumulative morbidity was similar in both groups but complicationsgrades 3-4 Clavien-Dindo-classification was significantly higher in the simultaneous group (25.4% versus 11% in the delayed group; p=0.025). Five-year OS and DFS rates were 47 and 28% respectively in the simultaneous group, compared with 50.3 and 26.1% in the delayed group (overall survival: p=0.871; progression-free survival: p=0.225). A simultaneous strategy was not an independent predictor of survival neither recurrence. Conclusions Results of this study suggest that simultaneous colorectal-liver resection can be safely performed at the same time in selected-patients with synchronous metastases with similar short- and long-term results that delayed strategy. The benefit of addition major liver-resections and rectal cancer by this approach is still controversial. Further studies are needed.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
456

E-AHPBA

YUSUF TANRIKULU1, KEMAL KISMET1, ZAFER SABUNCUOGLU3, OZGUR DANDIN2, SIBEL KILICOGLU4, ERDINC DEVRIM1, MEHMET ALI AKKUS1 1 Ankara Training and Research Hospital, Ankara, Turkey, 2BURSA MILITARY HOSPITAL, Bursa, Turkey, 3SULEYMAN DEMIREL UNIVERSITY, ISPARTA, Turkey, 4Ufuk University Faculty of Medicine, Ankara, Turkey

Objectives Liver ischemia reperfusion injury is important pathologic process leading to bodily systemic effects, liver injury, which results from many causes such as trauma, liver surgery, transplantation. Our study aimed to investigate protective effects of diosmin, a phlebotrophic drug with antioxidant and anti-inflammatory effects, in  liver ischemia reperfusion injury model. Method Forty rats were divided into 4 groups. Sham group, control group (ischemia-reperfusion), preoaperative treatment group (Diosmin- 50 mg/kg), and preoperative treatment group (Diosmin- 50 mg/kg/day for 10 days). İschemia reperfusion model was formed by clamping hepatic pedicle for a 60 minute of ischemia followed by liver reperfusion for another 90 minutes. Following procedures, blood and liver tissue samples were obtained from rats for biochemical and histopathologic evaluation. Results Control and treatment groups showed significant differences in hepatic function tests, plasma and tissue oxidative stress parameters. Samples in control group histopathologically showed morphologic abnormalities specific to ischemia reperfusion. Histomorphologic findings in treatment groups showed similar features with sham group. Conclusions It has been found that both preoperative and intraoperative diosmin treatment decreases cellular damage and protects cells from toxic effects in liver ischemia reperfusion injury. As a conclusion, diosmin may be used as a protective agent against ischemia reperfusion injury in elective and emergent liver surgical operations.

457

Abstracts

P212 The protective effect of diosmin on hepatic ischemia reperfusion injury: an experimental study

Abstracts

P213 Correlation between liver regeneration and operative morbidity after right and right extended hepatectomies
Natalia Ciobanu, Jâd Abi-Khalil, Georgios Katsanos, Maria Antonietta Bali, Raphaël Maréchal, Brigitte Ickx, Vincent Donckier, Valerio Lucidi Erasme University Hospital, Brussels, Belgium

Objectives Surgical resection is usually the only curative treatment of liver tumors. Major liver resection is sometimes necessary but not always feasable due to insufficient remnant liver volume. The objective of this study is to correlate postoperative liver regeneration with biological and clinical outcome after right (RH) and right extended hepatectomy(REH) for malignancies. Method 52 patients undergoing RH/REH for malignant tumor between 2005-2012 in whom complete pre-and postoperative liver imaging was available were reviewed. Operative indication was colorectal liver metastases 23(44,2%), hepatocellular carcinoma 14(26,9%), biliary tumors in 13(25%) and other tumors in 2(3,84%) cases. Preoperative portal vein embolization (PVE) has been performed in 30(57,69%) patients. Liver volumetry has been performed preoperatively and at 1, 3, 6 months after resection. Postoperative morbidity and biological evolution have been prospectively recorded. The evolution of remnant liver volume (RLV) hypertrophy has been analized and compared depending on post-operative Dindo-Clavien morbidity score. Results  Overall morbidity was 61,5%, major complications representing 40,38%. Average preoperative RLV was 596ml or 40,8% of total liver volume (TLV) and 0,86% of body weight. The average TLV at 1, 3 and 6 month postoperatively was of 899ml, 1000ml and 1074ml representing a volumetric hypertrophy rate of 55%, 27% and 14% between each control. At 3 months cirrhotic livers had a 40,7% volume increase vs 79% for non-cirrhotic. Liver hyperthrophy in minor/non-complicated was of 59,26% vs 48,88% in complicated patients after 1month, but no significant difference occured 3months postoperatively.   Conclusions Liver regeneration is mostly obtained at 1 month after major liver resection, no significant hypertrophy occurs after 3rd month. Liver regeneration rate is lower in cirrhotic livers and seems to be more correlated with morbidity after right or right extended hepatectomy in the first month.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
458

E-AHPBA

Christian Philipp Kaudel, Fabian Bartsch, Janine Baumgart, Jens Mittler, Hauke Lang University Clinic Mainz, Department of General, Visceral and Transplantation Surgery, Mainz, Germany

Objectives Intrahepatic cholangiocarcinoma (CCC) often requires major hepatectomy. Postoperative liver volume regeneration alter the liver anatomy dramatically. In case of intrahepatic CCC recurrence 3 D reconstruction of the intrahapatic vessel anatomy and topography of CCC nodules is necessary for resection planning and contributes to identify and preserve areas at risk to prevent devascularisation or venous congestion. Method A diagnostic and planning protocol for repeat hepatectomy using virtual three-dimensional reconstruction of the liver anatomy followed by the simulation of different resections with their particular functional future remnant liver volume (RLV) and corresponding areas at risk for ischemia or venous congestion was established. We report about a patient who underwent a right hemihepatectomy due to intrahepatic CCC and presented with a tumor recurrence in liver seg. IV during follow up.   Results After completing the preoperative planning protocol with final 3 D reconstruction and simulated virtual liver resection a limited resection with respect to the intrahepatic vessel anatomy and their related areas at risk was successfully proceeded.   Conclusions Eventhough repeat hepatectomy even for recurrent intrahepatic CCC can be performed safely. We recommand 3 D virtual resection simulation. As it contributes to improve the surgeon’s idea of the intrahepatic vascular anatomy especially of accessory vessels and results in an increased remnant liver volume through identification of the areas at risk.  

459

Abstracts

P214 Contribution of 3D simulation analysis on resection planning of a repeat hepatectomy due to recurrence of intrahepatic CCC

Luca Aldrighetti1, Giulio Belli2, Luigi Boni3, Umberto Cillo4, Giuseppe Ettorre5, Luciano De Carlis6, Antonio Pinna7, Luciano Casciola8, Fulvio Calise9 1 Ospedale San Raffaele, Milano, Italy, 2Ospedale S.M.Loreto Nuovo, Napoli, Italy, 3A.O.U.Fondazione Macchi, Varese, Italy, 4A.O.U.Università degli Studi, Padova, Italy, 5A.O.San Camillo-Forlanini, Roma, Italy, 6A.O.Niguarda Cà Granda, Milano, Italy, 7Policlinico S.Orsola-Malpighi, Bologna, Italy, 8Ospedale San Matteo degli Infermi, Spoleto, Italy, 9 A.O.Cardarelli, Napoli, Italy

P215 The Italian Experience in Minimally Invasive Surgery of the Liver: A National Survey.

Abstracts

Objectives  To provide an overview about the current spread of the minimally invasive approach for liver resections in Italy. Method Questionnaire about Minimally Invasive Liver Resections (MILR) was sent to all Italian surgical centers (mailing lists of Italian Chapter IHPBA and Italian Society of Surgery). Only MILR were taken into consideration, including totally laparoscopic, hand-assisted, single-port and robotic. Tumour characteristics, technical approaches and the extent of resection were assessed and analysed in details. Intraoperative data about technical devices, vascular control and number of liver resections were recorded. Reasons for conversion to open, perioperative deaths and complications were also recorded. Volume of MILR cases and total liver resections were compared in each center. Results  1497 MILRs from 39 centers (median 27 patients/center, range 1-145, period 1995-2012) were collected. One third of all centers (13/39) had specific hepatobiliary activity (> 500 hepatectomies). 11 Centers performed > 60 MILRs. Correlation between MILR activity and hepatobiliary background wasn’t relevant. Conversion rate was 10.7% (180/1677 patients). Benign and malignant diagnoses were 27.5% and 72.5%; HCC was the most frequent indication. Resections were multiport totally laparoscopic in 92.6%. Left lateral sectionectomy was the most frequent procedure (23.8%). Minor resections were 92.9%. Mortality and morbidity were 0.2% and 22.8%. The weighted mean postoperative length of stay was 5 days. Conclusions In recent years, the minimally invasive approach for liver resections has been significantly widespreading in Italy, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries.

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
460

E-AHPBA

Georgios C. Sotiropoulos, Andreas Paul Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, NRW, Germany

Objectives Intrahepatic cholangiocarcinoma (ICC) remains a rare primary hepatic malignancy. The aim of this study was to explore the long-term survival after surgery for ICC. Method Patients undergoing hepatectomy in curative intent in our Institution and either having a postoperative followup >5 years or died during the follow-up were considered. Demographic, operative and pathological parameters were examined. Statistical analysis included nominal logistic regression, absolute and Kaplan-Meier survival analysis. Results The study encompassed 83 patients with a postoperative follow-up from 76-146 months. Sixteen patients (19%) survived for more than 5-years after the operation, one of them 64 months following an R1-resection. Multifocal tumor (p=0.0214), macrovascular invasion (p=0.0321), lymphatic invasion (p=0.0331), and surgical radicalness/R-status (p=0.008), were predictive of 5-year survival. Kaplan-Meier analysis and absolute survival rates at 5-year were similar (22% and 19%, respectively).   Conclusions 5-year Kaplan-Meier survival estimates are similar to the corresponding absolute survival rates in the case of ICC. Interestingly, rather lymphatic invasion than lymph nodes infiltration had a significant prognostic role in the 5-year survival in our series.

461

Abstracts

P216 Long-term outcome after surgery for intrahepatic cholangiocarcinoma:  A 5-year survival rate based analysis

Abstracts

Sasa Mickovic1, Darko Mirkovic1, Miroslav Mitrovic1, Mihailo Bezmarevic1, Milan Jovanovic1, Ivana Tufegdzic2 1 Clinic for General Surgery, Department for Hepatobiliary and Pancreatic Surgery, Military Medical Academy, Belgrade, Serbia, 2Institute for Pathology and Forensic Medicine, Military Medical Academy, Belgrade, Serbia Objectives  Cavernous liver hemangioma could sometimes have enormous proportions, thus being symptomatic. It is defined as gygantic if greater than 5 cm. Enucleation is considered as desirable method of choice, possible to be performed laparoscopically, but open surgery is neccesary when more liver is affected occupying a greater part of the abdomen. Intraoperative ultrasonography set  resection line, while it is sometimes neccesary to do isolated vascular occlusion to reduce intraoperative blood loss. Method  A female 41-year-old patient presented to the Clinic due to frequent abdominal disorders, bloating, respiratory complications, and subjective feeling of abdomen growing. Hemangioma had been previously clinically and diagnosticly followed up for 3 years. MSCT, MRI and selective angiography confirmed the presence of a giant formation in the liver, the left lobe predominantly, without hepatic veins obstruction, nor thrombosis of the portal vein and the lower vena cava. Results Intraoperatively, a gigant hemangioma (30 x 20 x 20 cm) in the liver segments II, III and IV was found occupying the abdomen part extending to the pelvis. A typical anatomic  resection (left hepatectomy) was performed controled with selective inflow arterial occlusion. Technically, resection was done without significant intraoperative blood loss, with no need for transfusion, and uneventful postoperative course.   Conclusions Conservative treatment and follow-up is the method of choice for asympthomatic hemangiomas, but in case of progressive growth, enormous size and the presence of complications, surgery is the method of choice for its successful removal. Considering the benign origin of the disease, liver resection should be IOUS controlled with minimal blood loss and liver maximally preserved.

P217 Giant liver hemangioma

EUROPEAN-AFRICAN HEPATO PANCREATO BILIARY ASSOCIATION

Congress
462

E-AHPBA

Klaas Govaert1, Maarten Nijkamp1,2, Benjamin Emmink1, Zing Cheung1, Ernst Steller1, Szabolcs Fatrai1, Menno de Bruijn1, Onno Kranenburg1, Inne Borel Rinkes1 1 University Medical Center Utrecht, Utrecht, The Netherlands, 2Diakonessenhuis, Utrecht, The Netherlands

Objectives To assess the contribution of hypoxia and bone marrow-derived cells to aggressive outgrowth of micrometastases following liver surgery.  Method The contribution of hematopoietic cell types was studied in mice lacking specific components of the immune system and in irradiated mice lacking all bone marrow-derived cells. Tumor cells were derived from colorectal cancer patients and from a metastatic tumor cell line. Hypoxia-induced changes in stem cell- and differentiation marker expression, clone-forming potential and metastatic capacity were assessed. The effect of radiofrquency ablation and vascular clamping on cancer stem cell (CSC) characteristics was performed in mice bearing murine colorectal micrometastasis or patient-derived liver metastases, respectively. Results Immune cells and bone marrow-derived cells were not required for aggressive outgrowth of micro-metastases in surgery-treated livers. Rather, hypoxia was sufficient to promote invasion and accelerate metastatic outgrowth. This was associated with a rapid loss of differentiation markers and increased expression of CSC markers and clone-forming capacity. Likewise, metastases residing in ischemia-reperfusion-injured liver lobes acquired CSC characteristics. Despite their renowned general resistance to chemotherapy, clone-forming CSCs were readily killed by the hypoxia-activated pro-drug tirapazamine.  Conclusions Surgery-generated hypoxia in the liver causes rapid de-differentiation of tumor cells into immature CSCs with high clone- and metastasis-forming capacity. The results help explain the phenomenon of aggressive tumor recurrence following liver surgery and offer a potential strategy to kill aggressive CSCs by hypoxia-activated pro-drugs. 

463

Abstracts

P218 Hypoxia following liver surgery imposes an aggressive Cancer Stem Cell phenotype on residual tumor cells

Abstracts

CORREA-SANTILLAN VICTOR-MANUEL1,2, FLORES ALEXANDRA2, TOVAR GERARDO1,2, GONZALEZ OSCAR1,2, ALVAREZ ARNULFO2, ALVAREZ PAOLA2, CASTAÑEDA CLAUDIO2, CERDA CRISTINA1,2, MERAZ LUIS1,2, GONZALEZ JAIME1,2, BISMUTH HENRI3 1 UNIVERSIDAD DE GUADALAJARA, GUADALAJARA, JALISCO, Mexico, 2HOSPITAL CIVIL DE GUADALAJARA “FRAY ANTONIO ALCALDE”, GUADALAJARA, JALISCO, Mexico, 3HENRI BISMUTH HEPATOBILIARYINSTITUTE, VILLEJUIF, France

P219 Giant liver fibrosarcoma, fatal clinical presentation in a young adult female, a case report and literature review.

Objectives  To Present a very rare case of a liver tomour, this is a Giant Liver Fibrosarcoma, presented in a young adult with  acute adbominal pain at the emergency room , a 42 years old female with medical history of a slow and progressive abdominal mass grouth and weigth loss. To review in the medical literature the reports concerning these atypical liver tumours, their presentation, treatment and prognosis.    Method We present a case of  a 42 years old housewife admitted at ER due to acute abdominal pain, nausea, vomiting, mild pallor,  a giant, progressive and slow growth abdominal mass, respiratory distress, weakness, anemia and leukocytosis. Complete CT scan was performed, finding were: giant abdominal mass displacing abdomibal and pelvic structures. Tumor markers, including α-fetoprotein, CEA, CA 19-9 and βHCG, were all within normal limits, liver function test, kidney funtion, chemical panel and coagulogram in normal limits , (CBC) showed  8,4 g/dl hemoglobine and 16.1 leukocytes, neutrophilia and bands. After hemodinamic stabilization, the surgical oncologist te