ELECTRONIC POSTERS (EP01A-EP01E) e LIVER

EP01A - Electronic Poster: 1A - Liver Metastases outcomes of surgical treatment of colorectal liver metastases. EP01A-001 Methods: A retrospective analysis was conducted for INDICATIONS FOR OPEN LEFT consecutive patients undergoing liver resection for colo- LATERAL SECTIONECTOMY IN THE rectal liver metastases from 2000 to 2016. HBV carriers ERA OF LAPAROSCOPIC LIVER were matched with control by propensity scoring. SURGERY Results: 304 patients with known HBV carrier status who underwent resection of colorectal liver metastasis A. Chan, S. Jamdar, A. Sheen and A. Siriwardena were studied. From the 21 (6.9%) hepatitis B carriers, a Regional Hepato-Pancreato-Biliary Unit, Manchester more prolonged prothrombin time (12.1 vs. 11.3 sec, OR fi Royal In rmary, United Kingdom 1.42, p=0.027) was observed and fewer major resections Introduction: Following the Louisville and Morioka were performed (19.0% vs. 47.3%, OR 0.262, p=0.018). consensus conferences, laparoscopic left lateral sectionec- After 1:5 propensity score matching, they were tomy (LLS) is the standard of care for patients requiring compared with 105 controls with similar liver function, resection of segments II and III. This study examines tumour status and receiving similar treatments. Patients whether there remain any indications for the open operation with chronic hepatitis B enjoyed better disease free in current practice. survival (15.8 vs. 9.20 month, p=0.032). Overall sur- Methods: The study population is a consecutive series of vival (50.0 vs. 43.6 month, p=0.15) were similar. patients undergoing liver resection under the care of an Operating time (227 vs. 240min, OR 1.00, p=0.33), individual hepatobiliary surgeon (AKS) in a regionally blood loss (0.50 vs. 0.37 litre, OR 1.15, p=0.62), hos- accredited liver surgery service. 323 consecutive liver pital stay (6 vs. 6 day, OR 1.02, p=0.48), operative resections undertaken during the period January 2009 to morbidity (9.5% vs. 16.2%, OR 0.545, p=0.44) and October 2017 provide the study population. There was 1 mortality (0% vs. 1.0%, OR 1.62, p=0.77) were com- post-operative death (0.3% mortality). Operations where parable. The use of antiviral agents did not affect sur- LLS was the major component of the procedure are vival of HBV carriers. included. Patients undergoing left lobe metastasectomy Conclusion: Chronic HBV infection confers oncological as a component of major right-sided resection are benefit to surgical treatment of colorectal liver metastases. excluded. Case selection for surgery was reviewed prior Given satisfactory liver reserve, HBV carrier status did not to operation at a liver surgery multidisciplinary tumour affect operative morbidity or mortality. board. Results: There were 13 open LLS and 10 laparoscopic LLS. Contemporaneously stated indications for open LLS were: LLS + non-surface metastasectomy 4, LLS as part of synchronous liver and bowel surgery 2, LLS as part of re- do liver resection 2, large 5 cm tumour in II or III abutting IV 2 and patient preference 4. The proportion of LLS un- dertaken laparoscopically was greater in the second four years of this period (P=0.57; Non-significant; Fisher’s exact). Conclusions: Although open LLS as a component of other liver resections, re-do surgery or synchronous liver/bowel resection remains a safe procedure these should now be regarded as relative indications with progressively more patients being managed laparoscopically.

Figure 1Disease-free survival of HBV vs. non-HBV carrier EP01A-002 IMPACT OF HEPATITIS B CARRIER STATUS ON THE OUTCOMES OF SURGICAL TREATMENT OF EP01A-003 COLORECTAL LIVER METASTASES INTRAHEPATIC CHOLANGIOCARCINOMA MIMICKING K. P. Au, K. S. H. Chok, A. C. Y. Chan, W. C. Dai, T. T. Cheung and C. M. Lo A METASTATIC BREAST CANCER: A Department of Surgery, University of Hong Kong, Hong CASE REPORT Kong A. Nugroho1 and M. Mayasari2 Introduction: Chronic hepatitis B virus (HBV) infection is 1Digestive Surgery, Fatmawati General Hospital, and associated with a lower incidence of colorectal liver me- 2Surgery, St Carolus Hospital, Indonesia tastases. We explored the impact of HBV carrier status on Background: Bile ducts are not among the common sites of metastasis from breast cancer. We report an exceptional

HPB 2018, 20 (S2), S333eS504 S334 Electronic Posters (EP01A-EP01E) - Liver case of intrahepatic cholangiocarcinoma mimicking breast prior chemotherapy and SIRT shows that 13.6% of patients cancer liver metastases, 20 years after surgery of the pri- with initially inoperable disease undergo resection with low mary breast cancer surgery. procedure-related mortality. Case presentation: A 65-year-old woman who had un- dergone a right mastectomy 20 years earlier due to infil- trating ductal breast cancer and had remained tumor free, EP01A-005 presented with liver masses found during routine surveil- LIVER METASTASES FROM BREAST lance for breast cancer. Imaging showed features that were suggestive of a metastatic tumor of the liver. Left hemi- CANCER hepatectomy was performed with histological examination D. Kostov and V. Kostov reveal a adenocarcinoma, but cannot differentiate the Surgery, Naval Hospital, Bulgaria origin. Immunohistochemistry analysis demonstrated that Introduction: The role of hepatectomy for patients with the tumor was intrahepatic cholangiocarcinoma. liver metastases of breast cancer (LMBC) remains contro- Conclusions: A liver tumors found in breast cancer sur- versial. The purpose of this study is to share our experience vivor should always be considered and treated as a part of with hepatic resection in a relatively unselected group of the primary disease. patients with LMBC and analyse the prognostic factors and indications for surgery. Methods: In 2000 to 2012, 53 female patients with a mean EP01A-004 age of 53.2 years (range, 35 to 71 years) with LMBC LIVER RESECTION FOR COLORECTAL diagnosed by means of abdominal ultrasound, computed HEPATIC METASTASES AFTER tomography and/or magnetic resonance imaging in the hospital. Overall actuarial 1-, 3-, and 5-year survival rates SYSTEMIC CHEMOTHERAPY AND were calculated since the hepatic resection onwards using SELECTIVE INTERNAL RADIATION the Kaplan-Meier method. THERAPY WITH YTTRIUM-90 Results: Metastatic tumor size of 4 cm (p=0.06), R0 MICROSPHERES (SIRT): THE CURRENT resection (p=0.03), negative portal lymph nodes (p=0.03), WORLD EXPERIENCE response to chemotherapy (p= 0.01), and positive hormone receptor status (p=0.05) were associated with better sur- 1 1,2 M. Baltatzis and A. Siriwardena vival outcomes on univariate analysis. However, it did not 1 Regional Hepato-Pancreato-Biliary Unit, Manchester show survival benefits on multivariate analysis. The dis- fi 2 Royal In rmary, and Faculty of Medicine, University of ease-free survival and overall survival are 25.20 and 45 Manchester, United Kingdom months, respectively. The 1-, 3- and 5-year survival rates Introduction: Selective internal radiation therapy (SIRT) were 82.43%, 67.23%, and 39.55%, respectively. using yttrium-90 resin microspheres has been used with Conclusion: Selected patients with isolated LMBC may systemic chemotherapy to treat patients with unresectable benefit from surgical management; although, indications liver metastases. This study undertakes the first systematic remain unclear and the risks may outweigh the benefits in pooled assessment of the case profile, treatment history and patients with a generally poor prognosis. Improvements in outcome in patients with initially inoperable colorectal preoperative staging and progressive application of new hepatic metastases undergoing resection after systemic multimodality treatments will be the key to improved survival chemotherapy and SIRT. rates in this severe disease. The careful selection of patients is Methods: A systematic review of the literature was associated with a satisfactory long-term survival rate. performed using Medline and Embase for publications between January 1998 and August 2017. Keywords and “ ” MESH headings selective internal radiation therapy , EP01A-006 “Yttrium-99 radio embolization” and “liver metastases” were used. The study protocol was registered with PROS- LIVER METASTASES FROM PERO, (registration number: CRD42017072374). ESOPHAGEAL CARCINOMA Results: The study population comprises 120 patients un- D. Kostov and V. Kostov dergoing liver resection after chemotherapy and SIRT. The Surgery, Naval Hospital, Bulgaria conversion rate to liver resection in previously unresectable Introduction: Hepatectomy for liver metastases from patients is 13.6% overall. Extensive bi-lobar disease and/or esophageal squamous cell carcinoma (LMESCC) remains extent of liver involvement were reasons for initial non- controversial. We aimed at assessing the surgical results, resectability. All studies report a single application of clinicopathological features of LMESCC and prognostic SIRT. The most frequently delivered dose of radiation factors. therapy was 1.8 GBq. The interval from SIRT to surgery Methods: The outcome of 8 consecutive patients with ranged from 39 days to 9 months. Overall there were 4 synchronous (n = 3) or metachronous (n = 5) LMEC was (3.3%) deaths after liver resection in patients treated by retrospectively analyzed. Curatively, initial hepatectomies chemotherapy and SIRT. Histology confirmed evidence of such as segmentectomy and hemihepatectomy or non- microspheres in lesions with evidence of radiation-induced anatomical limited liver resection less extensive than peri-lesional fibrosis. There are no reports of liver failure segmentectomy followed complete primary esophageal from late radiation injury. cancer (EC) resections. Conclusions: This large pooled report of patients under- Results: Median survival time was 12 months (range, 8 - going liver resection for colorectal hepatic metastases after 22 months). The actuarial overall 12-, 36-, and 60-month

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S335 survival rates after hepatectomy were 87.5% (n = 7), 37.5% Conclusions: Adjacency to large hepatic veins is an inde- (n = 3), and 12.5% (n = 1), respectively. In multivariate pendent predictor of LR and reduced LSS following MWA analysis, absent EC adventitia invasion-hazard ratio (HR) indicating the existence of a heat-sink effect. 1; 95% confidence interval (CI) 1.4 - 8.4; P = 0.040; soli- tary LM-HR 1; 95% CI 1.4 - 12.0; P = 0.004, and curative liver resection with negative resection margin (R0)-HR 1, EP01A-009 95% CI 1.2 - 15.0; P = 0.002 were independent prognostic INTERVAL APPROACH: SHORT-TERM factors. Conclusions: Surgery of LMESCC is a good indication OUTCOMES OF THE NEW APPROACH in well-selected patients with an absent EC adventitia FOR PATIENTS WITH RECTAL invasion of primary tumor, single LMEC and attainment CANCER AND SYNCHRONOUS LIVER of R0 liver resection. For most LMESCC patients, how- METASTASES ever, there are no other therapeutic modalities. Thus H. Salvador Rosés, S. López-Ben, M. Casellas-Robert, systemic radiochemotherapy remains the best hope for a E. Castro-Gutierrez, L. Falgueras-Verdaguer, longer patient’s survival and an improved individual M. Albiol-Quer, A. Codina-Barreras, quality of life. A. Codina-Cazador and J. Figueras General and Digestive Surgery, University Hospital Dr. Josep Trueta of Girona, Spain EP01A-007 Background: The goal of treatment for patients with FACTORS PREDICTING DISEASE synchronous liver metastases (SLM) from rectal cancer is PROGRESSION FOLLOWING to achieve a complete resection of both tumor locations. For PERCUTANEOUS MICROWAVE patients with symptomatic locally advanced rectal cancer ABLATION OF COLORECTAL LIVER with resectable SLM at diagnosis, our usual strategy has fi METASTASIS: EVIDENCE FOR THE been the rectum rst approach (RF). However, since 2014, we advocate for the interval strategy (IS) that involves the HEAT SINK EFFECT administration of chemo-radiotherapy followed by the T. Urbonas1, M. Anderson2, A. Gordon-Weeks1, resection of the SLM in the interval of time between rectal S. I. Kabir1, Z. Soonawalla1, M. Silva1 and S. Reddy1 cancer radiation and rectal surgery. 1HPD Surgery Department, Oxford University Hospitals Methods: From 2010 to 2016, 16 patients were treated NHS Foundation Trust, and 2Radiology, Oxford University according to this new strategy and 19 were treated ac- Hospitals NHS Foundation Trust, United Kingdom cording RF strategy. Data were collected prospectively and Introduction: Microwave ablation (MWA) is a recognised analyzed with an intention-to-treat perspective. Complete treatment option for liver metastasis. The heat sink effect resection rate, duration of the treatment and morbi-mor- describes a process where local blood flow cools tissue, tality were the main outcomes. dissipating thermal energy and reducing treatment efficacy Results: The complete resection rate in the IS was higher in the setting of ablative therapies. The clinical relevance of (100%, n = 16) compared to the RF (74%, n = 14, p = the heat sink effect is unclear. 0.049) and the duration of the strategy was shorter (6 vs. 9 Methods: We retrospectively analysed a prospective months, respectively, p = 0.006). The incidence of severe database of patients who underwent percutaneous MWA complications after liver surgery was 14% (n = 2) in the RF of colorectal liver metastases at our institution. Imaging and 0% in the IS (p = 1.000), and after rectal surgery was and demographic characteristics were compared be- 24% (n = 4) and 12% (n = 2), respectively (p = 1.000). tween metastases that progressed following ablation and Conclusion: The IS is a feasible and safe strategy that those that did not. Multivariate survival analysis was procures higher level of complete resection rate in a shorter performed using the Cox proportional hazards model, period of time compared to RF strategy. survival estimates were determined using the Kaplan- Meier method and curves compared using the log rank method. EP01A-010 Results: 126 ablations in 87 patients met the inclusion TO DETERMINE IF THERE IS A criteria and were studied over a median follow-up DIFFERENCE IN OUTCOMES FOR period of 28 months. Local recurrence (LR) was detected in 43 (34.1%) ablations and on multivariate PATIENTS UNDERGOING analysis LR was associated with clinical risk score SYNCHRONOUS PRIMARY (CRS) 2 (OR 2.2 95% CI 1.25-3.3, p=0.029), pallia- COLORECTAL CANCER AND LIVER tive intent surgery (OR 3.6 95%CI 1.3-9.7, p=0.016) RESECTION WITH OR WITHOUT and adjacency (10mm) to a large hepatic vein (OR < PREOPERATIVE TREATMENT 7.595%CI 2.4-22.8, p 0.001). 1 2 3 fi M. N. D. Bin Abdul Aziz , Z. H. T. Teo , X. E. S. Choo , Overall survival (OS) was signi cantly reduced in pa- 4 4 4 tients with a CRS 2 (HR 2.2 95%CI 1.2-4.1, p=0.01) and V. G. Shelat , C. W. Huey , S. P. Junnarkar , W. L. Woon4, J. Samol5 and J. K. Low4 those undergoing palliative ablation (HR 2.5 95%CI 1.2- 1 5.0, p=0.004). Adjacency to a large hepatic vein was not Yong Loo Lin School of Medicine, National University of Singapore, 2Department of General Surgery, Tan Tock associated with reduced OS but was associated with liver 3 specific survival (LSS) (HR 4.66 95% CI 1.7-12.5, Seng Hospital, Department of Statistics and Applied p=0.004). Probability, National University of Singapore, Singapore, 4Hepatobiliary Unit, Department of General Surgery, Tan

HPB 2018, 20 (S2), S333eS504 S336 Electronic Posters (EP01A-EP01E) - Liver

Tock Seng Hospital, and 5Department of Medical upfront synchronous resection of colorectal primary and Oncology, Tan Tock Seng Hospital, Singapore liver metastases had statistically non-significant lower Aims: To report overall and progression-free survival recurrence rates. among patients who underwent synchronous resection of primary colorectal cancer and liver metastases with or without preoperative treatment. EP01A-011 Methods: We performed a retrospective analysis of pa- ANALYSIS OF THE PROGNOSIS OF tients who underwent liver resection for synchronous SURGERY FOR COLORECTAL LIVER colorectal metastases. We analyzed patient characteristics and baseline investigations following tumour board review. METASTASES BY PREOPERATIVE CT Recurrence and mortality were examined using Kaplan- SCAN IMAGES. COULD “CENTRAL Meier survival curves. TYPE” AND “BUDDING Results: Between 2010 and 2017, 111 patients underwent PHENOMENON“ BE PROGNOSTIC liver resection for colorectal adenocarcinoma of which 33 FACTORS? patients had synchronous resection of primary and meta- static liver tumour. 10 patients underwent preoperative K. Hiramatsu, T. Kato and T. Aoba treatment and 23 patients had upfront surgery. Median age General Surgery, Toyohashi Municipal Hospital, Japan was 58.1 vs 65.8 years respectively (p=0.0086). 3-year and Introduction: New preoperative computed tomography 5-year overall survival for all patients were 64.7% and (CT) findings were estimated for their predictive possibil- 30.8%, respectively, with no difference between both ities of survival and recurrence of first hepatectomies for groups (HR 1.971, 95%CI: 0.466-8.332, log rank test colorectal liver metastases (CRLM). p=0.3). Patients with preoperative treatment had poorer Methods: From January 2005 till December 2013, 110 first progression-free survival (log rank test p=0.0527). Median hepatectomies for CRLM were included. Age, gender, progression-free survival was 12.2 months in pretreatment primary site (Rectum), preoperative chemotherapy (NAC), group vs 19.0 months for patients with upfront surgery. adjuvant chemotherapy, adjuvant chemotherapy of colonic Patients with upfront surgery had fewer instances of surgery (ADJCOLON), major hepatectomy (MAJ), lymph extrahepatic recurrence compared to those with pretreat- node metastases, disease free interval between liver and ment (27.3% vs 87.5%, p=0.0198). More patients with colonic surgery less than 1 year (DFI), 5 or more metastases pretreatment had rectal cancer (70.0% vs 4.35%, (N5), maximum diameter of metastatic nodules 5cm or p=0.0002). The overall and progression-free survival for more, elevated CEA level, blood transfusion (BTF), patients with rectal and colon cancer was similar. extrahepatic metastases (EHM), positive liver resection margin (R) and CT findings of “Central type” (Central), which defined as the case that involved at least one root of the major vessels and “Budding phenomenon” (Budding), which defined as bud or satellite lesions from tumor bor- ders, were estimated for their recurrence (RFS) and overall survival (OS). Results: Univariate analysis showed R (p=0.000037), DFI (p=0.028), Number5 (p=0.0007), BTF (p=0.0065), EHM (p=0.014), Central (p=0.0052) and Budding (p=0.000037) were significant in OS and Rectum (p=0.0052), NAC (p=0.019), MAJ (p=0.0035), R (p=0.00025), ADJCOLON (p=0.025), DFI (p=0.00039), N5 (p=0.00000009), BTF Figure 1Progression-free survival curve (p=0.0039) and Budding (p=0.0033) were significant in RFS. Multivariate analysis showed Budding (p=0.012) was

EP01A-010 Table 1[Outcomes in terms of Survival] Overall survival All Pretreatment No pretreatment P-value 1-year overall survival 25 (96.3%) 7 (87.5%) 18 (100.0%) 0.308 3-year overall survival 11 (64.7%) 4 (66.7%) 7 (63.6%) 1.000 5-year overall survival 4 (30.8%) 1 (20.0%) 3 (37.5%) 1.000 Progression-free survival All Pretreatment No pretreatment P-value 1-year progression-free survival 16 (59.3%) 5 (71.4%) 11 (55.0%) 0.663 3-year progression-free survival 5 (21.7%) 0 (0.0%) 5 (27.8%) 0.545 5-year progression-free survival 2 (10.0%) 0 (0.0%) 2 (13.3%) 1.000

Conclusion: Selection of patients for preoperative treat- only independent risk factor of OS and Budding (p=0.017), ment did not result in statistically significant difference in N5 (p=0.014), Rectum (p=0.002), DFI (p=0.013) were in- mortality compared to upfront surgery. Patients who had dependent risk factors of RFS.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S337

Conclusion: In investigated preoperative CT findings, only Methods: Data were reviewed from 303 consecutive pa- “Budding phenomenon” could be risk factor of both sur- tients treated by curative liver resection for CLM between vival and recurrence of first hepatectomy for CRLM. January 2000 and December 2016. Repeat liver resection, single CLM, preoperative chemotherapy, and large metas- tases of 50mm or more were excluded. VSD was defined as EP01A-013 a ratio of minimum tumor to maximum tumor of 5 or more. CINICAL OUTCOME OF ALPPS: A Clinicopathological prognostic factors for survival were analyzed using a prospectively collected database. SINGLE INSTITUTE EXPERIENCE Results: Among the 80 patients included in the analytic N. Sakai1, H. Yoshitomi1, K. Furukawa1, T. Takayashiki1, cohort, 57 patients had No-VSD, and 23 patients had VSD. S. Kuboki1, S. Takano1, D. Suzuki1, S. Kagawa1, Remnant liver recurrence ratio was significantly high in the M. Miyazaki2 and M. Ohtsuka1 VSD group (65% vs. 37%, p=0.027). The Recurrence free 1Department of General Surgery, Chiba University survival rates at 3 years following liver resection for Graduate School of Medicine, and 2International Univer- MCLM in the VSD group was 8.7% compared to 29.0% in sity of Health and Welfare, Japan the No-VSD group (p=0.004). Multivariate analysis indi- Aim: To evaluate the impact of ALPPS on changes of cated that a preoperative CEA level > 50 ng/mL (risk ratio: future liver remnant volume (FLR) and short to mid-term 2.31, 95% CI: 1.03 to 5.19, p=0.042) and VSD (risk ratio: outcome after hepatic resection for advanced multiple/huge 1.99, 95% CI: 1.16 to 3.43, p=0.013) were independently liver tumors. associated with recurrence free survival after liver Patients: From 2004 to 2017, ALPPS was applied to 7 resection. patients who had insufficient FLR or liver dysfunction to Conclusions: VSD of MCLM is risk factor for remnant complete curative resection of primary or metastatic liver liver recurrence after liver resection. VSD type may be a tumors. good indication for preoperative chemotherapy. Results: Median age was 68 years old. Five patients were male and 2 was female. Diagnoses were colorectal liver metastases (CRLM) in 5 cases, hepatocellular carcinoma EP01A-015 (HCC) in 1 case and neuroendocrine tumor in 1 case. ALPPS IN PRIMARY UNRESECTABLE Complete resection by the second stage operation was LIVER TUMORS: FIRST RESULTS OF achieved in 6 cases. One case with HCC failed to achieve the second stage due to poor performance status. ALPPS TREATMENT was applied as a salvage in patients with insufficient FLR M. Vozdvizhenskiy1, A. Orlov2, V. Savinkov2, after portal vein embolization (PVE) in 2 cases (i.e. rescue A. Tyurin2 and S. Frolov2 ALPPS). Median value of ICG R15 except a HCC case was 1Samara State Medical University, and 2Samara State 14.4%. Interval from stage I to stage II was 14 days. FLR at Oncology Center initial CT volumetry was 29.2%. Volume increase of FLR Objectives: The aim of the study is to show the effec- after stage I per day was 30.8 ml/day and FLR reached to tiveness of the ALPPS (Associating Liver Partition and 48.8%. Postoperative mortality was zero in all patients. Portal vein Ligation for Staged hepatectomy) in the treat- MST was 14 months after ALPPS. Recurrences were found ment of primary unresectable liver metastasis of colorectal in all patients with CRLM. cancer (mCRC). Conclusion: ALPPS can be a strong option to improve Materials and methods: Treatment results of 20 patients resectability of advanced liver tumor even in the case with with mCRC were included in the retrospective analysis. liver dysfunction or insufficient FLR after PVE. Contri- ALPPS was performed in patients with insufficient volume bution of ALPPS to long-term survival remains unclear and and / or quality of the remnant (the ratio of the volume of needs to be determined with prospective studies. the remnant to the total volume of the liver was < 25% for patients with normal liver or < 30% and for patients with cholestasis or chemotherapy-induced injuries). The study EP01A-014 included 13 men, and 7 women. The average age of the VARIOUS SIZES DISTRIBUTION OF patients was 52.4 years. MULTIPLE COLORECTAL LIVER Most ALPPS patients were met for metastases of colo- rectal cancer in the liver (mCRC; N = 17). In one patient, METASTASES IS RISK FACTOR FOR the indication for ALPPS was liver cancer, one patient had REMNANT LIVER RECURRENCE gall bladder cancer, one patient had metastasis of uterine AFTER LIVER RESECTION cancer to the liver. Y. Fukami, A. Maeda, Y. Takayama, T. Takahashi, Results: The preoperative mean volume of the remnant was 403 M. Uji and Y. Kaneoka 3 Surgery, Ogaki Municipal Hospital, Japan cm . The average postoperative volume of the remnant after 6 Introduction: Various sizes distribution (VSD) of multiple days was 706 cm3. colorectal liver metastases (MCLM) may potentially have The average difference between the pre- and post- undetectable metastases of the liver. However, there is no operative volume of the remnant was 303 cm3; study comparing the surgical outcome of VSD and No- The average volume of the remnant is increased by 78.4%. VSD in patients with MCLM. This study was designed to Conclusion: ALPPS is an effective two-stage surgical compare the long-term outcomes and recurrence patterns technique. It makes it possible to avoid the development of after liver resection in patients with VSD versus No-VSD post-resection hepatic insufficiency. The most effective of MCLM.

HPB 2018, 20 (S2), S333eS504 S338 Electronic Posters (EP01A-EP01E) - Liver strategy was shown with metastases of colorectal cancer in metastases at the Department of Surgical Oncology, Saint the liver (mCRC). Elisabeth Cancer Institute, Bratislava, Slovak Republic. All primary breast tumors were diagnosed as an invasive breast cancer. Synchronous BCLM ocurred in 3 patients and 25 EP01A-016 patients presented with metachronous BCLM. One patient COLORECTAL LIVER METASTASIS had a concurrent resectable metastasis to the lung, the rest had metastatic disease confined to the liver. Median age of POST HEPATIC RESECTION: patients in the time of BCLM diagnosis was 55 years (range OUTCOMES AND PROGNOSTIC from 31 to 75 years). FACTORS STUDY Results: All resections were considered as R0. From H. S. Boo1, J. Razman1,C.Affirul2, Z. Zamri1 and among 28 resections we performed 10 major hepatic re- O. Hairol1 sections ( 4 segments) using Brisbane 2000 Nomenclature 1Department of General Surgery, Hospital University of hepatic anatomy and resection criteria. Minor procedures Kebangsaan Malaysia, and 2Department of Surgery, consisted of 3 left hepatectomies (3 segments) and 5 University Sains Islam Malaysia, Malaysia anatomic segmentectomies (including 2 bisegmentec- tomies), the rest were non-anatomic wedge resections. Background: Management of patients with colorectal liver There was no postoperative mortality within 60 days . All metastasis (CLM) is complex and the surgical decision postoperative complications were managed conservatively. process should be based on a comprehensive oncologic Median hospital stay was 9 days, ranging from 6-14 days. strategy. The study intends to review the outcomes of the Conclusion: Standard therapy for majority patients with patients who underwent colorectal liver metastasectomy BCLM remains systemic and hormonal therapy. Liver and identify related prognostic factors. resection could serve as an adjuvant treatment to systemic Methods: Patients who underwent liver resection from therapy in selected patients and as a part of multimodal January2010-December2016 were recruited. Demographic treatment in tertiary HPB centers can offer a safe option for and clinical characteristics, staging, treatment modality, delaying disease progression and thus improved survival. disease progression, morbidity and 90-day mortality data were collected and analyzed. The overall survival analysis was performed using Kaplan-Meier method. Results: 70patients underwent colorectal liver meta- EP01A-018 stasectomy. Two-third had synchronous liver metastases DO THE LONG-TERM BENEFITS OF during the initial presentation. The 90-day mortality was ALPPS MITIGATE THE 2.8 %.One-third recovered with no complication while half PERIOPERATIVE RISK? developed complications but amenable solely to pharma- K. Wanis1, V. Ardiles2, F. Alvarez2, M. Tun-Abraham3, cological treatment. 50% patients survived through 21 4 2 months post-operatively(1-85 months) with a 5-year sur- D. Linehan , E. de Santibanes and R. Hernandez-Alejandro5 vival rate of 55.6%. Up to half developed recurrence during 1 2 the follow up.Recurrence occurred within first year in 35% Harvard University, United States, Division of HPB Surgery, Department of Surgery, Liver Transplant Unit, of patients and after 3 years in 13% of patients respectively. 3 There was no obvious factor prognosticating disease Italian Hospital Buenos Aires, Argentina, Division of Transplantation, Western University, Canada, 4Depart- recurrence in this cohort. However, interestingly, those 5 with tumour size between 7-30 cm3 have lower risk of ment of Surgery, and Division of Transplantation/Hepa- disease recurrence as compared to those with tumour size < tobiliary Surgery, Department of Surgery, University of 7cm3. Recurrence of CLM is the only prognosticating Rochester, United States factor for overall survival. Those with recurrent disease Objectives: Associating Liver Partition and Portal vein have significantly 3.5 times higher risk of dying as Ligation for Staged hepatectomy (ALPPS) is an innovative compared to those without recurrent disease. two-staged hepatectomy which has elicited controversy Conclusion: Liver resection should be considered in all within the international hepatobiliary community. ALPPS suitable patients in order to improve their survival outcome. has been criticized for having high morbidity and mortality A close monitoring is imperative in view of early recurrence. and scant oncological and quality of life (QoL) outcome data. Demonstrating reasonable long-term benefits with acceptable short-term risk is necessary to support more EP01A-017 widespread endorsement of ALPPS. Methods: Prospectively collected data from two high- ROLE OF SURGICAL TREATMENT IN volume ALPPS centers were combined and analyzed for BREAST CANCER LIVER METASTASES disease-free (DFS) and overall survival (OS) from date of M. Sabol1, R. Donát2, J. Palaj2, P. Chvalný2, surgery. Only patients treated for CRLM with > 6 month D. Dyttert2 and S. Durdík2 post-operative follow-up were included. All patients had 1Dpt. of Surgical Oncology, St. Elisabeth Cancer Institute, bilateral CRLM with initially unresectable tumor load and and 2St. Elisabeth Cancer Institute, Slovakia received pre-operative chemotherapy. The well-validated Introduction: Isolated breast cancer liver metastases EORTC QLQ-C30 questionnaire was used to assess pa- ’ (BCLM) occur in 4-5% of metastatic breast cancer patients. tients QoL. Methods: Retrospective analysis of the treatment results Results: A total of 58 patients underwent ALPPS for was performed in patients who underwent hepatic resection CRLM, and 47 patients met inclusion criteria. There were for (BCLM). Between 2003 and 2017, totally 28 patients no perioperative mortalities, and the severe complication underwent hepatic resection for breast cancer liver rate was 21%. The 3-year disease free survival post ALPPS

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S339 was 28%, while the overall survival was 58%. Most pa- Methods: Patients whose imaging findings did not show tients experienced first recurrence in the liver (65%). Pa- extrahepatic disease were selected for hepatic resection. If tient reported QoL following ALPPS was similar to general R0 resection was available and the operative risk was low population reference values. in preoperative tests, the patients underwent surgery. Conclusions: In select patients, ALPPS results in low Results: Between 2011 and 2014, 6 patients underwent perioperative risk, reasonable overall survival, and excel- hepatic resection for BCLM. All patients received hepatic lent quality of life. Hepatic, not systemic, recurrence is the resection to achieve an R0 resection. The time interval most common site of relapse after ALPPS. between initial detection of breast cancer and that of liver metastases in the patients, excluding 1 patient with syn- chronous metastases, was 55.2 months. Major liver resec- EP01A-019 tion was performed in 4 patients. Differences were ANALYSIS OF RESULTS AFTER LIVER observed in the hormone receptor status between the pri- mary breast tumor and liver metastases; however, no dif- RESECTION FOR METASTASIS FROM ference was observed in the HER-2 status. The 1-year and NON-COLORECTAL AND NON- 3-year overall survival rates after hepatic resection were ENDOCRINE TUMORS 100% and 83.3%, respectively. The 1-year and 3-year H. -S. Kim disease free survival rates after hepatic resection were Surgery, Chonnam National University Medical School, 66.7% and 50.0%, respectively. Republic of Korea Conclusions: Curative resection may be considered as one of the multimodality treatments for BCLM. It shows benefit Objective: Liver metastasis from colorecal cancer and in selected patients; its selection criteria needs to be endocrine organs relatively well researched and reported. investigated. However, there have been few reports on outcome of liver metastasis from noncolorectal and non endocrinee organs. In this study ,we evaluate the prgosnostic factor among the patient who underwent hepatic resection with noncolorectal EP01A-021 nonendocrine liver metastasis. UTILITY OF IMAGE GUIDANCE IN THE Method: The overall study period was September 2005- LOCALIZATION OF DISAPPEARING July 2015. A total of 23 patients were selected from the two COLORECTAL LIVER METASTASES different hospital database and included in the analysis 1,2 1,3 1 1 Patients and tumors characteristics were reported. Overall L. Pak , J. Gagnière , P. Allen , V. Balachandran , ’ 1 1,4 1 survival and subgroup analyses based on different charac- M. D Angelica , R. DeMatteo , W. Jarnagin , A. Simpson1 and T. P. Kingham1 teristics were performed. 1 2 Results: Them Mean age of the patients was 57.9 11.5 Memorial Sloan Kettering Cancer Center, Brigham and Women’s Hospital, 3University Hospital of Clermont- years. Male was 15 (65.2%) and female 8 (34.8%). Primary 4 malignancies distribution resulted as follows: Genitourinary Ferrand, France, and University of Pennsylvania, United 7 (30.4%) Gastrointestinal 6 (26.1%) Pancreatic cancer 3 States (13.0%) Lung cance 2 (8.7%) Breast cancer 2 (8.7%) CBD Background: Colorectal liver metastases that demonstrate cancer 1 (4.3%) Melanoma 1 (4.3%) and Nasopharyngeal a complete radiographic response during chemotherapy are cancer 1 (4.3%) The overall survival rates at 1, 3, 5 years, increasingly common with advances in chemotherapy were 68.5% , 38.0% and 19.0% respectively .Presence of regimens and are described as disappearing liver metastases Neoajuvant treatment and recurrence after hepatic resection (DLMs). However, standard B-mode intraoperative sono- were significant different between Death and Survival graphic visualization of these lesions can be hindered by groups (21.4% vs 77.8%, P < 0.05) ,(78.6% vs 22.2%, P < chemotherapy-associated liver parenchyma changes. The 0.05) and Overal survival rate was high in the patients with objective of this study was to evaluate the use of an intra- Neoajuvant treatemnt (1 ,3 and 5yr: 88.9%, 77.8% and operative image guidance system, Explorer, to aid surgeons 51.9% vs 53.8%, 23.1% and 0 % P < 0.05). in the identification of DLMs initially undetected by ul- Conclusion: Neoajuvant treatemnt could have survival trasound (US) alone. benefit in the patient of noncolorectal nonendocrine liver Methods: In a single-arm prospective trial, patients with metastasis. colorectal liver metastases who were undergoing liver resection and/or ablation with one or more DLMs during neoadjuvant chemotherapy were enrolled. Intraoperatively, EP01A-020 a search for all DLMs using anatomic landmarks was initiated with standard B-mode US. Any DLM not located THE OBJECTIVE OF THIS STUDY WAS was then re-evaluated with the Explorer image guidance TO INVESTIGATE THE OUTCOMES OF system. The primary outcome was the proportion of SELECTED PATIENTS WITH BREAST sonographically occult DLMs that were subsequently CANCER LIVER METASTASES (BCLM) located with image guidance. WITHOUT EXTRAHEPATIC Results: Between April 2016 and November 2017, 25 patients with 61 DLMs were enrolled. 38 DLMs (62%) in METASTASES AFTER HEPATIC 14 patients (56%) could not be identified with US alone RESECTION and were interrogated with assistance of the Explorer S. P. Yun, H. I. Seo and M. H. Yoon system. Of these 38 DLMs, six (16%) DLMs in five pa- Pusan National University Hospital, Republic of Korea tients (36%) were subsequently located (Figure). The

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Explorer system changed the intraoperative surgical plan Conclusion: It’s important to consider not only H-classi- in four of these patients. fication but also LN metastasis and T4, to treat CRLM. Conclusions: The Explorer system can guide surgeons in However, H1 don’t need NAC. In contrast with that, in the identification of initially sonographically occult DLMs particular NAC for patients with T4 and LN metastasis may and facilitate improved surgical clearance of liver disease. have strategic significance in the sense of patient selection, because H2 relapse relatively rapidly.

EP01A-023 THE IMPACT OF PREOPERATIVE FLUOROURACIL, DOXORUBICIN AND STREPTOZOCIN ON THE OUTCOMES OF PATIENTS WITH PANCREATIC NEUROENDOCRINE LIVER METASTASES J. Cloyd, K. Omichi, T. Mizuno, C. -W. Tzeng, C. Conrad, Y. S. Chun, T. Aloia, A. Dasari and J. -N. Vauthey Surgical Oncology, University of Texas MD Anderson Cancer Center, United States Introduction: 5-fluorouracil, doxorubicin and streptozocin Figure [Image guidance use and treatment details] (FAS) is associated with substantial response rates in pancreatic neuroendocrine tumors but its efficacy prior to resection of pancreatic neuroendocrine liver metastases EP01A-022 (NELM) has not been previously evaluated. Methods: All patients who underwent R0/R1 resection of HOW SHOULD WE DO PERIOPERATIVE pancreatic NELM at a single institution between 1998-2015 CHEMOTHERAPY FOR COLORECTAL were included. The outcomes of patients treated with preop- CANCER LIVER METASTASES (CRLM)? erative FAS were compared to those of patients who were not. THE OPINION FROM SINGLE Results: Among 67 patients, 27 (40.3%) received preop- INSTITUTION BY RETROSPECTIVE erative FAS while 40 (59.7%) did not. Seventeen (63.0%) STUDY experienced a partial response according to RECIST criteria. Despite being associated with higher rates of syn- F. Hirokawa, M. Hayashi, M. Asakuma, K. Komeda, chronous disease (92.6% vs 45.0%, p< 0.0001), lymph T. Shinizu, Y. Inoue and K. Uchiyama node metastases (74.8% vs 40.0%, p< 0.05), and larger General and Gastroenterological Surgery, Osaka Medical tumor size (3.9cm vs 2.1cm, p< 0.001), patients who College, Japan received preoperative FAS had similar OS (108.2 vs 107.0 The most effective treatment for CRLM is surgical months, p=0.64) and RFS (25.1 vs 18.0 months, p=0.16) intervention, however the chemotherapy develops rapidly compared to patients who did not. recently. Therefore, we have to consider how we combine Among patients who presented with synchronous liver chemotherapy with an operation to develop an appropriate metastases (n=46), the median OS (97.3 vs 65.0 months, treatment strategy for CRLM. p=0.001) and RFS (24.8 vs 12.1 months, p=0.003) dura- Objective: We reviewed 282 patients who underwent tions were significantly greater among patients who hepatectomy for CRLM by December 2015. H1 and H2/ received preoperative FAS (Figure). Compared to a sepa- H3-classification at first time were 218 and 64 patients rate cohort of 24 patients with potentially resectable respectively, and preoperative chemotherapy (NAC) was pancreatic NELM treated with FAS alone, patients who performed in 21 and 22 patients respectively. We received FAS followed by liver resection had a signifi- explored the better combination of surgery and chemo- cantly longer median OS duration (59.6 vs 108.2 months, therapy using data above mentioned. H1: Number £4and p=0.01). size £5cm. Conclusion: The use of FAS prior to liver resection is Results: Multivariate analysis identified T4, LN metas- associated with improved OS and RFS compared to surgery tasis in CRC, age75, male, and R2 as factors related to alone among patients with advanced synchronous pancre- a poor prognosis in CRLM. As for H1, NAC was added atic neuroendocrine liver metastases. as the risk factor. NAC was often performed in syn- chronous liver metastases and age< 75, and 3 patients who received NAC progressed from H1 to H2. As for H2 EP01A-024 /3, NAC alone didn’t improve the prognosis, however, perioperative chemotherapy had a tendency to improve it CRYOSURGICAL TREATMENT (p=0.019). Even patients who received NAC didn’tin- OPTIONS OF PRIMARY AND crease intraoperative bleeding and postoperative METASTATIC LIVER CANCER complications. D. Ionkin1, A. Chzhao1, O. Zhavoronkova2, On the others hand, patients who didn’t received NAC Y. Stepanova2 and N. Karelskaya2 often relapsed within one year. Patients with T4 and LN 1General Surgery, and 2Radiology, A.V. Vishnevsky Insti- metastasis had a poor prognosis. tute of Surgery, Russian Federation

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Aim: Improving the life quality, and increase life expec- (combined with RFA in 2). The focal size: RFA group - tancy (in combination of chemotherapeutic treatment) in 28.78.4 mm, resections group - 33.822.9 mm. patients with primary (PLC) and metastatic liver cancer Results: RFA group: complete focus ablation was’t (MLC). achieved in 50%, which required additional interventions. Materials and methods: Cryodestruction (CD) have been The average duration of the disease-free period in suc- performed in 50 patients. I group: 10 (5 men/5 women) cessfully operated patients was 3.32 months. Complica- patients (49+6 years) with PLC: HCC-6, HCCC-4. II tions - 10%, no lethal outcomes. group: 40 (25 men/15 women) patients (57+6 years) with Resection group: R0 resection was achieved in 59%, the MLC: metastases of colorectal cancer (CRC) (17), average duration of the disease-free period was 1012 pancreatic cancer(13), gastric cancer(3), neuroendocrine months. Complications - 64%, 1 death. tumors(2), cancer of the bile ducts(2), MDP-cancer(1), Conclusion: Liver resections in patients with LCCM allow breast cancer(1), kidneys(1). "CRYO-MT” and "CRYO- to achieve radical surgery and longer remission compared 01” were used, as well as porous-sponge applicators made with RFA, but are accompanied by a large number of of titanium nickelide. The target temperature: -186oС. complications. However, RFA can be used many times Exposure time: 3-5 min. All patients subsequently under- when new focus appear, or with continued growth of the went adjuvant chemotherapy, supplemented with regional treated tumor, but the possibility of successful RFA clearly chemoembolization in 16 cases. correlates with the size of the focus. Results: In the postoperative period in I group intra- abdominal bleeding - 1(12.5%) case; renal and hepatic failure led to the development of the syndrome of multiple EP01A-026 organ failure and then to death on the 47th day after the PREDICTORS OF IMPROVED OVERALL intervention (liver resection+ CD+RFA) -1(12.5%). The survival rate (Kaplan-Meier): 6 months-87.5%, 12-75%, SURVIVAL AFTER RESECTION OF 24-62.5%, 28-50%. GASTRIC CANCER LIVER In the postoperative period in II group: intra-abdominal METASTASES fi bleeding -2(5%), gastric bleeding in 1(2.5%), biliary stula M. J. Temido1, H. Alexandrino1,2, R. Caetano Oliveira3, - 1(2,5%), ascites - 6(15%), hydrothorax - 4(10%), right E. Santos2, L. Ferreira4, R. Martins2, M. Serôdio2, lower lobe pneumonia - 2(5%). The survival rate (Kaplan- F. Castro e Sousa1, M. A. Cipriano3 and J. G. Tralhão1,2 Meier): 6 months-95%, 12-72%, 24-60%, 36-28%. 1Faculty of Medicine, University of Coimbra, 2Department Conclusion: CD in case of PLC and MLC unresectable of Surgery, 3Department of Pathology, Coimbra Univer- patients is greatly improves the quality of life of patients, sity Hospital, and 4Department of Surgery, St. Vincents primarily by reducing pain. CD in connection with adjuvant University Hospital, Ireland chemotherapy leads improveme in survival rates. Introduction: Hepatectomy (Hp) in the treatment of gastric cancer liver metastases (GCLM), although controversial, can be useful in selected patients. Patient EP01A-025 selection is of paramount importance. We intend to PLACE OF RADIOFREQUENCY evaluate clinical and pathological factors associated with THERMAL ABLATION IN TREATMENT improved outcome. OF PATIENTS WITH COLORECTAL Methods: Clinico-pathological review of 20 consecutive CANCER METASTASIS AFTER patients (13 men; mean age 66,4 years) that underwent surgical resection of GCLM in our department (February of PREVIOUS LIVER RESECTION 1997 to December of 2017). Metastases were synchronous Y. Gavrilov1, O. Zhavoronkova1, D. Ionkin2 and with the primary tumour in 16 cases. Single nodule in 12 Y. Stepanova1 patients; mean size was 34.223.2mm. Hp was minor in 17 1Radiology, and 2General Surgery, А.V. Vishnevsky Insti- cases and synchronous with gastrectomy in seven cases. tute of Surgery, Russian Federation 90-day postoperative morbidity graded according to Dindo- Aim: To evaluate the treatment results of the patients with Clavien. Statistical analysis with SPSSÔ v. 24.0 (log rank, recurrence liver colorectal cancer metastases (LCCM) after Kaplan-Meier and Cox regression). previous liver resection. Results: Major morbidity in four (21%) and mortality in Materials and methods: The analysis of 29 patients one patient (5%) (esophago-jejunal anastomosis dehis- treatment results (5610 years) with recurrent LCCM after cence). Median overall survival (OS) was 18 months and previous liver resection from 2005 to 2015 was carried out. 5-year survival was 21.2%. Two patients survived for over Hemihepatectomy was performed in 7(31,8%) cases, 10 years. Factors associated with a improved overall segmental resection - in 22(75,9%), primary resection was survival were: absence of major morbidity, interval be- supplemented with RFA of separate focus in 5 cases. tween surgeries longer than 8 months, intestinal type, Radical resection was’t achieved in 9, the disease-free location in antrum or body of the of gastric tumor and period was 12.08.8 months in other cases. metastases smaller than 20mm (p< 0.05). Independent With progression, the number of liver focus varied from predictors of better survival were: absence of major 1 to 5 (1.86). morbidity, metachronous resection, time between sur- The patients were divided into two groups: treated with geries, type, location and T of gastric tumor and size of the RFA (12 patients); underwent liver resection (19 patients) metastases (p< 0.05).

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Conclusions: The increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.

EP01A-028 REDO LIVER RESECTION IN RARE

Figure 1 Kaplen–Meyer curves of overall survival. A. In all the study PRIMARY NEUROENDOCRINE population (N=20), median and 5 year survival were 18 months and CARCINOMA OF THE GALLBLADDER 21.2%, respectively. B. Longer overall survival was observed in pa- (PURE LARGE CELL TYPE): tients with interval longer than 8 months between resection of the AGGRESSIVE APPROACH WITH primary tumor and hepatectomy (p=0.027). FAVORABLE OUTCOMES 1 2 2 2 Conclusion: Distal and early gastric cancer, as well as A. Abutaka , I. Sulieman , A. Elaffandi , W. Shehata and H. Khalaf2 metachronous resection, were independent predictors of 1 2 longer overall survival. Selected patients with GCLM will Hamad Medical Corporation, and Liver Unit, HPB and benefit from Hp. Transplant Surgery, Hamad Medical Corporation, Qatar Introduction: We are reporting a rare case of pure large cell neuroendocrine tumor of the gallbladder that was EP01A-027 treated with redo liver resection for recurrent metastases, and showed extended survival FUTURE LIVER REMNANT (FLR) Case report: A 67-year-old lady underwent an uneventful INCREASE IN PATIENTS WITH laparoscopic cholecystectomy. Histopathology showed a COLORECTAL LIVER METASTASES IS poorly differentiated, high grade, neuroendocrine tumor of HIGHEST THE FIRST WEEK AFTER the gallbladder of the large cell type, that was invading PORTAL VEIN OCCLUSION through the muscular wall, with perineural and angiolym- 1 1 2 3 phatic invasion. FDG-PET and MRI scans showed a re- K. Hasselgren , P. Sandström , B. Røsok , E. Sparrelid , sidual hepatic lesion at segment IVB/V, and chromogranin G. Lindell4, P. Nørgaard Larsen5, N. Schultz5, 6 7 1 was found to be highly elevated (982mcg/L). Central B. Isaksson , M. Rizell and B. Björnsson inferior hepatectomy and hilar lymphadenectomy were 1Departments of Surgery and Clinical and Experimental 2 done, and an incidental lesion found in segment III was also Medicine, Linköping University, Sweden, Department of resected by wedge excision. Follow up MRI 3 months post Hepato-Pancreato-Biliary Surgery, Oslo University Hospi- 3 operatively showed a metastatic liver lesion in segment II/ tal, Norway, Department of Clinical Science, Intervention III, and a redo liver resection was done (left lateral and Technology, Division of Surgery, Karolinska Institutet, segmentectomy), revealing similar histopathology. The Karolinska University Hospital, Sweden, 4Department of 5 patient remained disease free for 3 months from the second Surgery, Skane University Hospital, Sweden, Department of surgery (nearly 8 months post first liver resection) until she Surgical Gastroenterology and Transplantation, Rigshospi- was found to have a recurrent disease confined to the liver talet, University of Copenhagen, Denmark, 6Department of 7 on follow up imaging. She was started on chemotherapy, Surgery, Akademiska University Hospital, and Department and she remains to be alive and well with stable disease 22 of Transplantation and Liver Surgery, Sahlgrenska Acad- months from the initial diagnosis. emy, University of Gothenburg, Sweden Conclusion: This is the first report of repeat liver Introduction: Portal vein occlusion (PVO) is an estab- resection for metastasis from LCNEC of the gallbladder. lished method to increase the volume of the future liver An aggressive surgical approach for the treatment of remnant (FLR). The main reasons for not proceeding to liver metastases in this rare disease may provide radical hepatectomy is lack of volume increase or tumour prolonged overall survival in the absence of extrahe- progression due to a wait-time interval of up to 8 weeks. patic disease. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks. Method: Patients with colorectal liver metastases (CRLM) EP01A-029 and standardized future liver remnant (sFLR) < 30 % treated with PVO were prospectively included. All patients IS LIVER-FIRST APPROACH had at least one CT-evaluation before radical hepatectomy. BENEFICIAL IN PATIENTS WITH Results: Forty-eight patients were included. During the SYNCHRONOUS MULTIPLE BILOBAR first week after PVO, the kinetic growth rate (KGR) was 5.4 COLORECTAL LIVER METASTASES? A fi ( 4), compared to 1.5 ( 2) between the rst and second REVIEW OF OUR EXPERIENCE CT, p< 0.05. For patients reaching adequate FLR and therefore treated with radical hepatectomy, KGR was 7 ( M. Donadon, M. Cimino, A. Palmisano, L. Viganò, 4) the first week, compared to 4.3 ( 2) for patients who F. Procopio, D. Del Fabbro and G. Torzilli failed to reach a sufficient volume, (p=0.4). During the Department of Hepatobiliary and General Surgery, interval between the first and second CT, KGR was 2.2 ( Humanitas University, Humanitas Clinical and Research 2) respectively ( 0.1), p=0.017. Center, Italy

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Introduction: Whether the liver first approach is beneficial On the other hand, chemotherapy is administered for in patients with multiple bilobar synchronous colorectal patients with sCRLM that is unresectable or not suitable for liver metastases (CLM) undergoing one-stage hepatectomy hepatectomy prior to the hepatectomy. The aim of this (OSH) remains to be demonstrated. The aim of this study study is to evaluate outcome of hepatectomy following was to assess the feasibility and outcome of the liver-first chemotherapy for sCRLM approach for patients with synchronous CLM receiving Methods: Between April 2006 and March 2016, 141 OSH. consecutive sCRLM patients who underwent primary Methods: Between 2012 and 2016, 210 patients with tumor resection at our department. 44 patients underwent multiple bilobar (4) CLM, of which at least one in contact hepatectomy alone (S-group), 23 patients underwent hep- with first- or second-order portal branches and/or with he- atectomy following chemotherapy (CS-group), 74 patients patic vein at caval confluence, underwent OSH. Of these, were treated with chemotherapy alone (C-group). 19 (9%) patients underwent the liver-first approach as Results: Although tumor diameter was similar between S- approved by our multidisciplinary team. All patients group and CS-group, the number of liver metastasis was received perioperative system chemotherapy and had par- more in CS-Group than S-group. Duration of surgery, tial response or stable disease. blood loss, weight of resected liver, post-operative hospital Results: The median CLM number and size were 12 (range stays, rate of R0 resection and serious postoperative com- 5-45) and 3.7 (0.7-17 cm) respectively. The location of the plications was not different between S-group and CS-group primary tumor was in the rectum in 5 (26%) and in the (Table). Overall survival (OS) of S-group and CS-group colon in 14 (74%) patients. The median chemotherapy was similar, and better than C-group (3-years survival rate: courses were 11 (range 4-16). The strategy was completed 89.9% vs 85.6% vs 40.0%).In CS-group, relapse-free sur- in 18 patients (95%). One patient developed hepatic disease vival) was much better in patients with ETS (early tumor progression. 90-day postoperative morbidity and mortality shrinkage) than in those with non-ETS (Figure). were 26% and 0% after liver resection and 19% and 0% Conclusion: Although CS-group had more number of liver after colorectal resection. After a median follow-up of 19 metastasis, Hepatectomy following chemotherapy was months (range 6-33), the intention-to-treat 2-year overall performed with the safety and prognosis equivalent to survival was 40% (Figure). Twelve (63%) patients devel- hepatectomy without chemotherapy. ETS may be a useful oped disease recurrence. indicator of hepatectomy during chemotherapy in sCLM Conclusions: The liver-first approach is safe and feasible in patients. most of the patients with advanced synchronous CLM. Despite a high rate of disease recurrence, acceptable overall survival may be achieved. EP01A-031 THE ROLE OF PREOPERATIVE PET EXAMINATION FOR METASTATIC EP01A-030 LIVER CANCER FROM COLORECTAL OUTCOME OF HEPATECTOMY CANCER FOLLOWING CHEMOTHRAPY FOR SYNCHRONOUS LIVER METASTASIS Y. Kotera, S. Ariizumi, A. Omori, S. Yamashita and M. Yamamoto OF COLORECTAL CANCER Surgery, Tokyo Women’s Medical University, Japan Y. Senda, Y. Shimizu and S. Natsume The assessment for PET negative nodules has not been Department of Gastroenterological Surgery, Aichi Cancer determined yet. We try to determine the role of the PET Center Hospital, Japan negative nodules for the patients of colorectal liver

EP01A-030 Table [S-group vs CS-group] S-group (n [ 44) CS-group (n [ 23) P Maximum diameter of liver metastasis (cm) 4 (1-13) 3.5 (1-8.1) 0.62 Number of liber metastasis 2 (1-7) 5 (2-9) <0.001 Duration of surgery (min) 245 (80-621) 270 (153-722) 0.24 Blood loss (ml) 357 (5-4700) 420 (50-1350) 0.61 Weight of resected liver (g) 320 (15-1454) 325 (20-80) 0.97 Post-operative hospital stays 12 (8-23) 13.5 (8-25) 0.19 R0 resection (%) 41 (93.2%) 19 (86.4%) 0.36 Postoperative complication more than grade III* (%) 2 (4.6%) 3 (13.0%) 0.20

metastasis. (subjects and methods) 126 patients who un- Background: In our department, we re-evaluate surgical derwent PET before hepatectomy at our hospital between indication after 3 months watchful waiting following 2005 and 2017. In these cases, the effect of NAC, the resection of primary lesion for patients with resectable disease free survival rate (DFS) and overall survival rate synchronous liver metastasis of colorectal cancer (sCRLM) (OS) were examined, and the characteristics were to avoid unnecessary hepatectomy in consideration of compared and investigated in 49 patients who underwent occult metastatis. NAC and 77 cases who didn’t receive NAC. (Results)

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PET negative patients were 34patients (114 nodules) out EP01A-033 of 49 patients (197 nodules). 160 nodules out of 197 nodules were resected and 37 nodules were follow up. A INCIDENCE AND RISK FACTORS OF viable tumor was found in 147 nodules of 160 resected PORTAL VEIN OR BILE DUCT nodules, and 27 nodules out of 37 nodules which were INVASION IN COLORECTAL LIVER observed were relapsed. Total 174 nodules were deter- METASTASES mined to be viable tumors. Among the 34 recurrent pa- K. Goto, M. Narita, S. Jikihara, A. Maeda, M. Saji, tients, 18 patients relapsed due to relapse of PET negative R. Matsusue, H. Hata, T. Yamaguchi, T. Otani and I. Ikai nodules, 7 patients due to the appearance of new nodules Surgery, Kyoto Medical Center, Japan and 4 patients due to the other organ metastasis. Relapse of PET negative nodules occurred around 276 days on the Introduction: There are few reports about portal vein or other hand, 410days in the patients of appearance of new bile duct invasion (PBI) in colorectal liver metastases nodules. DFS and OS were prolonged in the patients of (CRLM). We experienced a case with CRLM having pos- relapse of PET-negative nodules compared with other itive resection margin due to portal vein invasion after non- recurrent patients (Discussion) Even PET revealed nega- anatomical resection. The aim of this study was to evaluate tive, viable cells remain in most of the tumors. (Conclu- the frequency of PBI and clinico-pathological factors to sion) it is desirable to resect all tumors even the tumor predict PBI. showed PET negative. Method: Between September 2009 and June 2017, 113 patients with CRLM underwent hepatectomy in our insti- tution. We defined “Pathological PBI” as pathologically diagnosed portal vein or bile duct invasion. “Radiological EP01A-032 PBI” was defined as the presence of any of following LIVER SURGERY OF BREAST CANCER radiological findings in dynamic CT; “the presence of A-P LIVER METASTASES: RAPID shunt or bile duct dilation in the peripheral region of the SURGICAL DECISION AFTER tumor” or “tumor thrombus in the portal vein”. Clinico- DIAGNOSIS DOES NOT NEGATIVELY pathological factors including primary tumor characteris- tics and CRLM characteristics were analyzed. IMPACT LONG-TERM RESULTS Results: Among 113 patients, 69.9%(71 patients) was 1 2 1 1 V. Lucidi , G. Liberale , M. Bez , D. Germanova , male, and median age at hepatectomy was 71 years old. 1 2 G. Katsanos and V. Donckier Anatomical resection was performed in 76 patients 1 Digestive Surgery e HPB e Transplantation, ULB e (67.2%). Pathological PBI was found in 29 patients 2 Hôpital Erasme, and Digestive Surgery, ULB e Institut (25.7%). On univariate analysis, “Primary T status was T4b Jules Bordet (80.0% vs 23.1%, p=0.015)” and “presence of radiological Introduction: Surgery could be indicated in selected pa- PBI (62.5% vs 15.7%, p< 0.01)” were associated with tients with breast cancer liver metastases (BCLM) but ac- pathological PBI. We could not find any clinical implica- curate identification of candidates for surgery remains a tion of PBI including recurrence and overall survival. challenge. We investigated if an observational period of Conclusions: PBI is not rare in CRLM and the presence of time after the diagnosis of BCLM could improve the se- PBI should be considered in whom primary T status was lection for surgery. T4b and PBI was suspected on preoperative CT. Recon- Methods: We performed a retrospective analysis of 72 sideration of the optimal surgical procedure for those pa- consecutive patients operated for BCLM between 2000 and tients may be necessary. 2015. Clinicopathologic and outcome data were compared between 2 groups: Early surgery (ES), including patients operated for BCLM 12 months after liver metastases EP01A-034 (LM) diagnosis, and late surgery (LS), including patients IS ONCOLOGICAL RESECTION operated >12 months after diagnosis. Results: Mean age was 48 years (28-74) at time of liver POSSIBLE IN HEPATIC RECURRENCE surgery. Median time between primary and LM diagnosis AFTER ALPPS PROCEDURE FOR was 35 months (0-211) and median time between LM COLORECTAL CANCER LIVER diagnosis and surgery was 12 months (0-134). Clinico- METASTASES? pathologic characteristics were similar in ES (n=37) and LS M. T. González-Nicolás Trébol, S. Genzor Rios, (n=35) patients. In the whole population, 1, 3 and 5-years A. Pérez Zapata, M. Sanchez Rubio, T. Gimenez Maurel, progression free (PFS) and overall (OS) survivals were J. R. Oliver Guillen and A. Serrablo Requejo respectively of 70%, 43%, 30% and 93%, 66%, 43%. In Cirugía General y del Aparato Digestivo, Hospital multivariate analysis, neither PFS nor OS differences were Universitario Miguel Servet, Spain observed between ES and LS groups (PFS - HR=1,13 p=0,72 and OS - HR=1,06, p=0,85 for LS), only primary Introduction: Liver resection represents the only curative tumor estrogen receptor positivity had a positive impact for option in diffuse liver metastatic disease. ALPPS (Associ- OS (HR=0,48 p=0,05). ating Liver Partition and Portal Vein Ligation for Staged Conclusion: No difference in survival was observed be- Hepatectomy) hepatic resection is possible only if the tween patients operated rapidly for BCLM as compared estimated future liver remanent (FLR) is 25% in healthy with patients operated after observational period, suggest- liver and 30% in patients with cirrhosis or chemotherapy ing that it is not necessary to postpone the surgery in pa- related liver disease. This technique is associated up to 12% tients with resectable LM. mortality and a morbidity between 53 to 85%.

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Method: We described two patients with colorectal cancer in patients with extensive CRLM, concerns may raise and diffuse metastatic hepatic disease who underwent regarding its role in disease progression. ALPPS hepatic resection with liver recurrence in follow-up time. Results: First patient was a 62-year-old man with right EP01A-036 colon adenocarcinoma and second patient was a 67-year- FEASIBILITY OF LAPAROSCOPIC old woman with sigmoid colon adenocarcinoma, both of them with diffuse metastatic liver disease with a good PARENCHYMAL SPARING response to chemotherapy after colorectal surgery. We HEPATECTOMIES: A SYSTEMATIC performed the ALPPS stages within 15 days period, after REVIEW AND META-ANALYSIS fi CT-Volumetry con rmed an adequate FLR. We observed a J. Kalil, J. Poirier and E. Schadde recurrence in liver remnant after 11 and 14 months, Rush University Medical Center, United States respectively, so, we decided to perform a rescue surgery in Introduction: Parenchymal sparing hepatectomy (PSH) the two patients. Disease-free survival after rescue surgery refers to liver resection with preservation of as much liver was more than 2 years and global survival from de initial parenchyma as possible. PSH may confer oncological diagnosis was 4 and 5 years. advantage over major hepatectomies, specifically in colo- Conclusion: ALPPS technique causes an important hy- rectal liver metastases (CRLM). PSH can be performed perplasia of the liver remnant with an adequate function in a laparoscopically, but access to the cranial segments is short time. In selected cases with enough liver remnant it is difficult. The objective of this systematic review is to possible to perform a rescue surgery with good disease-free analyze feasibility, safety, and oncologic outcomes of and global survival in patients with unresectable liver laparoscopic PSH (LPSH). disease. Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by seg- EP01A-035 ment(s) and data regarding operative time, blood loss, ONCOLOGICAL OUTCOMES OF length of hospital stay, complications, and R0 resection PORTAL VEIN EMBOLISATION were analyzed. FOLLOWED BY MAJOR LIVER Results: Of 351 studies screened for relevance, 48 studies RESECTION: A 6-YEAR EXPERIENCE were selected. After meeting inclusion criteria, ten publi- cations remained reporting data from 579 patients under- E. Martinou, M. Kostalas, R. Kumar, A. Riga, going LPSH. The most common indication was CRLM T. Worthington, A. Horton and N. Karanjia (58%) followed by hepatocellular carcinoma (16%). Of Hepatobiliary Surgery, Royal Surrey County Hospital, these resections, 132 (21.5%) were in the cranial segments. United Kingdom Median operating time was 190 minutes (range: 125-369 Introduction: Portal Vein Embolisation (PVE) is an minutes), median estimated blood loss was 200 cc (range: important adjunct in the surgical management of patients 100-450 cc), median length of hospital stay was 6 days with extensive colorectal liver metastases (CRLM). Evi- (range: 2-7 days). Conversion rate was 7% and complica- dence suggests that induction of liver hypertrophy after tions occurred in 17% of cases. No perioperative mortality PVE may promote tumour growth. The aim of this study was reported. No standardized reporting format for com- was to evaluate the impact of PVE on tumour growth and plications was used across studies. R0 resections were report oncological outcomes in patients with CRLM. achieved in 91% of cases. Methods: Patients who underwent PVE and major liver Conclusion: Laparoscopic PSH of difficult to reach liver resection for CRLM between 2009 - 2015 were identified tumors is feasible with acceptable operating times, blood and CT volumetric studies were performed. Post-operative loss, conversion and complication rates. In future studies, morbidity was defined as the percentage of Clavien-Dindo data on long term survival and specific tumor type recur- gradeIII post-operative complications. Values are rence should be reported. presented either as meanSD or median(IQR). Results: PVE was successfully performed in 62 patients and a 9.86.3% increase of the future liver remnant was EP01A-037 achieved, p=0.0001. There was no PVE associated DIAGNOSTIC PERFORMANCE OF THE morbidity. Tumour growth was observed in 40% and 23% of embolised and non-embolised liver lobes respectively FDG PET/CT IN PATIENTS WITH (p=0.463). However, on paired analysis no statistical dif- MUCINOUS COLORECTAL LIVER ference was identified in tumour volumes pre and post PVE METASTASES in both lobes, (p=0.582/p=0.378). 3(4.8%) patients devel- N. Russolillo, A. Borello, S. Langella, R. Lo Tesoriere, oped new disease after PVE and resection was not feasible. F. Forchino and A. Ferrero Either one (83.9%) or second stage (11.3%) liver resection General and Oncologcal Surgery, Mauriziano Hospital, was performed in 6(3) weeks post PVE. Postoperative Italy morbidity was 9.7%(n=6) and in-hospital mortality was Background: Positron emission tomography (PET) with 0%. Follow up was 3.34.1 years and local disease 18F-fluorodeoxyglucose (FDG) has gained acceptance for recurrence was 22%(n=13). Three and five-year survival staging of tumors. A significant lower sensitivity for rates were 68.5% and 46.3% respectively. mucinous type histology (mainly in gastric and lung can- Conclusions: Although PVE combined with major liver cers) has been reported. Few data are available on diagnostic resection appears to have favourable oncological outcomes

HPB 2018, 20 (S2), S333eS504 S346 Electronic Posters (EP01A-EP01E) - Liver performance of the FDG PET/CT in patients with mucinous SMAD4 mutation (HR 2.773; P< 0.0001). Among 237 colorectal liver metastases (mucCRLM). patients in the validation cohort, SMAD4-mutations were Methods: A retrospective review of all patients treated for significantly associated with worse 3-year OS rate (22% vs. mucCRLM who had undergone FDG-PET/CT at our 38%; P=0.012) and was an independent predictor for worse institution from 2004 and 2017 was performed. The orig- OS (HR, 1.647; P=0.032). inal clinical PET interpretation was used. The reference Conclusion: SMAD4 mutation is independently associated standard was given by histology and/or follow-up imaging. with worse outcomes in patients undergoing resection of Tumors comprising more than 50% mucinous carcinoma CLM. were diagnosed pathologically as mucCRLM. Diagnostic performance was assessed in organ and lesion -based. Results: 831 patients undergoing liver resections for EP01A-039 CRLM between 01/2004 and 11/2017, 131 had mucinous CIRRHOSIS POST SELECTIVE CRLM (15.7%). FDG-PET/CT was performed in 58 (44.2%) patients. According to pathological and follow-up INTERNAL RADIATION THERAPY-RISK data 171 hepatic lesions were detected. FGD PET/CT FACTORS AND PREVENTION confirmed 71 of them in 51 patients. 1 patient with negative A. Kermond, N. O’Rourke, D. Cavallucci and FDG PET/CT had a complete pathological response. 12 A. Jansen Van Rensberg (20.6%) patients presented a total of 13 extrahepatic de- Royal Brisbane Women’s Hospital, Australia posits. In the organ-based assessment FDG-PET/CT had Background: Selective internal radiation therapy (SIRT) is fi the sensitivity and speci city of 89.4% and 100% for he- an increasingly popular adjunct used in the multi-modal patic metastases, 66.7% and 95.6% for lung metastases and treatment of metastatic liver disease. The potential for 62.5% and 97.8% for lymph node metastases. In the lesion- interaction with other hepatotoxic therapeutics in common fi based analysis the sensitivity and the speci city for liver treatment regimens could put patients at higher risk of metastases were 60.7% and 93.4%, respectively. complications, particularly the development of cirrhosis. Conclusion: The limited value of FDG PET/CT in the Aim: To assess the incidence of patients developing fi mucinous histologic type is con rmed in patients with radiographic features of cirrhosis post the use of SIRT plus hepatic and extrahepatic metastases from colorectal cancer. bevacizumab, and identify risk factors in the combination of this therapy. Methods: A retrospective analysis of patients who received EP01A-038 SIRT as part of their therapy between the years of 2010- SMAD4 GENE MUTATION PREDICTS 2016 was performed. The primary cancer, SIRT dose, POOR PROGNOSIS IN PATIENTS chemotherapy agents, dose and timing of those agents, and UNDERGOING RESECTION FOR pre and post SIRT imaging were recorded. Results: Of 62 patients identified, 21 (33.8%) displayed COLORECTAL LIVER METASTASES post-SIRT radiographic features of cirrhosis. 52% of pa- T. Mizuno, J. M. Cloyd, K. Omichi, D. Vicente, tients with the evidence of cirrhosis had radiographic signs Y. S. Chun, C. Conrad, C. -W. D. Tzeng, S. H. Wei, of this within 6 months with the earliest at one month. 33% T. A. Aloia and J. -N. Vauthey of patients received a bevacizumab containing regimen. Surgical Oncology, University of Texas MD Anderson Patient’s who received bevacizumab were at a 2.3 times Cancer Center, United States higher risk of developing cirrhosis. Within this group, pa- Introduction: Dorsophilia protein, mothers against tient’s who received higher doses of bevacizumab within decapentaplegic homolog 4 (SMAD4) is a key mediator in 12 months either side of the SIRT were at 50% increased the transforming growth factor (TGF)-b signaling pathway risk of developing these cirrhotic changes. and SMAD4 gene mutations are thought to play a critical Conclusion: Patients receiving a bevacizumab containing role of in colorectal cancer (CRC) progression. However, regimen were at 2.3 times higher risk of developing little is known about its influence on survival in patients cirrhotic changes, SIRT dose did not correlate with undergoing resection for CLM. increased risk of cirrhotic features, however higher doses of Methods: Between 2005 and 2015, all patients with known bevacizumab if used within 12 months of SIRT doubled the SMAD4 mutation status who underwent resection of CLM risk of developing cirrhotic features. were identified. Patients with SMAD4 mutation were compared to those with SMAD4 wild type. Next, the prognostic value of SMAD4 mutation was validated in a EP01A-040 separate cohort of patients with synchronous stage IV CRC PARENCHYMAL SPARING LIVER who underwent systemic therapy alone. SURGERY FOR UNILATERAL Results: Of 278 patients, 37 (13%) were SMAD4 mutant while 241 (87%) were wild type. Overall survival (OS) COLORECTAL LIVER METASTASIS after hepatic resection was worse in SMAD4-mutant pa- DOES NOT INCREASE DISEASE tients compared to SMAD4 wild type (OS rate at 3 years, RECURRENCE OR REDUCE OVERALL 62% vs. 82%; P< 0.0001). Independent predictors for SURVIVAL worse OS were poor differentiation (hazard ratio [HR] M. Amprayil1, J. Kaczmarczyk2 and R. Padbury3 2.586; P=0.007), multiple tumors (HR 1.970; P=0.01), 1Southern Adelaide Local Health Network, 2Surgery, diameter greater than 3 cm Souther Adelaide Health Network, and 3Surgery, Southern (HR 1.752; P=0.017), R1 margin status (HR 2.452; Adelaide Local Health Network, Australia P=0.014), RAS mutation (HR 2.044; P=0.002), and

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S347

Introduction: Parenchymal Sparing Liver Surgery (PSLS) steatosis, fibrosis, congestion, nodular regenerative hyper- is a surgical philosophy which prioritises performing a plasia, damages from chemotherapy. The influence of limited resection for metastatic liver disease to maximise staging on patient prognosis was assessed by Kaplan-Meier the volume of the future liver remnant (FLR). It has shown survival analysis and the role of previous liver damage by a benefit in bi-lobar, deep-placed and advanced colorectal Cox’s regression method. liver metastasis (CRLM). Results: Out of 138 eligible patients 64 (46,4%) had syn- Aim: To compare PSLS to Major Hemi-Hepatectomy chronous metastases and 74 (53,6%) had metachronous (MHH) for unilateral CRLM. metastases. The survival analysis showed a worse survival Methods: A 10-year retrospective study was conducted rate in the former group (p=0.048). In the first group 24 using data collected from the South Australian Colorectal (37,5%) patients presented a preexisting liver damage. In Cancer database. MHH cases were then independently the second group the number of patients with damage was reviewed by a hepatobiliary surgeon to evaluate whether a 25 (33,8%). The presence of histological alterations of non- liver sparing approach was also feasible. Primary outcomes tumoral liver parenchyma wasn’t found to be significant in include: rates of liver and extra-hepatic recurrence, 5-year both cases (p-value=0,892; 0,725). disease-free intervals and overall survival. Secondary out- Conclusions: Patients with synchronous CRLM have a comes include: operative time, margin clearance, length of worse prognosis. The presence of histological alterations stay (LOS) resection and need for chemotherapy. does not have a significant influence on survival. Results: 132 patients were included in the study. 29 pa- tients who underwent MHH were also suitable for a liver- sparing approach. Patients who underwent PSLS vs MHH EP01A-042 has similar operative times (263.2 vs 299.6 mins, p = 0.09) TWO-STAGE HEPATECTOMY and LOS (7 vs 8 days, p = 0.25). However, they were more likely to have involved surgical margins (0.25 vs 0, p = COMBINED WITH CYTOREDUCTIVE 0.003) and undergo chemotherapy (0.5 vs 0.17, p = 0.002). SURGERY AND HYPERTHERMIC There were no significant differences in rates of liver INTRAPERITONEAL CHEMOTHERAPY recurrence (0.41 vs 0.28, p = 0.20), extrahepatic recurrence IN PATIENTS WITH SYNCHRONOUS (0.47 vs 0.45, p = 0.82), 5-year disease free intervals (0.38 BILOBAR COLORECTAL CANCER vs 0.37, p = 0.22) and 5-year overall survival (0.52 vs 0.53, p = 0.59). LIVER METASTASES AND Discussion: Despite the discrepancy in margin positivity, PERITONEAL METASTASES: INITIAL overall survival is similar between groups. EXPERIENCE J. H. Lim1, H. S. Kim2, J. S. Park2 and D. S. Yoon2 1Hepatobiliary and Pancreatic Surgery, Yonsei University EP01A-041 College of Medicine, Republic of Korea, and 2Yonsei EFFECT OF UNDERLYING LIVER University College of Medicine, Republic of Korea CONDITIONS ON SURGICAL OUTCOME Liver and peritoneum is most common metastatic lesion AFTER TREATMENT OF COLORECTAL in patients with colorectal cancer. Synchronous bilobar colorectal cancer liver metastases (CCLM) and peritoneal METASTASES metastases (PM) is known to be unresectable and dismal E. Monti1, G. Costantini1,2, G. Lionetto1, A. Peloso3, prognosis. However, although two stage hepatectomy A. Gallotti4, T. Manciulli1,5, A. Broglia1,2, S. Brugnatelli6, (TSH) failure rate and incomplete cytoreductive surgery S. Delfanti6 and M. Maestri1,2 (CRS) rate is still high, TSH in patient with CCLM and 1Department of Surgical e Clinical, Diagnostics and cytoreductive surgery with heated intraperitoneal chemo- Paediatric Sciences, University of Pavia, 2General Sur- therapy (HIPEC) in patient with PM have been adopted gery, IRCCS San Matteo Pavia, Italy, 3Division of worldwide as alternative treatment strategy. In our institu- Abdominal and Transplantation Surgery, Geneva Uni- tion, between 2017.03 and 2017.11, we have experienced versity Hospitals, Switzerland, 4Radiology, 5Tropical and six cases of TSH combined with CRS and HIPEC. Five Infectious Disease Unit, IRCCS San Matteo Pavia, Italy, patients received right hepatectomy after wedge resection and 6Oncology, IRCCS San Matteo Pavia, Italy and right portal vein ligation. One patient received associ- Introduction: Liver surgery is the only cure for patients ating liver partition and portal vein ligation for staged with colorectal liver metastases (CRLM). Current in- hepatectomy (ALPPS). Preoperative Mean percentage of dications include radically resectable cases with a safe future liver remnant was measured as 24.2% (range amount of functioning parenchyma remnant. The relative 21.5w30.2%), mean liver hypertrophy period is 22.3 days risk related to the metastatic status (synchronous versus (range 11w56 days). percentage of hypertrophied future metachronous), when underlying liver conditions can affect liver remnant after first stage was measured as 37% (range the liver reserve, is still debated. This single center study 32.8w43.9%). Among six patients, three patient received presents the analysis of resected CRLM patients assessing CRS with HIPEC at first stage operation. other three pa- the treatment outcome based on metastasis status and the tients received CRS with HIPEC at second stage operation. presence of non-tumoral liver damages. Complication rate (Clavien-Dinddo classification grade Methods: We included resectable patients with CRLM 3) was 33.3%. R0 resection of liver metastasis and operated in our unit from January 2004 to July 2017. We complete cytoreduction of PM was achieved in all patients reviewed clinical and histological records on tumoral and without mortality. Simultaneous TSH and CRS with non-tumoral liver sections and recorded the metastasis HIPEC is feasible and considered treatments in patients status and histological alterations such as HBV, HCV, HIV, with Synchronous bilobar CCRM and PM. more patients’

HPB 2018, 20 (S2), S333eS504 S348 Electronic Posters (EP01A-EP01E) - Liver enrollment was needed for evaluation of short and long- over 50 % of patients. Second or more hepatectomies are term outcome. Multimodal oncologic therapy can make applied to treat recurred metastases. The aim of this study is important advances in the prognosis of these patients. to assess efficiency and feasibility of repeat hepatectomy and to analyze prognostic factors after repeat hepatectomy. Two hundred forty-eight patients were diagnosed as EP01A-043 recurred CRLM between January 2003 and May 2016: SURVIVAL AFTER RESECTION OF Second hepatectomy and third hepatectomy were performed in 70 patients and 7 patients, respectively. The HEPATIC METASTATIC DISEASE IN other 171 patients did not undergo repeat hepatectomy. COLORECTAL CANCER: A TWELVE Clinical features were collected from medical records. We YEAR SINGLE CENTER EXPERIENCE compared overall survivals of repeat hepatectomy group G. Costantini1,2, A. Broglia1,2, G. Lionetto1, E. Monti1, and non-repeat hepatectomy group. We also investigated S. Delfanti3, A. Gallotti4, L. Cobianchi1,2, S. Zonta2, factors affecting overall and disease-free survivals of pa- T. Dominioni2 and M. Maestri1,2 tients who received repeat hepatectomy using univariate 1Department of Surgical - Clinical, Diagnostics and and multivariate analyses. fi Paediatric Sciences, University of Pavia, 2General Sur- Overall survival was signi cantly higher in repeat hep- gery, 3Oncology, and 4Radiology, IRCCS San Matteo atectomy group than that of non-repeat hepatectomy group < Pavia, Italy (p 0.01). The morbidity and mortality rates of second hepatectomy were 9.09 % and 0 %, and 3-year and 5-year Background: A radical hepatic resection plus poly- survival rates were 61.7 % and 50.1 %, respectively. The chemotherapy is the standard in the treatment of advanced rates of morbidity and mortality of third hepatectomy were hepatic metastatic colorectal disease. 28.6 % and 0 %, respectively. Number of hepatectomy was Material and methods: Between January 2004 and June only significant in disease-free survival (p< 0.01). There 2016, 126 patients affected by liver metastases of colorectal were no factors influencing overall survival. cancer followed up by multidisciplinary group at General Repeat hepatectomy can be necessary, effective and safe Surgery of IRCCS San Matteo of Pavia (Italy) were for treating recurred CRLM. Number of hepatectomy was selected under the concept of intention to treat (explorative significant factor affecting disease-free survival. versus resective surgery) and analyzed in order to identify the factors influencing survival and risk of recurrence. Survival and multivariate analysis were used to evaluate the significant effects of cancer stage, chemotherapy and EP01A-046 radicality of surgery. LOCAL DESTRUCTION METHODS OF Results: The multivariate data analysis shows that TREATMENT PRIMARY AND lymphnode involvement at primary tumor pathology is an METASTASIZED LIVER CANCERS adverse factor concerning survival and increases the risk of fi fi recurrence (p< 0.05) Above all no different survival was M. Trando lov, N. Prazdnikov E., M. M. Trando lov, demonstrated for R0 versus R1 surgical margins (p=ns). M. N. Rudakova, A. Y. Popov, S. V. Kostirev, Thus, a large debulking more than the achievement of a A. V. Prohorov, D. R. Zinatulin, A. N. Sisova and radical resection should be the aim of the surgical treatment V. S. Svetashov upon the liver disease. Neoadjuvant CHT in upfront A.I. Evdokimov Moscow State University of Medicine and resectable cases does not offer a significant benefit, while Dentistry, Russian Federation postoperative CHT ameliorateds the survival (p< 0.05). We studied 229 miniinvasive hypertensive energy in- Conclusion: The colorectal metastatic liver disease sur- terventions (radio frequency ( 139) microvave (70) and vival and recurrence are negatively influenced by the laser ablation (20)) in healing of unresectable primary (31 ) aggressiveness of the tumor biology (id est the nodal and metastatic (198) patients with hepatic tumors since involvement) however the microscopic achievement of a 2012 till 2017 year. radical resection does not seem such a mandatory feature of All the patients were undergoing polychemotherapy the resective surgery. As a R1 resection is effective in course before operation. Local distruction of mass in the improving the overall survival, probably the concept of liver a size of 0.5 to 4 cm were done by dermal and cancer debulking should be revised in further studies. transhepatique abord under the control of ultrasound in a mode of a real time. Monitoring of effectiveness has been initiated through С EP01A-044 ultrasound, T , MRI with intravenous bolus increasing in a dynamic perspective. RECURRED COLORECTAL LIVER Results: Life expectancy in radio frequency ablation was 1 METASTASIS FOLLOWING INITIAL year - 73,5 %, two years - 53,3 %, three years - 32,1 %, five HEPATECTOMY: IS REPEAT years 24,6 %. Life expectancy in microvave ablation was 1 HEPATECTOMY JUSTIFIED? year - 78,5%, two year-63,3%, three year - 58,3%. Consclution:Usage of local methods of thermal J. Park, S. -D. Lee, S. -S. Han, S. -H. Kim, S. -J. Park and destruction in sick patients allows us to decrease risk of S. W. Park post-op complications through low traumatic and mini- National Cancer Center, Republic of Korea invasive methods and to improve clinical outcome for the Liver resection is considered the only curative treatment patients with unresectable primary and metastatic hepatic modality for colorectal liver metastasis (CRLM). Recur- lesions and to improve cancer indications. rence rate after hepatectomy, however, has been reported

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S349

EP01A-047 difference in perioperative and oncologic outcomes in pa- tients with colorectal metastases (CRM) who underwent LAPAROSCOPIC VERSUS OPEN TWO- anatomical and non-anatomical resections. STAGE HEPATECTOMY FOR BILOBAR From January 2001 to December 2016, all patients who COLORECTAL LIVER METASTASES: A underwent liver resection for CLM from the Singapore MULTI-INSTITUTIONAL STUDY WITH General Hospital were analysed retrospectively. Patients PROPENSITY SCORE MATCHING with extrahepatic metastases and those treated with both anatomical resection (AR) and non-anatomical resection ANALYSIS (NAR) for CLM were excluded. S. Okumura, D. Fuks, C. Goumard, T. Kawai, J. Danion, Overall median survival, recurrence free survival (i.e. O. Soubrane, B. Gayet and O. Scatton intra and extrahepatic recurrence) and intrahepatic recur- 1 Department of Hepatobiliary Surgery and Liver Trans- rence free survival were 51, 30.5 and 23 months respec- 2 plantation, Hôpital Pitié-Salpêtrière, Institut Mutualiste tively. 104 (39.2%) and 161 (60.8%) patients underwent 3 Montsouris, and Hôpital Beaujon, France AR and NAR respectively. Introduction: The safety and feasibility of laparoscopic On univariate analysis, elevated CEA level and major two-stage hepatectomy (TSH) for bilobar colorectal liver liver resections were associated with AR. R0 resection and metastases (CRLM) is poorly evaluated. smaller liver metastases size were associated with NAR. Method: Eighty patients who underwent complete TSH for There was no difference in perioperative complications and bilobar CRLM between 2007 and 2017 at three centers blood transfusion requirements between the 2 surgical (Hôpital Pitié-Salpêtrière, Institut Mutualiste Montsouris, groups. Hôpital Saint-Antoine) were enrolled. Laparoscopic and KaplaneMeier (KM) univariate survival analysis open TSH were compared after propensity score matching showed no difference in overall survival and recurrence (PSM). free survival between AR and NAR with p-values of 0.559 Results: Laparoscopic TSH was performed in 35 patients, and 0.114 respectively. while open TSH was performed in 45 patients. After PSM, There is no significant difference in perioperative and 23 laparoscopic and 23 open patients had similar preop- oncologic outcomes between AR and NAR. Therefore, erative and oncological characteristics. For the first stage, a NAR can be used as a safe procedure to preserve liver laparoscopic approach showed a trend toward less com- parenchyma and achieve curative resection of CLM. plications (13.0% vs. 34.8%; P = 0.084) and significantly shorter hospital stay (4 vs. 7 days; P = 0.004). The interval period was comparable between the groups (2.3 vs. 2.5 EP01A-049 months; P = 0.750). For the second stage, a laparoscopic PROGNOSTIC FACTORS AFTER approach was associated with a trend toward less liver- specific complications (26.1% vs. 52.2%; P =0.070), HEPATECTOMY FOR LIVER significantly shorter hospital stay (8.5 vs. 14 days; P = METASTASES OF NON-COLORECTAL 0.008) and earlier administration of adjuvant chemo- AND NON-NEUROENDOCRINE therapy (1.6 vs. 2.0 months; P = 0.039). Overall survival CANCER: SINGLE CENTER (OS) and disease-free survival (DFS) rates were compa- EXPERIENCE rable between the groups (3-year OS: 95.7% vs. 87.5%; P = 0.889; 3-year DFS: 22.1% vs. 8.1%; P =0.373).Repeat E. Santos, H. Alexandrino, L. Ferreira, R. Nemésio, hepatectomy for intrahepatic recurrence was more R. Martins, M. Serôdio, J. G. Tralhão, F. Castro e Sousa and J. Soares Leite frequently performed in the laparoscopic TSH group 1 (57.1% vs. 11.1%; P =0.049). Department of Surgery, Coimbra University Hospital, 2Faculty of Medicine, University of Coimbra, and Conclusions: Laparoscopic TSH is safe and feasible for 3 bilobar CRLM in selected patients with comparable onco- Department of Surgery, St. Vincents University Hospital, logical outcomes to open TSH. Ireland Introduction: Hepatic resection (HR) remains controver- sial in patients with non-colorectal and non-neuroendocrine EP01A-048 hepatic metastases (NCRCNNECLM). However, selected patients may benefit from an aggressive surgical approach. OUTCOMES OF ANATOMICAL AND We evaluated the prognostic factors associated with NON-ANATOMICAL RESECTION FOR improved overall survival (OS) in a series of patients un- COLORECTAL LIVER METASTASES dergoing hepatectomy for NCRCNNECLM in a single R. Radhakrishnan, H. L. R. Chen, Y. Liu, J. Y. Teo and center. S. A. Sumarli Methods: Between January 1991 and September 2017, 1Yong Loo Lin School of Medicine, National University of 74 patients (42 women, 59 13 years) underwent hepa- Singapore, 2General Surgery, Singapore General Hospi- tectomy for NCRCNNECLM. The primary tumour ori- tal, 3National University of Singapore, and 4Singapore gins were: breast (22 cases, 30%), stomach (20 cases, General Hospital, Singapore 27%), pancreatobiliary (18 cases, 24%) and others (14 cases, 19%). Hepatic resection is the most effective therapy for pa- Synchronous presentation was observed in 31 cases tients with colorectal liver metastases (CLM) with 5 year (42%). Single metastasis in 39 cases (53.4%); size of the survival of up to 58%. This study’s aim is to evaluate the

HPB 2018, 20 (S2), S333eS504 S350 Electronic Posters (EP01A-EP01E) - Liver largest metastasis 30 mm (5-130). Metachronous resection EP01A-051 performed in 55 cases (74%), with median time interval of 14 months (0-158) between both procedures. Most patients IMPACT OF THE EVOLUTION OF underwent minor hepatectomy (58 cases, 78%). Median SURGICAL APPROACH ON AFC score of 4 (1-6). 90-day postoperative morbidity RADICALITY OF RESECTION FOR defined by the Dindo-Clavien classification. Statistical COLORECTAL LIVER METASTASES: analysis with SPSS (v23.0) Survival probabilities with EXPERIENCE OF A HIGH VOLUME Kaplan-Meyer, log-rank and Cox regression (significance with p< 0.05). HEPATOBILIARY SURGERY CENTER Results: Major morbidity was seen in 15 cases (20.3%) and E. Panettieri, F. Ardito, A. M. De Rose, M. Vellone and mortality in three (4%). Median and 5-year OS were 28 F. Giuliante months and 24%, respectively. Independent predictors of Hepatobiliary Surgery Unit, Catholic University of the improved OS were: non-pancreatobiliary origin of primary Sacred Heart, Italy tumour, metachronous resection and absence of major Background: Parenchymal-sparing resections are now morbidity (p < 0.05). considered as the treatment of choice for multiple colorectal liver metastases (CRLM). Aim of this study was to evaluate how the rate of major liver resections (MLR) and multiple parenchymal-sparing resections (MPSR) and their impact on surgical radicality changed during the years. Methods: Inclusion criteria were MLR and MPSR for CRLM performed between 1992 and 2016. The study period of time was divided into 5 groups (5 years each) to evaluate the trend rate of R0 resections and of MPSR. Results: During the study period of time, out of 792 patients resected for CRLM, 273 underwent MLR and 173 MPSR. Rate of resected bilobar CRLM increased over the years, from 12.1% (first period) to 66% (last period) (p< 0.001). Mean number of resected CRLM increased from 1.91.6 to 4.90.2 (p< 0.001). Rate of MLR significantly decreased from 53.2% to 28.1% (p< 0.001). Rate of MPSR significantly increased from 0 to 31.4% (p< 0.001). Overall R0 resection rate was 66.8% and it significantly decreased during the years (90.9% vs. 56.2%; p< 0.001). Overall R0 resection rate was not significantly different between MLR and MPSR (70.0% vs. 61.8%; p=0.07). During the last period of time R0 resec- tion rate was 57.3% in MLR and 55.1% in MPSR (p=0.76). Conclusions: During the study period of time MPSR progressively increased together with a decrease of MLR. R0 resection rate decreased due to the more complex and advanced resected disease, however R0 resection rate was similar between MLR and MPSR patients.

EP01A-052 RESULTS OF RESECTION OR RESECTION PLUS ABLATION OF COLORECTAL LIVER METASTASES: EVALUATING THEIR EFFECTS FOR A BETTER OUTCOME Figure 1 Over all survival in the study population (N = 74 patients) A. Chiappa1, D. Foschi2, M. G. Zampino3, F. Orsi4, undergoing hepatectomy for non-colorectal and non-neuroendocrine M. Venturino5, G. Pravettoni6, C. Ferrari7, G. Novelli7, hepatic metases. A. Kaplen–Meier graph of overall survival (5 years OS L. Macone8 and R. Biffi9 1 of 31.8% and median survival of 28 months). B. Kaplen–Meyer graph Unit of Innovative Technique Surgery, University of Milano/ 2 of overall survival demonstrating improved over all survival in patients European Institute of Oncology, Surgical-Oncologic and undergoing metachronous versus synchoronous resection (p < 0.001). Gastroenterologic Department, University of Milano/Hos- pital ’Luigi Sacco’, 3Division of Medical Oncology for Gastro-Intestinal and Neuro-Endocrine Tumours, European Conclusion: In selected cases HR can offer improved Institute of Oncology, 4Division of Interventional Radiology, survival to patients with NCRCNNECLM. Metachronous European Institute of Oncology, 5Division of Anesthesiology, resection, reflecting a more favourable tumor biology, is a European Institute of Oncology, 6Applied Research Division key factor for adequate selection of candidates for liver for Cognitive and Psychological Science, University of resection. Milano/European Institute of Oncology, 7School of General

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Surgery, Unit of Innovative Technique Surgery, University of performed multivariate analyses including the CRS (node- Milano/European Institute of Oncology, 8University of positive primary, disease-free interval from primary to Milano, and 9Division of Digestive Tract Surgery, European metastases < 12months, multiple liver metastases, largest Institute of Oncology, Italy hepatic tumor>5cm, and carcinoembryonic antigen Introduction: This study determines the oncologic level>200ng/mL) and mutational status of RAS and BRAF outcome of the combined resection and ablation strategy to determine the main risk factors of OS and DFS. for colorectal liver metastases (CRLM). Results: A total of 255 patients were eligible for analysis. Materials and methods: Between January 1994 and KRAS mutation was detected in 48% of the patients, BRAF December 2015, 373 patients underwent surgery for in 10%, NRAS in 8% and Herb3 in 0%. On multivariate CRLM. There were 284 patients who underwent hepatic analysis RAS mutation was associated with poor DFS resection only (Group 1) and 83 hepatic resection plus (HR=1.60;p=0.027), as were positive primary tumor lymph ablation (Group 2). node status (HR=1.92; p=0.006), bilobar distribution of Results: Group 2 patients had a higher incidence of mul- metastases (HR=2.08;p=0.006) and synchronous CRLM tiple metastases than Group 1 cases (100% in Group 2 vs. (HR=1.92;p=0.006). The main risk factors for OS on 28.2 % in Group 1; P < 0.001) and bilobar involvement multivariate analysis were the combination of positive (76.5% in Group 2 vs. 12.9% in Group 1; P < 0.001). primary tumor lymph node status (HR=3.02;p=0.0003) and Perioperative mortality was nil in either group with a higher RAS mutation (HR=1.68;p= 0.038). postoperative complication rate amongst Group 1 vs Group Conclusions: Only the positive primary tumor lymph node 2 cases (18 vs. 0, respectively). The median follow-up was status from the CRS remains as the main risk factor 90 months (range: 1-180) with a 5-year overall survival for predicting both DFS and OS. Additional factor, as RAS Group 1 and Group 2 of 51% and 80%, respectively mutation, may improve the prognostic power of the CRS. (P=0.193). The median disease-free survival for patients with R0 resection was 55%, 40% and 37% at 1, 2 and 3 years, respectively, and remained steadily higher (at 50%) EP01A-055 in those patients treated with resection combined with IMPACT OF COMPLICATIONS ON ablation out to 5 years (P=0.069). The only intraoperative LONG-TERM OUTCOMES AFTER ablation failure was for a large lesion (5 cm). Conclusions: Our data supports the use of intraoperative SURGERY OF COLORECTAL LIVER ablation when complete hepatic resection cannot be achieved. METASTASES M. C. Fernández-Moreno, D. Dorcaratto, I. Mora-Oliver, EP01A-053 M. Garcés-Albir, E. Muñoz-Forner, L. Sabater-Ortí and MUTATIONAL PROFILE J. Ortega-Serrano APPLICABILITY IN THE PROGNOSIS Hospital Clinico Universitario de Valencia, Spain OF RESECTED COLORECTAL LIVER Introduction: The relationship between postoperative fi METASTASES BEYOND THE complications (POC) and cancer-speci c outcomes after resection of colorectal liver metastases (CRLM) remains CLASSICAL CLINICAL RISK SCORE unclear. The aim of this study was to investigate the C. Dopazo-Taboada1, T. Sauri2, A. Herrando3, prognostic impact of POC after CRLM resection. J. Hernández3, A. Vivancos4, P. Nuciforo4, R. Charco1, Methods: Retrospective study of patients undergoing CRLM R. Dientsmann5, J. Tabernero2 and E. Elez2 resection between 2000 and 2016 at one tertiary hospital. POC 1Department of HPB Surgery and Transplants, Hospital were classified according to Dindo-Clavien grade, type of Universitario Vall d’Hebron, 2Department of Oncology, postoperative complication (medical, surgical or surgical site Research Unit for Molecular Therapy of Cancer, Vall infection) and the comprehensive complication index (CCI). d’Hebron Institut of Oncology, Hospital Universitario Vall Primary outcomes were overall (OS) and disease free survival d’Hebron, 3Department of Oncology, Vall d’Hebron (DFS). Patients’ demographic and oncologic features were Institut of Oncology, Hospital Universitario Vall collected and included in multivariate analysis. d’Hebron, 4Department of Oncology, Cancer Genomics Results: Of the 209 included patients, 89 patients (42%) Group, Vall d’Hebron Institut of Oncology, Hospital developed POC. POC had a negative impact on 3-5 years Universitario Vall d’Hebron, Universidad Autónoma de and median OS and DFS (3 years OS/DFS 57%/25% for Barcelona, Spain, and 5Department of Oncology, Group POC vs 68%/41% for no-POC, p=0,03/0,02, 5 years OS/ Oncology Data Science, Vall d’Hebron Institut of DFS 39%/21% for POC vs 52%/34% for no-POC, Oncology, Hospital Universitario Vall d’Hebron p=0,007/0,02, median OS/DFS 42/14 months for POC vs Background: Following resection of colorectal liver 68/20 months for no-POC, p=0,019/0,083). Patients who metastases(CRLM), at least 60% to 70% of patients recur at presented surgical site infections had worst oncologic a median of 16 months. In addition to the classical clinical outcomes than patients who did not (3 years OS/DFS 66%/ risk score(CRS) of Fong used to predict the outcome of 37% vs 50%/17%, p=0,085/0,008, 5 years OS/DFS 48%/ these patients, the predictive molecular markers are in 32% vs 35%/13%, p=0,13/0,006 and median OS/DFS 55/ increasing interest. 19 months vs 42/12 months, p=0,007/0,02 respectively). Objective: The aim of this study was to evaluate how the CCI > 26.2 was a risk factor for worst OS (48 months for mutational profile(RAS/BRAF) associated to the CRS CCI>26.2 vs 98 months for CCI< 26.2, p=0,007). Multi- impact in overall(OS) and disease-free survival(DFS). variate analysis confirmed these results. Methods: Patients with CRLM who underwent hepatec- Conclusion: Postoperative complications, especially surgical tomy in our institution between 2008 and 2016 were site infection, have a negative prognostic impact after surgical retrospectively analyzed from a prospective database. We resection of CRLM. CCI>26.2 is a predictor of worse OS.

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EP01A-058 colorectal liver metastases (CRLM), our center uses he- patic arterial infusion(HAI) in combination with systemic RADIOFREQUENCY ABLATION OF to intensify regional therapy. New approaches are needed LIVER METASTASES OF ENDOCRINE to monitor disease status to guide patient-tailored treat- TUMORS: WHAT IS THE LIMIT OF THE ment. We discovered a novel circulating hybrid cell(CHC): NUMBER. A CASE REPORT a cancer cell fusion product that can be isolated in pe- ripheral blood. We report on the use of CHCs as a N. Annane, F. Alibenamara, K. Haddad, A. Bennani and biomarker reflective of treatment response and disease L. Abid status. Surgery, EPH Bologhine IBN ZIri, Algeria Methods: Peripheral blood samples from patients with Introduction: VIPoma is uncommon neuroendocrine unresectable CRLM were obtained prior to initiation of tumor originating from the pancreas with a high potential HAI and at several time points during their treatment for developing liver metastases. VIPoma is associated with course. Flow cytometry was performed to evaluate CHCs secretory diarrhea and electrolyte disturbances. It is often and conventional circulating tumor cells(CTCs). manifested by an excess of hormone production. 50 to 75% Results: Over a 12-month period, four patients treated with are malignant. Their prognosis is bad. HAI+systemic therapy were followed. CHCs were detec- Observation: We present a patient of 50 years, without tible in peripheral blood and outnumbered CTCs. Across medical history, presenting liver metastases and isthmic patients, CHC levels increased with dose reductions in pancreatic VIPoma of 20 mm. The maximum of metastases chemotherapy and decreased with treatment intensification. was located in the right liver. He was operated on april CTCs did not increase until after there was radiographic 2014, intraoperative exploration found multiple right he- evidence of disease progression. Moreover, an increase in patic metastases about 20 mm in diameter and 3 hepatic CHCs was evident prior to elevations in CEA or radio- fi metastases from 10 to 25 mm and 100 whitish super cial graphic evidence in patients who developed extrahepatic lesions in left liver. Patient underwent radiofrequency of progression of disease (Figure). 100 lesions and metastasectomy of 2 peripheral metastases Conclusion: Our study supports that CHCs are potentially and a RFA of deep liver metastase in left liver, and ligation more sensitive than traditional biomarkers with increased of the right portal branch and central pancreatectomy for levels directly portending radiographic extrahepatic disease fi the Vipoma. The outcomes found a pancreatic grade I s- progression. We believe CHCs deserve further study as a tula with diarrhea for which he was treated by octreotide. novel non-invasive, sensitive liquid biopsy that can monitor Patient underwent 3 months later right hepatectomy with disease state and temporally assess treatment respons. RFA for one metastases in the left liver . Chemotherapy (Capecitabine) was administrated with octreoide. Patient is alive at 44 months remained asymptomatic, examination is normal, CT scanner showed no liver recurrences. Patient returned to a productive life. Conclusion: Vipoma is generally malignan endocrine tumor, resection improves patient survival. RFA may be feasible, effective and sustainable therapeutic modality for patients with metastatic VIPoma who are clinically symp- tomatic. An aggressive approach is warranted in liver me- tastases of vipoma.

Abstract figure A patient with unresectable multifocal rectal cancer EP01A-059 metastatic to the liver treated with hepatic arterial infusion (HAI) + USE OF CIRCULATING CANCER CELL systemic FOLFOX followed longitudinally. Red arrows indicate reduc- HYBRIDS TO MONITOR TREATMENT tion in chemotherapy. Yellow arrows indicates radiation therapy (XRT). RESPONSE TO HEPATIC ARTERIAL Black arrow indicates radiographic extrahepatic disease progression. INFUSION IN PATIENTS WITH CHCs rise with reduction in regional and systemic therapy and fall with COLORECTAL CANCER METASTATIC treatment intensification (here Pelvic XRT). The rise in CHCs precedes TO THE LIVER that of carcinoembryonic antigen (CEA) and any evidence of progres- L. Zarour1, J. Swain2, K. Billingsley3,4, C. Lopez4,5, sion on cross-sectional imaging. G. Vaccaro4,5, N. Nabavizadeh4,6, M. Wong2,4 and S. Mayo1,4 1Division of Surgical Oncology, 2Department of Cell Developmental & Cancer Biology, 3Department of Surgi- EP01A-060 cal Oncology, Oregon Health & Science University NOVEL ROLE FOR FATTY ACID 4 (OHSU), Knight Cancer Institute at OHSU, United BINDING PROTEIN-4 (FABP4) IN States, 5Division of Hematology and Medical Oncology, Oregon Health & Science University, and 6Department of HEPATOCELLULAR CARCINOMA Radiation Medicine, Oregon Health & Science University, (HCC) PROGRESSION United States M. Patetta1, Z. Stello1, J. Lee1, C. Jacobs2, K. Gersin1, 1 1 1 Introduction: Metastatic disease to the liver is the leading D. Iannitti , I. Mckillop and K. Thompson 1 2 cause of death in patients with metastatic colorectal Surgery, Carolinas Medical Center, and Pathology, cancer(mCRC). For patients with multifocal unresectable Carolinas Medical Center, United States

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Introduction: FABP4 is normally expressed in adipocytes and reviewed along with 30-day post-operative morbidity and macrophages and normally regulates intracellular lipid and mortality. trafficking. Recent data suggests FABP4 is elevated in non- Results: At index hepatectomy, major resection, positive alcoholic liver disease, and may be released into the cir- margins, 5 or more tumour deposits, poor tumour differ- culation to act as a paracrine/endocrine signaling molecule. entiation were all associated with poorer overall survival. This study sought to determine FABP4 expression and Similarly elevated serum neutrophils and neutrophil correlation with NAFLD activity score (NAS) in patients lymphocyte ratio were negatively associated with outcome. with liver disease, and identify mechanism(s) by which Repeat hepatectomy was performed in 57 patients with 1-, FABP4 may affect disease progression. 3- and 5-year survival of 75.7%, 34.8% and 19.7% Methods: FABP4 was measured in serum from patients respectively (median 26.5 months). Neither serum neutro- with and without liver disease by ELISA, and compared to phil count (p=0.42) nor neutrophil lymphocyte ratio NAS from biopsies. To examine the role of FABP4 in HCC (p=0.81) were shown to have prognostic effect in patients cell function, human HCC cells (HepG2 and HuH7) were undergoing repeat hepatectomy. The only negative pre- treated with exogenous FABP4 (0-100ng/mL) and dictor of survival following repeat hepatectomy was analyzed for p38-MAPK, Erk1/2, and JNK1/2 activity. In tumour diameter greater than 5cm (p=0.04). parallel, proliferation and migration assays were performed Conclusion: Despite a clear association between elevated using cells pretreated with inhibitors of p38MAPK neutrophil lymphocyte ratio and shorter overall survival (SB203580), Erk1/2 (U0126), or JNK1/2 (SP600125), following index hepatectomy, no such association exists followed by exogenous FABP4 treatment. following repeat resection. Further studies are needed to Results: Patients with NAFLD/ALD and HCC exhibited elucidate which patients might benefit most from repeat significantly elevated FABP4 serum-levels compared to hepatectomy. healthy subjects, and FABP4 levels correlated with increased NAS. Treatment of HCC cells with FABP4 resulted in increased phospho-Erk1/2 activity, but not EP01A-062 p38MAPK or JNK1/2 activity. Pretreatment with U0126 SINGLE PHOTON EMISSION abrogated FABP4-mediated Erk1/2 activation and signifi- cantly inhibited FABP4-mediated HCC cell proliferation COMPUTED TOMOGRAPHY (SPECT) IN and migration. THE PLANNING OF SURGICAL Conclusions: Serum FABP4 represents a novel circulating TACTICS IN EXTENSIVE RESECTIONS marker of underlying hepatosteatosis, and FABP4 pro- OF THE LIVER motes HCC proliferation/migration via an Erk1/2-depen- A. Shabunin, M. Tavobilov, D. Grekov and P. Drozdov dent pathway. These data suggest a potential role for City Clinical Hospital named by Botkin S.P., Russian FABP4 as a non-invasive biomarker for liver disease pro- Federation gression, and suggest elevated FABP4 levels in hepatos- teatosis may play a role in HCC development/progression. Objective: To determine the indications for stage treatment when planning extensive liver resections using SPECT/CT. Material and methods: From 2007 26 patients in the surgical clinic of the Botkin Hospital had anatomical EP01A-061 volume of FLR (aFLR) less than 30% in the planning of NEUTROPHIL LYMPHOCYTE RATIO advanced liver resections, which is an indication of portal DOES NOT PREDICT OUTCOME AT vein empbolisation (PVE), followed by resection (with REPEAT HEPATECTOMY FOR aFLR increase to 30% or more). From 2007 to 2014 two- COLORECTAL LIVER METASTASES stage treatment was applied to 15 patients (group 1). From 2015 to 2017, preoperative examination included SPECT/ F. Hand1, C. Harrington2, D. Maguire1, J. Geoghegan1 and 1 CT. The indication for a two-stage treatment was the E. Hoti volume of functioning FLR (fFLR) of less than 30% (group 1National Liver Unit, St. Vincents University Hospital, and 2 2). The second group included 11 patients. Royal College of Surgeons in Ireland, Ireland Results: In the first group (n = 15), all patients underwent Repeat hepatectomy for recurrent colorectal liver PVE, 9 of them operated: extended right-sided hemi- metastasis is a safe procedure with similar morbidity and hepatectomy (RPGE)-5, right-sided hemihepatectomy mortality to index resection. However, there remains (PGEGE)-4. Acute postoperative liver failure (PLF) ambiguity surrounding optimum patient selection for developed in 1 patient (11,1%). In the second group, the repeat surgery. We aimed to establish if neutrophil need for PVE was determined after receiving SPECT/CT lymphocyte ratio has a prognostic role following repeat data. In 5 patients, the volume of fFLR was 30% or more. hepatectomy. These patients were: PGGE-3, RPGGE-2. In 6 patients, the Methods: From 2005 to 2015, 379 patients meeting the volume of fFLR was less than 30%, and a two-stage inclusion criteria underwent hepatic resection for CRLM method of treatment was used. Radically operated 5: at our institution. In all, 322 underwent an index hepa- PGEGE - 3, RPGGE-2. There were no signs of PHI and tectomy and 57 second hepatectomies were performed. death in this group of patients. All clinicopathological data were obtained from a pro- Conclusions: In the planning of extensive liver resections, spectively maintained database. Variables associated the use of SPECT/CT can identify a group of patients with a with long-term survival following index and second high risk of acute PLF and carry out a set of measures for its hepatectomy were identified by Cox regression analyses surgical prevention.

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EP01A-063 patients with simultaneous liver and lung metastases syn- chronous with the primary tumour are lacking. SINUSOIDAL ENDOTHELIAL CELLS Methods: Eight patients with simultaneous liver and lung AND VASCULAR ENDOTHELIAL metastases synchronous with the primary tumour who un- GROWTH FACTOR ARE KEY PLAYERS derwent resection with curative intent were identified from IN AN IN-VITRO MODEL OF May 1st 2002 to December 31th 2016 within our database. OXALIPLATIN-INDUCED SINUSOIDAL Results: Out of those patients were 5 women, median age was 54,3 years (38,7 to 77,5). The site of primum was in OBSTRUCTION SYNDROME colon by 2 and in rectum by 6 patients. Simultaneous 1 1,2 1 1 A. S. Beierle , S. Knitter , S. Pesthy , G. Duwe , colorectal and liver resection were performed in 4 and liver 1,2 1 1 1 R. B. Schmuck , I. M. Sauer , M. Schmelzle , M. Bahra , first by 3 patients. Simultaneous liver and lung resection 1 1 J. Pratschke and A. Andreou was performed in 1 patient. In all procedures was the 30 1 Department of Surgery, Charité - Universitätsmedizin days’ mortality 0 and the morbidity grade Clavien- Dindo 2 Berlin, and Berlin Institute of Health (BIH), Germany IIIa or higher was in one patient. Tumour recidive was Introduction: Oxaliplatin as part of systemic treatment for diagnosed in 7 out of 8 patients with mean relapse- free colorectal liver metastases (CLM) has been associated with survival of 9 months (min 3, max 17 months). Six patients the development of sinusoidal obstruction syndrome died with overall survival of 36 months (17 to 46). One (SOS). While the role of hepatocytes and sinusoidal patient lives with tumour recidive 42 months and one is endothelial cells in the pathogenesis of SOS remains un- recidive free for 46 months after diagnosis. clear, bevacizumab, an inhibitor of vascular endothelial Conclusion: Despite unfavourable prognosis could some growth factor (VEGF), is considered to prevent SOS. The patients with synchronous and simultaneous liver and lung aim of this study was to analyse cytotoxicity of oxaliplatin- metastases of colorectal cancer profit from surgery in the based treatment regimens and expression of VEGF in an in- meaning of prolonged survival. Therapy planning in vitro model of SOS. multidisciplinary tumour board as well as multimodally Methods: Human hepatic sinusoidal endothelial cells treatment are considered to be a significant advantage. (HHSEC) and HepG2 cells (human liver cancer cell line) were incubated with either oxaliplatin, bevacizumab or both for 12 to 60 hours. Cytotoxicity was analysed by EP01A-065 CellTox green assay. Protein levels of VEGF and matrix THE RELATIONSHIP BETWEEN metallopeptidase 9 (MMP9) were measured by ELISA. Cytoskeletal changes were identified by F-Actin immuno- CIRCULATING TUMOUR CELLS AND fluorescence. Cell proliferation and migration were THE HISTOPATHOLOGICAL GROWTH analysed using a scratch assay. Liver transaminases were PATTERN OF RESECTABLE measured by photometric determination. COLORECTAL LIVER METASTASES Results: Supernatant of HHSEC had increased VEGF D. J. Höppener1, P. M. H. Nierop1, P. B. Vermeulen2,3, levels after 48h hours of treatment with oxaliplatin D. J. Grünhagen1 and C. Verhoef1 compared to supernatant of HepG2 cells (382.2 vs. 23.73 1Surgical Oncology, Erasmus MC, Kanker Instituut locatie pg/mL). Additional administration of bevacizumab on Danïel den Hoed, The Netherlands, 2Translational Cancer HHSEC facilitated a significantly decreased cytotoxicity Research Unit, GZA Hospitals & CORE Antwerp Uni- compared to oxaliplatin alone (4.13 vs. 5.52 RFU, versity, and 3HistoGeneX, Belgium P=0.004). Conclusion: Our findings suggest that oxaliplatin has a Introduction: Multiple studies have shown the prognostic major impact on HHSEC resulting in increased expression value of the histopathological growth pattern (HGP) for of VEGF as a key player of oxaliplatin-induced SOS. survival following resection of colorectal liver metastases Additionally, anti-VEGF seems to protect the HHSEC from (CRLM). Patients with a desmoplastic HGP (dHGP) the cytotoxic effect of oxaliplatin. These results may exhibit greatly improved survival compared to patients with improve our understanding of the pathogenesis of SOS and a non-desmoplastic HGP (non-dHGP). The current study optimize multimodal treatment of patients with CLM. investigated the relationship between circulating tumour cells (CTCs) and the HGP. Methods: Patients in whom CTCs were prospectively sampled (CellSearch System) in 30ml of arterial blood prior EP01A-064 to resection of isolated CRLM between June 2008 and May SURVIVAL OF THE COLORECTAL 2012 were eligible for inclusion. The HGP was retrospec- CANCER PATIENTS WITH tively scored by an experienced pathologist and at least two SYNCHRONOUS AND SIMULTANEOUS trained researchers using light-microscopy. Possible pre- LIVER AND LUNG METASTASES dictive clinicopathological variables for HGP were inves- tigated by fitting a multivariable regression model. The UNDERGOING RADICAL SURGERY detection rate of CTCs in patients with dHGP and non- M. Varga, A. Dinnewitzer, T. Jäger, J. Presl, J. Hutter and dHGP was investigated by a chi-squared test. K. Emmanuel Results: A total of 202 patients with CTC and HGP data Department of Surgery, Paracelsus Medical University, available were included. dHGP was observed in 54 patients Austria (26.7%) and non-dHGP in 148 patients (73.3%). CTCs Introduction: In patients with liver or lung metastasis of were detected in 84 (41.6%) of patients. A significantly colorectal cancer is the resection well established strategy. higher proportion of detectable CTCs was found in patients However, the data of overall and relapse- free survival in with non-dHGP (48.6%) compared to patients with dHGP

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(22.2%) (p=0.001). The only significant predictor for non- (CRLMs). Their presence is considered as a factor of poor dHGP was detectable CTCs (odds ratio: 2.39 95%CI prognosis and of early recurrence. Three types of treatment 1.07;5.63, p=0.037). are possible: the “classic” strategy, the “combined” strat- Conclusion: A significantly higher rate of circulating egy, and the “reverse” strategy. The purpose of our study is tumour cells were detected in patients with non-dHGP and to analyze the results of these three strategies on the overall detectable circulating tumor cells was the only significant survival rate, the survival rate without recurrence and the predictor for the presence of non-dHGP. complication rate. Methods: All patients treated for CRLMs between October 2000 and May 2015 were included in a single center. Three EP01A-066 groups were created based on their treatment: 1/ classic: LIVER RESECTION IN PATIENTS WITH treatment of primary tumor, then liver; 2/ combined: pri- mary tumor and liver treatment during the same surgery; 3/ METASTATIC BREAST CANCER reverse: liver, then primary tumor. M. Varga, E. Ahmic, O. Koch, A. Dinnewitzer and Results: 209 patients were included, 149 in the classic K. Emmanuel group, 34 in the combined group and 26 in the reverse Department of Surgery, Paracelsus Medical University, group. The overall survival rate at 5 years was 44% without Austria significant differences, with a median survival rate of 50 Introduction: Breast cancer is the secondary cause of months. The survival rate without recurrence was 24% at 5 cancer mortality in women. The majority of deaths are years, with a median survival rate without recurrence of 13 caused by metastasis. Isolated liver metastases are diag- months, without significant difference. The complication nosed in 2-12 % of patients. Liver resection is nowadays rate was significantly higher in the combined group, while part of the multidisciplinary therapy in selected patients. the hepatic resections were less extended. The data about long-term survival are scarce. The aim of Conclusion: All three strategies are feasible with a com- our study was to elucidate overall and recurrence- free parable survival rate. However, the combined strategy does survival of these patients. not give the best oncological results even if the patients Method: We identified 16 patients who underwent liver have more limited hepatic resections, probably caused by resection because of isolated breast cancer metastasis over a an excess of major postoperative complications. period between 04/2006 and 12/2017 at the University Hospital of Salzburg. Results: All patients were women, the median age was 64 EP01A-068 years (range 35- 76). The median time from diagnosis of PREDICTING LOCAL REGROWTH breast cancer to metastasectomy was 37 months (range 1- AFTER RADIOFREQUENCY ABLATION 189). Liver metastasectomy was performed in all except one patient in whom left hemihepatectomie was performed. OF COLORECTAL LIVER METASTASES Six resections (37,5%) were done laparoscopically. Com- BY 3D MERGING OF PRE- AND POST- plications grade Clavien- Dindo IIIb and higher was in 1 ABLATION IMAGING (6,25%) patient and 30 days mortality was 0%. Recurrence B. G. Sibinga Mulder1, P. Hendriks2, T. R. Baetens2, was diagnosed in 10 (62,5%) patients with median recur- A. van Erkel2, C. J. H. van de Velde1, A. L. Vahrmeijer1, rence-free survival of 15 months after liver resection (range M. C. Burgmans2 and J. S. D. Mieog1 4- 39). Six patients (37,5%) were alive without recurrence, 1Surgery, and 2Radiology, Leiden University Medical fi ve of them over 5 years. The overall survival in the whole Center, The Netherlands group was 45 months (range 7- 126). Introduction: Radiofrequency ablation (RFA) for colo- Conclusion: The resection of breast cancer liver metastasis rectal liver metastasis (CRLM) requires a wide margin to promises in significant portion of selected patients long prevent local recurrence(LR) , although the minimal term survival. Further parameters need to be identified for required margin is unknown. Moreover, no reliable tool is personalized therapy. available for post-ablation margin assessment. In this study, we evaluated feasibility of 3D margin assessment and correlation of minimal margins to LR. EP01A-067 Methods: Retrospectively 30 patients were included, all WHAT IS THE BEST STRATEGY FOR A treated with percutaneous RFA for a solitary CRLM. Pre- CURATIVE TREATMENT OF and post-ablation CT scans were loaded into RTx Mirada SYNCHRONOUS COLORECTAL LIVER software and merged by two independent radiologists METASTASES? based on venous structures in proximity of the tumor. Tumor and ablation volumes were determined on both 1 1 1 1 C. Maulat , L. Raoux , A. Hantoush Al Ali , D. Dousse , scans based on automatic contour detection. Subsequently, 2 2 3 4 N. Fares , R. Guimbaud , J. Selves , F. -Z. Mokrane , minimal margins were determined and correlated with 1 1 B. Suc and F. Muscari occurrence of LR within one year during follow-up. Inter- 1 2 Chirurgie Digestive et de Transplantation, Oncologie observer agreement was calculated. 3 4 Digestive, Anatomopathologie, and Radiologie, CHU Results: In twelve patients merging was too unreliable to Toulouse, Hôpital Rangueil, France assess the ablation margin, the remaining 18 patients, with Introduction: At the time of diagnosis, 14 to 17% of pa- high-quality merged scans, were included. Technical suc- tients have synchronous colorectal liver metastases cess was reported in all patients at the time of the

HPB 2018, 20 (S2), S333eS504 S356 Electronic Posters (EP01A-EP01E) - Liver procedure based on qualitative assessment. LR was by our CRC liver metastasis cohort. RAE1 knockdown detected in nine patients, of which eight tumors were in DLD1 and HCT116 cells repressed cell growth, in- incompletely ablated, compared with nine patients without vasion, and migration. LR, in whom eight tumors were completely ablated with a Conclusions: We discovered a CRC liver metastasis-spe- minimal obtained margin of 1 mm (p-value = 0.003). cific gene-RAE1,through intensive validation. RAE1 may There was perfect inter-observer agreement (K=1.000, p< function as a prognostic factor in CRC patients with liver 0.001). metastasis. Keywords: RAE1, colorectal cancer (CRC), Prognosis, Biomarker, Liver metastasis

EP01A-070 ONCOLOGIC BENEFIT OF REPEAT LIVER RESECTION IN PATIENTS WITH LIVER-ONLY RECURRENT COLORECTAL METASTASES S. T. Alexandrescu1, C. Zlate1, A. Diaconescu1, R. Grigorie1, D. Blanita1, S. Dima1, I. Gramaticu2, A. Croitoru2, D. Tomescu3 and I. Popescu1 1Dan Setlacec Centre of General Surgery and Liver Figure [Merged scans: LR or no LR] Transplantation, 2Department of Oncology, and 3Center of Anesthesiology and Intensive Care, Fundeni Clinical Institute, Romania Conclusion: Automated 3D margin assessment appears to Introduction: Although repeat liver resection (RLR) is predict LR. We will determine the potential of real-time recommended in patients with recurrent colorectal liver- margin assessment in improving local control by direct re- limited metastases (CLMs) after initial hepatectomy, ablation if necessary in a prospective, randomized clinical conflicting data regarding the actual oncologic benefitof trial. this approach were reported. Methods: Between March 1996 and February 2016, 566 patients with initially resectable CLMs underwent curative- EP01A-069 intent surgery. Out of these, 143 developed liver-limited RAE1 IS A NOVEL BIOMARKER TO recurrent metastases (RCLMs) and 67 of them underwent fi IMPROVE CLINICAL PREDICTION IN RLR (2-LR group). 499 patients underwent only the rst liver resection (1-LR group). In the 1-LR group, the sur- COLORECTAL CANCER LIVER vival was calculated from the time of initial hepatectomy, METASTASIS: INTEGRATING while in the 2-LR group, the survival was calculated BIOINFORMATICS ANALYSIS starting with the time of second hepatectomy. We L. Jingdong compared the oncologic outcomes of patients from these North Sichuan Medical College, China two groups. Results: The characteristics of the two groups were Background: Liver metastasis is common in patients with similar (Table). The differences in morbidity (p = colorectal cancer (CRC), and is correlated with poor 0.5091) and mortality (p = 0.7362) rates were not sig- outcome. It is crucial to target the key genes controlling nificant between the two groups. In 2-LR group, median pathogenesis in CRC liver metastasis. DFS (13 vs. 14 months, p = 0.144) and median OS (28 Methods: In this study, we performed an integrated bio- vs. 37 months, p = 0.393) were similar to those achieved informatics analysis of four CRC liver metastasis mRNAs in 1-LR group. Moreover, in patients with RCLMs, the expression datasets from Gene Expression Ominus survival rates were compared between patients who un- (GEO). The expression of RAE1 was validated in the derwent RLR (67 patients) and those who were not re- independent validation sample cohort. We knocked down resected (76 patients). The median OS was significantly the expression of RAE1 in Colon cancer cells expressing higher in patients who underwent RLR than in patients high level RAE1, after which cell proliferation, migration, who were not re-resected (30 vs. 18 months, respec- invasion were assayed. Xenograft mouse models were tively; p < 0.0001). used to determine the role of RAE1 in CRC tumorige- Conclusion: Repeat liver resection for recurrent CLMs nicity in vivo. offers similar oncologic benefits as the first hepatectomy, Results: RAE1 was demonstrated to be potentially significantly improving survival of patients with recurrent useful diagnostic markers in the clinical setting. CRC liver metastases. liver metastasis with a high level of RAE1 in tumor tissues had significantly shortened survival as revealed

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EP01A-070 Table[Characteristics and outcomes of 1-LR vs 2-LR group] One resection (1-LR group) Repeat resection (2-LR group) p value n[499 n[67 Male/Female 289/210 36/31 0.5142 <5cm/>=5cm CLMs 324/174 50/15 0.0689 Single/Multiple CLMs 303/196 40/25 1 Unilobar/Bilobar CLMs 389/110 52/13 0.8731 Minor/Major hepatectomy 403/96 54/12 1 Neoadjuvant chemo/No neoadjuvant chemo 105/394 10/57 0.3311 Major morbidity (grade 3-5 Dindo-Clavien) 59 (11.82%) 8 (11.94%) 1 Median DFS (months) 14 13 0.144 Median OS (months) 37 28 0.393

EP01A-071 EP01A-072 RESECTION OF HEPATIC AND PRINGLE MANEUVER AND RISK OF EXTRAHEPATIC RECURRENCE COLONIC LEAKAGE IN COMBINED FOLLOWING LIVER RESECTION FOR COLORECTAL AND HEPATIC COLORECTAL LIVER METASTASES: A RESECTIONS: MYTH OR REALITY? SINGLE CENTER ANALYSIS F. Ratti1, D. Fuks2, F. Cipriani1, B. Gayet1 and 1 E. Panettieri1, F. Ardito1, M. Chiappetta2, D. Nachira2, L. Aldrighetti 1 I. Scoleri1, M. Vellone1, S. Margaritora2 and F. Giuliante1 Hepatobiliary Surgery Division, IRCCS San Raffaele 2 1Hepatobiliary Surgery Unit, and 2Thoracic Surgery Unit, Hospital, Italy, and Department of Digestive Disease, Catholic University of the Sacred Heart, Italy Institut Mutualiste Montsouris, France Background: The role of repeated liver resections for Background: The aim of the present study was to compare patients with liver recurrence after hepatectomy for colo- the outcome of combined colorectal and hepatic resections rectal metastases (CRLM) is widely recognized. Aim of with and without pringle maneuver and to analyse the this study was to evaluate the outcome of patients resected possible effect of liver-related factors on colonic anasto- for both hepatic and extrahepatic recurrence after liver mosis leakage. resection. Methods: 250 Combined colorectal and hepatic resections Methods: Between 1992 and 2016, 792 patients have been performed in two european referral centers were stratified resected for CRLM at our institution. We evaluated the according to intraoperative use of Pringle maneuver. 71 outcome of patients who underwent resection for hepatic procedures with Pringle (Pringle group) were matched with and/or extrahepatic recurrence. 71 procedures without pringle (NoPringle group) using Results: During the study period of time 154 patients propensity scores in a 1:1 ratio. (19.4%) underwent recurrence resection after hepatectomy: Results: The two groups resulted similar in terms of pre- 103 patients (66.9%) underwent one recurrence resection, operative characteristics (distibution of rectal tumors and 31 (20.1%) two recurrence resections and 20 (13%) three or neoadjuvant treatments). Intraoperative blood loss was more recurrence resections, with a 5 years overall survival reduced in the Pringle Group (150 100 mL) compared respectively of 70.1%, 73.1% and 65.7% (p=0.508). Sixty- with the noPringle group(250 200 mL, p=0.05), while seven patients (43.5%) underwent only liver re-resection, postoperative morbidity (29.5% and 32.4% respectively) 59 (38.3%) only extrahepatic recurrence resection and 28 and incidence (9.9% in both groups) and severity of colonic (18.2%) both hepatic and extrahepatic recurrence resection, fistula. At uni- and multivariate analysis for liver-related with a 5 years survival of 57.9%, 63.9% and 81.1% factors potentially affecting risk of colonic fistula, a pre- (p=0.371). Thirty patients (19.5%) developed early recur- operative albumin level < 3.5 g/dL resulted associated with rence (< 6 months) after liver resections, with an overall leakage. Extension of liver resection, Pringle maneuver and survival at 5 years of 36.5% vs. 69.4% of patients without length of Pringle maneuver did not show a significant early recurrence (p=0.001) and a median survival of 40 vs. correlation with anastomotic leakage. 87 months. Patients without recurrence resection had a 5 Conclusion: The use of Pringle maneuver in the setting of years survival of 45.0% while patients with recurrence combined hepatic and colorectal resections allows to resection of 64.8% (p< 0.001), with a median survival of maintain a potential advantage in terms of reduction of 51 vs. 86 months. intraoperative bleeding, without negatively affecting the Conclusions: Recurrence resection showed an impact on risk of anastomotic leakage. On the contrary, an impaired overall survival in patients resected for CRLM, regardless synthesis of protein (resulting in a low preoperative level of of the site and the number of recurrences, and should be albumin) seems to affect the risk of leakage, as a result of an performed whenever feasible. ineffective wounds healing.

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EP01A-073 margin clearance. This study aims to compare R0 and R1 resections on oncologic outcomes. RESULTS OF CURATIVE STRATEGY IN Methods: From January 2001 to December 2016, all pa- PATIENTS WITH PERITONEAL AND tients who had liver resection for CLM at Singapore Gen- EXTRAPERITONEAL METASTASES eral Hospital were analysed retrospectively. Patients with FROM COLORECTAL CANCER extrahepatic metastases, macroscopic residual tumour and staged liver resections were excluded. S. Derieux, I. Sourrouille, M. Gelli, L. Benhaim, Results: Of the 290 patients analysed, 228 (78.6%) and 62 A. Mariani, M. Faron, C. Honoré, D. Elias and D. Goéré (21.4%) patients underwent R0 and R1 resection respec- Gustave Roussy, France tively. R1 resections were associated with bilobar, multiple Background: Curative treatment of peritoneal metastases and synchronous liver metastases, major liver resections from colorectal cancer (CRPM) relies on cytoreductive and adjuvant chemotherapy. surgery and hyperthermic intraperitoneal chemotherapy Independent factors of poor overall and recurrence free- fi (CRS/HIPEC). Bene ts of this strategy remain uncertain survival were primary colorectal tumour grade, presence of when CRPM are associated with extraperitoneal metastases perineural invasion, nodal status, carcinoembryonic antigen (EPM). The aim of this study was to compare outcomes of (CEA) levels, number and size of liver metastases. patients treated with CRS/HIPEC for CRPM, with or R1 resection was likely associated with local intrahepatic without EPM. recurrence. (HR: 0.74, 95% CI = 0.5 - 1.09, p = 0.122) Methods: This study included 331 consecutive patients However, on multivariate survival analysis, it was not an undergoing CRS/HIPEC for CRPM: 100 patients with independent predictor for overall and recurrence free EPM (EPM+) and 231 patients with isolated peritoneal survival. carcinomatosis (EPM-). Patients with ovarian metastases Conclusion: Underlying tumour biology is a strong pre- and no other EPM were included in EPM- group (n=75). dictor of oncologic outcomes. The prognostic impact of R1 Results: EPM were mainly located to the liver (75%,n=75) resection should be reviewed given that survival is similar and retroperitoneal lymph nodes (31%,n=31), and less to R0 resection in this current era of chemotherapy. frequently to the spleen (10%,n=10), lung (4%,n=4) or pleura (1%,n=1). Thirty-nine patients (39%) in EPM+ had EP01A-075 also ovarian metastases. Peritoneal carcinomatosis index COMPLICATIONS OF LIVER (PCI) was similar in EPM- (8[4-14]) and EPM+ (8[4-14], p=0.964), as were mortality (3% vs 4%, p=0.906) and RESECTIONS IN UNIVERSITY major morbidity rates (26% vs 33%, p=0.241). Median HOSPITAL OF PILSEN overall survival (mOS) and disease-free survival were T. Skalicky significantly higher in EPM- (56 vs 33 months, and 17 vs Dept of Surgery, Charles University, Medical Faculty 10 months, p< 0.01). We highlighted 3 prognostic groups Pilsen, Czech Republic < 1) EPM- with PCI 10 (mOS 98months), 2) EPM- with Introduction: Liver resection now means the only possi- < < < 10 PCI 15 (mOS 49months) or EPM+ with PCI 10 bility of curative treatment for patients with metastases of < < (mOS 52months, p=0.534), 3) EPM+ with 10 PCI 15 colorectal carcinoma of liver. > (mOS 29months) or PCI 15 whatever EPM (mOS Methods: The aim of this work was to evaluate the group 28months, p=0.842). of 550 patients in a retrospective way liver resection had Conclusion: CRS/HIPEC is feasible in patients with EPM, been performed in due to metastases of colorectal carci- without increasing postoperative morbidity and mortality noma at the Surgery Department of Faculty of Medicine of compared to patients without EPM. This curative strategy Charles University and University Hospital in Pilsen be- provides prolonged survival in selected patients with tween 2001 and March 2017. < limited CRPM (PCI 10). Results: There were 550 patients altogether having gone through the given resection in this period. The whole EP01A-074 morbidity of this group was 63,7%. The mortality of the PROGNOSTIC IMPACT OF TUMOUR group was 0,5%. The most frequent postoperative compli- BIOLOGY COMPARED TO SURGICAL cation was fluidothorax - 42,9%, loss of blood more than 500 MARGIN CLEARANCE FOR ml was considered to be the most frequent preoperative COLORECTAL LIVER METASTASES IN complication - 3,9%. Collections by the resection area /he- matoma, bilioma/ belonged among other frequent post- THE ERA OF MODERN operative complications - 33,8%. Fortunately, we noticed CHEMOTHERAPY AND SURGERY susceptible liver failure only in two patients, which means H. L. R. Chen1, R. Radhakrishnan2, Y. Liu2, 2,6%. In comparison with the same evaluation in the group of S. A. Sumarli1 and J. Y. Teo1 patients between 2001 and 2017, we determined the decrease 1Singapore General Hospital, and 2National University of of the occurence of postoperative bleeding by 4,5% and liver Singapore, Singapore failure by 3,8%. On the contrary, the amount of collections Background: Historically, microscopically incomplete R1 appeared at the resection area increased by almost 6,9%. resections have been associated with increased recurrence Conclusion: Curative liver resections for metastases of and lower survival rates for colorectal liver metastases colorectal carcinoma mean a high occurence of post- (CLMs). With advances in chemotherapy, there is a shift operative complications for patients but it is necessary to towards a more aggressive surgical approach towards liver solve only a small percentage of these in an invasive way. resection for CLMs. Recent studies have questioned the The effect of the surgery considerably exceeds possible prognostic significance of obtaining complete surgical risks for patients.

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EP01A-076 Introduction: Our previous study on the outcomes of radical treatment for neuroendocrine liver metastases (NET SIMULTANEOUS PROCEDURES FOR mets) found surgery the most commonly utilised therapy. COLORECTAL CANCERS WITH LIVER Radio-frequency ablation (RFA) and trans-arterial embo- METASTASES, WITH A SPECIAL FOCUS lisation (TAE) were only occasionally selected. Given the ON MAJOR LIVER RESECTIONS favourable morbidity and mortality of RFA and that sur- gery is palliative rather than curative for the majority, this V. Valdimarsson1, I. Syk2, G. Lindell1, A. Norén3, study aims to address why surgery was selected more than B. Isaksson3,4, P. Sandström5, M. Rizell6, B. Ardnor7 and RFA in the treatment of NET mets. C. Sturesson1,4 Methods: Pre-operative imaging of patients with NET 1Department of Clinical Sciences Lund, 2Department of mets between 1998 to 2016 undergoing treatment in a Clinical Sciences Malmö, Surgery, Lund University, Skane single specialist HPB/NET centre was reviewed retro- University Hospital, 3Department of Surgical Sciences, spectively againtst the interventional radiology consensus Uppsala University, 4Division of Surgery, Department for criteria for thermal ablation(CIRCE criteria). All patients Clinical Science, Intervention and Technology (CLIN- were assessed at the NET MDT meeting and considered for TEC), Karolinska Institute at Karolinska University Hos- each therapy. Interventional radiology records were pital, 5Department of Surgery and Department of Clinical checked to ensure ablation was not performed without and Experimental Medicine, Linköping University, MDT discussion. 6Department of Transplantation and Liver Surgery, Sahl- Results: Forty-seven patients were included. Thirty-nine grenska Academy, University of Gothenburg, and were treated with surgical resection, two had RFA, two had 7Department of Surgery, Umeå University Hospital, TAE, and four underwent both RFA and surgery. Reasons Sweden for not qualifying for RFA included a) absolute contrain- Background: Patients with synchronous colorectal liver dications: at least one lesion with diameter >3cm (n=24); metastases (sCRLM) are increasingly operated with liver simultaneous resection of extrahepatic disease (n=4); resection. The aim of the present study was to compare exophytic lesions (n=4); proximity to major hepatic outcomes in patients following a simultaneous resection of vasculature (n=1) and gallbladder (n=1)$ b) relative con- the primary cancer and the sCRLM and a staged resection traindications: a high number (>4) of hepatic metastases fi where the bowel is resected rst and the sCRLM are (n=4) and two lesions in close proximity(measuring >3cm resected at second stage (classical approach), using data in total) (n=1). Two patients eligible for RFA were treated from two nationwide registries in Sweden. operatively per surgeon preference. Methods: In this retrospective cohort study, clinical, Conclusions: The majority of patients with NET mets seen pathological and survival outcomes were compared be- in specialist centres are not appropriate for RFA if the tween the simultaneous approach and the classical CIRCE guidelines for ablation are followed. approach (2008-2015). Overall survival was calculated. fi Results: A total of 537 patients were identi ed, of which 160 EP01A-078 were treated with the simultaneous approach and 377 with the classical approach. The median follow-up was 41 CLINICAL SIGNIFICANCE OF months. The patients chosen for the simultaneous approach COLORECTAL LIVER METASTASES had more often node-positive primaries (87% vs 63%, p< NEWLY DETECTED DURING 0.001), colon primary (78% vs 69%, p=0.046), shorter total HEPATECTOMY < hospital stay (11 vs 15 days, p 0.001) and more often T. Mizuno < minor liver procedures (84% vs 59%, p 0.001). The Cancer Institute Hospital, Japan tumour burden score in the liver was the same (P=0.450). Background: Despite advances in imaging modalities, There was no difference in 5-year overall survival (p=0.110). intraoperative detection of new legions (newly detected A total of 25 patients had a major resection in the simulta- colorectal liver metastases : ND-CLM) is common in pa- neous group and 155 in the classical approach group. No 5- tients undergoing hepatectomy. However, clinical signifi- year overall survival difference was shown (P=0.198). cance of ND-CLM is still unknown. Discussion: No difference in overall survival was noted Methods: Data of 171 patients who underwent initial between the strategies. The simultaneous approach appears hepatectomy for colorectal liver metastases after preoper- to be safe even when evaluating major liver resection and ative chemotherapy were reviewed from 2010 to 2015. ND- primary tumour resection. CLM were defined as metastases newly confirmed during hepatectomy by visual inspection, palpation, or intra- EP01A-077 operative ultrasonography. Background characteristics and RADIO-FREQUENCY ABLATION FOR long-term outcomes of patients having ND-CLM were TREATMENT OF NET LIVER investigated. METASTASES: ASSESSMENT OF Results: Among 171 patients, ND-CLM were detected in 54 patients (31.6%). In patients having ND-CLM, the UTILISATION AT A SINGLE TERTIARY number of tumor was larger (P=0.0158) and the level of CENTRE CEA was higher (P=0.0035) than in those without ND- A. Tan1,2, J. Pape3, P. Lykoudis2,3 and B. Davidson2,3 CLM. Operative procedures were modified intraoperatively 1Royal College of Surgeons in Ireland, Ireland, 2Univer- because of detection of ND-CLM in 23 patients (42.6 %). sity College London, Royal Free Hospitals, and 3Royal However , ND-CLM did not preclude curative resection in Free London, United Kingdom any patients.

HPB 2018, 20 (S2), S333eS504 S360 Electronic Posters (EP01A-EP01E) - Liver

The 5-year recurrence-free (RFS) and overall survival EP01A-080 (OS) rates in patients with ND-CLM (28.1% and 29.0%) were worse than those without ND-CLM (39.5% [p= RESECTION FOR EXTRAHEPATIC 0.0079], 58.1% [p =0.0010]). In multivariate analysis, RECURRENCE AFTER LIVER having ND-CLM was found to be an independent risk TRANSPLANTATION FOR factor of impaired RFS (hazard ratio =1.81, p =0.0385) and HEPATOCELLULAR CARCINOMA OS (hazard ratio =2.06, p =0.0165 ). B. G. Na, E. C. Lee, S. H. Kim and S. J. Park Conclusions: Detection of new lesions during hepatectomy National Cancer Center, Republic of Korea negatively impacts on survival in patients undergoing sur- gery for colorectal liver metastases. Introduction: A few studies have been reported on extra- hepatic metastasis after liver transplantation (LT) for he- patocellular carcinoma (HCC). We investigated clinical outcomes of patients with extrahepatic recurrence (EHR) of EP01A-079 HCC after LT. LAPAROSCOPIC VERSUS OPEN Method: We retrospectively reviewed 395 patients who REPEAT LIVER RESECTION FOR underwent LT for HCC from March 2005 to December COLORECTAL LIVER METASTASES: A 2015. 92 patients (23.2%) were diagnosed with a HCC MULTICENTER PROPENSITY SCORE recurrence. Clinicopathological data of patients with EHR MATCHED STUDY were analyzed for overall survival rate and prognostic factors. 1 2 3 4 M. J. van der Poel , I. Dagher ,M.D’Hondt , F. Rotellar , Results: After a median follow-up of 25.3 months, 66 1 5 6 7 M. G. Besselink , L. Aldrighetti , R. Troisi , B. Gayet , patients (71.7%) initially presented with EHR. The sites of 8 9 B. Edwin and M. Abu Hilal EHR were lung (n=32), bone (n=12), lymph nodes (n=7), 1 Academic Medical Center Amsterdam, The Netherlands, adrenal gland (n=1), and others (n=14). Median time to 2 3 Antoine-Beclere Hospital, France, AZ Groeninge Hos- EHR was 7.4 months. Forty-five patients (68.1%) under- 4 pital, Belgium, University Clinic of Navarre, Spain, went curative resection for EHR. The 1, 3, 5-year overall 5 6 IRCCS San Raffaele Hospital, Italy, Ghent University survival rate of patients with EHR were 81.6%, 46.4%, and 7 Hospital, Belgium, Institut Mutualiste Montsouris, 33.1%. Resection for EHR was only a significant factor 8 9 France, Oslo University Hospital, Norway, and Uni- associated with multivariate analysis (HR 0.233, 95% CI versity Hospital Southampton NHS Trust, United Kingdom 0.114-0.474, p=0.0001). The 1, 3, 5-year OS of patients Background: Repeat liver resection (RLR) is a viable with resection and without resection for EHR were 91.1%, treatment strategy for recurrent colorectal liver metastases 64.0%, 41.8% and 60.7%, 0%, 0%, respectively (p < 0.05). (CRLM) but can be more demanding due to dense adhe- In subgroup analysis according to Milan criteria, overall sions and an altered anatomy. Laparotomy is most survival rate of patients who underwent resection for EHR frequently used in these cases, but initial reports have were better than those of patients without resection for EHR shown promising results for laparoscopic repeat liver in both within and beyond Milan group. resection (LRLR). The aim of this study was to present the Conclusions: Resection of EHR may be a beneficial largest to date, multicenter experience of LRLR and further treatment to increase survival rate after LT for HCC in establish patient selection criteria. selected patients. Methods: A multicenter retrospective propensity score matched study was performed including both LRLR and open RLR (ORLR) from 10 large European centers. Pa- EP01A-081 tients were matched based on propensity scores in a 1:1 MICROWAVE ABLATION FOR ratio. Propensity scores were calculated based on 12 pre- operative variables. Pre-, per- and postoperative outcomes COLORECTAL LIVER METASTASES were compared using paired tests. WITH 10-MM MARGIN: CAN WE Results: A total of 425 RLR were included. Out of 271 ACHIEVE THE SAME RESULTS OF LRLR, 105 could be matched to an ORLR. Baseline SURGERY? characteristics, including the extent (minor/major F. Ausania, R. Melendez, P. Senra, M. Paniagua, resection) and approach (open/laparoscopic) to the pre- R. Carracedo and I. Otero vious liver resection, were well balanced after matching. Surgery, Hospital Alvaro Cunqueiro de Vigo, Spain LRLR was associated with a shorter operative time (200 (123-273) vs 256 (199-320) minutes, P< 0.001), less Introduction: MWA has been traditionally considered a intraoperative blood loss (200 (50-450) vs 300 (100- tool complementary to surgery for colorectal liver metas- 600) ml, P=0.077) and a shorter postoperative hospital tases (CLM). Due to its higher local recurrence rate when stay (5 (3-8) vs 6 (5-8) days, P=0.028). Postoperative compared to surgical resection, use of MWA has been morbidity and mortality were similar between LRLR and historically limited to high-risk patients. However, no ORLR. studies have previously evaluated whether increasing the Conclusion: When performed by expert surgeons, LRLR is ablation margin could improve results. feasible and safe and seems to offer advantages compared The aim of this study is to assess whether adding a 10- to ORLR, regardless of the extent of and approach to the mm margin to lesion ablation can improve local control of previous liver resection. CLM.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S361

Methods: 53 lesions in 22 patients with CLM were Conclusion: Simultaneous resection of SCRLM is rela- consecutively treated with open MWA at our Institution tively safe, and even major hepatic resection can be from June 2012 to June 2017. Mean age was 64.5 years, recommented in carefully selected elderly patients. median size of the lesion was 23.8 (10-40) mm. Preoper- ative CEA level was 7.3 ng/ml. MWA was associated to liver resection in 16 patients (72.7%). Median follow-up EP01A-083 was 32.4 months. A 10-mm ablation margin was performed UTILITY OF HEPATIC MRI WITH in all cases. Ablation margin was confirmed with intra- operative ultrasound and liver MRI 30 days following the GADOXETIC ACID IN PREOPERATIVE procedure. STAGING OF COLORECTAL CANCER Results: Complication rate was 22%. No mortality was LIVER METASTASES observed. Median ablation area was 39 (30-50) mm. One J. Camps1, M. Paraira2, E. Herrero1, M. I. García1, fi patient received further ablation one month after the rst L. Martínez de la Maza1, J. Tur1, M. Galofré1 and procedure due to suspected residual disease. No local E. Cugat1 recurrence was observed at follow-up. Disease-free sur- 1Surgery Department, Hospital Universitari Mutua vival was 20 (4.8-55.2) months. Terrassa, and 2Radiology, Hospital Universitari Mutua Conclusion: When performed with a 10-mm safety Terrassa, Universitat de Barcelona, Spain margin, MWA offers very good oncological results and low Introduction: In the diagnosis of CRC liver metastases morbidity, and therefore it should be considered a good (CRCLM), accurate imaging techniques are essential to option not only in high-risk patients but also as an alter- plan an optimal treatment. Contrast-enhanced CT is the native to very aggressive surgery in selected cases. gold standard for the diagnosis of CRCLM. Gadoxetic acid (Gd-EOB-DTPA, Primovist) is an specific intracellular hepatic contrast that could provide increased detection rate EP01A-082 and better characterization of liver lesions.The aim of this IS SIMULTANEOUS RESECTION OF study is to evaluate the correlation between contrast- COLORECTAL CANCER AND enhanced CT and MRI-Primovist in the detection of SYNCHRONOUS LIVER METASTASES CRCLM. SAFE IN THE ELDERLY?: A SINGLE- Patient and methods: Between June 2010 and October 2017, 216 patients underwent surgery for CRCLM. 131 CENTER, RETROSPECTIVE COHORT patients underwent CT and MRI-Primovist preoperatively. STUDY CT detected 2.5 (0-21) liver lesions and MRI-Primovist S. W. Park1, S. J. Park1, S. H. Kim1 and J. H. Oh2 detected 2.8 (1-21). 1Center for Liver Cancer, and 2Center for Colorectal Number of detected liver lesions and their location was Cancer, National Cancer Center, Republic of Korea compared between tests. fi Introduction: The elderly population with liver metastasis Changes in the nal surgical decision due to the MRI- fi from colorectal cancer has been increasing. But the safety Primovist ndings were assessed. of simultaneous resections of colorectal cancer and syn- Results: In 87/131 (66%) cases there was a correlation in chronous liver metastases (SCRLM) in the elderly is not number and location of CRCLM between CT and MRI- fi established. Primovist. In 18 patients (14%) Primovist-MRI ndings Methods: This single-center retrospective cohort study changed in the surgical resection. In 13 cases (10%) this fi compared postoperative outcomes, Overall Survival(OS) strategy change was bene cial, allowing resection of and Disease-Free survival(DFS) after simultaneous colo- CRCLM not detected previously by CT. In 5 patients rectal and hepatic resections in different age groups. Clin- (3.8%) the information provided was a false positive. icopathologic data, treatments, and postoperative outcomes Conclusions: The routinely use of Primovist-MRI can give from patients who underwent simultaneous colorectal and additional information leading to changes in surgical hepatic resections at National Cancer Center, Korea from strategy in one tenth of the patients with a low rate of false 2001-2014 were reviewed. positives. Results: 443 patients(287 young patients < = 65 years old, 122 patients between 66 and 75 years old, and 34 elderly patients > 75 years old) underwent simultaneous resections EP01A-084 of colorectal cancer and liver metastases. IMPACT OF RESECTION MARGIN AND Young patients had lower ASA score (ASA score 1 in HISTOLOGICAL GROWTH PATTERN 46% versus 15.6% and 20.6%). The elderly less often un- AT RESECTION FOR COLORECTAL derwent major hepatectomy (51.6%, 48.4% versus 26.5%, p< 0.05). Mortality and severe morbidity were similar in LIVER METASTASIS: A PILOT STUDY each age group, but for minor hepatectomy, the elderly J. Helliwell1, R. Lathan1, J. I. Wyatt2 and J. P. A. Lodge3 more often experienced severe morbidity (12.3% versus 1University of Leeds, 2Department of Pathology, and 8.7% and 0%, p < 0.05). 3HPB and Transplant Unit, Leeds Teaching Hospitals The overall survival showed a significant difference in NHS Trust, United Kingdom favor of the younger patients (40.1% versus 32.4%, p = Introduction: The aims of this study were to investigate 0.005). However, with regard to disease-free survival, there the occurrence and site of tumour recurrence following was no significant difference between elderly and younger positive (R1) and negative (R0) resections for colo- patients. rectal liver metastasis, and to investigate the prognostic

HPB 2018, 20 (S2), S333eS504 S362 Electronic Posters (EP01A-EP01E) - Liver significance of histological growth patterns (desmoplastic were: histological response, size > 3 cm, R1 resection and vs non-desmoplastic). targeted therapy. Methods: 94 patients who underwent resection in 2012 Conclusion: The histological response must be specified in were included, to allow 5 years of follow up. The site of the anatomopathological reports because it has a major tumour recurrence was determined using follow-up radi- impact on OS and DFS. A non-radiological response and a ology and classified as marginal intrahepatic, distant intra- number of NACT > 7 are the two most pertinent predictive hepatic or extrahepatic. Histological growth patterns were factors of non-histological response. evaluated and related to overall and recurrence free survival. Results: 52 cases had a negative resection margin (R0) and 42 had a positive (defined as less than 1 mm) margin (R1). EP01A-087 Patients with a positive margin had lower recurrence free CLINICAL CASE OF FUSION-GUIDED- survival (Log-rank test, p=0.185). However, the pattern and timing of recurrence (marginal intrahepatic, distant intra- CONTRAST-ENHANCED hepatic, extrahepatic and no recurrence) was not found to ULTRASONOGRAPHY TO MARK be related to the resection margin status (p = 0.547). The 1-, MISSING COLORECTAL METASTASES 3- and 5- year survival for patients with a desmoplastic R. García-Pérez1, E. Ramirez2, P. Guarner2, M. Pavel2, growth pattern was 90%, 69% and 58% respectively. The V. Molina2, J. Ferrer2, S. Sánchez2, J. Fuster2, non-desmoplastic group had lower 1-, 3- and 5 year sur- G. -V. Juan Carlos2 and C. Fondevila2 vival rates at 85%, 61% and 48% respectively (p=0.408). 1HPB and Transplant Surgery, Hospital Clinic Barcelona, Conclusion: Poorer prognosis in the R1 group was not due and 2Hospital Clinic Barcelona, Spain to increased risk of marginal recurrence. The desmoplastic Introduction: Modern chemotherapy achieves the reduc- growth pattern appeared to predict improved survival rates, tion in size of colorectal cancer liver metastases (CRLM) to although this needs to be explored further with a larger such extent that they may disappear from radiological im- sample size. aging. Fusion-guided-contrast-enhanced Ultrasonography EP01A-086 marking consists in the fusion of real-time US and computed tomography/magnetic resonance (CT/MR) PREDICTIVE FACTORS AND IMPACT images. This technique allows a correct identification of ON OVERALL SURVIVAL (OS) AND missing metastases prior to surgery and the placement of DISEASE-FREE SURVIVAL (DFS) OF fiducial markers, making easier its identification and TRG OF RESECTED COLORECTAL resection during the surgical procedure. LIVER METASTASES (CRLM) AFTER Case presentation: A 71-year-old Caucasian man was admitted in our center with abdominal pain. CT scan was NEOADJUVANT CHEMOTHERAPY performed, showing large bowel obstruction secondary to a (NACT) tumor with 3 liver metastases. An extended right hemi- C. Maulat1, C. Serayssol1, F. Breibach2, colectomy was performed. The pathology report showed A. Hantoush Al Ali1, R. Guimbaud2, F. -Z. Mokrane3, moderately differentiated adenocarcinoma pT4N0. After the J. Selves2, B. Suc1 and F. Muscari1 surgical recovery was decided to proceed with chemo- 1Chirurgie Digestive et de Transplantation, 2Anatomopa- therapy, 10 courses of FOLFOX. After the treatment a CT thologie, and 3Radiologie, CHU Toulouse, Hôpital scan, PETCT and MRI were performed, showing 2 of the 3 Rangueil, France lesions. Prior to the liver surgery a gold fiducial marker was Introduction: The Rubbia-Brandt classification showed placed under Fusion-guided-contrast-enhanced Ultraso- that the Tumor Regression Grade had an influence on OS nography, were the Missing Metastasis was placed. During and DFS after resection of CRLM. This study evaluates the surgery we could easily identify the Missing Metastasis histological response and isolates the predictive factors of marked, performing 3 non-anatomical resections. The pa- histological response and its impact on OS and DFS. thology report showed complete pathological response with fi Methods: 150 patients were included by a single center. brosis, with no viable tumor cells in the three lesions, being fi Every slide was analyzed in double-blinded. Two the lesions not marked with coil calci ed. fi groups were isolated, the responders (R) who had TRG Conclusion: The placement of ducial markers by fusion between 1 and 3 and the non-responders (NR) who had USS-CT/MRI are an important tool to assist the surgeon TRG 4-5. Univariate and multivariate analysis were identifying the location liver metastases when disappear performed. after chemotherapy. The true impact of this technique to Results: 74 patients were responders and 76 were non-re- control liver progression has to be still investigated. sponders. The predictive factors of non-response after NACT are (multivariate analysis): NACT cycles > 7, non- radiological response to NACT, absence of reverse strat- EP01A-088 egy, repeated hepatectomy and colonic tumor. OS at 1, 3 ASSOCIATION OF DNA REPAIR and 5 years were 91%, 57% and 36%, respectively. DFS at MODULATION AND AGGRESSIVENESS 1, 3 and 5 years were 43%, 14% and 11%, respectively. Median OS and DFS of the responders were significantly IN COLORECTAL CANCER LIVER higher (OS: 4.5 vs 2.8 years, p=0.006; DFS: 14 vs 8.3 METASTASIS months, p= 0.002). Without microscopic tumor emboli, the N. Leguisamo1, G. Laporte2, H. Glória2, A. Luchese3, OS independent prognostic factors were: histological E. Cadore2, G. Montenegro2, V. Lau2 and A. Nocchi Kalil2 response, male, anti-angiogenic agents, two-steps protocol 1Fundação Universitária de Cardiologia, Instituto de and N+ status. The DFS independent prognostic factors Cardiologia do Rio Grande do Sul, 2Universidade Federal

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S363 de Ciências da Saúde de Porto Alegre, and 3Irmandade da PSM, there was a statistically significant difference favor- Santa Casa de Misericórdia de Porto Alegre, Brazil able to the LA group regarding operative time, blood loss, Introduction: Curative effectiveness of colorectal cancer length of hospital stay and the rate of morbidity. After liver metastases (CRCLM) is limited by poor understand- PSM, the difference was confirmed in blood loss (P=0.003) ing of the molecular pathways that drive metastases and and operative time (P=0.026) in favor of LA group. The recurrence. As previously reported by our group, in primary morbidity rate (>II Clavien-Dindo) was a same in the two colorectal cancer (CRC), DNA repair pathways imbalance groups (15%). Seventy-seven patients (77%) were followed reflects tumor aggressiveness. However, the role of this up. There were no differences in survival before and after system in CRCLM development is not clear. The aim of the PSM. Four years survival in LA and OA groups was 70%/ present study was to characterize the main DNA repair 68%, respectively before PSM and 72%/70%, respectively components in resected CRCLM. after PSM. Methods: Immunohistochemistry for MLH1 (mismatch Conclusions: Laparoscopic liver resection for CCLM may repair - MMR); OGG1 and MPG (base excision repair- be considered as an alternative option to open surgery in BER) and Ku80 (non-homologous end-joining - NHEJ) selected patients. was performed on CRCLM and healthy surrounding liver specimens obtained from patients who underwent to liver resection surgery. The association between staining and the EP01A-090 clinicopathological data was examined. EFFECT OF INFLAMMATION ON Results: Our preliminary data on eleven consecutive TUMOR PROGRESSION OF LIVER CRCLM patients showed negative or reduced MLH1 expression in 27% of the cases, indicating the presence of METASTASES OF COLORECTAL microsatellite instability. MMR pathway functionality in CARCINOMA IN AN EXPERIMENTAL liver metastases is associated with lower levels of CEA. MODEL While the reduction of Ku80 protein levels in neoplastic R. García-Pérez1, G. Cárdenas2, J. Ferrer2, A. Varona2,3, specimens is associated with unilateral occurrences of F. Al Shwely2, O. Gomez2, M. Pavel2, V. Molina2, CLCLM, increases in Ku80 and MPG contents are asso- C. Fondevila2 and J. Fuster2 ciated with greater number of metastatic hepatic lesions. 1HPB and Transplant Surgery, Hospital Clinic de Barce- Conclusion: The association between the overexpression lona, 2Hospital Clinic de Barcelona, and 3Hospital Virgen of BER glycosylase MPG and Ku80 NHEJ key-component de la Candelaria, Spain with features of tumor aggressiveness suggest a new field of Objectives: Mechanisms of inflammatory induction seem study for the comprehension of the molecular development to influence the regenerative process of the hepatic of CRCLM. remnant(FLR), induced by portal vein ligation associated with liver transection in ALPPS. The aim of this study is to elucidate the role of Kupffer cells(KC) after carrying out EP01A-089 ALPPS in a rat model of colorectal carcinoma(CRC) liver MINIMALLY INVASIVE VERSUS OPEN metastases. HEPATECTOMY FOR COLORECTAL Material and methods: 16 WAG / Rij rats were divided CANCER LIVER METASTASES: in 4 groups of 4 animals: intraparenchymal inoculation of fi COMPARATIVE ANALYSIS OF SHORT- syngenic CRC cells on FLR and rst stage of ALPPS 24 hours later (G1), first stage of ALPPS technique without TERM RESULTS AND SURVIVAL WITH previous inoculation (G2), first stage of ALPPS with PROPENSITY SCORE MATCHING previous inoculation on FLR (G3), and sham group (G4). M. Efanov1, R. Alikhanov1, V. Tsvirkun2, I. Kazakov1, The rats were sacrified and sampled 3 weeks after the A. Vankovich1, P. Kim1, K. Grendal1 and E. Zamanov1 procedure. The number and immunophenotype of 1HPB Surgery, Moscow Clinical Scientific Center n.a. A.S. KC(M1 or pro-inflammatory profileCOX-2+,M2orpro Loginov, and 2Moscow Clinical Scientific Center n.a. A.S. regenerative profile Arg-1 +) and Lymphocytes were Loginov, Russian Federation studied. Background: The objective of this study was to compare Results: In G1, the presence of intratumoral macrophages the results of laparoscopic hepatectomy with those of open was discrete, with predominance of M2 phenotype. G2 hepatectomy for colorectal cancer liver metastases (CCLM) showed an increase in KC, with hepatocytes and tumor using a propensity score matching (PSM) in our hospital cells negative for COX-2 expression.In G3 an evident fi settings. tumor progression was observed, as well as a very signi - Methods: A patient in the laparoscopic approach (LA) cant increase in the number of M1 KC in liver tissue, surgery group was randomly matched with another patient whereas the phenotype of intratumoral macrophages was in the open approach (OA) group using a 1:1 allocated ratio M2. Furthermore, we found few intratumoral T Lympho- fi with the nearest estimated propensity score. cyte in ltrate meanwhile there was a high number of them Results: From January 2010 to March 2017, a total of 215 surrounding the tumor. minimally invasive hepatectomies were consecutively Conclusions: The regenerative process established after fl performed, of which 60 for CCLM (LA group). At the same ALPPS is governed by a pro-in ammatory environment, period, 40 patients underwent open liver resection (OA in which macrophages seem to play an important role not group). In LA group the conversion rate was 3 % (n= 5). only in the hepatic regeneration, but also in the tumor The mortality rate was 0% in the OA and LA group. Prior to progression.

HPB 2018, 20 (S2), S333eS504 S364 Electronic Posters (EP01A-EP01E) - Liver

EP01A-092 Methods: All consecutive liver resections performed from 1 January 2012 to 31 December 2016 were included in our ANALYSIS OF LIVER ATROPHY AND analysis. Patients undergoing liver resection for indications REGENERATION FACTORS AFTER other than CRLM were excluded. A prospectively main- TOURNIQUET ALPPS TECHNIQUE IN tained database was interrogated for clinicopathological COLORECTAL LIVER METASTASES variables, operative details and postoperative outcomes. Survival curves were measured using Kaplan Meier. V. López-Lopez, R. Robles, R. Brusadin, Results: A total of 145 patients underwent resection of A. López-Conesa, A. Navarro, C. Martinez, B. Revilla, CRLM in the study period, 30 (20.7%) of whom underwent F. Alconchel, J. De la Peña and P. Parrilla laparoscopic resection. Median operative time in the lapa- Hospital Clinico Universitario ’Virgen de la Arrixaca’, roscopic group was 2.5h with 4 patients (13.3%) requiring Spain intraoperative blood transfusion. When outcomes of the Introduction: ALPPS mechanisms of regeneration of laparoscopic group were compared to those post open future left liver remnant and atrophy of right deportalized resection; major complications (Clavien Dindo grade 3 or lobe have not been stablished in humans. The aim of the more) were seen in 3.3% of the laparoscopic group versus study was to analyze molecular changes after Tourniquet- 9.5% in the open resection group (p=0.46). While the ALPPS in humans. laparoscopic group had a better 3 year survival (89.6% vs Methods: Between September 2011 and May 2017, 29 71.9%), no significant difference was appreciated in overall fi patients were included. Regeneration study: during rst survival between groups (p=0.294). stage a control biopsy before ALPPS-Tourniquet (right Conclusion: With careful patient selection, laparoscopic portal vein occlusion and tourniquet placement) was taken liver resection is feasible and can result in improved post- in the left lobe and 60 minutes after surgical technique operative outcomes. Our experience indicates a number (early regeneration), another biopsy was taken. At 9 days possible benefits following a laparoscopic approach (late regeneration), a biopsy was taken at the begining of including reduced major complication rate and comparable fi second stage. Atrophy study: during rst stage a control oncological outcomes. biopsy before ALPPS-Tourniquet (right portal vein occlu- sion and tourniquet placement), was taken in the right lobe and 60 minutes after right portal occlusion and tourniquet placement, another biopsy was taken. At 9 days (late at- EP01A-094 rophy), a biopsy was taken at the beginning of the second LAPAROSCOPIC COMBINED stage. Proinflammatory (IL1A, IL6, TNF-a, VEGFA, HGF, COLORECTAL AND LIVER RESECTION EGFR, c-Met, STAT3, NOS2), promitogenic (ENO1 y FOR METASTATIC COLORECTAL LEF-1), hypoxemic (HIF1A), and apoptotic (CASP-1, CANCER BAX3, DAPK3) factors were analyzed. Results: Regeneration statistically significant factors were I. Takorov, T. Lukanova, I. Vasilevski, V. Mihaylov, HGF, VEGFA, HIF1A, IL1A, IL6, STAT3, DAPK3, M. Iakova, E. Odisseeva and N. Vladov cMET, ENO1 (Basal vs 60’) and HGF, EGFR, NOS2 HPB and Transplant Surgery, Military Medical Academy, (Basal vs 2 stage). Atrophy statistically significant factors Bulgaria were DAPK3, NOS2 (Basal vs 60’) and HGF, VEGFA, Introduction: Nowadays, regarding a personalized multi- EGFR, IL6, DAPK3, BAX2, LEF1 (Basal vs 2 stage). modal approach, laparoscopic liver and colorectal re- Conclusions: After tourniquet placement and portal oc- sections, separately distinguished, are accepted as feasible, clusion, an early proliferative and regenerative process is safe and oncologically equivalent to open resections sur- produced promoted by proinflammatory activity that gical methods of treatment for colorectal carcinoma. decrease at second stage. However, there is still no consensus, regarding the appli- cability of combined laparoscopic colon and liver resection. The aim of the present study is to determine the feasibility EP01A-093 of combined different volume laparoscopic colon and liver resection in selected patients with primary colorectal cancer LAPAROSCOPIC LIVER RESECTION and synchronous liver metastases. FOR COLORECTAL LIVER Methods: From April 2014 to December 2017 sixteen METASTASES: OUTCOMES OF AN patients with primary CRC and a synchronous liver me- INITIAL EXPERIENCE COMPARED TO tastases underwent combined totally laparoscopic or “ ” OPEN RESECTION hybrid liver and colorectal surgery. Patient and tumor characteristics, operative variables, and postoperative out- F. Hand, C. Toale, R. Lahani, S. Cassidy, G. McEntee and comes were evaluated prospectively. J. Conneely Results: The primary tumor was located in the colon in 12 Hepatobiliary Surgery, Mater Misericordiae University patients and in the rectum - in 4 patients. Nine patients had a Hospital, Ireland solitary synchronous liver metastasis and 7 patients - mul- Minimally invasive surgery in the management of colo- tiple. The major hepatic resections were 6. Postoperative rectal liver metastases (CRLM) is increasing. Laparoscopic complications were observed in two patients (grade IIIa and liver resection is associated with reduced overall morbidity IIIb, respectively), mortality rate was zero. R0 resection was and favourable outcomes when compared to open resec- achieved in 14 patients, and in two patients laparoscopic tion. Here we report outcomes of laparoscopic liver resec- combined procedure was the first stage of a two-stage liver tion from a single centre, comparing morbidity and overall resection. Recurrent disease was found in two patients on survival to those undergoing open resection. the 3rd and on the 14th month respectively.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S365

Conclusion: Simultaneous laparoscopic colorectal and Background: Patients with better preoperative quality of liver resection appears to be feasible in selected patients life are more likely to recover well after surgery. The aim of with CRC and SLM on providing an adequate preoperative the present study was to analyze whether preoperative selection and combined surgical expertise. quality of life differs between patients undergoing the liver- first or bowel-first strategy for synchronous colorectal liver EP01A-095 metastases, and patients operated for metachronous liver OUTCOMES OF ALPPS FOR disease. BILATERAL COLORECTAL LIVER Method: The design is a quantitative cross-sectional study. The data collection method was a validated questionnaire METASTASES COMPARED TO THOSE for measuring quality of life (EORTC QLQ-C30). Patient OF ONE-STAGE PARENCHYMAL records were reviewed. All patients undergoing curative SPARING HEPATECTOMY: A resection for colorectal liver metastases between 2011 and MULTICENTER CASE-MATCH 2016 in a single center were prospectively included. ANALYSIS Results: The questionnaire response rate was 97% (317 patients). The median age of the study population was 69 M. Serenari1, L. Viganò2, M. Cimino2, C. Benini3, years, and men were overrepresented (59 %). No differ- M. Massani4, G. M. Ettorre5, A. Ferrero6, L. Aldrighetti7, 2 3 ences in preoperative quality of life were observed between G. Torzilli , E. Jovine and ALPPS Italian Registry patients undergoing liver-first surgery (78 patients), bowel- 1S.Orsola Malpighi Hospital, 2Humanitas Research Hos- first surgery (118 patients) and patients operated for pital, 3Maggiore Hospital, Bologna, Italy, 4Cà Foncello metachronous liver disease (121 patients) Patients over 69 Hospital, 5San Camillo Hospital, 6Mauriziano Hospital, years of age had higher ASA scores and poorer physical and 7San Raffaele Hospital, Italy function. Women experienced poorer overall quality of life Introduction: About 30% of patients with colorectal liver and poorer emotional function. Patients who received metastases (CRLM) are not initially resectable due to the chemotherapy had a tendency for more sleep problems (p = extent of hepatic disease. When the future liver remnant 0.056). (FLR) is regarded to be not sufficient, classic two stage Conclusion: No significant differences in preoperative hepatectomy or associating liver partition and portal vein quality of life were found between patients undergoing ligation for staged hepatectomy (ALPPS) can be performed liver-first surgery, bowel-first surgery and patients operated to get increase of the FLR. One-stage ultrasound-guided for metachronous liver disease; concluding that the quality parenchymal-sparing hepatectomy (OSH) may represent an of life is not dependent on the choice of strategy for alternative strategy for these patients. resection of synchronous colorectal liver metastases. Method: A retrospective analysis of patients enrolled within the ALPPS Italian Registry between 2005 and 2017 was performed. Patients undergoing ALPPS for 3 bilateral EP01A-097 CRLM were matched 1:2 with patients receiving a OSH at Humanitas Research Hospital. Patients were matched ac- SECOND CASE REPORT OF cording to the Fong Score (1-2/3/4-5); the contact of CRLM EXTREMITY PLEOMORPHIC with major intrahepatic vessels; the number of CRLM (3-7/ LIPOSARCOMA WITH ISOLATED 8); the number of CRLM in the left liver (< /3); and the LIVER METASTASIS TREATED WITH response to preoperative chemotherapy. The main end HEPATIC RESECTION, ADJUVANT points of the study were perioperative outcomes, overall (OS) and disease-free survival (DFS). CHEMOTHERAPY Results: Eighty-one patients were selected (27 ALPPS and K. Kobryn1, B. Gierej2, C. Smedding1, P. Rykowski1, 54 OSH) based on matching process. Demographic and P. Remiszewski1 and K. Zieniewicz1 tumor characteristics were similar between the two groups. 1General, Transplant and Liver Surgery, Medical Uni- The two treatments differed significantly in major versity of Warsaw, and 2Department of Pathology, Medi- morbidity (29.6% ALPPS vs 7.4% OSH, p=0.017) but with cal University of Warsaw, Poland similar mortality rate (7.4% vs 1.8%, p=0.256). Median OS Introduction: Pleomorphic liposarcoma (PLS) is defined (31.7 vs 31.4 months) and DFS (7.2 vs 7.3 months) were as a malignant high-grade sarcoma containing multi- comparable between the two groups. vacuolated lipoblasts. It is not only the least common Conclusions: This case-match study demonstrates that subtype accounting for 5% of all liposarcomas, but also the ALPPS and OSH for bilateral CRLM achieve comparable most aggressive, associated with only a 55-65% five-year OS and DFS, despite higher morbidity rates reported after survival rate. Manifestation of isolated metastasis in the ALPPS. liver is extremely rare (0.5%). Current therapeutic options are adjuvant radiotherapy or chemotherapy, surgical EP01A-096 resection with histologically negative margins. There are PREOPERATIVE QUALITY OF LIFE IN only three case reports of isolated liver metastases from an PATIENTS OPERATED WITH THE extremity liposarcoma of which, two reported a myxoid LIVER-FIRST STRATEGY FOR liposarcoma, and one case a pleomorphic liposarcoma as primary lesion. Our case is the second case reported in COLORECTAL LIVER METASTASES the world of extremity pleomorphic liposarcoma with P. Strandberg Holka, M. Aderup, S. Zangoei and isolated liver metastasis. C. Sturesson Case presentation: We present the case of B.K., a 39-year Skane University Hospital, Department of Clinical Sci- old male patient who has been admitted for treatment of ences Lund, Surgery, Lund University, Sweden metastasis in liver segment IVa from a surgically resected

HPB 2018, 20 (S2), S333eS504 S366 Electronic Posters (EP01A-EP01E) - Liver primary PLS within his right lower leg. Physical exami- EP01A-099 nation revealed a 1.5 cm protruding liver and no pain was elicited upon palpation. Our patient was treated with he- MANAGEMENT OF COLORECTAL patic IV segment resection and cholecystectomy followed LIVER METASTASIS (CLM) CLOSE TO by an uneventful recovery. Relapse of metastasis followed VASCULAR AXES IN PARENCHYMAL- 3 months post-operatively and gradually was localized in SPARING ERA: LIVER-SURGERY 2.0 BI- the bones, peritoneum, lungs, and eye. CENTRIC PILOT STUDY Conclusion: Although soft tissue sarcomas with liver 1 1 2 1 metastasis are extremely rare and there is more emphasis on M. Chetboun , R. Raheim , F. Panaro , S. Cavallari , A. Cayeux1, F. Fleres1, R. Memeo3, D. Sommacale1, the more prevalent types of malignancies, it nevertheless 1 1 deserves extensive research for developing standardized R. Kianmanesh and T. Piardi 1HPB, General and Endocrine Surgery, 2HPB Surgery, management guidelines as it is a demonstrably complex 3 and aggressive type of malignancy with dire outcomes and University Hospitals of Montpellier, and Policlinico di no ultimate cure. Bari, Chirurgia Generale e Trapianto di Fegato “M.Rubino”,Italy EP01A-098 Introduction: Parenchymal-sparing management with TARGETING EPIGENETIC local surgical and/or thermal ablation is the new standard treatment for CLM. However, thermal ablation is contra- REGULATION IN COLORECTAL indicated near deep vessels due to the risk of thrombosis. CANCER (CRC) LIVER METASTASES We report on the safety and surgeon feasibility of CLM S. Reddy1, C. Song1, P. Oliver2, D. Buchsbaum2 and management with a new generation of Microwave Thermal S. Varambally2 Ablation (MTA). 1Surgery, University of Alabama, and 2University of Methods: Patients were included prospectively in two HPB Alabama, United States expert centers when CLM was: 3cm of diameter and Introduction: Due to liver metastases, CRC is currently located near (5mm) significant vessels (3mm). A stan- the 3rd leading cause of cancer-related deaths worldwide. dardized treatment (watt/duration) was applied to CLM Treatment consists of surgery and conventional chemo- related to their size under ultrasound monitoring. therapy with modest results. The genetic changes as CRC The primary endpoint was the safety by review of vessel metastasize have not yet been elucidated and represent an thrombosis from abdominal computed tomography at area of study that can yield potential therapies. Here we postoperative days (POD) 7 and 30. characterize putative tumor suppressors identified from Results: From Mars-2015 to December-2017, 34 patients/ CRC liver metastases. 49 lesions were ablated in unique (74%;n=25) or multiple Methods: Patient samples were analyzed for gene expres- (26%;n=9) MTA procedure. CLM localization was pre- sion differences by the Nanostring platform after resection dominantly close to hepatic veins (79%;n=27). Liver of CRC primary tumors and associated liver metastases. resection was associated in 62% (n=21) of the patients. Epigenetic changes were subsequently characterized in At POD 30, there was no mortality or vessel thrombosis and vitro through manipulation of the histone methylase, one patient (3%) experienced severe complication due to left Enhancer of Zeste Homologue 2 (EZH2). pleural effusion (Clavien grade IIIa). All patients had access to Results: Nanostring analysis of cDNA from primary CRC adjuvant chemotherapy within the recommended time. with matched liver metastases after surgical resection (N=7) Conclusion: This study shows that CLM 3cm near deep demonstrated a 7.3 fold decrease in Phospholipase C vessels can be managed safely with a new generation of Epsilon 1 (PLCE1) expression. This was confirmed with thermal ablation. Western blotting in 14/15 samples for both PLCE1 and In the era of parenchymal-sparing liver surgery, the Phospholipase C Like-2 (PLCL2) (Figure A). The EZH2 reproducibility of MTA shows that it should be a part of the inhibitor GSK126 reactivated expression of both PLCE1 "toolbox” of modern surgeons. Early postoperative recov- and PLCL2 (Figure B). Additionally, GSK126 caused dose- ery could lead to an oncological benefit by allowing timely dependent cell death in CRC cell lines in vitro (Figure C). access to adjuvant chemotherapy. Conclusions: Our findings have established two novel tumor suppressors in CRC pathogenesis. Epigenetic control through EZH2 may have a role in treating this disease.

[Figure] Figure [Composite surgery with resection and MTA for CLM]

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S367

EP01A-100 portal branch (ZoneP) treated in a single step: the one stage hepatectomy (OSH). HCC PERITONEAL DROP Methods: 597 consecutive patients undergoing liver METASTASES: AGGRESSIVE CONTROL resection for CRLM (2002-2017) were considered. Sev- COMPORTS PROLONGED SURVIVAL enty-nine patients carrier of multiple (4) CRLM with A. Koffron, D. Bedi, S. Cohn, K. Putchakayala and bilateral ZoneH and ZoneP contact were treated with OSH. M. Alsibae Results: Sixteen(20%) patients received new devised sur- Surgery, Oakland University William Beaumont School of gical intervention (SERPS, transversal hepatectomy, mini- Medicine, United States mesohepatectomies, liver tunnels). Twelve(15%) patients received vascular reconstruction. Seven(9%) patients un- Introduction: HCC treatment has advanced significantly, derwent major hepatectomy associated with limited resec- leading to triumphant resection methods, and liver- tion. Sixty patients had at least one lesion detached from a directed therapy (arterial, ablative). Percutaneous biopsy ZoneH and ZoneP. Sixty-two patients(78%) had a thoraco- and ablations, while effective, risk dissemination of HCC, phenolaparotomy incision. Seven patients(9%) had an which is typically apparent later, following successful associated colon resection. resection/transplantation, hastening the demise of patients Median number of resected CRLMs was 10(4-48), due to the paucity of adjuvant treatments. We present a 28(35%) patients had >10 nodules. Eight(10%) patients cohort of patients with peritoneal HCC metastases, treated were R0, 14(18%) R1 vascular, 57(72%) R1parenchimal. with progressive cytoreductive surgical therapy (often- Mortality and morbidity rates were 3,8% and 33%. Five- times minimally-invasively), who experienced prolonged year survival was 22% (median overall survival 30 survival. months). Overall recurrence rate was 84% (63 patients), 22 Methods: Retrospective review of 42 patients possessing patients have liver only recurrence, 5 have extrahepatic peritoneal HCC following treatment. Patient data was only disease, 35 have combined intrahepatic and extrahe- examined for: primary procedure, preoperative biopsy, patic recurrence. Re hepatectomy was performed in 77 % pathology/surgical margins, peritoneal recurrence timing (17/22 patients) of patients with liver only recurrence. Cut and surgical interventions over the period of survivorship. surface recurrence occurred in 14 patients(18%). Results: All patients had abdominal imaging every three Conclusion: OSH in patients with multiple bilobar CRLM months as surveillance. All were found to have potential is a feasible and safe procedure. inciting procedural events: 22 percutaneous biopsy, 24 needle-delivered ablation, 2 microscopic-negative resection EP01A-102 margin. Average time to peritoneal disease identification, 10 mo. (range 4-14). All patients underwent progressively PREOPERATIVE LEUKOCYTES-BASED complex interventions (ex. percutaneous, laparoscopic, INFLAMMATORY SCORES IN open cytoreductive) during survivorship period. Average PATIENTS WITH COLORECTAL LIVER survival from stage IV diagnosis, 32 mo. (range 18-156). METASTASES: CAN WE COUNT ON Procedures during patient survivorship, average 4 (range 2- THEM? 7, 119/168 either percutaneous or minimally-invasive, 49 1,2 2 2 2 open cytoreductive surgery). Survival following open A. Dupré , R. Jones , R. Diaz-Nieto , S. Fenwick , G. Poston2 and H. Malik2 cytoreductive surgery ave. 9 mo. (range 5-17). 1 2 Discussion: It is intuitive that there is an potential proce- Centre Léon Bérard, France, and Aintree University dural cause in all patients (biopsy, needle-delivered ablation, Hospital, United Kingdom borderline positive surgical margin). The average time to Background and objectives: Neutrophil-to-lymphocyte peritoneal disease diagnosis (10mo.) was followed by pro- ratio (NLR), platelet-to-lymphocyte ratio (PLR), lympho- gressive interventions leading to extended survival in many cyte-to-monocyte ratio (LMR) are considered independent patients, suggesting thoughtful, escalating interventions prognostic factors for overall survival (OS) in primary lead to survival in patients suffering peritoneal HCC. colorectal cancer and there is growing interest in their use in colorectal liver metastasis (CLM). However, optimal cut- off values for these ratios have not been defined making comparison between series difficult. This study aimed to EP01A-101 confirm the prognostic value of inflammatory scores in TECHNICAL FEASIBILITY OF ONE patients undergoing resection for CLM. STAGE RESECTION IN PATIENTS Method: We retrospectively analysed data from 376 FORMALLY CONSIDERED consecutive patients who underwent liver surgery for CLM between June 2010 and August 2015. We assessed the UNRESECTABLE reproducibility of previously published ratios and deter- M. Cimino, L. Vigano’, F. Procopio, D. Del Fabbro, mined new cut-off values using the Cut-off Finder web- M. Donadon and G. Torzilli based tool. Relations between cut-off values and OS were Humanitas Research Hospital, Italy analysed with Kaplan-Meier log-rang survival analysis and Objectives: Multiple colorectal liver metastases (CRLM) multivariate Cox models. with bilateral intrahepatic main vascular contacts are Results: Three hundred forty-three patients had full pre- generally considered unresectable or at least amenable to operative blood tests for calculation of NLR, PLR and staged procedures in selected cases. We present perioper- LMR. The number of cut-off values which showed a sig- ative and long-term results of our series of patients with nificant discrimination for OS was 49/249 (19.7%) for bilateral intrahepatic contact with hepatic veins at the NLR, 28/316 (8.9%) for PLR and 22/214 (10.3%) for hepatocaval confluence (ZoneH) or with 1 and 2 order of LMR, all with a scattered distribution.

HPB 2018, 20 (S2), S333eS504 S368 Electronic Posters (EP01A-EP01E) - Liver fl Conclusion: In ammatory scores expressed as leukocytes EP01A-104 ratio are not reliable prognostic markers in patients with resectable CLM. LONG-TERM ONCOLOGICAL OUTCOMES OF TWO-STAGE EP01A-103 HEPATECTOMY FOR UNRESECTABLE INTRA-OPERATIVE HIGH INTENSITY COLORECTAL LIVER METASTASES: FOCUSED ULTRASOUND FOR FAST RESULTS OF A PROSPECTIVE STUDY AND LARGE VOLUME LIVER A. Dupré1, J. Gagnière2, G. Passot3, A. Ayav4, ABLATION. PRELIMINARY RESULTS F. Marchal5, S. Evrard6, F. Quenet7, J. -R. Delpero8 and 9 OF A PHASE II STUDY M. Rivoire 1Surgical Oncology, Centre Leon Berard, 2CHU Estaing, A. Dupré1,2, D. Melodelima2, D. Pérol3, Y. Chen3, 3CHU Lyon, 4CHU Nancy, 5Institut de Cancérologie de J. Vincenot2 and M. Rivoire2,3 Lorraine, 6Institut Bergonié, 7Institut du Cancer de 1Surgical Oncology, Centre Leon Berard, 2INSERM Montpellier Val d’Aurelle, 8Institut Paoli Calmettes, and LabTAU U1032, and 3Centre Léon Bérard, France 9Centre Léon Bérard, France Background: High intensity focused ultrasound (HIFU) is Introduction: Two-stage hepatectomy is a potentially a recent, non-ionizing and non invasive technology of focal curative treatment for initially unresectable bilobar colo- destruction. Independence from perfusion makes HIFU a rectal liver metastases. Only retrospective studies have promising technique for focal ablation of liver tumours. been published with various survival rates and drop-out Current technology is based on extra-corporeal treatment rates between the stages. which limits use of HIFU for the treatment of liver tumours. Methods: We previously conducted a prospective ran- Moreover elementary ablations are small and must be domized study to assess the efficacy of hyaluronic acid juxtaposed to treat supra-centimetric tumours, resulting in membranes to prevent adhesions between the two stages long-time treatment. between 2008 and 2010. We analysed the data of the pa- Methods: We developed an HIFU probe for intra-operative tients included in this study as a single cohort of patients to use and assessed the feasibility and efficacy of this device evaluate the oncological outcomes of two-stage hepatec- in patients with colorectal liver metastases (< 20mm). This tomies. Survival data are reported from the date of the first study was a prospective, single-centre phase I/II study. All liver surgery. ablations were performed in the area of liver scheduled for Results: Among the 54 patients randomized at the end of liver resection to avoid loss of chance. the first hepatectomy, 41 had both liver stages (drop-out Results: Twenty-eight patients were included. HIFU rate of 24%). In intent-to-treat analysis (n=54), 4-year ablations were created to ablate metastases with safety overall survival (OS) was 50% (CI95%: 36-62) and median margins in all directions. The exposure time varied from progression-free survival (PFS) was 12.5 months. In pa- 40 seconds to 370 seconds according to the diameter of tients who completed both stages (n=41), 4-year OS was the metastases to be treated. One metastasis of 10 mm in 59% (CI95%: 42-72). In patients who failed to have the diameter was ablated in 40 seconds with safety margins. second hepatectomy, 2-year OS was 38.5% (CI95%: 14- Using electronic focusing metastases of 2 cm in diameter 62). Except for completion of both stages, no prognostic were ablated with safety margins (> 3 mm in all di- factors were found in multivariate analysis. rections) in 370 seconds. The dimensions of these HIFU Conclusion: In intent-to-treat analysis, patients candidates ablations were a diameter of 48 4.9 mm and a long to two-stage hepatectomy achieve comparable oncological axis of 51 3.4 mm. No damage occurred to neigh- outcomes than those with resectable metastases. Prognostic boring tissues. of patients who failed the complete strategy had better Conclusion: Intra-operative HIFU can produce ablations of prognostic than expected. 5 centimeters in 6 minutes with a precision of 1-2mm and real-time monitoring (NCT01489787) EP01A-105 HEPATIC RESECTION FOR ENDOMETRIAL CANCER A. Lucchese1, A. Kalil1, V. Karam2, O. Ciacio2, G. Pittau2, D. Castaing2, D. Cherqui2, A. Sa Cunha2, E. Vibert2 and R. Adam2 1Surgical Oncology, Federal University of Health Sciences of Porto Alegre, Brazil, and 2Centre Hépato-Biliaire, AP- HP Hôpital Paul Brousse, Université Paris Sud, France Introduction: Historically, patients with liver metastases from uterine neoplasms have been treated with palliative intent. Surgery is proving to have an increasing role, but there are few studies in this setting, usually analyzing endometrium with others gynecological tumors. We report on a retrospective series of patients with liver Figure [HIFU ablation] metastases from uterine primaries that underwent hepatic resection at a reference center.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S369

Methods: We retrospective analyzed 11 patients who un- as well as to those reported in series of major liver resection derwent hepatic resection of endometrial cancer metastases without rectal surgery. in our institution. Data related to the primary tumor, hepatic and extrahepatic metastases and patient follow-up were collected. All patients were treated in a multidisciplinary EP01A-107 context. PERITUMORAL CD3+INFLAMMATION Results: During the last 35 years we resect 11 patients with metastases from endometrium. The median age was 56.4y AND NEUTROPHIL TO LYMPHOCYTE (43-70). All presented with metachronous metastases, with RATIO PREDICT OVERALL SURVIVAL a median interval between the surgery of the primary tumor IN PATIENTS AFFECTED BY and the metastases diagnosis of 53 months (12-150). Some COLORECTAL LIVER METASTASES presented with extrahepatic metastases, they were TREATED WITH SURGERY controlled more then 6 months before liver surgery by resection or radiation therapy or they were resected with the M. Cimino, M. Donadon, D. Mavilio, K. Hudspeth, liver surgery. A complete resection (R0) was achieved in 10 L. Di Tommaso, M. Roncalli and G. Torzilli patients (90.9%). The median survival was 3.4 years, and Humanitas Research Hospital, Italy the overall survival at 5 years was 50%. On univariate Background: Systemic and local inflammation plays an analysis extra hepatic disease (controlled before or resected important role in many cancers and colorectal liver me- with) was not a predictor of survival. tastases (CRLM). While the role of local immune response Conclusions: The survivals are surprisingly good in many mediated by CD3+ tumour infiltrating lymphocyte is well cases, even if they appear with an extra hepatic metastase. established new evidence on systemic inflammation and We should consider surgery especially in those patients cancer such as neutrophil-lymphocyte ratio (NLR) are with an interval free of disease more than 12 months. emerging. The aim of the study is to associate systemic and local inflammation to predict overall survival (OS) and recurrence free survival (RFS) in CRLM. EP01A-106 Methods: 128 patients (2008-2013) affected by CRLM treated with chemotherapy and surgery were analysed. SHORT AND LONG-TERM RESULTS OF Different cut-off were calculated with ROC curves for each SIMULTANEOUS RESECTION OF biomarkers and their relative outcome (OS or RFS). DISTAL RECTAL CANCER WITH Associating the two biomarkers three risk groups were SYNCHRONOUS LIVER METASTASES: determined: low risk group (two protective biomarkers) IN SEARCH OF A STRATEGY intermediate risk group (one protective biomarkers) high risk group (no protective biomarker). V. Ardiles, J. Goransky, M. de Santibañes, G. Rossi, Results: After a median of follow-up of 45 months, median P. Huespe and E. de Santibanes OS and RFS were 44 and 9 months respectively. For OS Hospital Italiano de Buenos Aires, Argentina 29(22.66 %), 59(46.09%) and 40(31.25%) patients were in Introduction: There is no consensus about the best treat- the low, intermediate and high risk group respectively.For ment option for patients with a primary rectal tumor and RFS 30(23.44%), 52(40.63%) and 46 (35.94%) patients metastatic disease, with only a few small series published to were in the low, intermediate and high risk group respec- date. Three different treatment strategies have been tively. Adjusted Cox regression analysis showed a worse described for the management of synchronous distal rectal OS survival and RFS increasing risk factors( intermediate cancer and liver metastases (SRCLM): the “classic”, the group HR 2.67 p=0.007 95%CI 1.31-5.42, high risk group “reversal”, and the “simultaneous” approaches. 2.86 p=0.005 95%CI 1.37-5.99 for OS) (intermediate group The aim of the current study was to determine the HR 2.01 p=0.029 95%CI 1.31-3.78, high risk group HR feasibility, safety and long-term outcomes of simultaneous 1.95 p=0.049 95%CI 1.00-3.77 for RFS). resection of distal rectal cancer and liver metastases Conclusion: Systemic and local immune response index performed by colorectal and hepatic surgeons of the same allow to stratify patients in different OS and RFS risk institution. groups. Methods: A retrospective review from a prospective practice-specific database was performed to identify all the < patients with distal rectal cancer ( 10 cm from the anal EP01B - Electronic Poster: 1B - Liver Primary verge) and synchronous liver metastases treated at the Tumours Department of Surgery of Hospital Italiano de Buenos Aires from January 2004 to December 2015. EP01B-001 Results: 48 patients with mid and low rectal tumors and PERIOPERATIVE IMMUNONUTRITION synchronous liver metastases represent the population IN MAJOR HEPATIC RESECTION: A analyzed. The 90 days mortality rate was 2% (n=1). Nine SYSTEMATIC REVIEW AND META- (18,7%) patients experienced severe complications (DCIII ANALYSIS and IV). The anastomotic leakage rate was 4% (n=2). 1 2 Estimated median overall survival rates for 1, 3 and 5 years C. S. Wong and S. -S. Liau 1 2 were 87%, 50% and 28% respectively. University of Edinburgh, and Department of Surgery, Conclusion: For patients with SRCLM, in centers with Addenbrookes Hospital Cambridge, United Kingdom experienced HPB and colorectal surgeons, simultaneous Aim: The role for immunonutrition after liver resection can be a reasonable option, with a morbimortality compa- remains unclear and controversial. We undertook a sys- rable to those published for classic and reversal approaches, tematic review to evaluate the effects of immunonutrition

HPB 2018, 20 (S2), S333eS504 S370 Electronic Posters (EP01A-EP01E) - Liver

(IM) on clinical outcomes of patients undergoing hepa- contribution to intrahepatic metastases and recurrence after tectomy or liver resection. HCC resection. Methods: Main electronic databases [MEDLINE via Conclusion: Exosomes played an important role in the Pubmed, EMBASE, Scopus, Web of Knowledge, intrahepatic metastasis and postoperative recurrence of Cochrane Central Register of Controlled Trials (CEN- HCC, suggested that cancer cell associated exosomes are of TRAL) and the Cochrane Library, and clinical trial registry great significance for the early diagnosis, clinical treatment (ClinicalTrial.gov)] were searched for studies reported and prognosis evaluation of HCC. clinical outcomes or effects of IM. The systematic review was conducted in accordance with the PRISMA guidelines and meta-analysis was analysed using fixed and random- EP01B-003 effects models. PLATELET-TO-LYMPHOCYTE RATIO Results: Ten RCTs were identified. A total of 960 patients AND LARGE TUMOR SIZE PREDICT (465 IM and 495 control) were included in the final pooled MICROVASCULAR INVASION AFTER analysis. Of these patients, 867 (90%) underwent hepa- RESECTION FOR HEPATOCELLULAR fi tectomy for primary hepatocellular carcinoma. IM signi - CARCINOMA cantly reduced post-operative wound infection (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.42 to 0.97; p = N. Rungsakulkij, S. Mingphruedhi, W. Suragul, 0.04). Although, the combined results showed that IM had P. Tangtawee, P. Muangkaew and S. Aeesoa a shorter hospital stay (MD -5.37 days, 95% CI -8.86 to Department of Surgery, Ramathibodi Hospital, Mahidol -1.88; p < 0.00001), there was significant heterogeneity University, Thailand observed across these studies. There was no statistically Introduction: Recurrence after curative resection of he- significant benefit on other post-operative morbidities of patocellular carcinoma (HCC) is associated with early interest (e.g. bile leak, liver failure, ascites) and mortality. death and poor prognosis. Microvascular invasion (mVI) is Conclusions: IM decreases wound infection rates and re- strongly associated with disease recurrence. Although duces length of stay. It should be recommended as routine many studies have examined the relationship between nutritional support as part of the Enhanced Recovery after various serum inflammatory indices and post-treatment Surgery (ERAS) programmes for hepatobiliary surgery. prognosis, little is known about preoperative predictors of microvascular invasion in HCC. EP01B-002 Methods: Patients who underwent curative hepatic resection HCC-DERIVED EXOSOMES DRIVE HCC for HCC at our institute from January 2006 to December PROGRESSION AND RECURRENCE BY 2016 were retrospectively reviewed. The associations be- tween mVI and various potential risk factors, including tumor EPITHELIAL-MESENCHYMAL size, hepatitis B and C virus infection, Child-Pugh scores, TRANSITION THROUGH MAPK/ERK platelet-to-lymphocyte ratio, and neutrophil-to-lymphocyte SIGNALING PATHWAY ratio, were analyzed. Optimal cut-off values were determined L. Chen and T. Song using receiver operating characteristic curves. Department of Hepatobiliary, Tianjin Medical University Results: A total of 330 HCC patients were enrolled in this Cancer Institute and Hospital, China study, of whom 74 (22.4%) had tumors with mVI. After univariate analysis, two parameters were significantly Introduction: The recurrence and intrahepatic metastases associated with mVI after hepatic resection: platelet-to- are two main reasons that restricting the survival of patients lymphocyte ratio 102 (odds ratio [OR] 2.385, p = 0.001) with Hepatocellular Carcinoma (HCC). In recent years, re- and tumor size 5 cm (OR 4.29, p < 0.001). Both variables searches on exosomes have demonstrated that they play an remained significant risk factors for mVI after multivariate important role in tumor progression and metastases. How- analysis: platelet-to-lymphocyte ratio 102 (OR 1.831, p = ever, their role in liver cancer is rarely reported. This study 0.034) and tumor size 5 cm (OR 3.791, p < 0.001). aims to provide a new idea and direction for the clinical Conclusions: Large tumor size (5 cm) and high platelet- diagnosis and treatment of HCC by revealing the role of to-lymphocyte ratio (102) are independent predictive exosomes in the development and recurrence of HCC. factors for mVI in HCC. This information may be helpful to Methods: The exosomes are prepared by ultracentrifuga- clinicians for preoperative decision-making. tion. The Western blot assay, chemotaxis assay, invasion assay, scratch assay and immunofluorescence assay were used to confirm the important role of tumor-associated EP01B-004 exosomes in the malignant transformation of tumor cells. 1a,25-DIHYDROXYVITAMIN D3 The animal experiments confirmed the important role of INHIBITS AFLATOXIN B1-INDUCED HCC-associated exosomes in intrahepatic metastasis and PROLIFERATION AND MALIGNANT postoperative recurrence of HCC. TRANSFORMATION OF HEPATIC Results: The results showed that the exosomes secreted PROGENITOR CELLS BY REGULATING from high metastatic potential cells could promote the low metastatic potential cells malignant transformation by PI3K/AKT AND HIPPO PATHWAYS epithelial-mesenchymal transition through MAPK/ERK L. Zhang and X. -P. Chen signaling pathway. The down regulation of Rab27a, a key Hepatic Surgery Center, Tongji Hospital, Tongji Medical gene regulating secretion of exosomes, could be inhibited College, Huazhong University of Science and Technology, the secretion of exosomes in tumor cells promoted the in- China vasion and metastasis of the cells. Animal experiments also Background: Hepatic progenitor cells (HPCs) might showed that tumor cell associated exosomes made a great be the origin of hepatocellular carcinoma. 1a, 25-

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S371 dihydroxyvitamin D3 (1, 25(OH)2D3) is capable of inhib- blood loss was 546.0562.8 ml, and blood transfusion was iting the proliferation of various cancer cells . This study 543.01035.2 ml. The median survival for HCC patients was conducted to determine the potential of 1a, 25(OH)2D3 was 631 days, with 1, 3, 5 year overall survival of 73.2%, to inhibit proliferation and malignant transformation of 28.8% and 19.6%, respectively. Liver cirrhosis, multiple HPCs induced by aflatoxin B1 (AFB1) and explore the nodules, tumor thrombosis and high AFP level were risk mechanism of inhibition. factors that affect postoperative survival. Methods: A rat HPC cell line, WB F-344 cells, were treated with AFB1, 1a, 25(OH)2D3 or combination. Cell proliferation, apoptosis, cell cycle, differentiation and in- EP01B-006 vasion were measured. ICR mice were exposed to AFB1 LAPAROSCOPIC LIVER RESECTION every day for 14 d, the liver function and immunohisto- chemistry were surveyed. FOR LARGE HCC: SHORT AND LONG Results: AFB1 exhibited the stimulative effects on the TERM OUTCOMES IN RELATION TO proliferation, dedifferentiation and invasion of HPCs. In TUMOR SIZE this period, the phosphorylation of AKT, expression of G. B. Levi Sandri1, G. Spoletini2, G. Vennarecci1, Yap, Taz, cyr61 and cyclin D1 were increased in cells. At E. Francone2, M. Abu Hilal2 and G. M. Ettorre3 the same time, phosphorylation of lats1, expression of p21 1Division of General Surgery and Liver Transplantation, Kip1 were reduced in AFB1-treated cells. When F-344 San Camillo Hospital, Italy, 2University Hospital South- cells were treated with AFB1 in combination with 1a, 3 a ampton, United Kingdom, and San Camillo Hospital, 25(OH)2D3, it was found that 1 , 25(OH)2D3 inhibited Italy these effects of AFB1 on HPCs. Meanwhile, the expression Introduction: Laparoscopic liver resection (LLR) has been and phosphorylation of the above pathways were reversed shown to be feasible, safe and oncologically efficient. The compared to treatment with AFB1 alone. experience with large hepatocellular carcinoma (HCC) is Conclusions: These results suggest that AFB1 could induce even more limited. In this study we aim to assess the impact proliferation, differentiation and transformation of HPCs, of tumor size on clinical and oncological outcomes in pa- and that an enhanced 1a, 25(OH) D negatively regulates 2 3 tients undergoing for HCC. the inductive effects of AFB1 on HPCs by suppressing the Methods: Between 2003 and 2016, 172 patients from two activation of Akt, activating Hippo pathways. high volume liver surgery centers underwent LLR for EP01B-005 HCC. Prospectively collected data were analyzed after stratification in 3 groups according to tumor major diameter 42573 CASES OF HEPATECTOMY IN (group 1: < 3 cm; group 2: 3-5 cm; group 3: 5 cm). CHINA: A MULTICENTER Results: Groups 1, 2 and 3 consisted of 82, 52 and 38 RETROSPECTIVE INVESTIGATION patients respectively. Minor and major resections were B. Zhang1, B. Zhang1, Y. Mao2, W. Zhou3, X. Chen1 and performed in 98,8% and 1,2% in group 1, in 90,4% and C. Wang4 9,6% in group 2, and in 68,4% and 31,6% in group 3 “ ” 1Surgery, Tongji Hospital of Huazhong University of Sci- respectively. Postero-superior technically major re- ence and Technology, 2Peking Union Medical College sections were performed in 15,8% patients in group 1, in Hospital, 3Eastern Hepatobiliary Surgery Hospital, 19,2% in group 2 and in 15,8% in group 3 respectively. < Second Military Medical University, and 4Department of Group 3 had higher conversion rates (p 0.001), more Surgery, Tongji Hospital of Huazhong University of Sci- frequent (p=0.056) and prolonged (p=0,075) pedicle < ence and Technology, China clamping, longer operative time (p 0.001), higher blood losses (p=0.025) and longer total hospital and intensive Hepatectomy is currently routinely performed in most care unit stays. hospitals in China. It is widely known that China owns the There were no differences in morbidity, mortality, largest population of liver diseases and the biggest number completeness of resection rates and long term outcomes of liver resection cases. However, we have no convincible between the three groups. data statistics to show the current status of hepatectomy Conclusion: LLR for HCC appears to be safe and onco- performed for patients with liver diseases in China. A logically efficient when performed in high volume HPB nationwide multicenter retrospective investigation and laparoscopic centers. Tumor size does not appear to involving 112 hospitals was performed to resolve this issue, impact negatively on the outcomes except for postoperative and focused on liver resection for patients with hepatocel- hospital stay. lular carcinoma (HCC). 42573 cases of hepatectomy were enrolled, and 18275 valid cases of liver resection for HCC patients were selected for statistical analysis. The epide- miology of HCC, distribution of hepatectomy, post- EP01B-009 operative complications and prognosis were finally PREOPERATIVE LYMPHOCYTE-TO- analyzed. 67% of the whole 42573 patients with hepatec- MONOCYTE RATIO IS USEFUL FOR tomy were HCC, and 84% of the HCC patients were male. STRATIFYING THE PROGNOSIS OF In the 18275 HCC patients, 81% had hepatitis B virus infection and 10% had hepatitis C virus infection. 38% of HCC PATIENTS WITH LOW CLIP the HCC patients had normal APF level, and other 35% had SCORES an AFP level lower than 400 ng/ml. In the study period, Y. Takagi, T. Shimizu, M. Ishizuka, T. Shiraki, S. Mori, 97% of the hepatectomy for HCC were performed with Y. Iso, M. Kato, T. Aoki and K. Kubota open surgery, and 23.81% had vascular exclusion tech- Second Department of Surgery, Dokkyo Medical Univer- niques. The operation time was 191.7105.6 min, the sity, Japan

HPB 2018, 20 (S2), S333eS504 S372 Electronic Posters (EP01A-EP01E) - Liver

Background: Previous study reported that cancer of the 0.63 (95% confidence interval [CI], 0.44-0.90). In the 233 liver Italian program (CLIP) scores could not stratify pairs of matched subjects, cumulative HCC incidence at 1, postoperative outcomes for hepatocellular carcinoma 3, 5 and 7 years were 1%, 6%, 7% and 15% and 1%, 6%, (HCC) patients with low CLIP scores (0-1). To resolve this 15% and 23% in splenectomy and non-splenectomy group, problem, we examined whether lymphocyte-to-monocyte respectively (Breslow test = 4.9, p=0.028). In multivariate ratio (LMR) could stratify the prognosis of such patients. analysis, splenectomy was an independent factor associated Methods: We reviewed 329 patients with newly diagnosed with reduced HCC incidence. In conclusions, splenectomy primary HCC who underwent liver resection. Among them, for treatment of hypersplenism may decrease the risk of we selected patients with low CLIP scores. Univariate and HCC development. multivariate analyses were performed to detect clinical factors that correlated with overall survival (OS), and their EP01B-011 cut-off values were identified using receiver operating SURGERY START TIMES AND LONG- characteristic (ROC) curve analyses. Kaplan-Meier anal- TERM OUTCOME AFTER PARTIAL ysis and the log-rank test were used for comparison of OS. Results: Univariate analyses revealed significant associa- HEPATECTOMY FOR tions between OS and AFP (>20/20, ng/mL), albumin (< HEPATOCELLULAR CARCINOMA 3.5/3.5, g/dL), anatomical resection (presence/absence), Q. Lu, Y. Lv and X. -F. Zhang Child-Pugh class (B/A), CRP (>0.3/0.3, mg/dL), Hepatobiliary Surgery, Xi’an Jiaotong University, China ICGR15 (>13/13, %), LMR (< 4.35/ 4.35), maximum Background: Surgery start times may affect long-term tumor size (>3.5/ 3.5, cm), number of tumors ( 2/1), outcomes in cancer patients. This study was designed to pathological differentiation (moderately or poorly/well), examine the effects of surgery start times on long-term 4 3 platelet count (< 14/14, 10 /mm ), PIVKA-II (>100/ outcome of patients undergoing partial hepatectomy (PH) 100, mAU/mL), portal hypertension (presence/absence), for hepatocellular carcinoma (HCC). portal vein invasion (vp1-3/vp0), PT % (< 75/75, %) and Methods: Patients undergoing PH for HCC between 2012 TNM stage (III, IV/I, II). Multivariate analysis revealed that and 2015 were included. All patients were divided into two LMR (< 4.35/4.35) was closely associated with OS groups according to the start times of surgery: group M (hazard ratio 1.973; 95% CI, 1.115-3.491; P = 0.020). (morning surgery, 8 a.m.-1 p.m.) and group A (afternoon Kaplan-Meier analysis and the log-rank test demonstrated surgery, 1 p.m.-6 p.m.). Oncologic outcomes were that a significant difference in OS was observed between compared by survival analysis with Kaplan-Meier methods patients with high LMR (>4.35) and those with low LMR between different groups. ( 4.35) (P =0.019). Results: A total of 231 patients were included in the study Conclusions: Preoperative LMR is useful for stratifying (141 in group M and 90 in group A). There was no dif- the prognosis of HCC patients with low CLIP scores (0-1). ference in age, body mass index, medical comorbidities (diabetes mellitus and cardiovascular disease), tumor size, EP01B-010 tumor location, tumor stage (TNM stage and BCLC stage), > SPLENECTOMY MAY DECREASE THE surgical procedures or surgical margin (all p 0.05). Pa- tients in group M had longer operation duration than those RISK OF HEPATOCELLULAR in group A (240 min vs 195 min, p=0.004). No differences CARCINOMA IN PATIENTS WITH LIVER were observed in overall survival of all patients between CIRRHOSIS: A MULTI-INSTITUTIONAL different groups (p= 0.53). In subgroup analysis, there was CASE-CONTROL STUDY still no difference in overall survival of patient with tumor stage (BCLC stage A: p= 0.08 and BCLC stage B+C: X. -F. Zhang and Y. Lv p=0.10) and surgical margin (1-10mm: p=0.68 and ＞ Hepatobiliary Surgery, Xi’an Jiaotong University, China 10mm: p=0.67) between group M and group A. Hypersplenism, a common consequence of liver Conclusion: Our results indicate equivalent long-term cirrhosis, is a risk factor promoting development of hepa- prognosis regardless of surgery start time in patients un- tocellular carcinoma (HCC). The present study aimed to dergoing PH for hepatocellular carcinoma, despite longer identify whether splenectomy for treatment of hyper- surgery duration for surgeries beginning in morning. splenism has any impact on HCC risk. 407 consecutive patients undergoing splenectomy for hypersplenism and 464 patients receiving medication treatments for liver cirrhosis (non-splenectomy) synchronously were included EP01B-012 from seven University Hospitals in China. Data on clinical IS THERE AN ONCOLOGICAL characteristics, treatment modalities and HCC incidence INTEREST IN THE COMBINATION OF during follow-up was collected and compared between CRS / HIPEC FOR PERITONEAL splenectomy and non-splenectomy groups. Propensity CARCINOMATOSIS OF HCC? RESULTS score matching was performed to generate matched pairs of OF A MULTICENTER INTERNATIONAL the patients. Multinomial Cox proportional hazard regres- sion analysis was performed to identify significant risk STUDY factors associated with HCC occurrence. The median S. Mehta1, L. Schwarz2, J. Spiliotis3, E. H. Akaishi4, follow-up was similar between the two groups (median, 63 D. Baratti5, P. H. Sugarbaker6, D. Goere7, F. Quenet8, and 62 months). Cumulative HCC incidence at 1, 3, 5 and 7 M. -C. Hsieh9 and V. Kepenekian10 years were 1%, 6%, 11% and 16% in splenectomy group, 1Department of Peritoneal Surface Oncology, Saifee and 2%, 10%, 17% and 24% in non-splenectomy group Hospital, India, 2Department of Digestive Surgery, Hôpi- (Breslow test = 7.7, p=0.005). The hazard ratio (HR) was tal Charles Nicolle, Rouen University Hospital, France,

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S373

3First Department of Surgical Oncology, Metaxa Cancer hepatitis C (SVR-HCC), and 479 HCC patients not Memorial Hospital, Greece, 4Centro de Oncologia Hos- achieving SVR or without interferon treatment (non-SVR pital Sirio Libanes, Brazil, 5Fondazione IRCCS Istituto HCC). Risk factors for survival outcome were investigated. Nazionale Dei Tumori di Milano, Italy, 6Washington Results: The 3-, 5-, 7-year recurrence-free survival rates Hospital Center, United States, 7Gustave Roussy, France, were 48%, 36%, 32% in NBNC-HCC patients, 36%, 20%, 8Institut du Cancer de Montpellier Val d’Aurelle j ICM Val 13% in non-SVR HCC patients, and 51%, 37%, 35% in d’Aurelle, France, 9Department of General Surgery, Wan- SVR-HCC patients (p< 0.001). The 3-,5-,7-year overall Fang Hospital, Taiwan, Republic of China, and survival rates were 78%, 61%, 49% in NBNC-HCC pa- 10Department of Surgical Oncology, Centre Hospitalier tients, 72%, 55%, 38% in non-SVR HCC patients, and Lyon Sud, Hospices Civils de Lyon, France 83%, 73%, 65% in SVR-HCC patients (p< 0.001). The Introduction: Peritoneal metastasis (PM) of hepatocellular prevalence of HCC-related death, liver-related death, and carcinoma (HCC) without distant spread are rare. The other death were 61%, 12%, and 27% in NBNC-HCC, related prognosis is poor without standard treatment 69%, 10%, and 21% in non-SVR HCC, and 81%, 0%, and available. The role of cytoreduction surgery (CRS) and 19% in SVR-HCC. With reference to SVR-HCC patients, hyperthermic intraperitoneal chemotherapy (HIPEC) is NBNC-HCC patients had no significant difference in poorly documented. recurrence-free survival, but had poor overall survival by Methods: An international multicentric cohort was multivariate analysis (hazard ratio; 1.58, 95% confidence constituted by retrospective analysis of 21 patients under- interval; 1.02-2.44, p=0.040). Among SVR-HCC patients, going CRS/HIPEC for PM of HCC between 1992 and 2016 multiple tumor was only prognostic factor for overall sur- from 10 reference centers of PSOGI. Data on clinical fea- vival by multivariate analysis. Meanwhile, in NBNC-HCC tures, treatment strategies, and survival outcomes were patients, Child-Pugh classification B, liver cirrhosis, and analyzed. portal invasion were identified as prognostic factors. Results: The median time interval from the diagnosis of Conclusion: NBNC-HCC patients had poor prognosis PM to the procedure was 4.5 months. The median peri- compared with SVR-HCC patients. Improvement of toneal cancer index was 14. Sixteen(76%) patients had background liver function might be required for NBNC- complete cytoreduction (CCR0-1). Ten patients(50%) had HCC patients. grades 3 to 4 complications. One(5%) patients died peri- operatively. The median duration of follow-up was 52.2 months. The median OS was 46.7 months. The projected EP01B-015 3y-OS and 5y-OS were 88.9 and 49.4% respectively. The SAFETY AND EFFICACY OF median OS for patients with CCR0-1 resection was not STEREOTACTIC BODY reached whereas it was 5.9 months for those with CCR2-3 resection after CRS(p=0.0005). The median RFS was 26.3 RADIOTHERAPY FOR months and projected RFS at 3 years of 36.5 months HEPATOCELLULAR CARCINOMA Three prognostic factors were associated with improved WITH PORTAL VEIN RFS in the univariate analysis: preoperative chemo- Y. Shui1,W.Yu2,Q.Hu2, X. Bai2, L. Shen2,T.Ma2, > therapy(p=0.0156), PCI 15(p=0.009), Number of T. Liang2 and Q. Wei1 chemotherapy agents used for HIPEC(p=0.005). 1Department of Radiation Oncology, The Second Affiliated Conclusion: CRS/HIPEC is a safe and effective approach Hospital, and 2The Second Affiliated Hospital, Zhejiang in selected patients with PM of HCC. Complete cytor- University School of Medicine, China eduction with HIPEC gives the patient a chance for a good Background: To report the safety, efficacy, and toxicity of relapse free and overall survival and should be considered stereotactic body radiotherapy (SBRT) for the treatment of as an option. advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). Materials and methods: Seventy patients treated with EP01B-013 Linac-based SBRT for HCC with PVTT between Dec 2015 SURVIVAL OUTCOMES OF NON-B, and June 2017 were analyzed. SBRT was designed to target NON-C HEPATOCELLULAR the tumor thrombosis and adjacent primary tumor (if it is CARCINOMA WITH REFERENCE TO feasible). Deliver a median total dose of 40Gy (range, 25- fi HEPATITIS C-RELATED 50Gy) in ve fractions during one week. Fourty patients received TACE(1-5 cycles) followed SBRT. Three patients HEPATOCELLULAR CARCINOMA received operation followed SBRT. H. Shinkawa, S. Tanaka, S. Takemura, T. Ito, A. Aota, Results: The median follow-up was 10 months. After six M. Koda, T. Miyazaki and S. Kubo months of SBRT, assessments of PVTT response showed Hepato-Biliary-Pancreatic Surgery, Osaka City Univer- complete response(CR) in 2 of 26 (7.6%) patients, partial sity, Japan response(PR) in 15 (57.6%), progression disease(PD) in Introduction: The current study aimed to investigate long- 6(23.0%),stable disease（SD）in 3 (11.5%), with an term outcome in patients with hepatocellular carcinoma objective response rate of 65.2%. No treatment-related (HCC) negative for hepatitis B surface antigen and hepatitis Grade 4/5 toxicity was seen within three months after C (HCV) antibody (NBNC-HCC) compared with HCV- SBRT. The one-year overall survival rate was 36.6%. The related HCC patients. predictive factor associated with better survival was Method: The subjects were 222 patients with NBNC-HCC, response to radiotherapy and SBRT followed by TACE. 80 HCC patients achieving sustained virological response Conclusions: Linac-based SBRT is a safe and effective (SVR) by preoperative interferon treatment for chronic treatment option for PVTT in HCC. Prospective

HPB 2018, 20 (S2), S333eS504 S374 Electronic Posters (EP01A-EP01E) - Liver randomized controlled trials are warranted to validate the venous thrombus and/or tumoral direct invasion of portal or role of SBRT in these patients. hepatic veins in any imaging before LR. The primary outcome was overall survival. Survival probabilities were estimated by the Kaplan-Meier method and predictors of EP01B-016 mortality were estimated by multivariate cox regression. ELUDING LIVER TRANSPLANTATION Results: 40 patients with HCC and MVI underwent LR. Table 1 IN POSTTEXT III AND IV HEPATOBLASTOMA: EXTENDED LIVER RESECTION IS WORTHWHILE [Table 1] A. Elgendi, S. Fadel, M. Elshafei and A. Shawky Variable N [ 40 Alexandria University, Egypt Sex, male (%) 33(82.5) Purpose: Primary liver transplantation is recommended for Age, years (IQR) 60(52 – 66) central POSTTEXT III and POSTTEXT IV hepato- Child-Pugh blastoma. Aim is to prospectively assess safety, oncological efficacy of aggressive non-transplant extended hepatic re- A (%) 36(90) sections in those patients. B (%) 4(10) Methods: Study included 18 children with central PRE- Liver Disease (%) TEXT III and IV, 3 had primary liver transplantation Hepatitis B 17(42.5) whereas 15 underwent hepatic resection after neoadjuvant Hepatitis C 12(30) chemotherapy. Results: Median tumor volume was 317 ml (range 135- None 9(22.5) 546). After 4 cycles chemotherapy, POST-TEXT was III in Other 2(5) 12 and IV in 3 patients. There was no perioperative mor- MELD (IQR) 7(7 – 8) tality. Postoperative complications were 2 bile leaks, one Platelets, 103/mL, median (IQR) 228(166 – 263) temporary decompensation and one sub-phrenic collection Number of tumors, median (IQR) 1(1– 2) requiring drainage. 1 and 3 years disease free survival was – 93.3% and 73.3% respectively. 3 years overall survival was Size biggest tumor, cm, (IQR) 8.3(5 11.4) 86.6%. Four patients developed recurrence, of which two AFP, ng/mL, median (IQR) 148(20 – 4954) died. Early recurrence within one year occurred in one Type of MVI patient. All recurrences were distant metastases. Portal vein (%) 28(70) Conclusions: Extended major hepatic resection for Hepatic vein (%) 12(30) selected cases of POST-TEXT III and IV hepatoblastoma is technically challenging but feasible approach with accept- Type of resection able morbidity and mortality rates. Oncological outcomes Right hepatectomy (%) 18(45) are comparable to liver transplantation without the long- Extended right hepatectomy (%) 9(22.5) term commitment of immunosuppression or donor risk and Left hepatectomy (%) 6(15) morbidity however; potential donor should always be pre- Extended left hepatectomy (%) 3(7.5) pared for plan B if needed. Other (%) 4(10) Tumor differentiation EP01B-017 Well (%) 1(2.5) OUTCOMES AND PREDICTORS OF Moderate (%) 22(55) MORTALITY AFTER LIVER Poor (%) 15(37.5) RESECTION FOR HEPATOCELLULAR Other (%) 2(5) CARCINOMA WITH MACROVASCULAR INVASION: A COHORT STUDY shows the demographic and clinical characteristics. In all 1 1 2 1 A. Gorgen , H. Muaddi , M. Massomian , W. Zhang , patients the preoperative MVI was confirmed in the path 1 1 2 1 I. D. McGilvray , A. Wei , S. Fischer , S. Gallinger , report. Complications 3a occurred in 12 (30%) patients. 1 1 P. Greig and G. Sapisochin HCC recurrence occurred in 25 (60%) patients. The median 1 2 Division of General Surgery, and Department of Pa- recurrence-free survival was 5 months. The median overall thology, Toronto General Hospital, University of Toronto, survival was 29 months. The 1-, 3- and 5-years actuarial Canada survival was 62%, 37% and 30% respectively. Figure 1 Background: Previous studies have shown a potential shows survival probabilities after LR. AFP>400ng/mL survival benefit of liver resection (LR) for patients with [HR 4.8 (95% CI 1.5 - 16)] and portal vein invasion on MVI but this approach is still controversial. The aim of this preoperative imaging [HR 6 (95% CI 1.4 - 25.5)] were study was to assess the postoperative and long-term out- independent predictors of mortality. comes after LR of patients with HCC with MVI identified Conclusion: LR for patients with HCC and MVI is asso- preoperatively. ciated with high incidence of postoperative complications. Methods: We included all patients with HCC and presence Acceptable 5-years survival may be achieved after LR for of MVI that were resected between January 2000 and patients with HCC and MVI. August 2016. Preoperative MVI was defined as enhancing

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S375

EP01B-018 were selected. Risk factors for LI were assessed by multivariate logisitc analysis and prognostic value of LI by AN ANALYSIS OF SURGICAL a Cox model. TREATMENT FOR IPNBS BASED ON Results: One hundred thirty consecutive patients met the THE CARCINOMA CASE IN inclusion criteria. Median age was 63 years and 109 pa- MYASTHENIA GRAVIS AND IGG4 tients (83%) underwent a major hepatectomy. Combined RELATED SCLEROSING CHOLANGITIS vascular resection was performed in 25 (19%) patients. LI was found in 56 patients (43%) and the median number of WITH AUTOIMMUNE PANCREATITIS invaded LN was 2.5 [1-21]. Multivariate analysis found PATIENT that LI was associated with satellitosis (HR=6.02;CI N. Ishido, A. Watanabe, K. Hattori, Y. Okubo, 95%:2.55-14.23; p< 0.0001) and perineural invasion H. Tsukayama, N. Kubota, T. Okumoto, T. Okamoto and (HR=4.81; CI95%:1.61-14.34; p=0.0004). Median survival Y. Kadowaki was 32.29 months (CI95%:23.24-40.0) with overall sur- Digestive System Surgery, Japanese Red Cross Kobe vival rates at 1,3,5,10 years of 83%,44%,28%,16%. Hospital, Japan Multivariate survival analysis identified as independent Intraductal papillary neoplasm of the bile duct (IPNB) prognostic factors LI (HR=1.84; CI95%:1.12-3.02; p=0.01) of the liver is a rare tumor whose long term clinical and satellitosis (HR=1.72;CI95%:1.05-2.85; p=0.03). behavior is still unknown. IPNBs were known as pre- Conclusions: LI represents an independent risk factors for cancerous lesion like IPMNs of the pancreas pathologi- overall survival in ICC. A systematic lymphadenectomy cally, but clinically, an optimal timing of surgical should be recommended at the time of ICC resection since treatment has not been discussed different from IPMNs. In LI cannot be predicted preoperatively. this study, we experienced a unique case of IPNB involving myasthenia gravis (MG) and IgG-4 related sclerosing cholangitis (IgG4-SC) with autoimmune EP01B-020 pancreatitis in a 65-year-old male patient. An initial 3cm THE OUTCOME OF ALPPS PROCEDURE simple cystic lesion in S3 liver had become aberrant with IN THE PATIENTS WITH peripheral biliary dilatation in 2 years. The impact of IgG4-SC gave some difficulty in deciding how to treat it. HEPATOCELLULAR CARCINOMA Finally, a left hepatectomy was completed with R0 T. H. Huang1, C. C. Chang1,W.F.Li2, T. L. Lin2, resection. The resected specimen revealed a gastric type Y. J. Chen2 and C. -C. Wang2 IPNB with carcinoma in situ. Steroids treatment was 1Chia-Yi Chang Gung Memorial Hospital, and 2Kaoh- inevitable for IgG4-SC and MG. Then IgG4-SC became siung Chang Gung Memorial Hospital, Taiwan, Republic exacerbated in a year and high dose steroid administration of China was critical. Intra- or extrahepatic bile duct cancer has not Introduction: The ALPPS procedures with benefit of rapid been detected in 2 years after surgery. IPNBs are biliary liver regeneration after hepatectomy are widely used in disorders with similar pathological features to IPMNs. patients with colorectal liver metastases. Insufficient future About 60% of IPNBs have developed in the left lobe of remnant liver volume after hepatectomy in patients with liver similar to our case, and the 5-year survival rate has chronic liver fibrosis who usually have defect in regener- been reported as 83.9%, 75.4% and 46.8% in gastric type, ation would result into hepatic failure. The aim of this study intestinal type and pancreaticobiliary type, respectively. is to review our experience with ALPPS procedure and However, the clinical behavior remains unclear. This case select suitable patients with hepatocellular carcinoma suggested the critical gist of IPNB’s biological behavior having chronic liver fibrosis. and optimal timing of surgery. Further analysis will be Methods: The present case series is a retrospective study in needed to clarify clinical essentials of IPNBs. patients with hepatocellular carcinoma and chronic liver fibrosis who underwent ALPPS procedures. Pre-operative survey, operative findings, and survival outcomes are EP01B-019 investigated. LYMPHNODE INVOLVEMENT IN Results: Twenty patients underwent ALPPS procedure for hepatocellular carcinoma with median follow up was 13 INTRAHEPATIC months (range=2-42). One of the patients couldn’t com- CHOLANGIOCARCINOMA: RISK plete stage II of the ALPPS procedure. The median FLRV FACTORS AND PROGNOSTIC VALUE increased to 515 from 368 ml after stage I operation ( p < P. Addeo, F. Faitot, H. Jedidi, E. Felli and P. Bachellier 0.05). The median hypertrophy rate was 43.1%. The University of Strasbourg, France median interval between stage I and II was 13 days. The Introduction: Lymphnode involvement (LI) can be found mean kinetic growth rate was 14.1 ml/day. The mean fi in one third of resected intrahepatic cholangiocarcinoma Metavir scoring of liver brosis was 2.2. Major complica- fi (ICC) but the role of systematic lymphadenectomy remains tion (Dindo-Clavien classi cation 3A) rate was 15.8% (3/ debated. We aimed to evaluate incidence, risk factors and 19) and no 30-days mortality occurred. The median dis- prognostic value of LI in ICCs. ease-free survival time was 7 months (range 2-42) and the Methods: A retrospective review of a prospectively held recurrence rate was 15.8% (3/19). database of resected ICCs between January 1995 and June Conclusion: ALPPS is a safe and feasible procedure for 2017 was performed. Only patients with curative resection marginally resectable or locally advanced HCC patient in fi and with available data regarding lymph node (LN) status the early stages of chronic liver brosis.

HPB 2018, 20 (S2), S333eS504 S376 Electronic Posters (EP01A-EP01E) - Liver

EP01B-021 miR-128, axin1, was determined by bioinformatics study, luciferase assay and Western blotting. A TREATMENT STRATEGY TO Results: Four pairs of liver tissues were selected for RNA ELDERLY HCC IS CONSIDERED FROM extraction. miRNA microarray and FDR calculation were THE ANALYSIS OF PROGNOSIS performed and four genes were selected due to the previous M. Sakoda1, S. Iino1, Y. Kawasaki1, M. Hashiguchi1, report on their correlation with HCC. The results of luciferase K. Tanoue1, H. Kurahara1, Y. Mataki1, K. Maemura1, assay and transfection of HepG2 cells indicated that miRNA- ’ S. Ueno2 and S. Natsugoe1 128 indeed binds to the 3 UTR of Axin1. In Western blotting 1Digestive Surgery, Breast and Thyroid Surgery, and miR-128 indeed decreased Axin1 protein levels, demon- 2Clinical Oncology, Kagoshima University, Japan strating that Axin1 is a target of miR-128 in HepG2 cells. Conclusion: In our study the up-regulation of miR-128 was Background: As a result of recent advances in therapeutic observed in clinical HCC tissues. The identification of miR- technology, the chance to treat elderly patient with hepa- 128 as oncomir and determination of its target gene Axin 1 tocellular carcinoma (HCC) has increased. However, it is will shed light on the pathogenesis of HCC. unclear whether it may be treated with the same criteria as youth for elderly patients. In this study, we evaluated prognosis of patients with primary HCC and considered EP01B-023 optimum treatment strategy for elderly patients. DIAPHRAGMATIC HERNIA AFTER Methods: The medical records of patients who underwent RADIOFREQUENCY ABLATION FOR treatment for primary HCC between 2000 and 2014, and HEPATOCELLULAR CARCINOMA registered with a data base of Kagoshima Liver Cancer C. K. Cho1, E. K. Park1 and H. J. Kim2 Study Group in Japan were studied. The patients were 1Surgery, Chonnam National University Medical School, < divided into two groups: youth group ( 80 years old, and 2Surgery, Suhgwang General Hospital, Republic of > n=1809) and elderly group ( 80 years old, n=197), and Korea prognostic factors in each generation group were analyzed. Introduction: Radiofrequency ablation (RFA) has been Results: Among elderly group, liver resection (LR), abla- widely accepted treatment for hepatocellular carcinoma tion (AB) and transcatheter arterial chemo-embolization (HCC) as primary choice for small HCC or alternative for (TACE) were performed in 33, 33 and 131 patients, unresectable cases. Because of the safety and effectiveness respectively. The 5-year overall survival (OS) rates of of procedure with a low mortality rate and a low major elderly group were 67, 77 and 32 % in LR, AB and TACE complication rate, the popularity of RFA has gradually group, respectively. There was no significant difference increased. As one of rare complication of RFA, diaphrag- between LR and AB group. There was no significant dif- matic hernia can occur after the procedure. There have been ference in median survival time between youth and elderly only ten case reports of diaphragmatic hernia developed group in each treatment. The multivariate analysis revealed after RFA for HCC in the literature. that ascites, maximum tumor size >3 cm and remote site Methods: We experienced and reviewed the three cases of metastasis remained as significant independent risk factors diaphragmatic hernia following RFA for HCC. for poorer OS in the elderly group. Results: The patients presented abdominal pain and vom- Conclusions: Appropriate selection of treatment for elderly iting, and computed tomography and chest PA revealed patients which considered clinical background and thera- diaphragmatic hernia showing colonic loops in the thoracic peutic invasiveness can expect the prognosis equal to youth cavity. Duration from RFA to development of symptoms group. was 19 months, 23 months and 38 months, respectively. EP01B-022 The location of HCC were hepatic dome, namely at the segment 7 in two cases and segment 4a in one case. One THE ROLE OF MIR-128 IN THE case were suspected diaphragmatic thermal injury at the PATHOGENESIS OF time of RFA on post-RFA CT, however follow-up CT after HEPATOCELLULAR CARCINOMA 3 months shows no diaphragmatic injury or bowel hernia- C. K. Cho and Y. S. Koh tion. For the treatment of diaphragmatic hernia, we Surgery, Chonnam National University Medical School, performed emergency operation of diaphragmatic repair in Republic of Korea two cases. However one case was tried to repair dia- phragmatic defect, but the operative repair was not possible Introduction: microRNAs(miRNAs) are endogenous non- due to severe adhesion. coding 21-23 nucleotide RNAs that are involved in post- Conclusion: Patients who have undergone RFA for HCC transcriptional regulation and they control various cellular adjacent to the diaphragm should be carefully followed up processes, one of which is tumorigenesis. miRNAs were for possible development of diaphragmatic hernia. reported to be implicated in the pathogenesis of hepato- cellular carcinoma (HCC) and the aim of this study is to evaluate the role of miRNAs in the development of HCC. Methods: To find yet-to-be-identified miRNAs associated EP01B-024 with HCC tumorigenesis, we carried out miRNA micro- A CASE OF PRIMARY HEPATIC array analysis with miRNAs extracted from normal and LEIOMYOMA DEVELOPED IN HCC liver tissues resected from same patients. Of the HEALTHY PATIENT miRNAs showing significantly different expression levels between normal and HCC liver tissues, we focused on miR- C. K. Cho 128. The difference in expression levels of miR-128 was Surgery, Chonnam National University Medical School, verified by real-time PCR. In addition, the target gene of Republic of Korea

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S377

Introduction: Primary hepatic leiomyoma(PHL) is very stage, BCLC stage, AFP level, vascular invasion, tumor rare, benign tumors developed from the smooth muscle of size, and portal vein invasion. HCC patients with higher the vessel or bile duct. It can be more observed in patients AROS levels showed higher recurrence and shorter DFS with immune suppression or organ transplantation. Because for both short-term and long-term compared to those with of the rareness of disease, the preoperative diagnosis of AROS-low group. Cox regression analysis demonstrated PHL is often difficult. that AROS is a significant predictor for recurrence and DFS Methods: A 42-year-old woman was referred to our hos- along with large tumor size, tumor multiplicity, vascular pital for further evaluation of hepatic mass detected during invasion, and poor tumor differentiation which are the routine screening examination. The patient was asymp- known prognostic factors. tomatic and had no history of liver disease, heavy alcohol Conclusions: Our findings on AROS as a prognostic consumption, or oral contraceptive usage. All the routine biomarker could be helpful for designing a strategy for the laboratory tests including tumor markers were within effective treatment and management of non-cirrhotic HCC. normal ranges. Abdominal CT demonstrated 7.4 x 7.1 cm sized well-defined mass in inferior portion of left liver that showed heterogenous enhancement in arterial phase, ho- EP01B-027 mogenous and delayed enhancement in delayed phase. In INTRAHEPATIC liver MRI, the mass showed low signal intensity on T1 and T2 weighted images. CHOLANGIOCARCINOMA Results: In laparotomy, 8 x 6 x 6 cm size tumor arised from ASSOCIATED WITH THE METABOLIC the caudate lobe of the liver was found. We performed SYNDROME: CHARACTERISTICS AND caudate lobe wedge resection including tumor with clear RESULTS OF LIVER RESECTION surgical margin. C. Hobeika1, F. Cauchy1, N. Poté2, S. Dokmak1, Microscopically, the tumor is composed of bland-look- M. Ronot3, F. Durand4, O. Farges1, V. Paradis2 and ing spindle cells with whirling pattern. Immunohisto- O. Soubrane1 chemical staining was positive for Actin, Desmin, 1HPB Surgery and Liver Transplantation Unit, 2Depart- Vimentin, Caldesmon and negative for CD34, C-kit, CK, ment of Pathology, 3Department of Radiology, and S-100, HMB-45, EMA. Pathologically, the tumor was 4Department of Hepatology, Hôpital Beaujon, France identified as PHL. Conclusion: PHL is a rare neoplasm and it should be Objective: To report short and long-term outcomes after considered differential diagnosis of other liver tumors. hepatectomy for intrahepatic cholangiocarcinoma (ICC) Herein, we report a case of PHL developed in healthy related to metabolic syndrome (MS). patient. Background: While the metabolic syndrome is being recognized as an important risk factor for ICC, MS-related ICC (MS+) remains poorly described. EP01B-026 Methods: All patients undergoing hepatectomy for ICC AROS IS A SIGNIFICANT BIOMARKER between 2000-2016 at a single center were retrospectively analyzed. The peri-operative characteristics, pathological FOR BOTH SHORT- AND LONG-TERM analysis and long-term outcomes of MS+ and ICC without PROGNOSIS IN NON-CIRRHOTIC HCC MS (MS-) were compared. J. W. Lee, K. S. Ahn, Y. H. Kim, K. J. Kang and Results: Among 115 resected ICC patients, 40 (34.8%) T. -S. Kim were MS+ and 75 (65.2%) were MS-. MS+ patients were Surgery, Keimyung University Dongsan Medical Center, more frequently classified ASA>2 (37.5 vs. 5.3%, Republic of Korea p=0.001) and exhibited increased Charlson comorbidity < Purpose: Despite a low risk of liver failure and preserved index (5 2 vs. 2 2, p 0.001) than MS- patients. While fi liver function, non-cirrhotic HCC has poor prognosis. To operative characteristics did not differ signi cantly be- improve clinical outcomes of the curative-intent treatment tween the two groups, MS+ experienced higher rates of in non-cirrhotic HCC, identification of prognostic factors major complications (62.5 vs. 29.3%, p=0.001). On accompanied by new treatment strategies are needed. In the multivariate analysis, MS+ was an independent risk factor current study, we evaluated AROS as a prognostic for both major complications (HR: 2.855, 95% CI: 1.072- biomarker in non-cirrhotic HCC. 7.599, p=0.036) and major cardiorespiratory complications Methods: mRNA levels of AROS was measured in tumor (HR=4.356, 95% CI: 1.503-12.622, p=0.007). Pathological and non-tumor tissues derived from 283 non-cirrhotic HCC analysis revealed that MS+ displayed higher rates of non- patients. Relationships between clinical characteristics and alcoholic fatty liver disease (60.0 vs. 31.1%, p=0.003) and AROS expression were analyzed using Chi square and non-alcoholic steatohepatitis (25 vs. 5.4%, p=0.005) but fi Fisher’s exact test. The prognostic significance of AROS signi cantly smaller lesions (64 vs. 76 mm, p=0.048). MS+ expression was analyzed using Kaplan-Meier curves and was independently associated with decreased risk of Cox regression models. recurrence (HR: 0.462, 95% CI: 0.241-0.887, p=0.020). Results: AROS was significantly up-regulated in tumors Conclusion: MS+ accounts for 35% of resected ICC pa- irrespective of tumor stage and BCLC stage. Additionally, tients. The prognosis of these patients seems to be more fi recurrent tissues revealed higher average levels of AROS favorable but the existence of signi cant cardiovascular than non-recurrent tissues for follow-up times of 2 years comorbidities increases postoperative morbidity and re- fi and 5 years and the differences were statistically significant. quires speci c management. High mRNA levels of AROS were associated with tumor

HPB 2018, 20 (S2), S333eS504 S378 Electronic Posters (EP01A-EP01E) - Liver

EP01B-028 excluded. Binary logistic regression were performed for predictive factors of PET-detected metastases. A cost- FUNCTIONAL SYNERGY OF CCAAT/ benefit analysis model was built with the costs and the ENHANCER-BINDING PROTEIN ALPHA consequence of change in treatment strategies. AND BETA PROMOTES ANTI- Results: Seventeen (11% in 152) patients had PET- PROLIFERATIVE EFFECT IN HCC detected metastases. In multivariate analysis, AFP>= 400 (Relative risk 4.3, 95%confidence interval 1.41- X. Zhao, V. Reebye and N. Habib 13.15,p=0.011) and bilobar involvement (Relative risk Surgery and Cancer, Imperial College London, United 4.21, 95%confidence interval 1.33-13.29,p=0.014) were Kingdom independent predictive factors. In cost-effectiveness Hepatocellular carcinoma (HCC) is generally accompa- study, twelve patients had altered their management nied by high morbidity and mortality as well as a low cure after PET-CT. For these 12 patients, three partial hep- rate. Decades of investigations have provided insight into atectomy ($712,320); eight TACE ($1,169,280) and one the molecular pathogenesis of HCC, where many studies ablation ($82,760) were avoided. If PET-CT were used fl have been focused on transcription factors and their in u- to 74 patients who had either AFP>=400 or bilobar ence in aberrant cell growth. CCAAT/enhancer-binding involvement, 14 of them were confirmed to have me- protein (C/EBP) has a family of transcription factors that tastases. $7689 per patient could be saved by the use of play a crucial role in cell proliferation and hepatocyte dual-tracer PET/CT. function. Small activating RNA (saRNA) presents itself as Conclusion: AFP< 400 along with unilobar disease can a novel and powerful tool for functional studies or treat- achieve good negative predictive value for PET-detected ment of various diseases, due to its capability of selectively metastases. Screening patients with either factors avoided enhancing the expression of target genes at transcriptional unnecessary procedure and was cost-effective for HCC fi level by binding speci c promoter regions. The 42 kDa work-up. isform of C/EBPa has been discovered as a Tumour Sup- pressor gene whilst the 30 kDa isform of C/EBPb is considered as an oncogene. The aim of this study was to find out if there is synergy by combining a saRNA to C/ EP01B-030 EBPa with a small interfering RNA (siRNA) to C/EBPb. TREATMENT STRATEGY FOR EARLY Three different HCC cell lines (HepG2, Hep3B and PLC/ RELAPSE CASES OF PRF/5) were used. Two of them (HepG2, Hep3B) were HEPATOCELLULAR CARCINOMA responsive to C/EPBA-saRNA, whilst PLC/PRF/5 was AFTER HEPATECTOMY non-responsive to C/EPBA-saRNA. We found that C/ EBPA activation promotes anti-proliferative effect in sen- M. Hayashi, S. Yamada, H. Takami, M. Suenaga, sitive HCC cell line, and combination of C/EPBA-saRNA F. Sonohara, H. Tanaka, D. Morimoto, M. Tashiro, and C/EBPB-siRNA rendered the resistant cell line. Our Y. Kato and Y. Kodera findings reveal that the addition of siRNA to C/EBPb Department of Gastroenterological Surgery, Nagoya converts resistant cell line into sensitive as it abrogates the University Graduate School of Medicine, Japan dominant oncogenic effect of the 30kDa isform of C/EBPb. Background: Treatment strategy for early hepatoma re- Functional synergy of C/EBPA and C/EBPB promotes currences after hepatectomy is controversial. anti-proliferative effect in HCC. Clinicopathological features of these cases and recom- mended treatment should be revealed. Methods: Surgically resected 233 hepatoma cases in the EP01B-029 single institution was included. Time until the relapse and clinicopathological data was examined. Especially, 95 DUAL TRACER PET-CT IN cases with solely intrahepatic metastases were divided into METASTATIC SCREENING OF 20 early recurrence group (< 7months, HCC-ER) and lately HEPATOCELLULAR CARCINOMA e A recurrence group (>7months, HCC-LR). COST-EFFECTIVENESS STUDY Results: In the cohort, 191 males / 42 females, and 161 hepatitis B,C infection cases / 72 non-B non-C cases were K. W. Chu and A. C. Chan included. Average following-up period was 44 months. Surgery, Queen Mary Hospital, University of Hong Kong, Tumor relapse was found in 127 cases (95 intrahepatic Hong Kong recurrences and 32 intrahepatic recurrences with distant fl Introduction: Dual-tracer PET-CT with 18F- udeox- metastases), and no relapse was found in 106 cases. Among yglucose and 11C-acetate was reported to be sensitive to 95 intrahepatic recurrences, HCC-ER was one of the sig- detect primary hepatocellular carcinoma (HCC) and its nificant poor prognostic factors of post-recurrence survival metastases. However, the exact role of dual-tracer PET-CT periods (HR=3.04, 95%CI:1.50-5.89, P=0.003). HCC-ER fi in the workup of has yet to be de ned. We aimed to identify specific clinicopathological factors were elevated AFP, predictive factors for PET-detected metastases and a cost- vascular invasion-positive, tumour size over 20mm and effective approach for the use of PET-CT to detect serosa invasion. As a local control therapy for HCC-ER metastases. cases, no prognostic difference was found between re- Methods: 198 patients were referred for HCC work up at hepatectomy and radiofrequency therapy. Queen Mary Hospital between December 2012 and Conclusion: To choose the therapy for recurrent hepatoma September 2015. All of them had pre-treatment triphasic cases, it’s important to focus on not only tumor character- CT/MRI and PET-CT. Patients(n=46) with previous treat- istics but also the duration until tumor relapses. ment and PET-CT as liver transplantation workup were

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S379

EP01B-031 Introduction: Bleeding is the most frequent complication of hepatocellular adenoma (HCA). We report our experi- REPEATED PARTIAL HEPATECTOMY ence in the management of this complication. AND LOCAL ABLATION THERAPIES Method: Between 1990 -2013, 56/263 (21%) HCA were IMPROVE LONG-TERM OUTCOME IN complicated by clinical bleeding and (Clinical, radiological PATIENTS WITH RECURRENT and histological) data were studied retrospectively. HEPATOCELLULAR CARCINOMA Results: The mean age was 38 (20-61) and 67% were in- flammatory. Four patients had hemodynamic instability J. Bednarsch1, Z. Czigany1, I. Amygdalos1, 1 1 1 (7%), 14 were transfused (25%) and no mortality. The D. Morales Santana , F. Meister , J. Böcker , mean size of HCA was 87 mm (35-160) while the mean W. Schöning1, C. H. C. Dejong2, U. P. Neumann1 and 1 size of the hematoma was 58 (10-150). In patients treated G. Lurje by urgent resection (n=6), delayed resection (n=43) and 1Department of Surgery and Transplantation, University 2 non-surgical management (n=7); arterial embolization was Hospital Aachen, Germany, and Department of Surgery, done in 0%, 15 (35%) and 7 (100%); and histological ne- Maastricht University Medical Center (MUMC), The crosis was observed in 0%, 13 (30%) and 3 (43%), Netherlands respectively. Urgent resection was associated with higher Background: Tumor recurrence after liver resection con- morbidity. Complete necrosis was observed in 13 operated tinues to impose a major problem in hepatocellular carci- patients (27%). Two degenerated HCA in the delayed noma (HCC). Here we aimed to evaluate prognostic resection group diagnosed and operated appropriately. Risk markers for disease-free (DFS) and overall survival (OS) in factors for complete necrosis on histology were the pres- HCC-patients who underwent liver resection in curative ence of embolization (92% vs 42%, p=0.001), hematoma intent. In addition, we investigated the effects of multi- presented > 60% of HCA size (85% vs 33%, p=0.046) and modal treatment modalities in a subgroup of patients with the presence of pure cystic lesion before surgery (92% vs HCC-recurrence. 8%, p< 0.001). In the subgroup managed without urgent Methods: Between 2010e2016 111 patients underwent surgery (n=50), surgery could be avoided in 40% of pa- surgical resection for HCC at our institution. Patients tients. In the follow-up period, no complication was with tumor recurrence (n=50) were treated with repeated observed. liver-resection alone (n=5), liver transplantation (n=1), Conclusions: Bleeding HCA is a frequent but controlled local-ablative procedures (n=5), transarterial chemo- complication and the modern management should include embolization (TACE) (n=3), sorafenib therapy (n=10), systematic arterial embolization and delayed resection. best supportive care (BSC) (n=16) or a combination or Surgical resection can be avoided in patients with complete multiple treatment modalities (n=15). The associations of necrosis on imaging. DFS and OS with histo-pathologic characteristics were assessed using univariate and multivariable cox regres- sion analyses. EP01B-033 Results: Median DFS was 31 months and median OS was 27 months. Milan criteria (p=0.045), macrovascular inva- OUTCOMES FOLLOWING PARTIAL sion (p=0.044) and tumor stage according to UICC HEPATECTOMY FOR SPONTANEOUS (p=0.003) were independently associated with DFS. Tumor RUPTURED HEPATOCELLULAR recurrence per se did not show an association with OS CARCINOMA: A PROPENSITY (p=0.228). However, patients with HCC-recurrence who MATCHED ANALYSIS underwent repeat-surgical or interventional treatment 1 1 1,2 3 showed significantly improved OS compared to patients D. Chua ,Y.X.Koh, C. Y. Chan , J. C. Allen , S. Y. Lee1,2, P. R. Jeyaraj1,2, P. C. Cheow1,2, A. Chung1,2, treated with palliative or sorafenib treatment alone (OS: 18 1,2 1,2 < L. L. Ooi and B. Goh months vs. 2 months; p 0.001). 1 Conclusions: Tumor recurrence alone is not associated Department of Hepatopancreatobiliary, Transplant Sur- gery, Singapore General Hospital, 2Duke-National Uni- with poor oncological outcome and repeat liver resections 3 as well as local-ablative procedures are crucial to improve versity of Singapore (NUS) Medical School, and Centre OS in HCC. for Quantitative Medicine, Duke-National University of Singapore (NUS) Medical School, Singapore Introduction: Spontaneous rupture of hepatocellular EP01B-032 carcinoma (srHCC) is a devastating sequelae of HCC with mortality rates well over 25%. Although various treat- BLEEDING OF HEPATOCELLULAR ment options have been proposed in the management of ADENOMA: A CONTROLLED srHCC, partial hepatectomy remains as the preferred COMPLICATION THAT CAN PROVIDE treatment modality as it not only achieves hemostasis, but SPONTANEOUS CURE also potentially curative resection. This study aims to appraise the role of partial hepatectomy in the manage- S. Dokmak1, F. Rasoaherinomenjanaha1, B. Aussilhou1, ment of srHCC using a propensity matched analysis. The F. Cauchy1, M. Ronot2, V. Paradis3, J. Belghiti1 and objective is to determine the impact of spontaneous O. Soubrane1 rupture on early mortality and early recurrence following 1HPB and Liver Transplantation, 2Department of Radi- partial hepatectomy. ology, and 3Department of Pathology, Beaujon Hospital, Methods: A total of 67 patients who presented to the Assistance Publique Hôpitaux de Paris, University Paris Singapore General Hospital (SGH) from 1st January 2000 VII, France

HPB 2018, 20 (S2), S333eS504 S380 Electronic Posters (EP01A-EP01E) - Liver st fi to 1 January 2015 were retrospectively identi ed from a EP01B-035 prospectively maintained institutional database. All pa- tients underwent emergent hepatectomy. In order to ensure PROGNOSTIC ROLE OF HEPPAR1 comparability, a propensity matched analysis was POSITIVE CIRCULATING performed using a 1:2 ratio of srHCC to patients with non- MICROPARTICLES AFTER ruptured HCC (nrHCC). HEPATECTOMY FOR Results: The 1, 3 and 5 year overall survival (OS) of pa- HEPATOCELLULAR CARCINOMA tients with srHCC was 63%, 44% and 38% respectively 1 1 2 3 with a median OS of 23.4 months whereas the 1, 3 and 5 C. Mele , F. Ardito , V. Abbate , I. Giarretta , F. R. Ponziani2, F. M. Vecchio4, M. Pompili2, R. Pola3, year disease free survival (DFS) was 43%, 21% and 15% 2 1 respectively. Following propensity matching, there was no A. Gasbarrini and F. Giuliante 1Hepatobiliary Surgery Unit, 2Internal Medicine and difference in OS (HR 0.76, CI 0.48-1.21, p=0.24) or 3 4 DFS(HR 0.72, CI 0.48-1.09, p=0.12) between srHCC and Gastroenterology, Vascular Medicine, and Pathology, nrHCC groups. Catholic University of the Sacred Heart, Italy Conclusion: This study demonstrates that partial hepatec- Background: Circulating microparticles (MPs) are novel tomy should be offered for the clinically stable patient with potential biomarkers in cancer patients. The prognostic role srHCC. of MPs expressing the antigen HepPar1, after liver resec- tion for hepatocellular carcinoma (HCC) is still unclear. The aim of this study was to investigate the prognostic role EP01B-034 of HepPar1+ MPs blood values after liver resection for HCC and their accuracy in detecting tumor recurrence. OUTCOMES AND PROGNOSTIC Methods: Between 2014 and 2017 we investigated the FACTORS OF SPONTANEOUS number of circulating HepPar1+ MPs in 22 patients within RUPTURED HEPATOCELLULAR 12 hours before hepatectomy e within 3 months after sur- CARCINOMA gery. Decreasing in number of circulating HepPar1+ MPs was correlated with HCC recurrence. W. Zhang1, Z. Zhang1, B. Zhang1, H. Liang2, W. Zhang1, Results: The median number of HepPar1+ MPs before S. Xiang1, L. Chen1, H. Dong1,Y.Wu1 and X. Chen1 hepatectomy was 644/mL (range 4-25,000), while it was 1Hepatic Surgery Center, Tongji Hospital, Tongji Medical 799/mL (range 0-47032) after hepatectomy. In 12/22 College, Huazhong University of Science and Technology, (54.5%) patients a decrease in number of HepPar1+ MPs of China, and 2Research Laboratory and Hepatic Surgery at least 25% after hepatectomy was observed. Overall HCC Center, Tongji Hospital, Tongji Medical College, Huaz- recurrence rate was 45.4%. At multivariate analysis in- hong University of Science and Technology, China crease or stability in number of HepPar1+ MPs following Introduction: Spontaneous tumor rupture is a rare and life- liver resection was the only significant predictor of HCC threatening complication of HCC.This study aimed to recurrence within 12 months (HR 7.000; p=0.043). investigate the outcomes of different management strate- Conclusions: Increase or stability of number of HepPar1+ gies and prognostic factors of patients with ruptured HCC. MPs following liver resection for HCC, was associated with Methods: The clinical data of 137 patients with sponta- early HCC recurrence, suggesting that MPs may be used as neously ruptured HCC from January 2010 to December prognostic marker of HCC recurrence in resected patients. 2015 were analyzed retrospectively. Results: Of the 137 patients, 53, 45, 3, and 36 patients underwent transcatheter arterial chemoembolization (TACE) alone, liver resection (LR) (LR alone or EP01B-036 TACE+LR combined), surgical hemostasis, or conserva- RESECTION CRITERIA OF tive therapy. The patients undergoing LR had longest HEPATOCELLULAR CARCINOMA WITH overall survival (OS). In the LR group, largest tumor COMPUTER-ASSISTED DIAGNOSIS size10cm and no tumor capsule were the only indepen- H. Nakayama and T. Takayama dent prognostic factors for poorer OS and recurrence-free Department of Digestive Surgery, Nihon University School survival (RFS). Hypovolemic shock was an independent of Medicine, Japan prognostic factor for poorer OS. The median time between diagnosis and LR was significantly longer in the Aim: To establish the adequate criteria for resection of TACE+LR group than in LR alone group (P< 0.01). The hepatocellular carcinoma (HCC) based upon preoperative differences in OS between the TACE+LR group and LR computer-assisted CT diagnosis and resected HCC image. alone group were not significant (P=0.955). However, the Methods: 232 patients with HCC were enrolled. The dents RFS is significantly better in the LR alone group than those and bumps of the outer contour of each HCC acquired from in the TACE+LR group(P=0.031). In the TACE alone preoperative CT were analyzed. And the shape of the cut group, AFP1000 ng/ml, largest tumor size10cm, no surface of the resected HCC was used. Those were classi- fi tumor capsule and unsuccessful embolization were signif- ed with cluster analysis and the overall prognosis were icantly associated with poorer OS. investigated. Conclusion: For resectable tumor, LR is the treatment of Results: The dent-area to tumor area ratio (s:S) and the s:S choice for patients with spontaneous ruptured HCC and ratio multiplied by the dent-depth to base ratio (s:S*d:t) fl preserved liver function. The delay in LR due to preoper- were used as feature values, re ecting the individual fi ative TACE may account for its worse RFS compared with shapes. The shapes were classi ed into three groups: Type I LR alone. In patients with an unresectable tumor, TACE (smooth: n=158), Type II (jagged: n=63), and Type III fi therapy alone improved survival over conservative therapy. (rough: n=11). The ve-year survival rates for Types I, II,

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S381 and III were 64, 53, and 0%, respectively (I vs. II, P=0.038; Background: The aim of the present study was to analyse I vs. III, P=0.001; II vs. III, P=0.002). The 3-year disease- the outcome benefit of laparoscopic approach specifically free survival rate of Type I with anatomical resection was in patients with BCLC-out patients. significantly longer than that with non-anatomical resection Material and methods: 209 patients who underwent (46% vs 23%, p=0.002). The equivalent diameter, circu- laparoscopic liver resection for HCC were stratified ac- larity, and s:S were calculated as morphological feature cording to characteristics of liver disease in BCLC-inLap values from the HCC cut surface image in 150 cases. HCCs Group (109 patients) and BCLC-outLap Group (142 pa- were classified into three groups: small round type, inter- tients). Each group was then matched in a 1:1 ratio with mediate type, and large notched type. Furthermore, the 5- patients operated by open approach using propensity scores. year overall survival rates were noted in 67%, 56%, and Short term outcomes were evaluated. The D of benefit 29% of each of these groups, respectively. associated with minimally invasive technique was evaluated Conclusions: Anatomical liver resection should be between BCLC-in and BCLC-out patients taking into ac- recommended for Type I HCC. The computer aided clas- count blood loss and morbidity rate as outcome indicators. sification was effective to help decied the resection area. Results: Laparoscopic series resulted in a statistically sig- nificant lower blood loss (150 vs 200, p=0.03; 200 vs 400, p=0.01), reduced morbidity (9.2% vs 14.7%, p=0.04; 13.4% EP01B-037 vs 22.5%, p=0.02), reduced incidence of hepatic decom- CYSTIC LESIONS OF THE LIVER pensation (4.6% vs 11%, p=0.01; 6.3% vs 14.1%, p=0.01) and shorter lenght of stay (3 vs 5 days, p=0.04; 4 vs 7 days, 1 1 2 T. Yonjen Tamang , H. Neupane and P. B. Thapa p=0.03) respectively in BCLC-in and BCLC-out patients. 1 2 Surgery, Chitwan Medical College, Nepal, and Depart- The D of benefit associated with laparoscopic approach was ment of Surgery, Kathmandu Medical College Teaching significantly wider in BCLC-out compared with BCLC-in Hospital, Nepal patients both in terms of blood loss (D50 vs D200 mL, Introduction: A variety of benign and malignant cystic p=0.03) and morbidity rate (D5.5% vs D9.1%, p=0.04). lesions of the liver have been described e.g., simple cyst, Conclusion: The favorable biological scenario associated hydatid cyst, biliary cystadenoma etc. Each cyst carries it’s with laparoscopic approach allows to obtain enhanced own risk of recurrence or malignant transformation, based benefits in the setting of more oncologically advanced liver on which the choice of surgery is made. However, often disease, constituting the prerequisite for an adequate sur- preoperative diagnosis is challenging leading to inadequate gical outcome. The push towards minimally invasiveness treatment. should not change surgical indication but create the basis Materials and method: Three cases of cystic lesion of the for a safer approach. liver which caused a diagnostic dilemma are included in the study. Two of them were managed by hepatic resection and EP01B-040 one by enucleation. MIDDLE HEPATIC VEIN-ORIENTED fi Result: The preoperative diagnosis of the rst case was ? HEPATECTOMY FOR TREATMENT OF hydatid cyst/ ? biliary cystadenoma based on CECT abdomen/pelvis findings. Right posterior sectionectomy HEPATOCELLULAR CARCINOMA: A was done. However, HPE report revealed embryonal sar- PRELIMINARY CLINICAL STUDY coma, confirmed by immunohistochemistry. X. Li and G. Ji In the second case, cystic lesion in segment VI and VII Liver Transplantation Center, The First Affiliated Hospital suspected to be hydatid cyst underwent pericystectomy. It was of Nanjing Medical University, China found to be mucinous biliary cystadenoma on HPE. A follow Introduction: The middle hepatic vein (MHV) indicates up CECT showed cystic lesion in segment VIII extending to the midplane of the liver. We aimed to determine the fi V with no calci cation for which right anterior sectionectomy prognostic relevance of MHV-oriented hepatectomy for fi was done. HPE recon rmed mucinous cystadenoma. treatment of hepatocellular carcinoma (HCC). The third case with segment V simple cyst with chole- Method: A retrospective study of 91 patients, who received lithiasis underwent laparoscopic cholecystectomy with radical treatment by hemihepatectomy at our institution fi deroo ng of cyst. HPE revealed biliary cystadenoma for between June 2006 and June 2015, was conducted. Surgical which enucleation of cyst was done subsequently. approaches were divided into MHV-oriented group and Conclusion: The diagnosis of cystic lesions of liver is conventional group according to full exposure of the MHV challenging. on the dissection plane. Early recurrence was defined as tumor recurrence within the first year after surgery. One-to- one propensity score matching (PSM) was performed to EP01B-039 minimize selection bias in surgical approaches. REAPPRAISAL OF THE ADVANTAGES Results: Among the 91 patients, left and right hemi- OF LAPAROSCOPIC LIVER RESECTION hepatectomy was performed in 30 and 61 patients. Mean tumor size was 9.9 cm (1.5 to 20.0 cm). Median survival FOR HCC IN AND OUT OF BCLC time was 48 months (2 to 127 months). The 1-,3- and 5-year CRITERIA: PROPENSITY SCORE BASED overall survival (OS) rates were 80.1%, 58.0%, and 41.8%, ANALYSIS respectively. Corresponding disease-free survival (DFS) F. Ratti, F. Cipriani, G. Fiorentini, M. Paganelli, rates were 57.7%, 37.4%, and 30.3%. There was no statistic M. Catena and L. Aldrighetti difference between the two groups in terms of OS and DFS; Hepatobiliary Surgery Division, IRCCS San Raffaele however, early recurrence rate in conventional group was Hospital, Italy significantly higher than that in MHV-oriented group. This

HPB 2018, 20 (S2), S333eS504 S382 Electronic Posters (EP01A-EP01E) - Liver result was further confirmed by PSM. Multivariate analysis Conclusion: Radical treatment for HCC with PVTT are showed that macrovascular invasion and satellite focus performed first by surgical procedure. And, multidisci- independently predicted OS, macrovascular invasion plinary treatment by postoperative TAI and immuno- independently predicted DFS, and surgical approach was therapy has been successful. an independent risk factor for early recurrence. Conclusions: MHV-oriented hepatectomy is associated with decreased early recurrence after radical resection of EP01B-042 HCC; however, tumor biology remains the main determi- IS THE IMMUNOHISTOCHEMICAL nant of prognosis. CLASSIFICATION OF RESECTED HEPATOCELLULAR ADENOMA < 5CM OF POTENTIAL CLINICAL INTEREST? C. Balabaud1, L. Chiche2, J. F. Blanc3, C. Laurent2, N. Frulio4, H. Trillaud4, C. Castain5, B. Le Bail5 and P. Bioulac-Sage1 1Inserm U 1053, Université Bordeaux, 2Service de Chir- urgie Digestive et Endocrinienne, 3Department of Hepato- Gastroenterology and Digestive Oncology, 4Department of Figure [MHV-oriented right (a) and left (b) hepatectomy] Radiology, and 5Depatment of Pathology, CHU Bordeaux, France Introduction: Hepatocellular adenomas (HCA)>5cm are EP01B-041 usually resected to prevent complications: bleeding, ma- MULTIDISCIPLINARY TREATMENTS lignant transformation. Immunohistochemical (IHC) clas- FOR HEPATOCELLULAR CARCINOMA sification, based on molecular data is thought to be useful to WITH MAJOR PORTAL VEIN TUMOR identify HCA at high risk of malignant transformation if ex THROMBUS 3 b-cat mutated and high risk of bleeding if ASS1+, inde- 1 2 2 2 pendently of their size. Unfortunately those HCA are S. Katagiri , S. Ariizumi , Y. Kotera , A. Oomori , fi 2 2 1 2 presently not identi ed by imaging. The aim of this study S. Yamashita , T. Kato , M. Hamano , H. Egawa , 1 2 was to know if complications occur in HCA 5 cm using T. Araida and M. Yamamoto IHC for their subtyping. 1Gastroenterological Surgery, Tokyo Women’s Medical 2 Methods: We reviewed our 218 resected cases with IHC University Yachiyo Medical Cemter, and Surgery, Tokyo data which include LFABP, CRP/or SAA, GS/b cat, ASS1. ’ Women s Medical University, Institute of Gastroenter- We had 65 LFABP negative cases, 70 CRP/SAA+ cases, ology, Japan 33 diffuse or starry sky GS cases meaning ex 3 mutations Aim: Portal vein tumor thrombosis (PVTT) complicated (20 b-IHCA and 13 b-HCA); 19 other type GS cases Hepatocellular carcinoma (HCC) has poor prognosis. We interpreted as possible ex 7/8 b-catenin HCA (10 b-IHCA will clarify the results of surgical treatment of HCC with and 9 b-HCA), 22 ASS1+HCA and 9 not classifiable HCA PVTT and pre-postoperative adjuvant therapy. We estab- (massive necrosis, or hemorrhage). Among them, we lish future treatment guidelines. retrieved HCA 5 cm with complications: clinically sig- Methods: We examined HCC with PVTT who underwent nificant bleeding or borderline/HCC lesion. hepatectomy for the first-line in 1632 pts in the early group Results: In 69 cases, main nodule was 5cm. There was no (1986-2005) and 634 pts in the late group (2006-2013). complications among all 23 LFABP negative or 21 CRP/ Results: Invasion of second and first branch and main trunk SAA+ HCA. On the opposite: a) borderline/HCC lesions of portal vein were 157 pts(9.6%). Operation time: 4.4hr were found in 1 ex3 b-HCA/16 b-HCA/b-IHCA and 2/7 (1.3-13), bleeding volume:1920g (180-33000), mortal- ASS1+HCA; b) clinical hemorrhage was present in 4/16 b- ity:7%. 81 pts underwent pre-postoperative adjuvant ther- HCA/b-IHCA, 2/7 ASS1+HCA and 2/2 not classifiable apy as a prospective cohort study. 5-year survival rate of HCA. preoperative TAI, postoperative intravenous port chemo- Conclusion: Complications (malignancy, severe hemor- therapy (5FU or doxorubicin), postoperative TAI (doxo- rhage) for nodules 5cm exist only for b-HCA and ASS1 rubicin or cisplatin + 5FU), immunotherapy (LAK + DC subtypes, showing the potential interest of IHC HCA vaccine), no adjuvant therapy was 38, 25, 58, 44, 0%, classification hoping that data obtained on liver biopsy will respectively. Postoperative TAI and immunotherapy were confirm these data. significantly better, and curability, rapture, Adjuvant ther- apy were extracted by multivariate analysis. Late group: 38pts(6%). Operation time: 4.1hr(2.9-8.3), bleeding volu- EP01B-043 me:860g(130-7000), mortality:0%. From the results of pre- postoperative adjuvant therapy, postoperative TAI IS BARIATRIC SURGERY A POTENTIAL (cisplatin or IAC + 5FU) or immunotherapy (DC + NEW TREATMENT FOR LARGE ATVAC) was performed in 15 out of 23 pts who had INFLAMMATORY HEPATOCELLULAR curative resection. The 5-year survival rate between the 3 ADENOMAS IN OBESE PATIENTS? groups of curative resection + adjuvant therapy (TAI, I. Khaoudy, L. Rebibo and J. -M. Regimbeau immunotherapy) (n=15), no adjuvant therapy (n=8), non- Digestive and Metabolic Surgery, Universitary Hospital of curative resection (n=8) is 57, 38, 0%, respectively. Amiens, France

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S383

Background: Surgical management is required for overall survival of the study group was 26% and 32% persistent hepatocellular adenoma (HCA) larger than 5cm respectively. or that increase in size associated with morbidity due to the Conclusion: The factors that predict an adverse outcome potential major resection and/or the presence of steatosis after surgery in patients with huge hepatocellular carci- for obese patients. An alternative approach consisting of nomas were presence of lymphovascular invasion, raised nutritional support allowing weight loss and a decrease in serum AFP and age 55 years. the size of the HCA. The present case report concerns a obese female with a large HCA, in whom bariatric surgery was proposed as a new approach to control body weight EP01B-045 and the size of the HCA. BICENTRIC SERIES OF 19 CASES OF Case report: We report the case of a 27-year-old obese woman (weight: 119kg; height: 1.60m; body mass index: HEPATOCARCINOMA IN HEALTHY 46.5kg/m2). An abdominal ultrasound revealed a mass in LIVER the right lobe of the liver. The CT-scan and liver MRI A. Lopez Marcano1, M. Serradilla Martin2, showed a HCA measuring 110x81mm. It was in contact J. M. Ramia Ángel1, A. Palomares Cano2, with the middle hepatic vein with a volume of 382cm3. If R. De La Plaza Llamas1, C. Vallejo Bernad2, resection was required, a right or central hepatectomy J. R. Oliver Guillén2, A. Manuel Vazquez1, would have been necessary. Histological examination R. Latorre Fragua1 and A. Medina Velasco1 confirmed the diagnosis of HCA. At 6-month follow-up on 1Hospital Universitario de Guadalajara, and 2Hospital weight-reducing diet and stopping the pill, liver MRI Miguel Servet de Zaragoza, Spain showed a 20% decrease in the size (100x77mm) and Hepatocellular carcinoma (HCC) is the most frequent volume (307cm3). Laparoscopic sleeve gastrectomy was hepatic neoplasm,90% of cases develop on cirrhotic or performed as day-case surgery. At 12 months after initial chronic liver disease patients because of chronic liver management, weight loss was 34kg and liver MRI showed inflammation, necrosis and regeneration cause mutations a 90% decrease in the size (43x37mm) and volume and development of HCC. However,10% of HCC develop (38cm3). on healthy non-cirrhotic liver. Conclusion: Bariatric surgery is a safe and effective We studied 19 patients with confirmed HCC and no method to achieve weight loss. Bariatric surgery could previous history of liver cirrhosis or chronic liver disease constitute an alternative treatment for very large IHCA in that underwent surgery in two HPB Units between January obese female patients requiring liver resection. 2007 and January 2017. Sex distribution: 13 males and 6 females. Mean age: 65 14 (Range 35-80 years). Past medical history: type II EP01B-044 diabetes mellitus (5), ex-enolism (2), Glucogenosis type I PROGNOSTIC FACTORS AND (1), liver cell adenoma (1), Allagille’s syndrome (1). Six SURVIVAL OUTCOMES OF SURGICAL patients presented increased AST/ALT values. Three pa- RESECTION OF HUGE tients showed elevated AFP. The average size was 111 mm (range: 38-210). Eleven patients (61%) present two radio- HEPATOCELLULAR CARCINOMAS logical tests suggesting HCC. In nine patients, preoperative J. S. Bhanu1, R. S. Ayloor1 and R. Ranganathan2 FNAC was performed but only six cases were conclusive 1Department of Surgical Oncology, and 2Department of with HCC. Biostatistics, Cancer Institute (WIA), India All patients underwent surgery. 7 right hepatectomies, 3 Introduction: The aim of the study was to analyze the left hepatectomies, 1 Left hepatectomy + segmentectomy various prognostic factors that influence survival and VIII and 8 segmentectomies were performed. clinical outcomes in patients undergoing liver resection in The mean hospital stay was 9.7 days (range: 6-19). patients with huge hepatocellular carcinomas ( 10cm). Morbidity: Clavien I- II (4), Clavien IVa (2). At the follow- Methods: Patients who underwent curative surgery be- up, 4 patients had recurrence that was surgically resected. tween 1991 and 2011 for huge hepatocellular carcinoma Conclusions: Radiological diagnosis of HCC in healthy were analyzed. Various prognostic factors that influenced liver is not always easy. Size is higher that HCC in cirrhotic the survival were studied. patients. Surgical resection is the treatment of choice usu- Results: The median age of the study population was 52 ally major hepatectomies due to huge size. Healthy pa- years. The number of patients who underwent liver resec- renchyma let surgeons perform these major resections with tion with huge hepatocellular carcinoma during the study low major morbidity. Relapse could be surgically treated. period was 17, this included 14 males and 3 females. The median serum AFP in the study population was 132.3ng/ml (Range 2 to 187000ng/ml). Hepatitis B was positive in EP01B-046 41.2% of the cases. Cirrhosis was prevalent in 64.7% of the ADVANTAGES OF LAPAROSCOPIC cases. The mean blood loss was 1000ml. There was no RADIOFREQUENCY ABLATION OVER instance of post-hepatectomy liver failure. Margin posi- tivity rate was seen in one case. The mean size of the PERCUTANEOUS RADIOFREQUENCY resected specimen was 13.9cm. The overall recurrence rate ABLATION IN HEPATOCELLULAR was 76.5%. The factors that predict an adverse outcome CARCINOMA after univariate analysis were presence of lypmphovascular I. Song, K. Chun and S. Kim invasion (p=0.047), age 55 years (p=0.021) and raised Surgery, Chungnam National University, Republic of serum AFP (p=0.041). The 5 year disease-free survival and Korea

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Background: Laparoscopic radiofrequency ablation the influence of the tumor to each of the portal vein points (LRFA) is used to treat hepatocellular carcinomas (HCCs) in accordance to the “Tumor Domination Ratio (TDR)”, that are relatively inaccessible otherwise, and is more ac- and determined the hepatectomy area so that the sum of curate than percutaneous RFA (PRFA). However, only a TDR was maximized under limited resectable hepatic few studies have compared survival outcomes between volume LRFA and PRFA in patients with HCC. Results: S7 HCC patients are shown. Figure 1 shows the Aims: This study aimed to compare the efficacy of LRFA effect of tumor based on “TDR”. The color depicts the and PRFA for HCC treatment. degree of TDR, starting with Grey (< 1%), Yellow Methods: Patients who underwent PRFA or LRFA as an (w50%), and Red (100%). Figure 2 shows the results of initial treatment modality between April 2005 and April automatic depiction of optimal resection area under limited 2016 were enrolled in the study. The overall and recur- hepatic volume. Due to limited hepatic volume, the areas rence-free survival rates were examined for each patient. with high TDR (red + yellow = purple) were depicted as Additionally, propensity score matching was performed for resection area, and the areas with low TDR (grey) were the 2 groups. clearly omitted. Results: The baseline characteristics of patients in the PRFA and LRFA groups showed several minor differences. Multivariate analysis showed that the RFA method was not EP01B-048 a critical determinant of recurrence-free or overall survival INCIDENTAL INTRAOPERATIVE (p=0.069 and p=0.406). Among patients who underwent RFA as the initial treatment modality, there was no sig- MULTIPLE BILE DUCT ADENOMAS nificant effect of the RFA method on survival. After pro- FOUND IN CONJUNCTION WITH pensity-score matching, univariate analysis showed a HEPATOCELLULAR CARCINOMA fi signi cant difference in overall survival between PRFA M. Lyon1,2, S. Soudararajian3, S. Shang4, S. Munoz5 and and LRFA (p=0.031). Multivariate analysis showed that G. Xiao1 LRFA could be one of the strongest factors contributed to 1Multi-Organ Transplantation and Hepato-Pancreato- improve overall survival in HCC patients (hazard ratio: Biliary Surgery, Hahnemann University Hospital, Drexel 0.108, p=0.040). Furthermore, our data were shown that University College of Medicine, 2General Surgery, Inspira LRFA limited multiple intrahepatic recurrences and Health Network, 3Department of Pathology, 4Department prevented marginal recurrence. of Radiology, and 5Division of Hepatology and Gastoen- Conclusions: LRFA appears to be superior to PRFA, and terology, Hahnemann University Hospital, Drexel Uni- can help reduce mortality in HCC patients. versity College of Medicine, United States Literature reviews from 1999-2016 determined bile duct adenoma (BDA) to be a very rare benign tumor. EP01B-047 BDA usually presents as a single nodular lesion, most DEVELOPMENT OF NEW SOFTWARE often found incidentally and is very difficult to distin- ENABLING AUTOMATIC guish from hepatocellular carcinoma (HCC) on imaging. IDENTIFICATION OF OPTIMAL We present a case of multiple BDAs in a patient with a HEPATIC RESECTION AREA, known HCC. Patient is a 65-year-old male, non-cirrhotic, cured hep- INCORPORATING PREOPERATIVE atitis C after Harvoni treatment, with one 4.0 cm lesion LIVER FUNCTION found on CT in segment 6. Due to the difficulty of diag- M. Shimoda1, T. Maryuyama1, K. Nishida1, J. Shimazaki1, nosis based on CT and MRI, biopsy was performed and J. Asaoka2, Y. Oshiro2 and S. Suzuki1 confirmed HCC. Intra-operatively four other nodular le- 1Department of Gastroenterological Surgery, and sions, in addition to the 4.0 cm HCC, were found involving 2Department of Gastroenterological Surgery, Tokyo both lobes of the liver surface. Sizes varied from 3 to 7 mm, Medical University, Ibaraki Medical Center., Japan intraoperative ultrasound did not view other lesions. Aim: Deciding the area for hepatectomy is one of the most Intraoperative diagnosis was one HCC with four other important factor upon conducting hepatic subsegmentec- small HCCs, possible HCC intrahepatic metastasis. Partial tomy for the treatment of HCC. Common method imple- liver resection with several liver wedge resections was mented today is to utilize 3D simulation software such as performed, all lesions were resected and the patient Synapse Vincent and manually determine the hepatec- recovered well. tomy area. In cases such as hepatic cirrhosis, the resect- Pathology results showed 4cm HCC in segment 6 and < able area will be limited due to lower liver function, and four small ( 1cm) BDAs of segments 2, 3, 6, and 7. < determining hepatectomy area becomes more challenging. BDA is a rare benign liver tumor, usually a small ( We have developed an additive function to our original 5mm) singular lesion and rarely presents together with 3D HSS simulation software which automatically simu- HCC. Our case showed multiple BDAs can coexist with lates optimal hepatectomy area under limited resectable HCC. From our literature search, this has never been re- fi hepatic volume. ported. This is the rst case of multiple BDAs in Material and methods: Six patients with independent conjunction with HCC. Increased knowledge and aware- case of HCC scheduled to undergo hepatic subsegmen- ness is essential to appropriately diagnose and treat tectomy were accrued in this study. We have quantified patients.

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of BCLC criteria for operability. Outcomes of these pa- tients validate HKLC as a more pragmatic scoring system in the Indian context.

EP01B-050 FAMILIAL HEPATOCELLULAR CARCINOMA IN A NON HEPATITIS B ENDEMIC AREA: A CASE REPORT AND REVIEW OF LITERATURE R. Trivikraman1, B. Singh1 and M. Parage2 1Department of Surgical Gastroenterology and Liver Transplantation, and 2Department of Pathology, Glenea- gles Global Hospitals, India Hepatocellular carcinoma (HCC) is the sixth most common malignancy worldwide. The majority of the cases are Hepatitis B or C virus (HBV, HCV) related. Familial Figure [liver] Figure A and B: Lesions found in segment 2 and 7 clustering of HCC is known in HBV endemic areas. There consistent with BDA. Figure C: Gross specimen from segment 6 with are also genetic alterations which have been identified in confirmed HCC. families with HCC in non endemic areas. We report such a family of two siblings diagnosed with HCC at a young age who presented to us. One patient had incurable disease and the other patient underwent curative surgery. We also review relevant literature of familial HCC through this case EP01B-049 report. EVALUATION OF HONG KONG LIVER CANCER (HKLC) CLASSIFICATION FOR HEPATOCELLULAR CARCINOMA EP01B-051 (HCC) PATIENTS UNDERGOING ASS1+HEPATOCELLULAR ADENOMA, SURGICAL RESECTION AT TERTIARY A NEW AND MAJOR SUBTYPE CARE CANCER CENTRE IN INDIA P. Bioulac-Sage1, L. Chiche2, C. Laurent2, J. F. Blanc3, S. Patkar, S. Kurunkar, K. Khobragade and M. Goel B. Le Bail3, N. Frulio3, A. A. Raymond4, F. Saltel4 and Surgical Oncology, Tata Memorial Hospital, India C. Balabaud4 1 2 Aim: We aim to evaluate the prognostic Hong Kong Liver Inserm U 1053, Université Bordeaux, Service de Chir- 3 Cancer (HKLC) classification scheme in an Indian context urgie Digestive et Endocrinienne, CHU Bordeaux, CHU 4 by applying it to patients undergoing surgery for HCC at Bordeaux, and Université Bordeaux, France Tata Memorial Hospital. Introduction: A new hepatocellular (HCA) subgroup has Methods: 102 patients of HCC who underwent surgery at been identified among unclassified HCA (UHCA: 10%) Tata memorial hospital, from Dec 2010 to June 2015 were using 2 different approaches: gene mutation1 and prote- evaluated. The HKLC classification was compared with the omics2 and 2 immunohistochemical (IHC) methods: Barcelona Clinic Liver Cancer (BCLC) classification in PTGDS1 and ASS12 terms of discriminatory ability and effectiveness of treat- Methods: We reviewed personal and consults resected ment recommendation. HCA classified as UHCA, i.e. expressing LFABP, but not Results and discussion: Out of 102 patients who under- CRP, no abnormal GS allowing exclusion of known HCA went surgical intervention, 23 were HKLC stage 1, 64 were subtypes. ASS1 was performed by IHC2. HKLC stage 2 and 12 belonged to HKLC stage 3. HKLC Results: We collected 22 personal and 11 consult HCA identified subsets of BCLC intermediate- and advanced- with ASS1 overexpression in the tumor in comparison stage patients for more aggressive treatments which with non-tumoral liver. All cases were women and were improved our survival outcomes., BCLC-B patients who characteristic on H&E; 5 had borderline lesions, 2 with were classified as HKLC-2, the survival benefit of radical HCC foci. Clinical data were available in all 22 personal surgery, compared with transarterial chemoembolization, cases: mean age 38 (23-50); 20/20 on oral contraceptives was substantial (5-year survival probability, 77.1 % v/s (mean duration 19 years); 15 were overweight (9 with 18.7% reported in literature). BCLC-C patients who were BMI > 30). 7/22 were admitted in emergency for severe classified as HKLC-3, the survival benefit of surgical hemorrhage and among them 2 had tumors < 5cm. excision compared with systemic therapy was even more Nodule was solitary in 11 cases; 2 had adenomatosis. pronounced (5-year survival probability, 66.3%% v/s Mean size of largest nodule was 7 cm (1.3- 23 cm). 6 0.0%). At a median follow up of 35 months, the estimated 5 patients had arterial hypertension and 5 diabetes. 11/22 year DFS was 25% and OS was 74% across all the surgical cases tested were classified as shHCA1;2ofthemtested resected patients. by IHC were PTGDS negative. In addition 2 cases clas- Conclusions: In the Indian setting with more patients sified as UHCA by gene mutation were ASS1+ with H&E presenting with larger tumors but with good child status, characteristics of ASS1+HCA which finally represent surgery remains a feasible option even though they fall out 10% in our HCA cohort.

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Conclusion: ASS1+HCA is a characteristic subgroup both Introduction: Fibrolamellar hepatocellular carcinoma (FL- on clinical (hemorrhagic risk even for small tumors) and HCC) has conventionally been considered to be a histologic pathological ground. ASS1 is the 4th marker of the IHC variant of hepatocellular carcinoma (HCC). It typically HCA classification. occurs in normal livers without underlying liver fibrosis or 1Nault et al Gastroenterology 2017; cirrhosis. Many series have mentioned that FL-HCC is less 2Henriet et al Hepatology 2017. aggressive than conventional HCC. The aim of this study is to identify tumor characteristics, surgical outcomes, sur- vival and recurrence of FL-HCC and does it differ from EP01B-052 HCC. THE EXPRESSION OF CD163+ AND Aims and methods: This is a retrospective study including 22 patients with a pathologic diagnosis of FL-HCC who CD68+ MACROPHAGE IN underwent hepatectomy over a 15-year period. HEPATOCELLULAR CARCINOMA Results: There were 11 male and 11 female with a median K. Minami, K. Hiwatashi, M. Sakoda, S. Iino, age of 29 years (range from 21 to 58 years). Two (9%) M. Hashiguchi, Y. Kawasaki, H. Kurahara, Y. Mataki, patients had hepatitis C viral infection and only 2 (9%) K. Maemura and S. Natsugoe patients had alpha-fetoprotein level > 200 ng/mL. The Digestive Surgery, Kagoshima, Japan median size of the tumors was 12 cm (range from 5-20 cm). Background: Hepatocellular carcinoma (HCC) is the most Vascular invasion was detected in 5 (23%) patients. Four common liver cancer. Chronic infection with hepatitis virus (18%) patients had lymph node metastases. The median type B and type C is a risk factor for the development of follow up period was 42 mo and the 5-year survival was HCC . 65%. Five (23%) patients had a recurrent disease, 4 of them Tumor-associated macrophages (TAMs) are related to had a second surgery with 36 mo median time interval. fi myeloid-derived suppressor cells and are key prototypic Vascular invasion is the only signi cant negative prog- components of smoldering inflammation that drive nostic factor. neoplastic progression. In this study, we evaluated the Conclusion: FL-HCC has a favorable prognosis than expression of CD68, CD163, in TAMs in HCC specimens common HCC and should be suspected in young patients using immunohistochemistry, and assessed the relationship with non cirrhotic liver. Aggressive surgical resection between these markers and clinicopathological features in should be done for all patients. Repeated hepatectomy or patients with HCC. excision of recurrent disease should be considered for these Patients and methods: 105 patients with primary HCC patients as it has a relatively indolent course. were treated using hepatic resection at our department . Samples from 105 HCC patients were evaluated using immunohistochemistry. EP01B-054 We evaluated the expression of CD68, as a pan-macro- SOME INCREASING OF THE LEVEL OF phage marker or M1 marker, and CD163, as an M2 marker AFP BEFORE OPERATION HAD used to evaluate and classify Tumor-associated macro- RELATION TO OVERALL SURVIVAL phages (TAMs). Results: High expression of CD68 and CD163 appeared to RATES IN RFA AS FIRST THERAPY FOR be associated with worse outcome. CD68 positive cells SMALL HCC were significantly higher in patients with stage IV cancer. S. Yamashita, S. Ariizumi, Y. Kotera, A. Ohmori, T. Kato, CD68 positive cells were tended to be higher in patients S. Nemoto, S. Katagiri, Y. Egawa and M. Yamamoto with median tumor size 3.5 cm and in patients with Department of Surgery, Institute of Gastroenterology, poorly differentiated HCC. CD163 positive cells were also Tokyo Women’s Medical University, Japan fi signi cantly higher in patients with median tumor size Introduction: Radio frequency ablation (RFA) for hepa- 3.5 cm and in patients with poorly differentiated HCC. tocellular carcinoma (HCC) were the importance thera- Conclusion: This study showed that high expression of peutic strategy. The gross classification by The General CD68 and CD163 appeared to be associated with worse Rules of the Clinical and Pathological Study of Primary outcome. Further studies are needed to determine the Liver Cancer and tumor size were very important for HCC cross-interaction between diverse TAMs and the tumor therapy. For our surgical outcome and result of pathology microenvironment. based on the gross classification from 1990 to 1994, our RFA indication was less than 30 mm and simple nodular type (SN) or small nodular type with indistinct margin fi EP01B-053 (SNIM). We presented that there were no signi cant dif- ference of rate of disease-free (DFS) and overall survival CLINICOPATHOLOGICAL FEATURES rates (OS) between HR and RFA. This time, we studied AND SURGICAL OUTCOME OF relations between outcome of RFA and tumor marker AFP. PATIENTS WITH FIBROLAMELLAR Methods: 40 cases checked level of AFP two time before HEPATOCELLULAR CARCINOMA. operation, undergoing first therapy by RFA from 2009 to DOES IT DIFFERS FROM COMMON 2012 were studied. We evaluated DSF, OS by a group with HEPATOCELLULAR CARCINOMA? increasing of level of AFP (UP group) or not increasing (non-UP group). E. El Hanafy Results: In the group (n=22) and non-UP group (n=18), Gastroenterology Surgical and Transplantation Center, level of AFP at first time were 2-191 (median: 17) and 3- Faculty of Medicine, Mansoura University, Egypt 102 ng/ml (median: 7.5), level of AFP at second time were

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3-298 (median: 18), 2-65 ng/ml (median: 7). The 5 years Aim: To evaluate clinico-pathological profile, periopera- DSF of UP group or non-UP group were 18.8%, 27.3% tive and short term outcomes of patients undergoing liver (p=0.645), and the 5 OS were 48.1%, 84.2% (p=0.04). resections for oncological indications. Conclusion: In RFA as first therapy for SN- or SNIM-type Materials and methods: Analysis of patients undergoing HCC (< 30 mm, single nodule), it was suggested :that liver resections from June 2010 to October 2017. some increasing of the level of AFP before operation had Results: Five hundred and one patients were operated relation to OS. during the study period. Median age was 55 years (M: F 1.66:1). Forty-three patients (8.6%) had benign disease and 458 (91.4%) patients had malignant disease. Most common primary malignant were hepatocellular carcinoma (HCC) EP01B-055 161 (32.1%), intra hepatic cholangiocarcinomas (IHCC) 39 TRANSARTERIAL (7.8%) and perihilar cholangiocarcinomas (pHCCA) 30 CHEMOEMBOLISATION FOR NON- (6.0%). Most commonly resected secondary neoplasm was RESECTED HEPATOCELLULAR metastases from colorectal cancer (MCRC) 123 (24.6%). Major hepatic resections (3 segments) were performed in CARCINOMA, A 10 YEAR EXPERIENCE 217 patients. Overall morbidity was 22.7% (n=114) and FROM A SINGLE TERTIARY CENTRE mortality was 3.4% (n=17). Z. Wang, V. G. Shelat, C. W. T. Huey and W. Woon Chronic HBV infection was commonest etiology for General Surgery, Tan Tock Seng Hospital, Singapore HCC (n=36, 51.4%). Seventy (43.5%) with HCC were Background: Transarterial chemoembolisation (TACE) is cirrhotic. TACE was performed as bridge to surgery in 48 an established treatment modality for patients with Hepa- patients (29.8%). R0 resection was feasible in 148 (91.9%). tocellular Carcinoma (HCC). We present our 10 year R0 resection was feasible in 65.21% (n=45) of patients experience with single and repeated TACE in HCC patients. with cholangiocarcinoma. Methodology: This is a retrospective analysis of 341 Fifty-seven (46.34%) of 123 MCRC patients operated TACE procedures performed between 2004 and 2014 in a had synchronous metastases. Simultaneous resection was tertiary centre. performed in 26 where a major hepatectomy with left Results: A total of 346 TACE were performed in 174 pa- colonic or rectal resection performed in 5 cases. R0 resec- tients with HCC. 271 (78%) procedures were performed on tion rate was 90.2% (n=111). male patients. 193 (56%) and 38 (11%) procedures were Conclusion: Outside transplant setting, this is the largest performed on Hepatitis B and Hepatitis C patients respec- series of liver resections from India. Resection for liver tively. 259 (75%) procedures were performed on Child- tumors still plays a major role and can be performed with Pugh A patients, 84 (24%) on Child-Pugh B patients and 3 acceptable morbidity and mortality in resource constraint (< 1%) on Child-Pugh C patients. 150 (43%) procedures population were performed on BCLC A patients who declined or were unfit for surgery, 168 (49%) on BCLC B patients, 18 (5%) EP01B-057 on BCLC C patients and 5 (1%) on BCLC D patients. TRANSARTERIAL 82 (47%) patients had 1 TACE session, 45 (26%) pa- CHEMOEMBOLIZATION FOR tients had 2 sessions and 47 (27%) patients had 3 or more INOPERABLE HEPATOCELLULAR sessions. Overall TACE related mortality is 2.6%. This CARCINOMA e A SINGLE CENTER 6- represented a TACE related mortality of 3.6% for Child- Pugh B & C patients and 2.3% for Child-Pugh A patients. YEAR EXPERIENCE The overall complication rates stood at 9.5% with a 15% E. Malcevs1, A. Ozolins1,2, A. Veiss1, J. Vilmanis1,2, rate for single TACE. The complication rate for repeated J. Savlovskis1 and J. Gardovskis1,2 TACE was 16% with no TACE related mortality. 1Pauls Stradins Clinical University Hospital, and 2Rigas Conclusion: TACE is well tolerated in our experience Stradins University, Latvia among HCC patients with normal functioning and Introduction: Hepatocellular carcinoma (HCC) is the sixth compromised liver function, not amenable for curative most common cancer worldwide in terms of number of treatment. Repeated TACE is well tolerated with no cases and it is the third most common cause of death from increased mortality. cancer. Targeted transarterial chemoembolization (TACE) therapy is currently the standard treatment for advanced HCC in selected cases. EP01B-056 Methods: A retrospective study was conducted with FIVE HUNDRED ONCOLOGICAL LIVER advanced HCC patients who underwent TACE in the time fi RESECTIONS: SINGLE CENTRE period from 2011 until 2016. Manipulation ef ciency and survival outcomes were analyzed. Biopsy and CT imaging EXPERIENCE FROM TATA MEMORIAL diagnosed a total of 37 patients with advanced HCC. Pa- HOSPITAL, MUMBAI tients were evaluated according to Barcelona Clinic Liver K. Khobragade, A. Kanetkar, S. Kurunkar, S. Patkar and Cancer (BCLC) staging by a multidisciplinary team and M. Goel advised TACE as the treatment option. Department Of Surgical Oncology, Tata Memorial Hos- Results: Mean patient age was 64.21 11.05 years. The pital, India female-to-male ratio was 1,86. Tumor was localized in

HPB 2018, 20 (S2), S333eS504 S388 Electronic Posters (EP01A-EP01E) - Liver right, left and both lobes in 26, 3, 14 cases respectively. EP01B-060 Tumor size was >5 cm in 24 (55.8%) cases and < 5cmin 19 cases (44.2%). Treatment was done by DC BeadÔ 100- COMBINED HEPATOCARCINOMA- 300mm or HepasphereÔ 150-200mm. Five patients (11.6%) CHOLANGIOCARCINOMA IN received 1 TACE procedure, 11 patients (25.6%) received PATIENTS TREATED AS 2, 9 patients (20.9%) received 3, 8 patients (18.6%) HEPATOCARCINOMA received 4 and 10 patients (23.3%) received >4 TACE L. A. Martinez Insfran1, B. Gomez Perez1, procedures respectively. For treatment result evaluation we P. Ramirez Romero1, L. Barona2, G. Carbonell3, used modified RECIST - relation between necrotic and still F. Alconchel Gago1, P. Cascales Campos1, vascularized lesions. F. Sanchez Bueno1, R. Robles Campos1, Conclusion: Chemoembolization with or without doxoru- P. Parrilla Paricio1 and Trasplante Hepatico bicin microspheres is a safe and effective procedure for 1Department of General Surgery, Hospital Universitario advanced inoperable HCC. A single center experience Virgen de la Arrixaca, 2Hospital Universitario Virgen de showed that studies and routine protocol are required for la Arrixaca, and 3Department of Radiology, Hospital analyzing the outcomes and efficacy of TACE. Universitario Virgen de la Arrixaca, Spain Introduction: Mixed Hepatocarcinoma-chol- angiocarcinoma is a rare tumor with difficult diagnosis, EP01B-058 sharing genetic, molecular, clinical, analytical and even SURGICAL RESECTION VS radiological similarities. Since immunohistochemistry is RADIOFREQUENCY ABLATION FOR necessary for its definitive diagnosis and the worst prog- HEPATOCELLULAR CARCINOMA: A nosis, it poses a challenge for diagnosis and an early PROPENSITY SCORE MATCHING treatment. We analyze the results of this tumors among ANALYSIS transplanted and resected patients from January 2011 to August 2017, evaluating clinical, radiological, and analyt- M. F. Valentini, G. Scialandrone, S. Roselli, P. Panzera, ical aspects, as well as the role of Immunohistochemistry in R. Memeo and L. G. Lupo the pathological diagnosis. Università di Bari, Italy Methods: We made a retrospective analysis of resected and Background: Surgical resection and local ablative thera- liver transplanted since January 2011, through a review of pies represent the most frequent first line treatment adopted the pathological results database. The 3 selected cases were in HCC treatment. Studies that directly compared Hepatic evaluated by optical microscopy by two pathologists and Resection (HR) and Radiofrequency Ablation (RFA) report the images of arteriography with chemoembilization by a discrepant results. radiologist. Patient and methods: In this retrospective study we Results: The 3 patients were male, with a mean age of 62 enolled 411 patientsundergoing to RFA and 147 patients years, a history of alcoholism, carriers of HIV, HBV and / or undergoing to HR between January 2006 and August 2017 HCV. With the initial diagnosis of hepatocellular carcinoma were enrolled. The Outcome in terms of Overall Survival on the cirrhotic liver, transarterial chemoembolization was (OS) and Recurrence free Survival (RFS) was analysed. performed for "downstage” during the waiting list trying to The Propensity Score Matching (PSM) method was adop- meet the Milan Criteria for the Liver Transplant. Two of ted to select comparable cohorts of patients. them were transplanted and one was resected laparoscopi- Results: The native comparison between HR group and cally. Regarding the pathological examination, immunihis- RFA group reveals significant differences as regards de- tochemistry revealed a definitive diagnosis of Classical mographic characteristics, liver function and underlying Combined Hepato-Cholangiocarcinoma according to the disease, tumour features (number and size), OS ( p< WHO classification. Everyone is free of disease at the pre- 0.0001)andRFS(p< 0.0001). Eighty-one patient pairs sent time. with HCC within Milan Criteria, were selected with the Conclusions: Hepato-Cholangiocarcinoma is an infrequent PSM; the RFA group shows better OS and RFS than HR tumor, diagnosed exclusively by its immunohistochemical group ( 5yOS 49.9% vs. 35.8%, p=0.003 and5yRFS pattern. Despite the diversity of published results, resection 58.3% vs. 30.6%, p=0.012, respectively). Cox propor- and liver transplantation are the curative alternatives that tional Hazard analysis demonstrates that choosing can be proposed in these cases. Treatment (p=0.004), total Bilirubin (p=0.032)and Neutrophil-Lymphocyte Ratio (NLR, p=0.016)werein- dependent prognostic factors for OS; Treatment EP01B-062 (p=0.001), total Bilirubin (p=0.008), NLR (p=0.003) FACTORS AFFECTING THE SURVIVAL and HCV-RNA (p=0.001) were independent prognostic factors for RFS. AND RECURRENCE AFTER LIVER Conclusion: This study suggests that Local Ablation is RESECTION FOR HCC IN PATIENTS equivalent to or better treatment option than Surgical WITH HCV GENOTYPE IV INDUCED Resection in patients with primitive HCC within Milan LIVER CIRRHOSIS Criteria, a reliable alternative to hepatic resection in pa- M. Amer tients with functional and anatomical limitation, as first- Students’ Hospital - Mansoura University, Egypt line treatment for Down staging and Bridge for liver transplantation.

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Cirrhosis is the most important risk factor associated adenocarcinoma. Afterwards, it was performed a left with HCC and more than 80% of HCC develops in cirrhotic hepatic trissegmentectomy. The anatomopathological livers. Despite many treatment options, the prognosis of evidenced a moderately differentiated cholangiocarcinoma. HCC remains dismal. A majority of patients presented with One year after the procedure the patient is practicing his advanced or unresectable disease. Even for those patients normal activities and without disease recurrence. who undergo resection, the recurrence rates are high. Conclusion: Through this case report, it is presented the The aim of this work was to study the clinical and rare association between TB and liver malignancies.The pathological factors influencing the outcome after liver association between chronic inflammatory diseases and resection of HCC in patients with HCV genotype IV malignancies is already published in the literature. It is induced cirrhosis known that TB induces immunossupression, this might The present study was done on 175 patients with HCV facilitate the oncogenic potential for other malignancies. genotype iV induced liver cirrhosis who underwent hepatic Thus it is crucial in this disease to search differential resection for HCC in GEC, Mansoura University, During diagnosis of malignancies. the period from October 2000 to June 2010. Results: Recurrence after liver resection occurred in 49.1 % of patients and the overall 5 years survival was 21%. The EP01B-064 most important factors affecting the recurrence were cut LONG TERM FOLLOW-UP FOR margin infiltration, vascular invasion, lymph nodes infil- tration and absence of capsule while tumor differentiation HEPATIC ARTERIAL INFUSION was the most important factor affecting the survival. CHEMOTHERAPY OF 5- Conclusion: Liver cirrhosis has a major impact on the FLUOROURACIL AND CISPLATIN prognosis of HCC patients, and its severity must be AFTER CURATIVE RESECTION OF considered when selecting treatments that can be tolerated HEPATOCELLULAR CARCINOMA by patients with HCC.Liver resection has been considered a 1 1 2 2 fi K. S. Kim , S. Y. Rho , S. U. Kim ,D.Y.Kim and reasonable rst-line treatment for cirrhotic patients with 2 HCC and preserved liver function. S. H. Ahn 1Surgery, and 2Medicine, Yonsei University College of Medicine, Republic of Korea EP01B-063 Background and aims: Many recent studies suggest that postoperative hepatic artery-infusion chemotherapy INTRAHEPATIC (HAIC) in hepatocellular carcinoma(HCC) can effectively CHOLANGIOCARCINOMA IN A and safely reduce intrahepatic recurrence and improve the PATIENT WITH PULMONARY overall survival. In this study, we investigated 10 years TUBERCULOSIS: A CASE REPORT follow-up of patients who underwent HAIC after curative resection of HCC. F. Freire Lisboa Junior1, W. Vieira da Mota2, Materials and methods: We retrospectively reviewed R. Melo Campos2, A. de Araujo Lima Liguori3, medical records in last 10 years follow-up period of pro- S. Hulliane Freitas Pinheiro3, R. de Lima França3, spectively recruited HCC patients who underwent the J. Medeiros Santos3, A. Alves Sobrinho3 and adjuvant HAIC with 5-FU and cisplatin after curative I. Godeiro de Oliveira Maranhão3 resection of HCC. Total 128 patients were included and 31 1General Surgery, Hospital Universitario Onofre Lopes, patients underwent HAIC who were highly suspected 2Universidade Potiguar, and 3Hospital Universitario recurrence in final pathologic report. Every 4 weeks, four Onofre Lopes, HUOL/UFRN, Brazil cyscles of HAIC were given to patients in HAIC group. Introduction: Tuberculosis (TB) frequently manifests as Results: . Platelet count and alpha-fetoprotein (AFP) pulmonary disease. However, it can be presented in other levels HAIC group were higher than non-HAIC group in places including solid organs, mimetizing a wide range of statistically. However MELD score was higher in non- disorders like intrahepatic cholangiocarcinoma, which little HAIC group. Proportion of above T2 and portal vein, attention has been given to it for its rarity. microvascular invasion in HAIC group were statistically Methods: Case report and literature review. different from non-HAIC group. There were no statisti- Case report: A 65-year-old male patient was admitted to cally differences between two groups regarding to not our department with productive cough, weight loss, only overall survival (p value=0.568) but also disease-free orthopnea and paroxysmal nocturnal dyspnea. According survival (p value=0.975). Even after propensity score fi to the clinical symptoms and radiological ndings, TB was matching, there were no statistically significant differ- suspected initially. ences in analysis of overall survival (p value=0.740) Results: During the investigation for pulmonary malig- and disease-free survival (p- value=0.769). In subgroup nancy, it was performed a Computed Tomography (CT) analysis, especially above T2, HAIC group seems to fl which evidenced pleuropulmonary uid collection sug- be more favorable in overall survival, however there fi gestive of empyema and a hypodense image of in ltrative was no statistically significance between two groups aspect, irregular contour, with peripheral enhancement to (p value=0.512). contrast intrahepatic invading segments III, IV and V and Conclusion: In this study, we could not find any statistical fi diaphragm in ltration/hepatic abscess. oncologic benefit in long-term overall survival and disease- Subsequently, it was performed a intraoperative biopsy free survival in statistically. of round ligament through laparoscopy and that confirmed

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EP01B-065 Method: We have searched EMBASE, Medline and The Cochrane Library databases in order to find all studies LIVER RESECTION FOR BENIGN SOLID reporting morbidity in patients undergoing LLR vs. OLR. LIVER TUMORS: PATIENT The statistical analysis was performed using RevMan 5.3. CHARACTERISTICS, INDICATIONS Quality of studies was assessed by the Newcastle-Ottawa AND OUTCOMES and Jadad scales. The study followed the PRISMA guidelines. S. H. Wei1, M. I. Chavez2, J. D. Velasco1, Results: From 3,852 articles revealed in an initial search, E. M. Arvide1 and J. N. Vauthey1 43 (N=5,100 patients) matched the inclusion criteria. All of 1Surgical Oncology, MD Anderson Cancer Center, and the studies except one were non-randomized trials. There 2Surgical Oncology, Medical College of Wisconsin, United was a significant trend of submitting patients with smaller States lesions to LLR (MD -0.26 95%CI: -0.42 to -0.10) Pooled Background: There remains much variance and contro- risk ratios analysis showed a statistically significant versy in the treatment and clinical management of benign reduction in overall morbidity in LLR group (15.59% vs. liver tumors. The indications for surgical intervention for 29.88%, RR=0.53, 95%CI: 0.47-0.60). There were no these such tumors include symptom management, risk of differences between groups in terms of mortality (1.58% vs. complications, and suspicion of malignancy. The aim of 2.96%, p=0.05) and both 3- and 5-year overall and disease- this study is to analyze the indications and outcomes after free survival. resection of benign solid liver lesions from patients treated Conclusion: The meta-analysis showed that LLR is bene- at a large comprehensive cancer institution. ficial in terms of safety over OLR. Having said that, these Methods: 93 patients received liver resection for benign results are based on non-randomized trials which may be solid liver tumors at MD Anderson Cancer Center from biased due to differences in tumor size between groups. 1998 to 2017. The patient records were reviewed retro- Thus, we are calling for randomization in upcoming spectively, including demographic, peri-operative, and studies. outcome parameters. Results: The study group includes 75 females and 18 males with the average age of 45 years old. 37 patients with hemangiomas (39.8%), 28 patients with hepatocellular adenomas (30.1%), 17 patients with focal nodular hyper- plasia (18.3%), 7 patients (8.6%) with other solid tumors (angiomyolipoma, hemangioendothelioma, pecoma, etc). Symptom management and risk of complications were the most common preoperative indication in our series. 38 patients underwent a major hepatectomy (40.8%). The post-operative mortality rate was zero, but the post-opera- tive complication rate was 21.5% and the peri-operative blood transfusion rate was 16.1%. The median follow-up of 19 months, 92 patients (99%) were alive and two patients (2.2%) developed malignancy degeneration. Outcomes: Although liver resection can be performed safely in well-selected patients without mortality, there still remains a risk of complication. Surgical intervention should be carefully evaluated on an individualized basis utilizing an evidence-based treatment algorithm.

Table [Pooled estimates of overall morbidity LLR vs OLR] EP01B-066 A PLEA FOR RANDOMIZED TRIALS: SYSTEMATIC REVIEW AND META- EP01B-067 ANALYSIS ON POSTOPERATIVE TRANS-ARTERIAL OUTCOMES IN PURE LAPAROSCOPIC CHEMOEMBOLIZATION (TACE) IN AND OPEN LIVER SURGERY FOR PATIENTS WITH UNRESECTABLE HEPATOCELLULAR CARCINOMA HEPATOCELLULAR CARCINOMA: 7 J. Witowski1,2, M. Wysocki1,2, M. Sitkowski1, Z. Malina1, YEARS EXPERIENCE FROM BORNEO, 1 1 1 M. Rubinkiewicz , M. Mizera , N. Gajewska , MALAYSIA ł 1,2  1,2 1,2 P. Ma czak , A. Budzynski and M. Pedziwiatr 1 2 2 1 Î R. ,. H. B. Chua , M. F. Idris and N. A. Nik Abdullah 2nd Department of General Sugery, Jagiellonian Univer- 1 2 General Surgery (Hepatobiliary), Sarawak General sity Medical College, and Centre for Research, Training 2 and Innovation in Surgery (CERTAIN Surgery), Poland Hospital, Malaysia, and Surgery, Sarawak General Hospital, Malaysia Introduction: The aim of our study was to compare the outcomes of pure laparoscopic (LLR) and open (OLR) liver Aims: To evaluate the outcome following transarterial resections in patients with hepatocellular carcinoma. chemoembolization(TACE) and to identify the predictors

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S391 of survival rate in patients with unresectable hepatocellular P = .824) and recurrence sites were almost similar between carcinoma(HCC). the two groups. Material and methods: Cross-sectional study of HCC Conclusion: Selected advanced age HCC patients can patients referred to our centre (2011-2017) were subjected undergo liver resection safely and can benefit from long- to clinical, biochemical and radiological examination. term HCC control comparable with that of their younger TACE was performed in those who deemed unresectable counterparts. lesion based on BCLC guideline with ECOG 0 and 1. Each patient underwent average of 2-3 session of TACE by using EP01B-070 chemotherapeutic agent doxorubicin and lipiodol infusion. Results: Total of 103 patients (76 males, 27 females; IMPACT OF ANATOMICAL RESECTION mode age (60-69 years) were subjected to (212) sessions FOR HEPATOCELLULAR CARCINOMA of TACE. The hepatitis status for the patients is :Hepatits WITH MICRO-PORTAL INVASION B-59(57.3%); Hepatitis C-7(6.8%);and non Hepatitis B/ (VP1): A MULTI-INSTITUTIONAL C-37(35.9%). The Child’s classification consists of STUDY BY THE KYUSHU STUDY ’ ’ Child s A -80(77.7%), Child s B -17(16.5%) followed by GROUP OF LIVER SURGERY Child’s C -6(5.8%) patients. Tumor lesions 5cm in 31(30.1%) patients, >5-10 cm in 31(30.1%) patients, and M. Hidaka, S. Eguchi and the Kyushu Study Group of >10 cm in 41(39.8%) patients. Median follow-up was 12 Liver Surgery months (range:1- 36 months). Median survival time is Surgery, Nagasaki University Graduate School of 2.794 years. No adverse post-procedure complications Biomedical Sciences, Japan were encountered. Overall survival rate was 73.79%, Background: Prognostic factors of liver resection for he- 58.25%, 54.37%, 50.49%, and 46.6% at 1,2,3,4 and 5 patocellular carcinoma (HCC) have been reported as years, respectively. Tumor size emerged as an important vascular invasion. The anatomical resection for HCC has predictor of survival. been reported as the optimal outcome to avoid the intra- Conclusion: We concluded that TACE offers highest sur- hepatic spread by portal dissemination but the opposite vival rate in the 1st year , followed by the numbers gradually results also reported. The aim of this study was to elucidate decreasing the subsequent years. Tumor size is recognized the influence of anatomical resection for HCC with micro- as a significant predictor marker for survival rate in which portal vascular invasion (vp1). the larger the tumor, the shorter the survival rate. Methods: Clinical chart review were performed to 546 patients of HCC with vp1. We retrospectively evaluated the recurrence free survival (RFS) between anatomical (AR) EP01B-069 and non-anatomical resection (NAR). The influence of AR HEPATIC RESECTION FOR on survival and recurrence free survival rates was analyzed in patients which were selected by propensity score HEPATOCELLULAR CARCINOMA IN matching(PSM) and prognostic factors were identified. The ELDERLY PATIENTS AGED 80 YEARS recurrence pattern was analyzed between these groups. AND OLDER Results: A total of 546 patients were enrolled, 422 in AR K. Fukushima, H. Motoyama, A. Kobayashi, group and 124 in NAR group. There was no differences of T. Yokoyama, A. Shimizu, T. Notake, H. Sakai, 5-year survival and RFS rate between these PSM groups. In K. Hosoda and S. -I. Miyagawa subgroup analysis, there were no differences of survival First Department of Surgery, Shinshu University, Japan and RFS in patients with HCC equal to less than 2cm, 2 - 5 cm and over 5 cm. Introduction: Previous studies have shown surgical In multivariate analysis, hepatitis C, PIVKAII 380 resection provide comparable long-term outcomes in mAU/ml, tumor diameter 5cm and age 70 were sig- selected elderly patients and younger patients with hepa- nificant predictors of poorer RFS after liver resection. The tocellular carcinoma (HCC), without increasing the opera- local recurrence was significantly occurred in NAR group tive risks. However, the significance of age on the surgical than AR group. outcomes has not been fully evaluated. The aim of this Conclusion: Although the local recurrence around resec- study was to evaluate the impact of advanced age (80 years tion site was suppressed by AR, the anatomical resection old and over) on the short- and long-term outcomes in HCC for HCC with vp1 was not contributed to the RFS and patients undergoing hepatectomy. overall survival rates after hepatectomy. Methods: Between April 1990 and September 2017, a total of 1000 HCC patients were referred to our department. Among these, 36 advanced age patients and 668 younger patients had undergone initial and curative liver resection. EP01B-071 Pre-, intra-, and postoperative clinicopathological variables PREDICTORS OF SURVIVAL were analyzed. FOLLOWING TRANS-ARTERIAL Results: There was no 30-day mortality, but one in-hospital CHEMOEMBOLIZATION FOR THE death in younger group. Overall and severe (Clavien-Dindo PALLIATIVE TREATMENT OF classification grade III or more) morbidity rates were similar between the two age groups (58.3% vs. 53.3%; P = HEPATOCELLULAR CARCINOMA .555, 22.2% vs, 20.1%; P = .753, respectively). Although M. Hughes1, S. Kelly1, T. Drake2, T. Bird2, J. Powell1, the 5-year survival rate in the elderly patients was signifi- A. Adair1 and S. Wigmore2 cantly lower than that in younger patients (39.7% vs. 1Royal Infirmary of Edinburgh, and 2University of Edin- 57.7%; P = .015), recurrence rate (71.6% vs. 73.2%; burgh, United Kingdom

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Introduction: Hepatocellular carcinoma (HCC) inci- Results: Among 441 patients, 279 were diagnosed HCC dence is increasing worldwide. Trans-arterial chemo- with Computed Tomography (CT) and MRI both, 79 pa- embolization (TACE) can prolong survival for those in tients were diagnosed with additional EOB-MRI because of whom curative treatment is contra-indicated. This study uncertain diagnosis in CT, and 83 patients were founded aimed to determine factors associated with survival in additional lesion in EOB-MRI. Overall survival analysis patients undergoing palliative TACE treatment of hepa- showed no statistically difference between the single and tocellular carcinoma. addtional lesion groups, and there was a significant dif- Methods: A retrospective analysis was performed of pro- ference between the single and multiple HCC groups. spectively collected data on all patients within Edinburgh, However, in disease-free survival analysis, there was no Scotland receiving palliative TACE therapy for HCC be- difference between multiple HCC and addtional lesion tween January 2009 and October 2016. Kaplan-Meier groups, but only single HCC group showed statistically survival curves and Cox-Proportional Hazard Ratio uni- favorable results. Single HCC group (median 80 months, variate and multivariate analyses were performed to 95% CI [64.002-89.986]) vs multiple HCC group (median determine characteristics associated with increased survival 24 months, 95% CI [17.483-30.517]) vs ANHHN group benefit. Severity of liver disease was measured by UKELD (median 32 months, 95% CI [21.135-42.865]). score, a variant of MELD score. Conclusion: Patients with ANHHN showed similar dis- Results: 93 patients (mean age 66.79.1 years) underwent ease-free survival compared to multiple HCC, but overall palliative TACE therapy. One and three year survival was survival was similar to that of single HCC. Therefore, a 81% and 32% respectively. The mean UKELD score was single overt HCC with ANHHN should be considered a 49.23.3. Patients had a median of two tumours (range 1- surgical candidate and combined active treatment is 21) of maximum median size 38 (IQR 27-50) millimetres. recommended if their liver function is allowed. Improved survival was observed in those patients who underwent more than one TACE (p=0.0002), had a maximum size of tumour under four centimetres (p=0.01) EP01B-073 and a UKELD score of under 50 (p=0.03). An increased RUPTURED HEPATOCELLULAR UKELD score was the only independent predictor of worse survival (HR 1.134 [95% CI 1.016-1.265] p=0.025). Portal ADENOMA DURING PREGNANCY. hypertension, increased age, comorbidity or multifocal WILL SUBTYPE IDENTIFICATION HCC were not associated with worse survival following BECOME CLINICALLY RELEVANT? multivariate analysis. L. Chiche1, D. Cappellen2, J. F. Blanc3, C. Laurent4, Conclusions: In patients with HCC undergoing palliative C. Castain4, B. Le Bail4, C. Balabaud3 and TACE procedure, increased UKELD score is the only P. Bioulac-Sage3 predictor of worse survival. This could be utilized during 1Service de Chirurgie Digestive et Endocrinienne, CHU the patient selection process and risk assessment when Bordeaux, 2Inserm U 1053, Université Bordeaux, determining management of HCC. 3Université Bordeaux, and 4CHU Bordeaux, France Background: During pregnancy the risk of rupture of he- patocellular adenomas (HCA) is associated with a potential EP01B-072 foetal and maternal mortality. The aim of the study was to PROGNOSIS AFTER CURATIVE look for HCA complications during pregnancies. TREATMENTS OF ADDITIONAL NON- Material and methods: We retrieved four cases of HYPERVASCULAR HYPOINTENSE ruptured HCA among our series of resected phenotypically NODULES DETECTED BY EOB-MRI IN A characterized HCA. Results: The 4 cases were primipara at 30, 31, 36, 40 weeks RESECTABLE HEPATOCELLULAR of amenorrhea. The 3 first cases had a cesarean following CARCINOMA the hemorrhage. In the last case cesarean occurred 6 days S. Y. Rho, D. H. Han, K. S. Kim, G. H. Choi and after a planned indication. Two out of four children survive. J. S. Choi The outcome of the women was good. The subtyping Department of Surgery, Yonsei University College of revealed 2 b-HCA ex7, 1 b-HCA ex3 S45 and 1 ASS1+ Medicine, Republic of Korea HCA. For comparison, the respective % of acute hemor- Introduction: It is known that Gadolinium Ethoxybenzyl rhagic bleeding in our population of 218 resected HCA < Diethylenetriamine Pentaacetic Acid enhanced magnetic was 10 % in H-HCA, IHCA, b-IHCA but 27.2% in b- resonance imaging (EOB-MRI) improved the detection of HCA (all ex3 S45 , ex7) and 31.8% in ASS1+HCA. hepatocellular carcinoma (HCC). In preoperative MRI, No complication occurred among our resected HCA additional non-hypervascular hypointense nodule cases (190 women): 131 pregnancies after (17 cases) or fi (ANHHN) is found sometimes, however there are only few prior (120 cases) surgery; 21 pregnancies occurred ve studies about prognosis of curative treatments of ANHHN years preceding surgery, among them, 4 - phenotypically and primary HCC lesion together. different from the 4 ruptured cases- occurring in less than 1 Method and materials: We retrospectively reviewed year. medical records and preoperative images of 441 HCC pa- Discussion: ASS1+HCA and b-HCA (ex3 S45 and 7/8) tients who underwent surgical curative treatment at Yonsei HCA at a higher risk of bleeding may perhaps favor HCA Cancer Center from January 2008 to December 2012. dramatic hemorrhage during pregnancy.

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Conclusion: The results of this small series need to be EP01B-075 confirmed through an international registration for pregnant patients with proven HCA to identify if these subtypes are HEPATOCELLULAR CARCINOMA true risk factors in this context. WITH EXTRAHEPATIC PRIMARY MALIGNANCIES I. Y. Park1,G.H.Na1 and H. J. Choi2 EP01B-074 1Surgery, Bucheon St. Mary Hospital, and 2Surgery, Seoul MANAGEMENT OUTCOMES OF St. Mary Hospital, Catholic University of Korea, Republic PRIMARY HEPATIC of Korea NEUROENDOCRINE TUMORS Hepatocellular carcinoma (HCC) is a common neoplasm in the world. The prolonged survival of HCC patients have V. K. Gunasekaran, K. Palaniappan, G. Shetty, lead to increase the incidence of the number of extrahepatic A. Rammohan and M. Rela primary extrahepatic malignancies (EHPM). Institute of Liver Disease and Transplantation, Gleneagles A retrospective analysis of 230 patients with HCC during Global Health City, India 2007 to 2017 was performed. We experienced 11 cases of Introduction: Primary hepatic neuroendocrine tumors HCC with EHPM which account for 4.8 % of HCC cases in (PHNETs) represent 0.3% of all neuroendocrine tumors our department. Their mean ages were 59.5 6.4 years. (NETs) and less than 150 cases have been reported in the Nine patients were man and two are women. The associated English literature since its first report in 1958. This study malignancies were: stomach cancer (CA), colon CA, thyroid aims to analyze the management outcomes of patients who CA, esophageal CA, renal CA and gallbladder CA, with underwent surgery for PHNETs. number of cases being three, three, two, one, one and one, Methods: The medical records of patients diagnosed and respectively. Eight cases were treated with liver resection operated for PHNETs in the Institute of Liver Diseases and and two cases were treated with transarterial chemo- Transplantation, Gleneagles Global Health City, between emblization. The EHPM were treated synchronously in 2010 and 2017 were reviewed. There were 7 patients seven cases and metachronously in three cases. Five patients diagnosed with PHNETs during the study period. The survived, four patients died and two were lost to follow-up. clinical characteristics, imaging, surgical procedures, The causes of mortality were mainly HCC related problems. complications, histo-pathological characteristics, adjuvant EHPM in HCC patients is rare. They do not significantly therapy, mortality and morbidity rates, disease free survival influence the survival of patient with HCC. Therapeutic and overall survival were reviewed. difficulties are still present in these patients. Effective Results: The median age at presentation was 45 years treatments should be developed to prolong the survival in (range, 25-68 years). There were 6 male and 1 female these patients. patients. Abdominal pain was the most common symp- tom. All had non-functional NETs. Four extended hep- EP01B-076 atectomies (2 right and 2 left), 2 right hepatectomies and DYNAMIC CONTRAST ENHANCED a non-anatomical resection(seg 5/6) were performed achieving R0 resection in all patients. The mean post- PERFUSION CT IMAGING, AS AN operative hospital stay was 10.3days (7-17 days). EARLY PREDICTOR FOR TUMOUR Five patients received adjuvant long-acting sandostatin. RESPONSE TO SORAFENIB The postoperative morbidity was 14.7%(bile leak in 1 TREATMENT IN PATIENTS WITH patient requiring drainage). Histopathological examina- ADVANCED HCC LESIONS tion showed well differentiated Grade 2 tumors in all S. Famularo1, A. Pecorelli2, G. Querques2, patients. The median follow up was 34 months(1-55 C. Talei Franzesi2, S. Drago2, S. Lombardi2, A. Giani1, months). There were 2 recurrences (28.5%); one had F. Romano1 and D. Ippolito2 disease progression inspite of chemotherapy and 1Surgery, Ospedale San Gerardo, and 2Radiology, Ospe- succumbed to the disease and the other had radio- dale San Gerardo, Università Milano-Bicocca, Italy frequency ablation of recurrence. Conclusion: Complete surgical resection of PHNETs Introduction: To determine the prognostic value of CT- fl provides excellent disease free and overall survival. perfusion (CT-p) imaging in evaluation of blood ow

EP01B-074Table 1 [Management of Primary Hepatic NETs] S.No Age Sex Location (Segments) Surgery Ki - 67 Overall survival Disease free survival 1 40/Male 3/4/5 Extended left hepatectomy 10 55 42 2 45/Male 4/5/6/7/8 Extended right hepatectomy 6 40 40 3 25/Female 4/5/6/7/8 Extended right hepatectomy 5 34 34 4 45/Male 5/6/7 Right hepatectomy 8 14 14 5 55/Male 5 Right hepatectomy with 413 13 extrahepatic biliary tract excision 6 38/Male 5/6 Non Anatomical resection 5 10 4 7 68/Male 4/5/6/7/8 Extended left hepatectomy 6 1 1

HPB 2018, 20 (S2), S333eS504 S394 Electronic Posters (EP01A-EP01E) - Liver changes related to therapeutics effects of sorafenib, by analysis, there was a significant associationbetween AFP+ quantitative analysis of tumor vascularization. and EPCAM+ with serum AFP level. Diameter 5 cm was Materials and methods: Eighty-one CT-p study were associatewith EPCAM+and, angiolymphatic invasion performed in 22 patients with histoloigcally proven HCC with APF+. In multivariate analysis, onlytumors 5cm treated with antiangiogenetic therapy. CT-p were was significantly associated with EpCAM+ (OR = 8.7; performed at baseline and during treatment follow-up(ev- CI= 95% 1,27-100,0; p = 0.022). The overall survival rate ery 3 months) on 256 multidetectorCT (iCT, Philips), with was 74.9%, 69.4%, 69.4% and 53.5% at 12, 24, 36 and 48 following parameters:100 Kv,100 mAs;16 dynamic slices/ months, respectively. scan;40 dynamic scans;50 ml of contrast medium.Target Conclusion: A considerable number ofpatients with lesions and surrounding parenchyma were evaluated using EpCAM+ HCC would benefit from a specific target a dedicated software which generated a quantitative colour therapy. map of vascularization. Following perfusion parameters were considered: Hepatic perfusion(HP);Arterial Perfusio- n(AP);Blood volume(BV);Hepatic Perfusion Index(HPI) EP01B-078 and Time to Peak(TTP) and statistically compared between LIVER RESECTION FOR PRIMARY responders (complete response,stable disease or partial response) and non responders. HEPATIC ANGIOSARCOMA: SINGLE Results: Percentage variation of perfusion parameters CENTER EXPERIENCE WITH 10 CASES (DHP), from baseline to follow-up study, was assessed and V. Tripke1, S. Heinrich1, T. Huber1, M. Heise1, correlated with response classified according to mRECIST B. Straub2 and H. Lang1 progression criteria. Responders group showed a significant 1Department of General, Visceral and Transplantation reduction of values in HCC target lesions after anti- Surgery, and 2Department of Pathology, University Hos- angiogenic therapy (HP 29.423.7vs51.916.8; AP pital of Mainz, Germany < 29.8 25.5vs52.2 17.9;p 0.01), in comparison to non- Introduction: Primary hepatic angiosarcoma (PHA) is a fi responders which demonstrated an increase or no signi - rare tumor entity, representing only 1-2% of all primary cant variation after treatment (HP 42.5 28.3 vs liver malignancies. Although treatment guidelines have not 38.5 11.8;AP 37.5 22.6 vs 35.9 11.2). Moreoever, p- been established, radical surgical resection is considered fi CT values were signi cantly higher(p=0.05) at baseline in the best treatment choice at the moment. responders compared to the non-responders. When patients Methods: All resections of PHA from January 2002 until fi were strati ed into mRECIST, a higher survival rate was June 2017 were identified from our prospective institutional observed in the responder group compared to the non- database. We analyzed the completeness of resection, dis- responder (48.6%vs28.6%). ease-free survival (DFS) and overall survival (OS). fi Conclusion: The identi cation of response predictors, by Results: We identified 10 patients with PHA. One patient quantitative analysis of perfusion parameters, might help had exploration only due to diffuse tumor spread and died 3 fi clinicians in selection of patients who may bene t from months after operation, while 9 patients had a potentially targeted-therapy,allowing for optimization of individual- curative resection. All cases were histologically examined ized treatment. and confirmed again by our pathologist. There was no inhospital mortality. The median follow-up after surgery was 11 months (range: 3-140 months). 4 out of 9 patients EP01B-077 (44%) were alive until last follow-up with 3 of them IMMUNOHISTOCHEMICAL without recurrence 10, 16 and 140 months after surgery. EXPRESSION OF EPCAM AND ALFA- Another patient without PHA recurrence died 59 months FETOPROTEIN IN HEPATOCELULLAR after surgery from pancreatic cancer. 5 patients had PHA recurrence. Two of these died 3 months after surgery each, CARCINOMA while 2 other patients died after 11 and 17 months. One L. D. P. Lima1, V. Resende2, J. P. Lemos2, J. B. Sancio2, patient with PHA recurrence is still alive 10 months after P. T. V. Vidigal3 and C. J. Machado4 surgery. The median OS after potentially curative resection 1Universidade Federal de Minas Gerais, 2Surgery, was 18 months and the median DFS was 10 months. 3Patologic Anatomy, and 4Preventive Medicine, Univer- Conclusion: Despite the high recurrence rate of PHA, sidade Federal de Minas Gerais, Brazil complete surgical resection seems to be a suitable treatment Introduction: Epithelial cell adhesion molecule (EpCAM) in patients with PHA. has beenproposed as a marker for cancer stem cells in human hepatocellular carcinoma(HCC) and for develop- ment of novel target therapies. The aim of this study was EP01B-079 toinvestigate the expression of EPCAM and alfa-fetopro- REDUCED EXPRESSION OF tein (AFP) in HCC by immunohistochemistry and the as- INTERLEUKIN-13 RECEPTOR ALPHA2 sociation with clinicopathological characteristics. Methods: This study included Child Pugh A HCC patients PROMOTES GROWTH OF undergoing to curativesurgical resection. HEPATOCELLULAR CARCINOMA Results: There was a significant difference in the ratio X. Long1, W. Chen1, H. Liang1, Q. Cheng1, B. Zhang1, betweenthe different phenotypes (p = 0.002). There were Q. Chen2 and X. Chen1 12 (29.3%) EPCAM positive tumorsand 29(70.7%) 1Hepatic Surgery Center, and 2Division of Gastroenter- negative. EpCAM+ expression was associated with AFP+ ology and Hepatology, Tongji Hospital, Tongji Medical (OR = 12.5,CI=95% 1.9-84.1, p< 0.001). In univariate

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S395

College, Huazhong University of Science and Technology, survival rate (RFS) between the two groups (p = 0.178). China NAs therapy could benefit the OS for early stage HCC Introduction: Interleukin-13 receptor alpha2 (IL13Ra2) patients (p = 0.028), and for advanced stage HCC patients has been reported to be associated with invasion and only after the level of lactate was adjusted (p < 0.05). metastasis of digestive cancers including colorectal cancer Patients with advanced stage HCC in treatment group had a and pancreatic cancer. However, little is known about its higher value of lactate than those in control group (p = role on hepatocellular carcinoma (HCC). This study aims to 0.001). Besides, patients with advanced stage HCC had a investigate the effect of IL13Ra2 on the progression of higher value of lactate than patients with early stage HCC HCC. in both groups (p < 0.05). Methods: Expression of IL13Ra2 was measured on 81 Conclusions: NAs would benefit the long - term outcomes Human liver tissue samples, which were collected from of early stage HBV - related HCC patients after curative patients received hepatectomy, by immunohistochemistry liver resection. However, the long - term outcomes and on 14 HCC cell lines by western blot. Independents improvement effect of NAs therapy is counteracted by the factors, overall survival (OS) and recurrence-free survival adverse effect of elevated lactate for patients with advanced (RFS) of patients were compared between high-IL13Ra2 stage HBV - related HCC after curative liver resection. expression group and low-IL13Ra2 group.HepG2 and SMMC7721 HCC cell lines were selected to knock down IL13Ra2 expression by PLKO-Tet-On lentivirus. Cell EP01B-081 Counting Kit-8 (CCK-8) assays and colony formation THE ADEQUATE RESECTION MARGIN assays were performed on selected cell lines. HepG2-vector OF HEPATOCELLULAR CARCINOMA and HepG2-sh IL13Ra2 cells were used to perform in vivo tumorigenicity assay. ACCORDING TO THE TUMOR Results: IL13Ra2 showed higher expression in adjacent- MICROENVIRONMENT tumor tissues than tumor tissues (P< 0.001). Differentia- S. Kim1, S. H. Kim1, M. -Y. Cho2, M. Y. Kim3 and tion of HCC was the only independent factor associated S. K. Baik3 with IL13Ra2 expression in tumor tissues (HR: 0.19, 95% 1Department of Surgery, 2Department of Pathology, and CI: 0.067-0.538, P =0.002). No significant difference of OS 3Department of Internal Medicine, Yonsei University and RFS were found between high-IL13Ra2 expression Wonju College of Medicine, Wonju Severance Christian group and low-IL13Ra2 group. Knockdown of IL13Ra2 Hospital, Republic of Korea promoted growth of HepG2 and SMMC7721 cells. Sub- a Background: There is no consensus on the safe resection cutaneous tumors from HepG2-sh IL13R 2 cells showed margin in patients with hepatocellular carcinoma (HCC). < larger in volume and heavier in weight (P 0.05), in We investigated the change of tumor microenvironment comparison to their empty control. according to the resection margin. Conclusion: Our research clarified that reduced expression a Methods: We prospectively collected the specimen of 60 of IL13R 2 promoted growth of hepatocellular carcinoma. patients with HCC. We selected three portions of speci- mens as follows: tumor, 1cm and 2cm margin normal tissue. We investigated the expression status of tumor EP01B-080 microenvironment genes. We compared the expression THE EFFECT OF ANTIVIRAL status according to recurrence, HCC gross type and posi- TREATMENT FOR HEPATITIS B tron emission tomography (PET) positivity. We divided the VIRUS - RELATED HEPATOCELLULAR patients into two groups as follows: group 1 included expanding and vaguely nodular types whereas group 2 CARCINOMA PATIENTS AFTER included nodular with perinodular extension, multinodular CURATIVE LIVER RESECTION WAS confluent and infiltrative types. IMPAIRED BY ELEVATED LACTATE Results: Group 2 had a higher prevalence of PET positive J. Zhao1 and W. Zhang2 [6 (37.5%) vs 10 (62.5%)] and recurrence [5 (16.7%) vs 17 1Hepatic Surgery Center, and 2Hepatic Surgical Center, (56.7%)]. However, in cases with more than 1cm resection Tongji Hospital, Tongji Medical College, Huazhong Uni- margin, there was no difference of recurrence rate [9 (75%), fi versity of Science and Technology, China p=0.017 vs 8 (44.4%), p=0.06]. Beta-catenin was signi - cantly decreased and E-cadherin was significantly Background: Nucleoside and nucleotide analogues (NAs) increased according to the resection margin in group 1. has a risk of mitochondrial toxicity and therefore induces Group 2 and PET positive patients did not show any sig- rising of lactate. We aim to evaluate the impact of lactate on nificant change of beta-catenin and E-cadherin until 2cm the NAs therapy in hepatitis B virus (HBV)- related hepa- resection margin. tocellular cancer (HCC) patients after curative liver Conclusions: Our data suggest that patients with HCC of resection. expanding and vaguely nodular gross types may safely Methods: 557 HBV - related HCC patients were enrolled undergo surgical resection with a narrow resection and divided into treatment and control group according to margin and patients with HCC of nodular with peri- whether they received NAs therapy or not. Perioperative nodular extension, multinodular confluent and infiltrative and prognosis data were retrospectively reviewed. gross type must undergo surgical resection with more Results: Patients in treatment group had a better overall than 2cm resection margin because of tumor microenvi- survival rate (OS) than those in control group (p = 0.036). ronment condition. There was no significant difference of recurrence - free

HPB 2018, 20 (S2), S333eS504 S396 Electronic Posters (EP01A-EP01E) - Liver

EP01B-082 consequences of this tumor remain unclear. Surgical resection should be recommended in patients with large BLEEDING UNDIFFENTIATED tumors (more than 5 cm in diameter) or progressive EMBRYONAL SARCOMA OF THE enlargement or malignant tendency. Majority of very LIVER IN AN ADOLESCENT limited case report series demonstrate very good outcomes V. M. Leow1,2, I. S. Mohamad3 and M. K. Subramaniam2 after surgical therapy, but case reports of aggressive ma- 1Oncology, AMDI, USM, 2HPB Unit, Department of Sur- lignant PEComas with rapid systemic dissemination were gery, Hospital Sultanah Bahiyah, Malaysia, and published. 3Department of Surgery, Universiti Sains Malaysia, The authors present analysis of three case reports of Malaysia borderline malignant hepatic perivascular epithelioid cell tumors with analysis of published literature. Undifferentiated embryonal sarcoma (UES) of the liver The work was supported by the project (Ministry of is a highly aggressive tumor. This rare entity of tumor af- Defence) "Long-term development plan for the organiza- fects predominantly the children, it has been reported in tion in 1011,” a Ministry of Health - RVO (FN HK, adults. Herein, we present an adolescent who complained 00179906). of painful huge upper abdominal mass. A 16-year-old adolescent male experienced painful right upper abdominal mass for the one week. CT showed a huge cystic mass occupying the whole right liver pushing the EP01B-084 right hemi-diaphragm upward and left liver laterally. There EARLY DERANGEMENT OF THE was presence of fluid around the liver. He underwent lap- INTERNATIONAL NORMALIZED arotomy and right hepatectomy. Operative findings RATIO (INR) PREDICTS LIVER revealed the tumor has already ruptured prior to the surgery INSUFFICIENCY FOLLOWING LIVER and was partially sealed off by the diaphragm. The surgery was successfully performed and the patient was discharges RESECTION FOR HEPATOCELLULAR well. However, he was readmitted with right pleural effu- CARCINOMA sion which was treated with percutaneous drainage. He was A. N. Silva1, M. Greensmith1, R. Praseedom1, T. C. See2, started on chemotherapy. Three-monthly CT surveillance R. Brais3, B. Basu4, G. J. Alexander5, M. Hoare6, did not show any signs of recurrence, but small right pleural P. Gibbs1 and A. Balakrishnan1 lesion. Six month post-operatively, the patient remained 1HPB Surgery, 2Radiology, 3Pathology, 4Oncology, well and still on chemotherapy as well as close 5University College London, United Kingdom, and surveillance. 6Hepatology, University of Cambridge and Addenbrooke’s Like most of the sarcomas, regardless of tumor histo- Hospital, United Kingdom genesis, complete surgical resection is the treatment Introduction: Surgical resection, where appropriate, re- armamentarium. Adjuvant chemotherapy is recommended mains one of the best treatment options for hepatocellular to ensure better survival. Chemotherapy regimens reported carcinoma (HCC), however outcomes can be compromised in the literature include ifosfamide, doxorubicin, cisplatin, by development of liver insufficiency. We reviewed our and etoposide. A study has reported a recurrence rate of up experience of liver resection for HCC to identify factors to 40% in patients with clear margin of resection but that may affect survival or predict development of post- without adjuvant chemotherapy. operative liver insufficiency in these patients. Given its poor prognosis, adult embryonal sarcoma of the Methods: The records of all patients undergoing liver liver should be managed with multimodal interventions in resection for hepatocellular carcinoma at our university- order to minimize the recurrence rates. affiliated tertiary centre between1999-2017 were examined. Liver insufficiency was defined as per the International EP01B-083 Study Group for Liver Surgery (ISGLS) criteria. The Cox proportional hazards model was used to detect univariate LIVER PECOMAS and multivariate correlations with overall survival (OS) and  1,2 3 4 Z. Subrt , A. Ferko , M. Podhola and Kaplan Meier analysis was used for determination of 1-year M. Linter-Kapisinská4 and 5-year survival. 1Department of Military Surgery, University of Defence, Results: 111 patients underwent liver resection for HCC Faculty of MIlitary Health Sciences, 2Department of Sur- during this time. 30-day and 90-day mortality for this gery, University Hospital and Medical Faculty of Charles cohort was 0.9%, with 89% 1-year survival and 60% 5-year University in Hradec Králové, 3Comenius University in survival. Derangement of INR and bilirubin levels, as well Bratislava, Jessenius Medical Faculty in Martin and as large calibre vascular invasion on histology, were University Hospital Martin, and 4Fingerland Institute of significantly associated with poorer OS (p< 0.05) on uni- Pathology, Charles University Medical Faculty Hradec variate analysis, however only elevated INR was signifi- Králové, University Hospital Hradec Králové, Czech cantly associated with poorer OS on multivariate analysis Republic (p=0.032). Liver insufficiency occurred in 19% of patients Hepatic perivascular epithelioid cell neoplasm (n=21) post-operatively. Notably, no patient with normal (PEComa) is a rare type of primary liver tumor derived INR on post-operative day 2 developed liver insufficiency from mezenchymal cells. In imaging studies can hepatic (p=0.03). PEComa mimic other liver tumors such as HCC, liver Conclusion: Liver resection for HCC can be performed hemangioma, metastases or FNH. The definitive diag- with low post-operative mortality. Our data suggests that nosis is usually made by microscopic verification and INR levels on the second post-operative day could allow imunohistochemical staining. Clinical and prognostic early identification of patients at risk of developing

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S397 subsequent liver insufficiency to facilitate optimization and leading to late diagnosis. Due to its ability to masquerade improve outcomes. other liver tumors, misdiagnosis is common. Methods and results: Here we present a case of a 52 years old man who presented with an incidentally EP01B-085 detected space occupying lesion(SOL) in liver with STEREOTACTIC IMAGE-GUIDED features of atypical hepatocellular carcinoma on imaging and fine needle aspiration cytology. He underwent a left MICROWAVE ABLATION FOR hepatectomy and the final histology was a surprise in the HEPATOCELLULAR CARCINOMA form of hepatic lymphoma. He underwent appropriate P. Tinguely1, A. Lachenmayer1, V. Banz1, M. Maurer2 and chemotherapy post surgery and is asymptomatic at D. Candinas1 follow up. 1Department of Visceral Surgery and Medicine, Inselspi- Conclusions: Primary hepatic lymphoma is very rare tal, Bern University Hospital, and 2Department of Diag- tumor and is amenable to therapy. Most of the times the nostic, Interventional and Pediatric Radiology, Inselspital, diagnosis revealed on post op histopathology in operable University Hospital, University of Bern, Switzerland lesions. In cases of inoperable liver SOL with atypical Introduction: Stereotactic navigation has been proposed to features liver biopsy can be considered. enhance precision in tumor targeting for local ablation of HCC, however reports of large patient series remain scarce. We report therapeutic efficacy of percutaneous stereotactic EP01B-088 image-guided microwave ablation (SIMWA) for HCC. TRACKING KERATIN 19-POSITIVE Methods: All patients treated with SIMWA for HCC at our CANCER STEM CELLS USING CYFRA institution between January 2015 and December 2017 were 21-1 IN HEPATOCELLULAR included for this retrospective analysis. Interventions were performed in a team of surgeons and radiologists, using a CARCINOMA CT-based navigation system allowing trajectory planning, T. Kawai, T. Ishii, K. Yasuchika, S. Ogiso, T. Minami, stereotactic tumor targeting and immediate treatment vali- Y. Miyauchi, H. Kojima, K. Fukumitsu and S. Uemoto dation. Therapeutic efficacy was measured as local recur- Department of Surgery, Graduate School of Medicine rence and overall survival survival. Kyoto University, Japan Results: Ninety-two patients underwent 163 SIMWA Backgrounds: Cancer stem cells (CSCs) have been procedures, most patients being CHILD A (74.2%). A attracting increasing attention as a new target for cancer median of 1 (range 1-4) tumors were ablated per treatment therapies. However, the current lack of tools for easy session with mean tumor size of 16mm (5-43mm). Fourty- assessment of CSCs prevents the development of thera- three patients (44.3%) had one or more previous HCC peutic strategies for hepatocellular carcinoma (HCC). We treatments and 14 (14.4%) were transplanted afterwards. previously showed that keratin 19 (K19) is a novel HCC- No major or liver-specific complications occurred. Of the CSCs marker associated with transforming growth factor 77 patients with a minimum follow-up of 6 months, mean beta (TGFb)/Smad pathway, and TGFb receptor 1 inhibitor OS was 13.9 months after SIMWA and 23.7 months after is a new therapeutic agent for K19+ HCC-CSCs. Here, we initial diagnosis. Local recurrence occurred in 20/131 examined whether K19+ HCC-CSCs can be tracked using (15.2%) lesions, which were successfully re-ablated in 14 K19 fragment (CYFRA 21-1). and operated in 2 cases (12.2%). Fifteen (11.5%) of these Methods: K19 expression were evaluated in consecutive recurrent patients had simultaneous disease progression. 255 HCC patients who underwent liver resection or trans- Tumor size 3 cm was significantly correlated with local plantation. Preoperative serum CYFRA 21-1 were recurrence (p=0.005). compared in K19+/K19- patients. Using HCC cell lines Conclusion: SIMWA is safe and effective for the treatment encoding with K19 promoter-driven enhanced GFP, su- of HCC and might offer a curative treatment approach for pernatant CYFRA 21-1 were examined in FACS-isolated patients with inoperable and conventionally not ablatable K19+/K19- cells. lesions due to more precise minimal invasive ablation. Results: K19 expression was significantly correlated with preoperative serum CYFRA 21-1, and postoperative poor prognosis in both liver resection and transplantation EP01B-087 groups. ROC analyses revealed that serum CYFRA 21-1 PRIMARY HEPATIC LYMPHOMA was the statistically significant and the most sensitive pre- MIMICKING HEPATOCELLULAR dictor of tumor K19 expression among preoperative labo- ratory test values in both groups. Additionally, FACS- CARCINOMA: CASE REPORT isolated K19+ cells displayed significantly higher super- S. R. V. Gunturi, D. Sarma, V. Thumma, natant CYFRA 21-1. Gain/loss of K19 function experi- J. R. Bathalapalli, N. Kunduru, G. R. Gondu, ments confirmed that K19 regulates CYFRA 21-1 through H. K. Dubey and B. Nagari TGFb/Smad pathway. Surgical Gastroenterology, Nizams Institute of Medical Conclusion: CYFRA 21-1 is useful for tracking K19+ Sciences, India HCC-CSCs, and would contribute the development of Introduction: Primary hepatic lymphoma (PHL) is a very precision medicine for K19+ HCC including the indication rare malignancy presenting with non specific symptoms of liver resection/transplantation.

HPB 2018, 20 (S2), S333eS504 S398 Electronic Posters (EP01A-EP01E) - Liver

EP01B-089 Method: A retrospective review of patients presenting with ruptured HCC between 2005 and 2015 in a tertiary centre. PREDICTORS OF HEPATOCELLULAR Patients who underwent resection for ruptured HCC (group CARCINOMA (HCC) RECURRENCE A) were identified and these subjects were matched with AFTER ORTHOTOPIC LIVER non-ruptured HCC (group B) patients using a propensity TRANSPLANT (OLT), A SINGLE score based on logistic regression analysis. INSTITUTION REVIEW Results: A cohort of 34 patients (27 male:7 female) was identified. Definitive management with surgical resection, A. Shinde1, J. Miller2, F. Alemi1 and A. Annamalai1 1 2 TACE (transarterial chemoembolisation) and TAE (trans- St Vincent Medical Center, and CHLA, United States arterial embolisation) were associated with median sur- Introduction: OLT remains the definitive treatment for vivals of 104 (95% CI:37.6-170.4), 48 (95% CI:0-118.6) cirrhosis complicated by HCC, and is directed by the Model and 0.5 (95% CI: < 000.5-1.3) month respectively. There for End-Stage Liver Disease (MELD) to prioritize patients was no difference in the mean overall survival between by disease severity. Current methods of severity assess- group A (78.3 months) and group B (99 months, p=0.347) ment in the setting of HCC do not account for underlying or mean disease-free survival (60.8 vs 38.4 months, recurrence risk. p=0.397). Methods: We conducted a retrospective review of Conclusions: In selected patients with ruptured HCC, liver consecutive HCC patients undergoing OLT from 1/2010- resection is associated with the most favourable outcome. 12/2014 at a single center. HCC recurrence after OLT, AFP Rupture is not a prognostic factor for patients with HCC (at diagnosis and time of transplant (TOT)), radiologic/ who undergo resection. pathologic tumor burden at TOT, number/location of tumors, tumor differentiation, viral loads and genotypes, and MELD were analyzed. EP01B-091 Results: 110 patients with HCC underwent OLT. Seventy seven patients remained recurrence-free, 9 developed SURGICAL RESECTION OF recurrence, 16 died of other causes, and 8 were excluded for HEPATOCELLULAR CARCINOMA e incomplete data. INITIAL EXPERIENCE AND RESULTS Recurrence was associated with: OF A NEWLY ESTABLISHED HPB UNIT 1) elevated AFP from diagnosis to TOT (p=0.0166, J. Constantino, A. Logrado, M. Sá, C. Prudente, C. Daniel, average change of +17.1 with recurrence and -131 ng/ml J. Pereira and C. Casimiro without recurrence), and pathologic explant factors Serviço de Cirurgia Geral - Unidade de Cirurgia HBP, including tumor stage (p=0.0375), microvascular invasion Centro Hospitalar Tondela-Viseu, Portugal (p=0.0007, OR=18.5), gross vascular invasion (p=0.006, OR=20.25), pathology outside UCSF criteria (p=0.0209), Hepatic resection of hepatocellular carcinoma (HCC) is a and tumor differentiation. major operation in high-risk patients, with a postoperative No relationships were observed between recurrence and death rate of 5% in most recent series. 1) viral loads, From July 2015 to December 2017, 17 patients under- 2) absolute AFP levels, went liver resection (LR) as treatment for HCC at our unit. 3) imaging findings outside MILAN/UCSF criteria The aim was to review our experience with LR in the 4) number or location of tumor in explant treatment of patients with HCC, in a newly formed HPB 5) volume of high grade tumor, unit, evaluating patient characteristics, surgical technique, 6) days from diagnosis to OLT, or results and survival. A prospectively maintained database 7) native Na-MELD/allocation-MELD. was used. Conclusion: Absolute AFP, MELD, viral load, tumor Fourteen patients were male (82.3%), with an average burden, and wait time to transplant are not good indicators age of 71 years (Min 51; Max 78), and with 53% of the of HCC recurrence. Instead, AFP trajectory or tumor dif- patients being cirrhotic. Operative time was 208 minutes ferentiation has more utility in predicting recurrence risk. (Min 90; Max 360), with two patients needing intra- operative blood transfusion. A total of 2 subsegmentec- tomies, 10 monosegmentectomies, 2 bisegmentectomies, and 3 major hepatectomies were performed. One patient EP01B-090 underwent laparoscopic liver resection. Median tumor size LIVER RESECTION FOR RUPTURED was 4,2cm (Min 1; Max 22). Median hospital stay was 12 HEPATOCELLULAR CARCINOMA e A days (Min 6; Max 33). There was one perioperative death PROPENSITY MATCHED ANALYSIS due to sepsis and multiorgan failure. Three patients (17.6%) died during follow up due to disease recurrence and pro- N. Pinsker, M. Papoulas, M. Sodergren, K. Menon, gression. There are 76.4% of patients alive. A. Suddle, P. Srinivasan, A. Prachalias and N. Heaton This small series underlines that LR for HCC is a safe Institute of Liver Studies, King’s College Hospital NHS and feasible procedure, although a longer follow up is Foundation Trust, United Kingdom warranted to accurately determine overall and disease free Introduction: Ruptured hepatocellular carcinoma (HCC) survival. is rare in the Western world and robust data regarding LR for HCC should be offered as the first option to pa- standardised treatment is lacking. This study evaluates tients with preserved hepatic function and limited disease treatment strategies and the effect of rupture as a potential who do not fulfill the criteria or are too old for liver adverse prognostic indicator among patients with HCC that transplant. undergo resection.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S399

EP01B-092 Methods: We present three cases of liver lesions mimicking HCC according to LIRADS classification. BENIGN LIVER TUMORS. NEW Results: APPROACH AND EXPERIENCE IN 145 Case 1: 49 year old male with diagnosis of cirrhosis. PATIENTS Multiple LIRAD V liver nodules were detected in MRI, M. A. Secchi1, L. Rossi2, M. Cantaberta3 and E. Mateljam2 along with an elevated Alphafetoprotein(1414,36ng/DL). 1Surgery, Instituto Universitario Italiano de Rosar- Angiography revealed multiple vascularized nodules and fi io.IUNIR, 2Surgery, Modelo Clinic of Rufino.IUNIR, and an arterio-portal stula of the right hepatic artery, that was 3Surgery, Italian Hospital and IUNIR. Rosario, Argentina embolized. After the procedure nodules disappeared and the Alphafetroprotein was normal. Aim: The purpose of this study is to evaluate the current Case 2: 56 year old male patient with history of HCV tendency to diagnosis and management in our practice. compensated cirrhosis, and a emergency splenectomy 20 Methods: Benign tumors to be discussed include: hyper- years ago. He presented a LIRAD V 25mm nodule in plasia, adenomas, hamartomas, hemangiomas and non- segment VI, that showed arterial phase enhancement with parasitic cysts. Improvements in diagnosis and manage- posterior wash out. Surgical resection was indicated, the ment can be defined as: better understanding of the natural pathology report informed splenic tissue. history of each type of tumor, modern imaging techniques Case 3: 62 years old male patient, with decompensated in assuring a precise diagnosis of tumor nature (HCA from alcoholic cirrhosis. MRI reported LIRADS V liver nodule. a well differentiated HCC) , new minimally invasive Orthotopic liver transplant was performed, the pathology laparoscopic surgical approach: diagnostic and resectional reported cavernous haemangioma. procedures, and safer liver resections. Conclusions: Arterioportal fistulas, haemangiomas and Results: Between 1990 and 2016, we diagnosed benign liver splenosis can mimic lesions compatible with liver tumors in 145 patients in 2 specialized HPB units. 91 hepatocarcinoma. of these tumors (55 solid and 36 liquid) were operated and 54 are clinically followed (F.Up). 1) Focal nodular hiperplasia (FNH) symptomatic and > 10 cm: 8 Resections., 7 F.Up in small FNH EP01B-094 2) Hepatocellular adenoma (HCA): 36 Resections. and HEPATOCELLULAR CARCINOMA F.Up of 9 asymptomatic with multiple HCA. (others 5, not MIMICKING LIVER ABSCESS included, were Carcinoma, ) B. Celik1,A.F.K.Gok1, F. Ekiz1, C. Ibis1, 3) Solid mesenchymal hamartoma: 2 Resections. H. Karatay2 and A. Poyanlõ3 4) Hemangiomas: 4 Resections. and 18 F.Up 1General Surgery Division of HPB Surgery & Liver 5) Benign liquid 5.1) Simple biliary cysts = Type 1: 22 Transplantation, 2Department of Pathology, and patients: 3 Resections. (lobar cysts) and 19 laparoscopic 3Department of Radiology, Istanbul University Istanbul (resections. of the dome in 10),.2) Policystosis (PLC): 6 Res.: Medical Faculty, Turkey 3 symptomatic type 2 PLC and 1 type 3 PLC and 10 F.up 6) Cystadenomas: 8 Resections. Hepatocellular carcinoma (HCC) is the most frequent Morbidity was 10% (9/91). No mortality. primary malignancy of the liver which can be presented in Conclusions: A close imaging assessment is mandatory many different clinical situations. Beyond the well-known due to the natural history of HCA. In some cases, the risk factors it can also be seen without any of them. We laparoscopic biopsy with IO frozen in the section study. present the successful management of a patient with HCC mimicking a liver abscess. EP01B-093 A 20-year-old woman admitted to the emergency department with high fever, abdominal pain, and elevated LIVER IMAGES MIMICKING white blood count, c-reactive protein level. Ultra- HEPATOCARCINOMA sonogarphy and computed tomography of the abdomen A. Cristiano, F. Isasa, P. Mateo, M. Lenz, R. Vergara, revealed a huge heterogeneous mass in the left liver E. Quiñonez, J. P. Duran, I. Suzuki and J. F. Mattera containing air bubbles inside. Liver transaminases were Liver Trasplant and HPB Surgery, Hospital de Alta elevated. The further radiologic evaluation through mag- Complejidad El Cruce, Argentina netic resonance scan revealed that the mass is a solid tumor Introduction: Hepatocellular carcinoma(HCC) is the sixth with necrotic areas. After intravenous antibiotics and fluid cause of cancer related deaths. Chronic liver disease is the support, the patient was rapidly prepared for surgery. The most important risk factor associated to this entity. surgical exploration showed a huge tumor originating from Diagnosis is based on imaging findings and patient’s left lateral liver section. Left lateral sectionectomy was clinical background. performed. The patient was discharged after an uneventful Several staging scores have been proposed based on postoperative period. Histopathological examination cross-sectional images. LIRADs classification has been revealed a HCC with over 90% coagulative necrosis with adopted by liver transplants centers to standardize diag- negative surgical margins. nostic criteria, based on contrast enhancement and HCC can be presented with different clinical scenarios. morphological patterns. Prompt imaging and meticulous radiologic interpretation is Nevertheless, the use of these scores without pertinent the key to success in the management of liver masses clinical evaluation may lead to misdiagnosis of certain presenting with acute abdominal pain and fever. lesions in cirrhotic and non-cirrhotic patients.

HPB 2018, 20 (S2), S333eS504 S400 Electronic Posters (EP01A-EP01E) - Liver

EP01B-095 Introduction: Clear cell HCC is a rare variant of HCC, ac- counting for 7.5%-12.5% of all liver cancer cases with a better PRIMARY TUMORS OF THE LIVER: prognosis compared to other variants. Our study compares the HEPATOCELLULAR CARCINOMA AND demographic, clinical differences between Clear cell HCC & CHOLANGIOCARCINOMA GENOMIC HCC NOS using population based database. CHARACTERIZATION Material and methods: Surveillance, Epidemiology, & End results (SEER) database (1973 - 2013) was abstracted R. Martins1,2,3, I. P. Ribeiro4,5, I. Tavares5, to understand the demographic & clinical differences be- A. M. Abrantes3,4, M. F. Botelho3,4, J. B. Melo4,5,6, tween Clear cell HCC & HCC NOS. Student t-test was used E. Furtado1, J. G. Tralhão1,2,3, I. M. Carreira4,5,6 and to compare continuous variables & Chi squared test for F. Castro e Sousa7,8 categorical variables. Cumulative life table analysis was 1Liver Transplant Department, 2Surgery Department - used to compare long term survival. HBP Unit, Coimbra University Hospital, 3Biophysics Results: Mean age at presentation was 63 12.2 years for Institute, IBILI, Faculty of Medicine, 4CIMAGO (Center of HCC NOS compared to 65.7 12.8 for Clear cell HCC Investigation on Environment Genetics and Oncobiology), patients. Both entities were more common in Caucasians Faculty of Medicine, University of Coimbra, Portugal, males. Resection was performed more often for Clear cell 5Cytogenetics and Genomics Laboratory, Faculty of HCC patients (39.7%) compared to HCC NOS patients Medicine, 6CNC (Center of Neuroscience and Cellular (20.8%). Cancer specific & overall mortality was higher for Biology), Faculty of Medicine, 7Surgery Department, HCC NOS patients (61.5%, 81.4%) compared to Clear cell Coimbra University Hospital, and 8Faculty of Medicine - HCC patients (52%, 71.1%). The mean survival in months University of Coimbra, Portugal and the overall 5 year cancer specific survival was higher Introduction: Hepatocellular carcinoma (HCC) and chol- for Clear cell HCC patients (22.230.2 months & 23%) angiocarcinoma (CC) are the two most common primary compared to HCC NOS patients (16.228.4 months & 15%). hepatic neoplasms. Its increasing incidence, morbidity and Conclusions: Clear cell variant accounts for very few pa- mortality are a therapeutic challenge. CC is commonly clas- tients with HCC (0.4%) especially in older patients & has fi si ed as intrahepatic and extrahepatic, based on anatomical better long term survival compared to HCC NOS. Under- location. The prognosis of these two types of tumors is usu- standing of this rare variant is ever evolving with a need to ally poor since the diagnosis is not easy to obtain. The aim of improve screening protocols, aiming at early diagnosis & this study was to perform a genomic characterization of HCC timely surgical intervention. and intrahepatic (ICC) and extrahepatic (ECC) CC patients. Method: The genomic characterization was performed by EP01C - Electronic Poster: 1C - Liver Surgical Array Comparative Genomic Hybridization (aCGH) in 11 Outcomes HCC, 6 ECC and 7 ICC patients. Results: The results obtained revealed some common al- EP01C-001 terations between the patients of each group. Several HCC TOWARDS ZERO MORTALITY IN patients revealed gain of 1q, 2q37.2, 8q, 14q32.33 and ELECTIVE LIVER SURGERY 17q21.31 and loss of 3q26.1, 6p22.2 and 12p13.31. S. Jegatheeswaran1, P. Stathakis1, M. Parker1,2, Regarding the ICC patients, the most common alterations S. Jamdar1 and A. Siriwardena1 observed were gain of 2q37.3 and Xp and loss of 3p, 6p25.3, 1Regional Hepato-Pancreato-Biliary Unit, Manchester 11q11, 14q, 16q, Yp and Yq. The patients of ECC also Royal Infirmary, and 2Manchester Royal Infirmary, Crit- revealed some common alterations namely gain of 2q37.3, ical Care Unit, United Kingdom 6p25.3 and 16p25.3 and loss of 3q26.1, 6p25.3-22.3, Introduction: Elective liver surgery can be undertaken with 12p13.31, 17p, 18q, Yp. Some of these alterations are also low mortality. This study reports outcome of a protocolised common between patients of these three different groups. approach to patient selection, surgery and peri-operative care. Conclusions: These regions contain genes whose alteration Methods: The study population is a consecutive series of may be related to the development of these tumors. The patients undergoing liver resection under the care of an genomic characterization of these patients is important to the individual hepatobiliary surgeon (AKS) in the regionally study of such tumors since it allows to find potential bio- accredited liver surgery service in Manchester, UK. 323 markers of both diagnosis and prognosis which is essential consecutive liver resections undertaken during the period for achieving an earlier diagnosis and improving treatments. January 2009 to October 2017 provide the study popula- tion. All patients >65 yrs of age (and younger pts under- EP01B-096 going complex liver surgery) underwent cardiopulmonary DEMOGRAPHIC AND CLINICAL exercise testing (CPET) with those having poor perfor- OUTCOMES OF PATIENTS WITH mance being excluded from surgery. Patients had arterial HEPATOCELLULAR CARCINOMA NOS and central venous pressure monitoring and most had COMPARED WITH CLEAR CELL epidural analgesia. No pharmacological reduction of CVP HEPATOCELLULAR CARCINOMA: A was employed. Liver transection was undertaken with CUSA (Valleylab, UK) with intermittent inflow occlusion. UNITED STATES POPULATION BASED All-cause, episode-related, in-hospital mortality is reported. ANALYSIS (SEER 1973-2013) Data were recorded prospectively. M. Kaushik, S. Patil, A. Kandilis and M. Jacobs Results: There were 123 (38%) major resections classified Hepato-pancreato-Biliary Surgery, St John Providence as hemi-hepatectomy (or more extensive). 35 patients Hospital and Medical Center, Michigan State University, (11%) required blood transfusion; median 0 (range 0 - 32 United States units; 4 patients required more than 2 units). There was 1

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S401 death [3000g extended right hepatectomy on veno-venous Hospital, Southeast University, 3Capital Medical Univer- bypass with death due to post-operative liver failure]. The sity Cancer Center, 4Eastern Hepatobiliary Surgery Hos- post-operative mortality rate was 0.3%. pital, Second Military Medical University, 5Southeast Conclusions: This type of case series is typically skewed University, and 6Chinese University of Hong Kong, China by case selection bias, ascertainment and reporting bias but Introduction: We aimed to investigate the influences accepting these limitations, good results can be achieved in of tumor rupture on the observed survivals and con- liver surgery with low peri-operative mortality over a sus- ditional survival probabilities of patients received tained period of time using a protocolised approach to pa- hepatectomy. tient selection and peri-operative care. Method: A consecutive cohort of patients who under- went partial hepatectomy for HCC between 2009 and EP01C-002 2013 was divided into tumor rupture group and non- SEVERE ACUTE KIDNEY INJURY rupture group. Propensity scores analyses were used to FOLLOWING MAJOR LIVER compare the observed survivals and conditional survival RESECTION WITHOUT PORTAL probabilities between these two groups. Prognostic fac- tors for overall survival(OS) and progressive-free survi- CLAMPING: INCIDENCE, RISK val(PFS) were identified by univariable and multivariable FACTORS AND IMPACT ON SHORT- analyses. TERM OUTCOMES Results: 916 HCC patients who underwent curative J. Garnier1,2, M. Faucher3, U. Marchese1, H. Meillat1, resection were divided into two groups: the rupture group D. Mokart3, J. Ewald1, J. -R. Delpero1,2 and O. Turrini1,2 (106) and the non-rupture group (810). Propensity score 1Department of Surgical Oncology, Institut Paoli Calm- matching analysis created 89 pairs of patients with ettes, 2Aix Marseille University, and 3Department of comparative background and tumor characteristics. Anesthesiology and Critical Care, Institut Paoli Calmettes, Tumor rupture was significantly associated with increased France risks of OS (p< 0.01). Tumor rupture was significantly associated with increased risks of PFS before, while not Introduction: Acute kidney injury (AKI) following major after propensity matching. Multivariable Cox regression hepatectomy (MH) remains inadequately investigated. This analyses showed that tumor rupture was an independent retrospective study aimed to assess the risk factors and risk factor associated with OS. There were significant prognostic value of AKI on short-term outcomes following differences between two groups for conditional proba- MH without portal pedicle clamping. bilities of OS and PFS for additional 6 months and 1 year Methods: From January 2014 through June 2017, 111 before propensity matching, while not after propensity consecutive patients underwent MH without portal pedicle matching clamping, but with intraoperative low-crystalloid infusion. Kidney Disease Improving Global Outcomes stages II and III were classified as severe AKI. Results: A total of 102 patients did not develop AKI or only AKI stage I (92%, control group), whereas 9 patients developed severe AKI (8%, severe AKI group). Hepatec- tomy (P=0.002) and surgery (P=0.011) durations were longer in the severe AKI group. Clavien-Dindo grades 3 to 5 morbidity (55% versus 9%, P=0.001), liver failure (P=0.017), and 90-day mortality (33% versus 2%, P=0.003) were significantly higher in the severe AKI group. After a multivariate analysis, the duration of hepatectomy (cut-off: 250 minutes; P=0.029) and urea serum levels on post- operative day 3 (P=0.006) were identified as independent predictors of severe AKI. Discussion: Severe AKI, which was not rare, was associ- ated with poor short-term outcomes, and can be predicted by hepatectomy duration greater than 250 minutes.

EP01C-003 CONDITIONAL PROBABILITY OF

SURVIVAL IN PATIENTS WITH Figure [figure] SPONTANEOUS TUMOR RUPTURE ON HEPATOCELLULAR CARCINOMA Conclusions: The present study identified that spontaneous AFTER PARTIAL HEPATECTOMY: A tumor rupture was an independent risk factor influencing PROPENSITY SCORE MATCHING OS, while not PFS of patients with HCC following partial ANALYSIS hepatectomy. Moreover, the conditional probabilities of OS Q. Zhu1,2, G. Qiao3,C.Xu4, Y. Yang5,Z.Yu5, Z. Cheng5, and PFS of patients for additional 6 months and 1 year in W. Y. Lau6 and J. Zhou5 the rupture and non-rupture groups showed no differences 1Department of Hepatobiliary Surgery, 2Department of after propensity matching. Hepatobiliary Surgery Research Institute, Zhongda

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EP01C-004 ruptured were matched for comparison. Patients in rHCC had more Child B cirrhosis (11.3% vs 4.3%, p=0.007). The LONG-TERM FOLLOW-UP AFTER postoperative outcome including complication rate and LAPAROSCOPIC HEPATECTOMY: A hospital stay were similar. The tumor pathology was similar CASE-MATCHED SURVIVAL ANALYSIS in both groups, so as the disease recurrent pattern. However F. Chan, K. C. Cheng, Y. P. Yeung and K. M. Ho rHCC patients had earlier disease recurrence and poorer Surgery, Kwong Wah Hospital, Hong Kong overall survival (5-years 26.5% vs 45.2%, p=0.006). Further analysis on TMN staging suggested that rHCC Introduction: Despite the widespread popularity of lapa- patients did better than stage IIIB patients (5-year 26.5% vs roscopic surgery, laparoscopic liver resection (LLR) re- 18.9%, 0.008), suggesting T4 stage IIIC for rHCC may not mains in evolution. Only laparoscopic left lateral be the correct prediction. sectionectomy and wedge resection are considered standard Conclusions: RHCC patients had inferior overall survival practice. Technical considerations aside, oncological as compared to those patients without ruptured. These pa- integrity is of utmost importance. This study aimed to tients may not fit into T4 stage IIIC TMN staging. compare long term outcomes for patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC). Method: HCC patients who received hepatectomy from EP01C-006 1993 to 2016 were included. Excluding tumors larger than THE RESULTS OF LIVER RESECTION 5cm, 1:2 propensity score matching was performed be- WITH INTRAOPERATIVE tween laparoscopic and open hepatectomies by age, gender, ULTRASOUND FOR tumor size, lympho-vascular invasion and cirrhosis. 5-year HEPATOCELLULAR CARCINOMA IN overall survival (OS) and disease free survival (DFS) were compared. VIETNAM Results: 31 LLRs were matched to 67 open resection. K. K. Dang1, N. Q. Nguyen1 and T. V. Le2 LLRs patients had better overall survival (89% vs 51%; 1Viet Duc University Hospital, Viet Nam, and 2Hepato- p=0.025). They exhibited a trend of superior disease-free biliary and Pancreatic Surgery, 108 Central Military survival (47% vs 19%; p= 0.321). Superior survival Hospital, Viet Nam remained upon sub-group analysis of stage I (OS 90% vs Aim: To evaluate the value of intraoperative ultrasound and 67%; p=0.769, DFS 52% vs 29%; p=0.912) as well as stage early results of liver resection for hepatocellular carcinoma. II HCC (OS 88% vs 43%; p=0.045, DFS 40% Vs 8%; Materials and method: Uncontrolled study enrolled 30 p=0.421). patients underwent liver resection for hepatocellular carci- Conclusion: LLR may confer better survival in this well- noma with intraoperative ultrasound in Viet Duc university matched cohort. LLR should be advocated for good risk hospital and central military hospital 108. patients with HCC less than 5cm. Results: There were 26 male, and 4 female with average age of 49,4 11,2 (26-68 years old). The chronic HBV infection rate is 96,7%, AFP level more than 400 ng/ml EP01C-005 found in 36,7% of patients. Major hepatectomy rate was SURVIVAL OUTCOME OF OPERATED 30%, minor hepatectomy rate was 70%. Intraoperative ul- SPONTANEOUS RUPTURED trasound detected new tumors in 10% cases, and changed e the operative plans in 20% of cases. There was no mor- HEPATOCELLULAR CARCINOMA A tality, and 36,6% morbidities, in which, majority were PROPENSITY SCORE MATCHING pleural effusion. Median of hospital stay was 11 days. ANALYSIS Conclusion: Intraoperative ultrasound is simple and W. H. She, A. Chan, K. W. Ma, S. Tsang, W. C. Dai, feasible which help the surgeon detected new tumor in 10% K. Chok, K. Ng, T. T. Cheung and C. M. Lo of all cases and change the strategy of operation in 20% Surgery, University of Hong Kong, Hong Kong cases. Introduction: Patients presented with ruptured hepatocel- lular carcinoma (rHCC) were staged as T4 disease in 7th edition TNM staging. However, studies suggested contra- EP01C-008 dictory results including poorer outcome or non-inferiority IMPACT OF SURVEILLANCE ON overall survival in patients who were operated. This study SURVIVAL OF HEPATITIS B PATIENTS aimed to identify the outcome of patients presented with WITH RESECTABLE rHCC and compared with the current TMN staging. HEPATOCELLULAR CARCINOMA: A Methods: A retrospective review of patients with rHCC STUDY FROM CHINA who were able to undergo interval hepatectomy from 1989 to 2015 was performed. The perioeperative details, clinical Z. Li, H. Zhang, J. Han, H. Xing, H. Wu and T. Yang course, pathological data and survival outcome were stud- Second Military Medical University, China ied. Propensity score matching analysis was performed for Introduction: To assess the effectiveness of surveillance tumor size and number in 1:3 for those without ruptured. on postoperative survival of hepatitis B patients who un- The Kaplan-Meier method was used for survival analysis derwent curative resection for hepatocellular carcinoma and log-rank test was used for survival comparison. (HCC), based on a large cohort from China. Results: There were total 115 patients who had rHCC Methods: Data were retrospectively collected from patients underwent hepatectomy. 345 patients without tumor with hepatitis B virus (HBV) infection who underwent

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S403 curative resection for HCC from 2003 to 2012. We lobe is a safe and feasible technique providing promising reviewed the medical history of potential surveillance re- short-term outcomes and oncological results. cipients at least 2 years prior to HCC diagnosis and divided the cohort into two groups, patients who were diagnosed from surveillance and patients who had not received any EP01C-010 surveillance before their diagnosis of HCC. We determined LAPAROSCOPIC VS OPEN the significance of surveillance in postoperative outcomes, including recurrent rate, mortality, overall survival (OS) HEPATECTOMY FOR and relapse-free survival (RFS). Additionally, the inde- HEPATOCELLULAR CARCINOMA IN pendent predictive factors for better OS and RFS were PATIENTS WITH CIRRHOSIS: A META- identified. ANALYSIS OF THE LONG-TERM Results: A total of 948 patients with HBV-related HCC SURVIVAL OUTCOMES were enrolled, of which 357 (37.7%) had received 2-8 (median times: 4) surveillances 2 years prior to HCC E. L. Goh, S. Chidambaram and S. Ma diagnosis. Pre-diagnosis surveillance was associated with Imperial College London, United Kingdom 56.4% (HR 0.436, 95% CI 0.362-0.525) and 63.2% (HR Background: In patients with hepatocellular carcinoma 0.368, 95% CI 0.297-0.456) reductions in postoperative (HCC) and cirrhosis, laparoscopic hepatectomy (LH) con- recurrent rate and mortality after curative resection of HCC, fers short-term benefits over open hepatectomy (OH) but respectively. The median OS and RFS of patients with the long-term outcomes of this procedure are unclear. This surveillance prior of HCC diagnosis were longer than those meta-analysis aims to compare the long-term survival patients without surveillance (106.5 vs. 43.1 months, and outcomes of LH and OH in patients with HCC and un- 75.1 vs. 45.4 months, both P < 0.001). Multivariate Cox derlying cirrhosis. analysis identified surveillance as an independent protec- Methods: EMBASE, MEDLINE and Scopus databases tive factor of better OS and RFS. were searched from date of inception to 7th October 2016. Conclusions: Pre-diagnosis surveillance may predict better Controlled clinical studies comparing LH to OH for HCC survival for hepatitis B patients after curative resection of in cirrhotic patients, which reported long-term overall and HCC. disease-free survival were included. The studies were evaluated using the MOOSE guidelines and Newcastle- Ottawa Scale. Data were extracted and analysed using a fi EP01C-009 xed-effects model. Results: Five non-randomised, retrospective observational ROBOTIC-ASSISTED CAUDATE LOBE studies representing 888 patients were included. LH was LIVER RESECTION: INITIAL associated with significantly lower tumour recurrence [OR: OUTCOMES 0.65, 95% CI: 0.48, 0.89] and conferred greater overall M. V. Marino1, A. L. Komorowski2 and G. Shabat3 survival at 1- [HR: 0.41, 95% CI: 0.25, 0.68], 3- [HR: 0.63, 1Emergency and General Surgery, Azienda Ospedaliera 95% CI: 0.46, 0.87] and 5-years [HR: 0.60, 95% CI: 0.45, Villa Sofia-Cervello, Italy, 2Oncologic Surgery, Maria 0.80]. With LH, there was higher disease-free survival at 1- Skłodowska-Curie Memorial Institute of Oncology Cancer year [HR: 0.71, 95% CI: 0.53, 0.96], but not at 3- [HR: Centre, Poland, and 3Surgery, Brigham and Woman’s 0.89, 95% CI: 0.70, 1.14]; and 5-years [HR: 0.85, 95% CI: Hospital (BWH) Harvard Medical School, United States 0.70, 1.04]. Conclusions: Laparoscopic surgery is associated with Introduction: Firstly described in 2002, the robotic liver comparable postoperative and survival outcomes in pa- surgery has not spread widely due to its high cost and the tients with HCC and cirrhosis. With careful selection of lack of a standardized training program. Still being patients, this approach is safe, feasible and advantageous. considered as a "development in progress” technique, it has potential, however, to overcome the traditional limitations of the laparoscopic approach in liver interventions. EP01C-011 Methods: We analyzed the postoperative outcomes of 20 COMPARATIVE CLINICAL OUTCOMES patients who had underwent the robotic resection of OF LIVER RESECTION FOR caudate lobe from March 2015 to May 2017 in order to evaluate the advantages of robotic technique in hands of a HEPATOCELLULAR CARCINOMA young surgeon. WITH AND WITHOUT BILE DUCT Results: The mean operative time was 258 min (150-522) TUMOR THROMBUS: SINGLE CENTRE and the estimated blood loss 137 ml (50-359), in none of EXPERIENCE the cases a blood transfusion was required. No patient un- W. Lapisatepun, A. Leewatanakul, S. Junrungsee, derwent a conversion to open surgery; the overall morbidity T. Sundhu and A. Chotirosniramit was 2/20 (10%) and all the complications occurred (biliary Surgery, Chiang Mai University, Thailand fistula and pleural effusion) didn’t require a surgical revi- sion. At histological examination, the mean diameter tumor Introduction: Hepatocullular carcinoma(HCC) presenting size was 2,63 cm and we achieved a R0-resection rate of with obstructive juandice caused by bile duct tumor 100%. The reoperation and 90-day mortality rates were thrombus(BDTT) is an uncommon event. The role of both null. The 1-year overall and disease free-survival rates hepatectomy and clinical outcomes are remaining contro- were 100% and 80%, respectively. versy. The aim of this study was to evaluate clinical out- Conclusions: Despite several concerns regarding the cost- comes after hepatectomy for HCC with BDTT comparing effectiveness, the full robotic partial resection of caudate to non-BDTT.

HPB 2018, 20 (S2), S333eS504 S404 Electronic Posters (EP01A-EP01E) - Liver

Methods: 22 HCC patients with BDTT who underwent EP01C-012 hepatectomy were retrospective reviewed of shot and long- term outcomes comparing with 111 HCC patients without COMBINED LIVER AND INFERIOR BDTT. An impacted of BDTT to clinical outcome and VENA CAVA RESECTION WITH survival benefit after surgical resection was analyzed. RECONSTRUCTION USING ARTIFICIAL Results: HCC with BDTT group presenting with higher VASCULAR GRAFT FOR LIVER level of serum total bilirubin, alpha-fetoprotein and CA 19- TUMORS 9. Six HCC patients with BDTT (26.1%) received preop- 1,2 2 2 2,3 erative percutaneous transhepatic biliary drainage(PTBD). Y. Tomimaru , H. Eguchi , Y. Iwagami , H. Wada , K. Goto2, S. Kobayashi2, K. Dono1, Y. Doki2, All HCC with BDTT cases received major hepatectomy VS 2 2,4 32.4% in non-BDTT group. The HCC patients with BDTT M. Mori and H. Nagano 1Department of Gastroenterological Surgery, Toyonaka who underwent hepatectomy have longer operative time 2 (420 VS 217 minute), more blood loss (1,200 VS 500 ml) Municipal Hospital, Department of Gastroenterological and higher morbidity(53.5% VS 16.7%). The 1-, 3- and 5- Surgery, Graduate School of Medicine, Osaka University, 3Department of Gastroenterological Surgery, Osaka In- year survival rates of BDTT group were 85.7%, 71.4%, and 4 71.4%, respectively. These were slightly lower than non- ternational Cancer Institute, and Department of Gastro- BDTT group (97.3%, 82.9%, and 81.1%, respectively) but enterological, Breast and Endocrine Surgery, Yamaguchi no statistical significant (P-value = 0.208). BDTT was not University Graduate School of Medicine, Japan showed impact to survival and recurrence (P-value = 0.608, Introduction: In cases with liver tumors accompanied with 0.807). inferior IVC invasion, IVC resection is sometimes required

EP01C-011 Table [Univariate and multivariate analysis for survival] Prognostic factors No. of patients, n (%) Univariable analysis p-value Multivariable analysis p-value Crude HR (95%CI) Adjusted HR (95%CI) Bile duct tumor thrombus Yes 21 (15.9) 1.78 (0.72-4.40) 0.214 1.28 (0.50-3.29) 0.608 No 111 (84.1) 1.00 1.00 Largest tumor diameter (cm) 5 61 (46.2) 2.68 (1.20-5.97) 0.016 2.74 (1.21-6.18) 0.015 < 5 71 (53.8) 1.00 1.00 Margin positive 21 (15.9) 2.21 (0.93-5.22) 0.072 Margin negative 111 (84.1) 1.00

as a chance for cure with liver resection. Furthermore, IVC reconstruction with artificial vascular graft is also needed after the resection when area of defect after the IVC resection is large. There have been few reports of cases with IVC reconstruction using the graft. Methods: The study included 12 cases undergoing liver resection with IVC resection and subsequent reconstruction using artificial vascular graft. Surgical outcome of the cases were investigated. Results: The resected liver tumor was intrahepatic chol- angiocarcinoma in four cases, metastatic liver tumor from colorectal cancer in three, liver sarcoma in two, adrenal cancer in one, malignant lymphoma in one, and inflam- matory pseudotumor in one. IVC resection and recon- struction was performed under IVC clamp with remnant liver perfusion in six cases, and under THVE in six cases. Figure [Comparison for survival function of HCC patients] ePTFE graft was used for IVC patch in one case and for replacement of the entire circumference of IVC in 11 cases Median operative time was 650 min. (range; 360 to 1050 Conclusions: Bile duct obstruction from tumor thrombus min.) and blood loss was 2600 mL (range; 1196 to 8030 does not imply as an advanced disease. HCC with BDTT mL). Postoperative complication developed in two pa- patients can achieve favorable surgical outcomes and long tients; bleeding in one and bile leakage in the other one. term survival after liver resection when appropriate oper- There were no operative mortality cases. During post- ation is carefully selected. operative follow-up period, no complications associated with the graft were observed and the grafts remained patent in all the cases.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S405

Conclusion: These results suggested favorable outcome of conducted. Preoperative parameters were assessed and liver resection with IVC resection and reconstruction using analyzed for their predictive value of PHLF/I. Definitions artificial vascular graft. used included the 50-50, International Study Group of Liver Surgery (ISGLS) and Memorial Sloan Kettering Cancer Centre (MSKCC) criteria. EP01C-013 Results: 848 patients underwent liver resections for HCC RADIO-FREQUENCY ABLATION OR between 2001-2013, of which 157 underwent right hep- atectomy (RH) and extended right hepatectomy (ERH). RESECTION OF SMALL LIVER The prevalence of PHLF/I was 7%, 41% and 28% for the TUMOURS 50-50, ISGLS and MSKCC criteria, respectively. There M. Zarivchatskiy, I. Mugatarov, E. Kamenskikh and were no significant differences in PHLF/I between RH G. Bogatyreva and ERH. Model for End-Stage Liver Disease (MELD) Surgical Dept., E.A.Vagner Perm State Medical Univer- score and bilirubin were the strongest independent pre- sity, Russian Federation dictors for PHLF/I based on the 50-50 and ISGLS/ Introduction: Frequency of primary hepatic cancer makes MSKCC criteria, respectively. Predictive models were 3-5 persons per 100 000, metastatic cancer is 20-30 times developed for each criteria with multiple logistic higher. Metastatic lesions of the liver are diagnosed in 20- regression. 50% of patients during primary visit to a doctor. Opera- Conclusion: MELD score, bilirubin, alpha-fetoprotein and fi bility of hepatic cancer is not more than 15-20% that dic- platelet count had signi cant predictive value for PHLF/I < tates usage of radio-frequency ablation (RFA) in combined (all p 0.05). A composite score based on these factors can treatment. guide physicians to better select patients undergoing Methods: Two hundred thirty five patients with primary extensive resections to minimize PHLF. and metastatic tumours of the liver were treated from 2012 till 2017. The mean age was 63, 67, 1. Metastases of EP01C-015 colorectal cancer were diagnosed in 143 (60,8%) patients, ANATOMICAL RESECTION VERSUS hepatocellular carcinoma - in 30 (12,8%), cancer metasta- LIMITED NON-ANATOMICAL ses of the other organs - in 62 (26,4%). Size of liver foci RESECTION FOR SOLITARY varied from 1,5 to 6 sm. Atypical liver resections were HEPATOCELLULAR CARCINOMA performed to 86 patients, RFA was fulfilled to 149 patients. Size of tumours in RFA was not more than 5 sm. (HCC): A RETROSPECTIVE STUDY OF Chemotherapy was applied to all the patients. 1515 CASES Results: Postoperative complications after atypical re- C. Wang, B. H. Zhang, B. X. Zhang and X. P. Chen sections of the liver occurred in 5, 81% (n=5) cases: Hepatic Surgery Center, Department of Surgery, Tongji bleeding - in 2 (2, 33%), biloma - in 1 (1, 16%), Hospital, Huazhong University of Science and Technol- subdiaphragmatic abscess - in 1 (1, 16%), pleuritis - in 1 (1, ogy, China 16%) case. After RFA complications were observed in 4 (2, HCC is one of the most common primary malignancies fi 68%) cases: hematoma, biliary stula, subdiaphragmatic and surgical resection remains the only curative treatment. abscess, reactive pleuritis. Survival rate after atypical liver The optimal resection choice in patients with solitary HCC resections during 3-5 years was 44, 6% and 26, 8% is controversial with regards to underlying diseases, respectively, after RFA - 42, 4% and 22, 9%. remnant functional hepatic parenchyma and substantial Conclusion: Usage of atypical resections is rational for heterogeneity of HCC. The aim of this retrospective small subcapsular located tumours. For intraparenchymatous investigation was to determine whether anatomical resec- located tumours RFA is recommended. tion (AR) is superior to limited non-anatomical resection (NAR) for single HCC. From January 2013 to December 2015, 1515 EP01C-014 consecutive patients received solitary HCC resection POST-HEPATECTOMY LIVER FAILURE were selected from a database of 3835 cases. Among IN CIRRHOTIC PATIENTS them, 859 patients underwent anatomical resection (AR Group) and the other 656 cases had non-anatomical UNDERGOING EXTENSIVE LIVER resection (NAR Group). Basic characteristics, tumor RESECTIONS e AN ASIAN EXPERIENCE factors, intra- and post-operation characteristics, mor- S. Y. Lee1,2, K. M. Chin1, J. C. Allen2, J. Y. Teo1, tality, recurrence and metastasis patterns were compared J. H. Kam1,Y.X.Koh1, B. K. Goh1,2, P. C. Cheow1,2, between groups. A. Chung1,2 and C. Y. Chan1,2 There was no significant difference in basic characteris- 1Department of Hepatopancreatobiliary and Transplant tics, tumor locations, post-operative complication or mor- Surgery, Singapore General Hospital, and 2Duke-National tality between AR and NAR Group. AR Group presented University of Singapore (NUS) Medical School, Singapore longer surgery time (p< 0.001), while blood loss and Aim: To determine the prevalence of post-hepatectomy transfusion showed no difference. AR Group obtained liver failure/insufficiency (PHLF/I) in extensive hepatic optimal prognosis with total recurrence rate lower than that resections for hepatocellular carcinoma (HCC) and to in NAR Group (p< 0.001). NAR Group presented higher assess the predictive value of preoperative factors for post- rates of intrahepatic, resection margin and adjacent segment hepatectomy liver failure or insufficiency (PHLF/I). recurrences. However, AR Group showed higher distal Methods: A retrospective review of patients who under- segment recurrence, which might due to death caused by went liver resections for HCC between 2001-2013 was intrahepatic recurrence in NAR Group before distal

HPB 2018, 20 (S2), S333eS504 S406 Electronic Posters (EP01A-EP01E) - Liver recurrence happened. No statistical difference was observed hours after a successful enteroscopic procedure, the patient in lung or abdominal metastasis. developed severe abdominal pain and liver insufficiency Patients can clinically benefit from anatomical and major with elevation of ammonia, aminotransferases, bilirubin resection provided with well-preserved liver function. and CRP levels. Investigation revealed thrombosis of the Further prospective randomized controlled trials were right portal vein and liver necrosis. The patient underwent requested to determine this conclusion. right hepatectomy on Day 5 due to increasing toxemia and progressing cavity decay within the right lobe. The right hepatic duct was separated during resection in but the je- junal anastomosis to the left hepatic duct was preserved. Results: The status of the patient improved quickly and iver function became be normal. Necrolysis of the paren- chyma within the right liver lobe, thrombosis of the right portal vein and normal arterial inflow were found intra- operatively and confirmed by a pathologist. The diagnosis, course of clinical events and phases of treatment were carefully documented and constitute the essence of the presentation. Conclusions: Portal vein thrombosis is an unlikely but possible complication of enteroscopic dilatation of stenotic biliary anastomosis. The severity of toxemia in the patient may be partly explained by pre-existing cholangitis. The Figure [Inclusive criteria and exclusive criteria] decision to operate though hard to undertake in such cir- cumstances appeared to be justified.

EP01C-015 Table [Postoperative recurrence and metastasis] Non-anatomical Group (n[859) Anatomical Group (n[656) P value Lung metastasis, no. (%) 7 (0.81) 10 (1.52) .688 Abdominal metastasis, no. (%) 1 (0.12) 3 (0.46) .870 Intrahepatic recurrence, no. (%) 331 (38.53) 197 (30.03) <.001 Resection margin recurrence, no. (%) 169 (19.67) 52 (7.93) <.001 Adjacent segment recurrence, no. (%) 133 (15.48) 88 (13.41) .026 Distal segment recurrence, no. (%) 29 (3.38) 57 (8.69) <.001 Recurrence time, (months) 11.95±9.42 10.67±9.13 .287 Total, no. (%) 338 (39.35) 210 (32.01) <.001

EP01C-016 EP01C-017 RIGHT HEPATECTOMY DUE TO RIGHT PERIOPERATIVE OUTCOMES OF LIVER LOBE NECROSIS CAUSED BY LAPAROSCOPIC RERESECTION FOR THROMBOSIS OF RIGHT PORTAL VEIN RECURRENT HCC: COMPARISON AFTER HIGH-PRESSURE BALLOON WITH OPEN RERESECTION FOR ENTEROSCOPIC DILATATION OF RECURRENT HCC AND HEPATICO-JEJUNAL ANASTOMOSIS LAPAROSCOPIC RESECTION FOR 1 1 1  2 W. Otto , M. Skalski , W. Figiel , E. Wolinska and PRIMARY HCC K. Zieniewicz1 1General, Transplant & Liver Surgery, Medical University B. K. P. Goh, N. Syn, J. Y. Teo, S. Y. Lee, P. C. Cheow, of Warsaw, and 2Pathology, Medical University of P. Chow, L. Ooi, A. Chung and C. Y. Chan Warsaw, Poland Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore Introduction: Enteroscopic balloon dilatation of narrowed biliary-enteric anastomosis after repair of an iatrogenic bile Background: The role of laparoscopic repeat liver resec- duct injury is invaluable despite possible complications. tion (LRLR) for recurrent hepatocellular carcinoma (rHCC) Portal vein thrombosis with necrosis of the liver paren- remains controversial today. This study aims to determine fi chyma as a result of the procedure has never been reported, the safety and ef cacy of LRLR for rHCC. however. Methods: Twenty patients underwent LRLR for rHCC Methods: A 63-year-old-woman who was presented with between 2015 to 2017. The control groups consisted of 79 cholangitis due to stenosis of hepatico-jejunal anastomosis open RLR (ORLR) for rHCC and 185 LLR for primary that developed 15 years after the reconstruction. Three HCC. We undertook propensity-score adjusted analyses

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S407 and 1:1 propensity-score matching for the comparison of for cholangiocarcinoma is safe and effective, which is LRLR vs ORLR. Comparison of LRLR vs LLR was done helpful to accelerate the postoperative recovery of the using multivariable regression models with adjustment for patients. clinically-relevant covariates. Results: Twenty patients underwent LLR with 3 open conversions (15%). Both propensity score-adjusted and 1:1 EP01C-019 fi -matching demonstrated that LRLR was signi cantly DIFFERENT UPREGULATION OF associated with a longer operation time but shorter hospital stay compared to ORLR. Comparison between LRLR vs TENASCIN C EXPRESSION IN THE LLR demonstrated that patients undergoing LLR were REMNANT LIVER FOLLOWING significantly older, had smaller tumors, longer operation DIFFERENT VOLUMES OF time and decreased frequency of Pringle’s maneuver HEPATECTOMY applied. There was no difference in the other key periop- C. Li, L. Gao and X. Ge erative outcomes. Institute of Hepatobiliary Surgery, Chinese PLA General Conclusion: The results of this study demonstrate that in Hospital, China highly-selected patients, LRLR for rHCC is feasible and safe. LRLR is associated with a longer operation time but Introduction: Post-hepatectomy liver failure (PHLF) re- shorter hospitalization compared to ORLR. Moreover, mains the most feared postoperative complication in fi other than a longer operation time; LRLR was associated hepatobiliary surgery. Once PHLF occurs, it is dif cult to with similar perioperative outcomes compared to LLR for reverse; thus, more targets for either prevention or therapy primary HCC. are needed to reduce mortality after liver surgery. Methods: Rat models with 68%, 85% or 90% partial hepatectomy (68PH, 85PH and 90PH, respectively) were used in this study. Real-time RT-PCR, immunostaining and EP01C-018 ELISA were used to determine the gene expression. The EFFICACY ANALYSIS OF USING survival rate, liver regeneration and liver injury were also ENHANCED RECOVERY AFTER assessed. SURGERY IN PERIOPERATIVE PERIOD Results: The hepatic tenascin C (TNC) mRNA and serum OF RADICAL SURGERY FOR TNC levels were significantly upregulated after 68PH, CHOLANGIOCARCINOMA 85PH and 90PH compared with Sham rats, and there was a correlation between TNC upregulation and the volume of Y. Shao, T. Aji, B. Ran, T. Jiang and H. Wen resected liver. In particular, TNC expression in 90PH rats, The First Affiliated Hospital, Xinjiang Medical University, which can cause lethal liver failure, was much higher than China that in the 85PH and 68PH rats. The high expression of Objective: To investigate the safety and efficacy of using TNC in the 90PH group was related to liver hyperperfusion, enhanced recovery after surgery (ERAS) in perioperative more severe liver injury, and inhibited liver regeneration. In period of patients undergoing radical surgery for addition, we also found for the first time that treatment with cholangiocarcinoma. the endotoxin LPS tremendously enhanced hepatic TNC Methods: The clinical data of a total of 149 patients un- expression and serum levels in rats that underwent 85PH dergoing radical surgery for cholangiocarcinoma from and 90PH. April 2013 to April 2017 were collected. Of the patients, 73 Conclusions: It was found for the first time that hepatic cases received ERAS perioperative management (ERAS TNC expression and serum TNC levels were significantly group), and 76 cases received traditional perioperative upregulated after different volumes of hepatectomy and management (traditional group). The surgical procedures in were correlated with the volume of resected liver, and this either group included partial hepatectomy with chol- upregulation of TNC in the 90PH rats was possibly related edochojejunostomy, choledochojejunostomy and pancrea- to the occurrence of PHLF. ticoduodenectomy. The main clinical variables were compared between the two whole groups of patients or between subgroups of patients with same surgical EP01C-021 procedure. PARENCHYMA-PRESERVING Results: The preoperative general data showed no statis- tical difference either between the two whole groups of ANATOMICAL LIVER RESECTION patients or between subgroups of patients with same sur- USING 3D IMAGE ANALYSIS RESULTS gical procedure (all P>0.05). After surgery, the compari- IN LONG-TERM PRESERVATION OF sons either between the two whole groups of patients or LIVER FUNCTIONAL RESERVE AFTER between subgroups of patients with same surgical proced- SURGERY ure showed that the liver function parameters and/or re- O. Itano1, Y. Abe2, M. Shinoda2, M. Kitago2, H. Yagi2, covery parameters in ERAS group were more or less 2 1 1 1 fi < T. Wakabayashi , S. Imai , S. Fujii , M. Yoshida and signi cantly superior to those in traditional group (all P 2 fi Y. Kitagawa 0.05). No signi cant difference was noted in incidence of 1 complications between the two whole groups of patients or Department of Hepato-Biliary-Pancreatic & Gastroin- testinal Surgery, International University of Health and between subgroups of patients with same surgical proced- 2 ure (all P>0.05). Welfare School of Medicine, and Department of Surgery, Conclusion: Using ERAS in perioperative period in the Keio University, Japan perioperative period of patients undergoing radical surgery

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Introduction: Long-term recovery of liver function Conclusions: Long-term oncological outcomes were following surgery is important to improve the quality of comparable between LLR and OLR for selected patients. multimodal treatment. In this study, we showed the LLR was associated with multiple benefits, even in selected advantage of a parenchyma-sparing anatomical liver patients with cirrhosis who underwent major hepatectomy. resection (PSAR) that which resects only the minimum LLR for HCC performed by an experienced surgeon could area required corresponding Glisson’spediclesofthe be considered as a safe and feasible alternative to OLR in liver tumor. selected patients. Methods: We evaluated the outcomes of 52 PSAR cases and it was analyzed by 3D image analysis how much liver parenchyma was preserved compared to a conventional EP01C-024 anatomical resection (CAR) virtually performed in 3D LAPROSCOPIC LIVER RESECTION FOR image of the same cases. The overall and recurrence-free survivals of HCC cases after PSAR were compared to those HEPATOCELLULAR CARCINOMA: 5- after conventional liver resection by one-to-two propensity YEAR EXPERIENCE AT A SINGLE case-matched analysis. CENTER Results: All cases were performed laparoscopically. H. Choi1,2, J. -W. Choi1,2, D. H. Ryu1,2 and Y. Xu2 Median operative time was 362 minutes. Median blood loss 1Surgery, and 2Surgery, Chungbuk National University was 150mL. Pathological examination showed R0 re- College of Medicine, Republic of Korea sections in all cases. The average ratio of the remnant liver Background: Laparoscopic liver resection for hepatocel- to the total liver in PSAR cases was 18.6% more than that lular carcinoma(HCC) has become an increasingly popular with conventional anatomical resection. The OS and the operation, even in the presence of liver cirrhosis. Here we RFS of HCC cases after PSAR were not significantly evaluate the outcomes of laparoscopic liver resection for different from those after conventional liver resection. HCC at a single center. Conclusion: PSAR showed less resected liver parenchyma Methods: From November 2011 to August 2016, 24 pa- and comparable treatment results compared to CAR and tients with HCC underwent various laparoscopic liver safely performed laparoscopically. resection at a single institution. The operation was performed by one team of surgeons. The clinical data of these patients were retrospectively reviewed and analyzed EP01C-022 by reviewing the medical records, radiologic images and LONG-TERM AND PERIOPERATIVE pathologic reports. OUTCOME EVALUATION OF PURE Results: The mean age of the patients was 58 years(range LAPAROSCOPIC LIVER RESECTION 41-80 years) and 22 patients were men. The types of VERSUS OPEN LIVER RESECTION FOR resection were resection of one segment (7 cases), resection of two segments (9 cases), resection of three segments (2 HEPATOCELLULAR CARCINOMA cases) and four segments (6 cases). The mean tumor size K. -H. Kim, Y. -I. Yoon, D. -H. Jung, G. C. Park, was 3.4 cm (range 0.8-10 cm). The mean resection margin T. -Y. Ha, D. -B. Moon, G. -W. Song, C. S. Ahn and was 17.9mm (range 1-50 mm). The median follow-up S. -G. Lee duration was 29 months (range 4-45 months). The 3-year Asan Medical Center, University of Ulsan College of overall survival rates were 83.3%. Medicine, Republic of Korea Conclusion: Laparoscopic liver resection for HCC is Introduction: With the increase of laparoscopic ap- feasible, safe with good oncologic outcomes. Major liver proaches related to HCC, the oncological adequacy of resection is possible with improved surgeon’s skill and laparoscopic liver resection (LLR) compared with open experience. liver resection (OLR) has become an important topic of debate. This study aimed to compare the perioperative and long-term oncological outcomes of LLR with those of OLR EP01C-025 for hepatocellular carcinoma (HCC) using propensity score XRCC2 PROMOTES CANCER matching (PSM). PROGRESSION BY REGULATING P53/ Methods: We retrospectively reviewed medical records of patients with HCC who underwent liver resection between P21 SIGNALING PATHWAY IN July 2007 and April 2016 at our center. A total of 2335 HEPATOCELLULAR CARCINOMA patients were included in this study and divided into LLR E. Zhang, Z. Huang and X. Chen (n=264) and OLR (n=2071) groups. Tongji Medical College Huazhong University of Science Results: After 1:2 PSM , there were 217 and 434 patients in and Technology, China the LLR and OLR groups, respectively. The LLR group Introduction: X-ray repair cross-complementing gene 2 < had a shorter hospital stay (8.9 vs. 14.8 days, P 0.001) and (XRCC2) plays an important role in DNA damage repair. lower postoperative morbidity (6.5% vs. 12.0%, P=0.022). However, how the expression of XRCC2 was regulated in The 1-, 3-, and 5-year overall survival rates were 98.1%, the progression of hepatocellular carcinoma(HCC) remains 87.0%, and 78.6%, respectively, in the LLR group, and unknown. The aim of this study is to investigated the 98.3%, 90.8%, and 84.3%, respectively, in the OLR group expression of XRCC2 in HCC and to unravel the under- (P=0.570). The 1-, 3-, and 5-year disease-free survival rates lying mechanism of XRCC2 in HCC. were 81.0%, 62.0%, and 49.1%, respectively, in the LLR Methods: The expression of XRCC2 in tissues from HCC group, and 85.3%, 64.7%, and 56.2%, respectively, in the patients was analyzed using a microarray and real-time OLR group (P=0.563). PCR. The effects of XRCC2 on cell proliferation and

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S409 fl tumorigenesis in HCC cells were analyzed by ow EP01C-027 cytometry, colony formation assays and CCK8 assays. The correlation between XRCC2 expression and long-term ENHANCED RECOVERY AFTER outcomes after liver resection, as well as the potential SURGERY FOR HEPATECTOMY e A molecular mechanism of XRCC2 in regulating the prolif- SINGLE CENTRE’S ATTEMPT AT eration in HCC cells were also addressed. REDUCING HOSPITAL STAY Results: The expression of XRCC2 was higher in tumor M. Mohd Shukri1, A. Azman1, R. Jarmin1, H. A. Othman1, tissues and HCC cell lines compared to the adjacent liver Z. Zuhdi1, A. C. Arrifin2, I. S. Mohammad3 and C. Ian1 tissues and normal liver cell lines. The expression level of 1Surgery, University Kebangsaan Malaysia, 2Sugery, and XRCC2 has a reverse relationship with the long-term 3Surgery, University Sains Malaysia, Malaysia outcomes after liver resection. Down-regulating the expression of XRCC2 in HCC cell strains could inhibit Introduction: Enhanced recovery after surgery (ERAS), is the proliferation of HCC cells by inducing S-phase arrest a safe, reliable and cost effective method to shorten hospital and cell apoptosis in vitro and in vivo. Further study in- stay. This study was carried out to compare the outcomes of dicates that down-regulating the expression of XRCC2 open hepatectomy managed with ERAS vs conventional could induce the up-regulation of p53/p21 signaling care (CC). The primary objective was to observe whether pathway. the implementation of ERAS resulted in shorter post- Conclusion: This study provides novel insights into the operative hospital stay. role of XRCC2 in controlling HCC cell proliferation and Methods: A prospective observational study was carried tumorigenesis, and identifies XRCC2 as a potential prog- out comparing outcomes on patients who underwent open nostic marker and therapeutic target. hepatectomy from January 2010 to March 2017 in our institution. The ERAS protocol used has been validated to be safe and feasible for patients undergoing open hepa- tectomy. CC group were patients who underwent similar EP01C-026 matched operations prior to the implementation of the CLINICAL SCORING MODEL protocol. Subjects were further divided into minor resection DETERMINES SURGICAL MODALITY ( 2 segments) and major resection ( 3 contiguous seg- FOR SOLITARYA AND SMALL ments). . HEPATOCELLULAR CARCINOMA Results: A total of 34 patients for ERAS and 48 patients for CC group were recruited. Postoperative hospital stay for WITH CHILD-PUGH A LIVER ERAS was slightly shorter (5.6 days vs 6.4 days) p = 0.138 FUNCTION although not statistically significant. Compliance to target E. Zhang and Z. Huang discharge in the ERAS group was 43.8% (7 patients) and Tongji Medical College Huazhong University of Science 13.6% (3 patients) respectively. No difference in morbidity, and Technology, China mortality or readmission rates between the groups were Introduction: Previous study indicated that clinical observed. scoring model (CSM) could accurately predict the Conclusion: ERAS is safe and feasible for open hepatec- severity of cirrhosis. This study aimed to compare the tomy. It has the potential to reduce postoperative hospital therapeutic efficacy of liver resection (LR) and percu- stay and accelerate recovery. Although not statistically taneous microwave coagulation therapy(PMCT) for significant, we believe that with a larger sample size and solitary and small hepatocellular carcinoma (HCC) minor adjustments to the protocol, a more definitive result using CSM. would be achieved favouring the use of ERAS. Methods: In this study, 228 patients with single HCC 3cm and Child-Pugh A liver function were retrospectively reviewed. Among these patients, 131 patients underwent LR, EP01C-028 and 97 patients received PMCT. The short and long-term THE EFFECT OF DONOR RACE- outcomes were compared between the two procedures. MATCHING ON OVERALL SURVIVAL Results: There was no 90-days mortality in either group. Major complications were significantly more frequent in FOR AFRICAN AMERICAN PATIENTS the LR group compared to the PMCT group (18.8% vs UNDERGOING LIVER 4.6%, p=0.003). The 1-, 3-, and 5-year overall survival(OS) TRANSPLANTATION FOR rates for the LR group and PMCT group were 97.2%, HEPATOCELLULAR CARCINOMA 91.6%, 65.2% and 90.1%, 72.4%, 42%, respectively ( J. Silva, S. Tsai, K. Christians, C. Clarke, H. Mogal, p=0.006). The 1-, 3-, and 5-year disease-free survival K. Saeian and T. C. Gamblin (DFS) rates for the LR group and PMCT group were Surgery, Medical College of Wisconsin, United States 95.4%, 74.5%, 51.7% and 83.4%, 51.2%, 31.5%,respec- tively (p=0.004). Nevertheless, subgroup analyses sug- Introduction: Liver transplantation (LT) is the preferred gested that HCC patients with CSM score 4, PMCT may treatment for early hepatocellular carcinoma (HCC) in provide long-term outcomes that are similar to LR and select patients. Differences in outcomes following LT has lower complications. been previously described between recipient races, but the fi Conclusions: LR may provide better OS and DFS rates role of donor race is not well-de ned. This study sought to than PMCT for solitary HCC 3 cm and Child-Pugh A examine the effect of donor-recipient race-matching on liver function. PMCT should be optimal choice for HCC overall survival following liver transplantation for HCC in patients with CSM score 4. African Americans (AA).

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Methods: Adult AA patients with HCC undergoing liver vascular invasion (p=0.0002) for affecting the overall sur- transplantation were identified using the Organ Procure- vival of the ER group. ment and Transplantation Network database (1994-2015). Conclusion: Preoperative NLR more than 1.99 and Recipient and donor demographic and clinical character- elevated GPS and presence of lymphovascular invasion istics were collected. Patients were separated into unad- were independent risk factors for ER of single lesion HCC justed cohorts based on whether the liver donor was AA with HBV LC patients after curative resection. (matched) or another race (unmatched). The primary outcome was overall survival (OS), which was analyzed by log-rank test and graphed using Kaplan-Meier method. EP01C-030 Multivariate regression modeling was used to determine IMPACT OF THE LEARNING-CURVE adjusted hazard ratios (HR) for OS. Results: Of 1,384 AA patients identified, 325 (23.5%) WITH PARENCHYMA SPARING were race-matched. Matched patients experienced signifi- HEPATECTOMY FOR DEEP TUMORS: cantly better median overall survival compared to the un- TIME VS COMPLEXITY? matched cohort (135 vs. 78 months, p=0.007). Multivariate P. G. Vacca1, N. Roffi1, C. Gianfaldoni1, R. Balestri1, analysis revealed an adjusted hazard ratio of 0.66 for race- M. Puccini1, E. Rossi1, G. Licitra2, P. Colombatto3, matched transplantation (95% CI: 0.49-0.88; p=0.004). P. Buccianti1 and L. Urbani1 fi Matched patients also experienced improved ve-year 1General Surgery, 2Anestesiology, and 3Hepatology, survival (64.2% vs. 56.9%; p=0.019). Azienda Ospedaliero-Universitaria Pisana, Italy Conclusion: African American HCC patients undergoing Introduction: Parenchyma sparing hepatectomy (PSH) liver transplantation experienced significantly improved assures adequate future liver remnant (FLR) for deep overall survival when the donor race matched the recipient located tumors, however, PSH requires complex surgical race. Donor-recipient race-matching remained an inde- procedures with a learning curve that has never been pendent predictor of improved survival after adjusting for analysed. comorbidities and disease characteristics. Race-matching Methods: Data from 127 consecutive patients treated with should be considered in the process of organ allocation, as a PSH during the first 9 years of practice were registered in it may impact long-term survival in African Americans. a prospective database. Two patients with preoperative total > EP01C-029 bilirubin 5 mg/dl were excluded. The initial period (4y) of low (< 14/y) and the later period (5y) of high (>14/y) case VALIDATION OF RISK FACTORS volume were compared. AFFECTING THE EARLY Results: Low (n=24) and high (n=101) case volume groups RECURRENCE OF SINGLE LESION were comparable (P>0.05) for patient’s baseline charac- HEPATOCELLULAR CARCINOMA teristics, PSH requiring HV exposure/resection (92% vs WITH HBV RELATED LIVER 78%), PSH with vascular reconstruction (25% vs 25%), extrahepatic surgical procedures (25% vs 28%), median CIRRHOSIS PATIENTS AFTER blood loss (150 vs 150 ml), blood transfusion (37% vs CURATIVE RESECTION 27%), overall (50% vs 38%) and severe (8% vs 8%) post- W. -B. Kim, W. -J. Kim, T. -W. Im, S. -B. Choi and operative complications, and median length of stay (8.5 vs 9 P. -J. Park days). Overall 90-day mortality was 1.6%. In high volume Korea University Guro Hospital, Republic of Korea case period there was an increasing attitude in first/second Background: Early recurrence is associated with poor order glissonian pedicles exposure (33% vs 68%; P=0.001) prognosis after curative resection for hepatocellular carci- and the mean largest lesion size was greater (41 24 cm vs noma (HCC). This study was designed to validate the risk 55 37 cm, P=0.034). Furthermore the operative time was factors affecting the early recurrence of single lesion HCC shorter (714 316 min vs 595 242 min, P=0.048) and the with HBV related liver cirrhosis (LC) patients. resected liver surface per minute was larger (0.93 0.35 2 2 Methods: 132 cases of consecutive HCC patients were cm /min vs 1.44 0.69 cm /min, P=0.001). fi enrolled in our institution between Jan 2005 and Dec 2015. Conclusions: The learning curve had signi cant impact on We divided the cohort into two groups: early recurrence operative time and on liver-cut surface area per minute, in fi group(ER) which has recurrence within 12 months after spite of an increased attitude in rst/second order glissonian resection, and non-early recurrence group (NER). Survival pedicles exposure and increased lesion size. rate, univariate and multivariate analysis were performed to identify variables associated with early recurrence. Results: The selected cut-off values with sufficient sensi- EP01C-031 tivity and specificity were 1.99 for Neutrophil-to-Lympho- CONTINUOUS ADHERENCE TO cyte Ratio (NLR). When comparing the ER group with NER ESTABLISHED ENHANCED RECOVERY group, significant differences were observed in the level of PIVKA (p=0.007), NLR (p=0.001), GPS (p=0.001), PROGRAM IN PATIENTS UNDERGOING Edmonson-Steiner (ES) grading (p=0.002), tumor necrosis HEPATECTOMY AND (p=0.004) and lymphovascular invasion (LVI) (P=0.001). PANCREATECTOMY DOES NOT ER groups has statistically significant lower overall RESULT IN ADDITIONAL DECREASE survival rate than NER groups (p=0.000). OF HOSPITAL LENGTH OF STAY By multivariate analysis, there were significant differ- ences in NLR more than 1.99 (p=0.000), elevated Glasgow A. Cocieru Akron City Hospital, United States Prognostic Score (GPS) (p=0.004) and presence of lympho-

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Aim of study: ERAS protocols are reported to decrease a mean of 93.5%,with a median of 79%.The second pro- length of stay in patients undergoing routine HPB pro- cedure was performed after 7 days.The only postoperative cedures. We researched a possibility of progressive complication observed in one patient was an asymptomatic improvement in length of stay in patients undergoing he- right pleural effusion.There was no 90-day mortality. patic and pancreatic resections within established ERAS Conclusion: In this report, The ALPPS technique effec- protocol. tively increased the resectability of otherwise inoperable Methods: 99 consecutive patients undergoing pancreatic liver tumors.This is technically demanding and should be and hepatic resections at a single institution and managed undertaken only with proper training in high volume centres. by a similar ERAS protocol were divided in “early “(50 patients) and “late” (49 patients) groups. Both groups were statistically identical in demographics and range of pro- EP01C-034 fi cedures performed. Overall and procedure-speci c com- SEX DIFFERENCES IN EARLY AND plications, readmission and reoperation rates were analyzed. Categorical variables were statistically compared LATE RECURRENCE AFTER LIVER using Fisher exact test and continuous variables using t-test RESECTION OF HEPATOCELLULAR and Mann-Whitney U-test when appropriate. CARCINOMA: A MULTICENTER STUDY Results: There were 32 hepatectomies /18 pancreatec- FROM CHINA tomies in the “early” cohort and 22 hepatectomies/29 H. Zhang1*, J. Han2*, Z. L. Li2*, Y. H. Zhou3*, pancreatectomies in the “late” cohort. Overall complica- T. H. Chen4*, H. Wang5*,W.M.Gu6*, W. Y. Lau2,7*, tions rate was 38.8%, 30 days readmission and reoperation F. Shen2* and T. Yang2* rate of 16.1% and 5%. There was 1 mortality (1%). Group 1Department of Hepatobiliary Surgery, Eastern Hepato- -specific complication rate (40 vs 38.7%, p=0.8), read- biliary Surgery Hospital, 2Department of Hepatobiliary mission rate (0 vs 12.2%, p=0.4), reoperation rate (6% vs Surgery, Eastern Hepatobiliary Surgery Hospital, Second 4%, p=1.0) and mortality ( 2 vs 0%, p=1.0) were not sta- Military Medical University, China, 3Department of tistically significant between groups. There was no Hepatobiliary Surgery, Pu’er People’s Hospital, improvement in median length of stay (7 days) between the 4Department of General Surgery, Ziyang First People’s “early” and “late” group. Hospital, 5Department of General Surgery, Liuyang Peo- Conclusion: Continuous adherence to established ERAS ple’s Hospital, 6First Department of General Surgery, protocol does not result in additional decrease in length of Fourth Hospital of Harbin, and 7Faculty of Medicine, hospital stay in patients undergoing hepatectomy and Chinese University of Hong Kong, China pancreatectomy. Introduction: There is a striking sex difference in inci- dence of hepatocellular carcinoma (HCC), with a strong predominance for males. However, the impact of sex on the EP01C-033 incidence of recurrence after curative resection of HCC ALPPS PROCEDURE: A REPORT OF remains controversial. To assess sex differences in the risks THE FIRST THREE CASES FROM GCC of recurrence and mortality for patients undergone curative resection of HCC. COUNTRIES Methods: Data from 1,228 males and 207 females HCC I. Al Hasan, A. Algarni, H. Almodhaibiri and S. Alzulfah patients undergone curative resection between 2004 and Surgery, Prince Sultan Military Medical City, Saudi 2014 at five institutions in China were retrospectively Arabia analyzed. Patients’ baseline characteristics, operative vari- Background: Resection is the only curative treatment ables, and rates of early recurrence ( 2 years after resec- option for malignant liver tumors.Liver insufficiency is one tion), late recurrence (> 2 years) and cancer-specific of the most serious postoperative complications of patients mortality (CSM) were evaluated and compared. Multivar- undergoing extensive liver resections.A new strategy to iable competing-risks regression analyses were performed increase the resectability for patients with marginally to identify predictors associated with CSM, early and late resectable liver tumors previously considered to be unre- recurrence. sectable was reported by Baumgart et al. in 2011.This Results: The early recurrence rates between males and technique consists of a two-staged hepatectomy with initial females were similar (43.3% vs. 42.0%, P = 0.728), but the portal vein ligation and in situ splitting of the liver paren- late recurrence and CSM rates in males were higher when chyma, and it is known as ALPPS. compared to females (17.2% vs. 11.2%, P = 0.044; 42.8% Aim: To report our first series of patients with marginally vs. 34.3%, P = 0.022). Multivariable competing-risks resectable liver tumors previously considered to be unre- regression analyses revealed no sex difference in early sectable treated with ALPPS.All had a high tumor load recurrence; however, males had significantly higher late requiring staged hepatectomy after chemotherapy respon- recurrence rate [hazard ratio (HR), 1.752; 95% CI, 1.145- se,a predicted future liver remnant (FLR)< 30%,and good 2.682; P = 0.010] and CSM rate (HR, 1.307; 95% CI, performance status. 1.015-1.683; P = 0.038) than females. Results: The median age was 55 years with an average Conclusions: Males had significantly higher late recur- BMI of 31.6kg/m2.All patients were diagnosed with colo- rence and CSM rates after curative resection than females. rectal liver metastases.The ratio of FLR to TLV before the This suggests postoperative surveillance for HCC recur- first procedure ranged from 0.17 to 0.21.In all patients, a rence be varied by sex, especially for patients without rapid growth of the FLR was observed.Estimates of the recurrence at 2 years after resection. FRL volume prior to surgical treatment ranged from 276 to 377cc,with a mean of 343 cc.The FRL volume increase had All authors contributed equally to this work.

HPB 2018, 20 (S2), S333eS504 S412 Electronic Posters (EP01A-EP01E) - Liver

Conclusion: Surgical indication for advanced liver tumors was expanded with the spread of PTPE/TIPE. On the other hand, there are still post-operative complication in the case of right and left hepatic tri-segmentectomy or HPD, biliary tract reconstruction, pre-operative biliary drainage.

EP01C-036 LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA WITH TUMOR THROMBUS IN THE INFERIOR VENA CAVA AND RIGHT ATRIUM S. Mori, T. Aoki, T. Shimizu, K. Tani, K. H. Park, T. Matsumoto, T. Shiraki, Y. Iso, M. Kato and K. Kubota Department of Gastroenterological Surgery, Dokkyo Medical University, Japan Background: In patients with hepatocellular carcinoma (HCC) who have tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA), only liver resection (LR) can offer a possibility of minimizing the risk of sudden death and improving the chance of survival. However, LR Figure Cumulative incidence of early recurrence (2 years after requires a high level of surgical skill and careful surgical resection, A), late recurrence(>years after resection ,B) and cancer- planning. Here we show a video detailing our surgical approach for LR in HCC patients with TT in the IVC and specific mortality (CSM, C) from competing-risk model stratified by sex. RA, and the outcomes obtained. Methods: Eight patients who underwent LR for HCC with TT in the IVC and RA between 2000 and 2017 were retrospectively analyzed. EP01C-035 Results: Five patients were classified as Child-Pugh A, and ANALYSIS OF PTPE/TIPE FROM THE 3 as Child-Pugh B. Three patients had lung metastasis POINT OF VIEW OF SURGICAL before surgery. TT extending into the RA from the IVC was COMPLICATION observed in 4 patients. The median operation time and blood loss were 466 min and 2558 ml, respectively. K. Fukumitsu, T. Ishii, S. Seo, K. Taura, H. Okajima, Clavien-Dindo grade 0, II, and IIIa complications were T. Kaido and S. Uemoto observed in 2, 2, and 4 patients, respectively. There was no Kyoto University Hospital, Japan in-hospital mortality. The 1- and 2-year overall survival Introduction: Percutaneous trans-hepatic or trans-ileoce- (OS) rates were 50% and 18.8%, respectively, with the cal portal vein embolization (PTPE/TIPE) has been median survival time was 371 days. Univariate analysis performed widely. This study shows the analysis of PTPE/ revealed that AFP>1000 ng/ml and BMI< 20 kg/m2 were TIPE from the point of view of surgical complication. associated with poor OS (P = 0.022 and P = 0.032). Methods: 135 cases that were performed PTPE/TIPE to Conclusions: LR is useful for minimizing the risk of perform hepatectomy during past ten years, from June 2007 sudden death and short-term survival in HCC patients with to May 2017. Liver volume was measured using Computed TT in the IVC and RA. However, additional treatments will tomography data and liver function was measured using be needed for further improvement of survival. Tc-GSA. The post-operative complication was analyzed using Clavien-Dindo classification of surgical complication (CD). EP01C-037 Results: Among 135 cases, 27 cases were not performed ONCOLOGIC OUTCOME ANALYSIS OF hepatectomy (insufficient volume; 5 cases, tumor progres- TWO-STAGE HEPATECTOMY WITH sion; 22 cases) and 108 cases were performed. The growth PORTAL VEIN EMBOLIZATION rate of remnant liver volume was 1.270.27 times, and that of function was 1.530.50. By the comparison between VERSUS ASSOCIATING LIVER CD1-3 and CD4-5 cases, the volume of remnant liver was PARTITION AND PORTAL VEIN 41.38.8% vs 36.88.3% (P=0.04), the growth rate of LIGATION FOR PATIENTS WITH remnant liver volume was 1.320.22 vs 1.250.23 COLORECTAL LIVER METASTASES (P=0.24), and the growth rate of remnant liver function was J. Bednarsch1, T. F. Ulmer1, Z. Czigany1, I. Amygdalos1, 1.590.54 vs 1.400.36 (P=0.16). As for a surgical form, D. Morales Santana1, F. Meister1, J. Böcker1, the percentage of right or left hepatic tri-segmentectomy or C. H. C. Dejong2, U. P. Neumann1 and G. Lurje1 hepato-pancreatoduodenectomy (HPD) was 35.3% vs 1Department of Surgery and Transplantation, University 65.2%, and that of biliary reconstruction was 52.9% vs Hospital Aachen, and 2Department of Surgery, Maastricht 87.0%. As for the effect of pre-operative biliary drainage, University Medical Center (MUMC), Netherlands cases with CD4-5 with pre-operative biliary drainage was 30.4% and that without drainage was 11.5%. Background: In addition to the traditional two-staged hepatectomy (TSH) with portal vein embolization (PVE)

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S413 approach, associating liver partition and portal vein ligation (ALPPS) has been introduced as a novel and rapid TSH- EP01C-040 technique recently. Both procedures allow complete re- INITIAL EXPERIENCE WITH 72 sections in otherwise non-resectable disease. Little is known CONSECUTIVE ROBOTIC-ASSISTED about the oncological outcome of TSH/PVE versus ALPPS. Material and methods: Between 2011-2016, 52 patients LAPAROSCOPIC HEPATOBILIARY AND with colorectal liver metastases (CRLM) underwent TSH/ PANCREATIC SURGERIES AT PVE, whereas 21 patients with CRLM were treated with the SINGAPORE GENERAL HOSPITAL novel ALPPS procedure at our institution. Associations be- T. Kabir1,Y.X.Koh1, J. Y. Teo1, S. Y. Lee1, C. Y. Chan1, ’ tween oncological outcome and patients characteristics were P. Chow Ka Hoe2 and B. K. P. Goh1 assessed by univariate and multivariable survival analysis. 1Department of Hepatopancreatobiliary and Transplant Results: In 27% (14/52) of all patients undergoing TSH/ Surgery, Singapore General Hospital, and 2Division of PVE for CRLM, the second step was not completed due to Surgical Oncology, National Cancer Centre Singapore, fi an insuf cient future liver remnant (FLR). Out of these, 11 Singapore patients were treated with salvage ALPPS. Even though the Introduction: Presently, experience with robotic-assisted mean comprehensive complication index (CCI) was higher laparoscopic (RAL) hepatobiliary and pancreatic (HBP) in the ALPPS- (4125) compared to the TSH/PVE-cohort surgery is increasing but remains limited world-wide. In (2525; p=0.021), no significant differences in mortality this study, we report our early experience with robotic HBP were observed (TSH/PVE vs. ALPPS, 2/41 vs. 2/21 surgery. p=0.481). Both cohorts did not show a significant differ- Method: Retrospective review of the first 72 consecutive ence in median overall survival (OS) (TSH/PVE vs. patients who underwent RAL HBP surgery at a single ALPPS, 29 months vs. 33 months, p=0.507). institution between 2013 to 2017. Conclusion: Even though ALPPS was associated with an Results: The operations performed were: 30 pancreatic increased perioperative morbidity, CRLM-patients under- surgeries including 8 pancreatoduodenectomies, 4 going TSH/PVE versus ALPPS did not show significant extended pancreatectomies with adjacent organ/vascular differences in OS. As such, patient selection is of utmost resection and 10 spleen-saving pancreatectomies; 27 hep- clinical importance and salvage ALPPS may be a suitable atectomies including 9 major hepatectomies and 4 approach for TSH/PVE patients with insufficient inter- concomitant hilar lymphadenectomies; and 15 biliary pro- stage hypertrophy of the FLR. cedures including 5 hepaticojejunostomies. There were 2 EP01C-039 (2.8%) open conversions due to bleeding during hepatec- tomy and tumor extending to the celiac axis during LIVER RESECTION IN A NON- pancreatectomy. There were 8 (11.1%) major morbidities ACADEMIC CENTER IN PORTUGAL (>grade 2) and no 30-day/in-hospital mortality. The major J. Pereira, J. Constantino, M. Sá and C. Casimiro morbidities were all grade 3 including 2 reoperations (grade General Surgery, Centro Hospitalar Tondela-Viseu, 3b) for a port-site hernia and a hepaticojejunostomy leak. Portugal The median postoperative stay for RAL pancreatic surgery Introduction: Growth of medical knowledge has produced was 6.5 (range, 3-36) days and for RAL hepatectomy was 5 deep remodeling needs in the midst of Medical Specialties. In (range, 3-33) days. fi this context, several disciplines emerged within General Conclusions: Our initial experience con rms the feasibility Surgery that, not being subspecialties, have been practiced and safety of RAL HPB surgery even for complex procedures with increasing autonomy, particularly in larger hospitals. In such as pancreatoduodenectomies, extended pancreatec- 2010, a surgical Hepatic, Pancreatic and Biliary study group tomies, major hepatectomies and bilio-enteric anastomoses. was created in the General Surgery Department of the Au- thors’ Hospital and has been developing its activity including EP01C-041 liver resection. After eight years of surgical activity, the EARLY FUNCTIONAL RESPONSE Authors evaluate their results and compare them with the AFTER PORTAL VEIN EMBOLIZATION literature, particularly with those of high volume centers. e DIFFERENCE BETWEEN FUTURE Material and methods: The Authors analyzed the regis- LIVER REMNANT AND EMBOLIZED trations of their prospective database, including all patients undergoing elective liver resection between January 2010 LIVER RELATIVE ENHANCEMENT AS and December 2017. A MARKER OF IMPROVED Results: The overall morbidity rate was 21.5%, 60% of HEPATOCELLULAR RESERVE fi which related to hepato-speci c complications. The per- M. Duque1, H. Alexandrino1,2, H. Donato3, E. Santos2, centage of severe complications (Clavien Dindo-III and IV) L. Ferreira4, M. Serôdio2, P. Donato1,3, F. Castro e Sousa1, was 9%. Mortality was 2%. Five percent of patients required F. Caseiro Alves1,3 and J. G. Tralhão1,2 re-intervention. In the subgroup of patients with colorectal 1Faculty of Medicine, University of Coimbra, 2Department metastases, used for quality control of oncological care, the 1, of Surgery, 3Department of Radiology, Coimbra Univer- 3 and 5-year survival rates are respectively 92, 81 and 48%. sity Hospital, Portugal, and 4Department of Surgery, St. Conclusions: The results are similar to those published in Vincents University Hospital, Ireland the literature of high volume centers. More than the Introduction: Hepatic functional reserve (HFR) assess- volume, the quality of care is reflected by the way the pa- ment is crucial before major hepatectomy (mHep) partic- tient is evaluated, treated and followed. If appropriate re- ularly if portal vein embolization (PVE) is necessary, given sources and methodology are used, patients needing liver the significant risk of post-hepatectomy liver failure resection can be operated safely in non-academic centers.

HPB 2018, 20 (S2), S333eS504 S414 Electronic Posters (EP01A-EP01E) - Liver

(PHLF). Functional response of the Future Liver Remnant EP01C-042 (FLR) to PVE probably occurs prior to volumetric changes. SURGICAL RESECTION VERSUS Magnetic Resonance Imaging with hepatic-specific contrast (MRI-HSC) is a promising tool combining both RADIOFREQUENCY ABLATION FOR volumetric and signal intensity (SI) measurements, SINGLE HEPATOCELLULAR reflecting both liver anatomy and function. We intend to CARCINOMA LESS THAN 2 CM analyse the role of early MRI-HSC in the post-PVE C. -Y. Hsiao1, C. -M. Ho2, Y. -M. Wu2, M. -C. Ho2, assessment of HFR before mHep. R. -H. Hu2 and P. -H. Lee2 Methods: Nine patients undergoing mHep after PVE 1Department of Surgery, National Taiwan University (69.6 11 years; six men) were prospectively studied with Hospital Yun-Lin Branch, Taiwan, and 2Department of MRI-HSC before and 10 days after PVE. We retrospec- Surgery, National Taiwan University Hospital, Taiwan, tively selected eleven control patients who underwent Republic of China mHep after PVE studied only with volumetry (6312 Introduction: Surgical resection (SR) and radiofrequency years; six men). We measured FLR volume, degree of ablation (RFA) are treatment options for early-stage hepa- hypertrophy and kinetic growth rate (KGR) for both tocellular carcinoma (HCC). Whether tumor recurrence and groups. We also analysed embolized liver (EL) and FLR SI long-term survival favor either treatment has not been well- and relative enhancement (RE) before and after PVE. Sta- established. We aimed to compare the efficacy of both tistical significance with p< 0.05 (SPPS v21.0). treatments for single HCC less than 2 cm. Results: Volumetric-only parameters failed to correlate Methods: Between 2007 and 2015, a total of 401 patients with post-hepatectomy liver function and morbidity. (SR group, 241; RFA group, 160) with single HCC less After PVE, EL RE significantly dropped in patients who than 2 cm were retrospectively included in a tertiary care did not develop PHLF (p=0.026). In these patients, the center. The overall survival (OS) and recurrence-free sur- difference between FLR and EL RE significantly vival (RFS) were compared between groups. increased after PVE (p=0.012). Furthermore, FLR IS Results: Among 401 patients, the median time of follow-up significantly decreased after PVE in patients who was 19.5 months (IQR, 9.7 to 49.4 months). The overall developed PHLF (p=0.05). tumor recurrence rate was 15.6 versus 27.8 % respectively in the SR group and the RFA group. The 1-, 3-, 5- year OS rates were 100, 97.3, and 93.6 % respectively in the SR group, compared with 99.5, 87.7, and 72.9 % in the RFA group (P < 0.001). The 1-, 3-, 5- year RFS rates were 94.7, 85.4, and 79.7 % in the SR group, and 87.6, 62.0, and 44.9 % in the RFA group (P < 0.001). Conclusion: Surgical resection provides better OS and RFS compared with RFA for patients with single HCC less than 2 cm. Surgical resection is warranted as the first-line treatment in these patients.

EP01C-043 IMPACT OF PERFORMANCE STATUS ON RECURRENCE AND SURVIVAL AFTER LIVER RESECTION FOR PATIENTS WITH HEPATOCELLULAR CARCINOMA: A CHINESE MULTICENTER STUDY H. Wu1*, H. Xing1*, J. Han1*, Y. H. Zhou2*,W.M.Gu3*, J. H. Zhong4*, T. H. Chen5*, Y. Y. Zeng6*, F. Shen1* and T. Yang1* 1Department of Hepatobiliary Surgery, Eastern Hepato- biliary Surgery Hospital, Second Military Medical Uni- versity, 2Department of Hepatobiliary Surgery, Pu’er Figure 1 Early functional assessment after Portal Vein Embolization People’s Hospital, 3First Department of General Surgery, (PVE) with Magnetic Resonance Imaging with hepatic-specific contrast Fourth Hospital of Harbin, 4Department of Hepatobiliary (MRI-HSC). A. The difference between future liver remnant (FLR) and Surgery, Affiliated Tumor Hospital of Guangxi Medical embolized liver relative enhancement significantly increased after PVE University, 5Department of General Surgery, Ziyang First in patients who did not develop (PHLF) (P = 0.012). B. Illustrative image People’s Hospital, and 6Department of Hepatobiliary of the difference in relative enhancement between the FLR and Surgery, Mengchao Hepatobiliary Hospital, Fujian Med- embolized liver 10 days after right in a patient that had an uneventful ical University, China outcome after right hepatectomy. Introduction: According to the BCLC staging, advanced hepatocellular carcinoma (HCC) could be determined only Conclusion: Early changes in sectorial function assessed with MRI-HSC can be used to define response to PVE, predicting patients at risk of developing PHLF. All authors contributed equally to this work.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S415 if performance status (PS) is 1w2, which was not recom- Background: Hepatic resection combined with resection mended performing hepatectomy. In the real clinical and reconstruction of major vessels often represents the only practice, however, PS is not a key indicator of hepatectomy potential curative therapy for hepatic tumors with suspected for HCC. We aimed to investigate the impact of PS on vascular invasion. However, reconstruction demands com- recurrence and survival after HCC resection. plex hepatobiliary and vascular procedures. We aimed to Methods: Multicenter data of 1,531 Chinese patients un- review the results of combined liver and vascular resections. dergoing liver resection of HCC between 2005 and 2015 Methods: We performed a retrospective analysis of 17 were retrospectively analyzed. They were divided into PS patients who underwent combined liver and vascular 0 group and PS 1 group. Perioperative mortality and resection between 2005 and 2017 at the Medical University morbidity, overall survival (OS) and recurrence-free sur- of Innsbruck. vival (RFS) were compared, and multivariable Cox- Results: Resections were done for 13 primary and 4 met- regression analyses of OS and RFS were performed. astatic tumors and included 15 major and 2 minor hepa- Results: The perioperative mortality and major morbidity rates tectomies. Affected vessels were portal vein (n=10), ofPS0and1patientsweresimilar(P = 0.875 and 0.235, hepatic artery (n=3), infrahepatic vena cava (n=2), aorta respectively). The median OS and RFS of PS 1 patients were (n=1) and hepatic vein (n=1). A venous (41%) or arterial significantly poorer than PS 0 patients (both P < 0.001). (24%) end-to-end-anastomosis or an alloplastic, (29%) or Multivariable analyses revealed that PS 1 was independent risk xenologue (6%) reconstruction was performed. The median factors of OS (HR: 1.301, P < 0.001) and RFS (HR: 1.420, P = age was 60 (SD:10.9). There was no 90d-mortality, 90d- 0.007). In the subgroup analysis, the OS and RFS of PS 1 morbidity was 67%. Complications included postoperative patients without vascular invasion (VI)/extrahepatic metastasis bile leak (29%), liver failure, multi-organ-failure, post- (ES) were significantly better than PS 1 patients with VI/ES. operative bleeding (all: 6%) and 6 re-operations (35%). Conclusions: Liver resection of HCC for PS 1 patients was With a median follow-up of 18 months, median survival as safe as for PS 0 patients. Although PS 1 was an inde- time was 13 months (range 4 - 102). The 1- and 3-year pendent risk factor of recurrence and survival, the prog- overall survival rates were 100% and 60%, respectively. nosis after liver resection was still acceptable, especially Tumor recurrence occurred in 10 patients with a 1-year when without VI/ES. disease-free survival rate of 77%. Conclusions: Aggressive surgical management of liver tumors offers the only chance for cure. Liver resection combined with vascular resection is a feasible procedure that can be performed with higher but acceptable morbidity leading to long-term outcome in selected patients when surgery is carried out in a specialized hepatobiliary center.

EP01C-045 METABOLIC PROFILING OF FATAL LIVER FAILURE AFTER HEPATECTOMY: VALUE OF EXTEMPORANEOUS HR-MAS- NMRMETABOLOMICS F. Faitot1,2, S. Battini2, R. Elisa2, P. Addeo3, P. Bachellier3 and I. -J. Namer2,4 1Department of Hepatopancreatic and Endocrine Surgery Figure 1 Overall survival curves (A) and recurrence-free survival curves and Liver Transplantation, Hopitaux Universitaires de 2 of the performance status (PS) 0 and PS 1 groups in the entire cohort. Strasbourg, Icube Laboratory, Université de Strasbourg, 3 4 Overall survival curves (C) and recurrence-free survival curves (D) of the Hopitaux Universitaires de Strasbourg, and Department PS 1 patients without vascular invasion (VI) nor extraheptic metastasis of Nuclear Medicine, Hopitaux Universitaires de Stras- (ES) and PS 1 patients with VI or ES (all p < 0.001 by log-rank test). bourg, France Introduction: The goal of the study was to evaluate real-time metabolomics as a tool to predict posthepatectomy liver fail- ure (PHLF) and identify potential early metabolic biomarkers. EP01C-044 Liver metabolism has been scarcely evaluated as a tool to predict liver failure after hepatectomy. The main limitation is MAJOR VASCULAR RESECTION AND represented by techniques used for global metabolism esti- RECONSTRUCTION COMBINED WITH mation that are not compatible with clinical time. LIVER RESECTION FOR PRIMARY AND Methods: End-hepatectomy liver biopsies (n=56) and METASTATIC HEPATIC TUMORS cirrhotic liver biospies (n=36) were analyzed using high- resolution magic-angle spinning nuclear magnetic resonance E. Braunwarth, V. Kröpfl, F. Primavesi, B. Cardini, spectroscopy (Brucker Advance III spectrometer). The R. Oberhuber, M. Maglione, C. Margreiter, metabolic profiles were compared between patients dying S. Schneeberger, D. Öfner and S. Stättner from PHLF and patients surviving hepatectomy at high risk Department for Visceral, Transplantation- and Thoracic of PHLF using PLS-DA. Metabolites significantly associ- Surgery, Medical University Innsbruck, Austria ated to fatal liver failure (FLF) were identified through

HPB 2018, 20 (S2), S333eS504 S416 Electronic Posters (EP01A-EP01E) - Liver network analysis and compared to metabolites predicting EP01C-047 ACLF in an independent cohort of cirrhotic patients. Results: Metabolic profiling could be achieved in 30 mi- LONG-TERM SURVIVAL AFTER nutes. It predicted FLF with an excellent accuracy HEPATIC RESECTION FOR LIVER (Q2=0.516) with a sensibility of 100%. Intrahepatic con- METASTASIS FROM BILIARY TRACT / tent in neoglucogenic amino acids (alanine, isoleucine, PANCREATIC CANCER glutamine and valine; p< 0.05) was significantly higher in T. Niguma, T. Kojima, N. Watanabe, T. Sakata, patients experiencing FLF as well as low glycer- K. Suemori and T. Mimura ophosphocholine (AUROC=0.856; IC95% 0.738-0.974) Surgery, Okayama Saiseikai General Hospital, Japan and high choline/glycerophosphocholine ratio (p=0.011). The metabolic changes identified in this population were Background: The resection of the liver metastasis from different from those observed in ACLF patients. The biliary tract / pancreatic cancer has almost been given up, changes are consistent with Warburg effect that is because of supposedly being a poor prognosis. observed in multicellular proliferating systems. Method: Between May 1990 and May 2017, 64 biliary Conclusion: HR-MAS-NMR metabolomics is a powerful tract / pancreatic cancer patients underwent hepatic tool to predict liver failure after hepatectomy and is clini- resection with the intention of being cured. 21 had intra- cally relevant given its real-time application. The identified hepatic cholangiocarcinoma (ICC), 9 had extra-hepatic metabolic derangements could lead to evaluate metabolic cholangiocarcinoma (ECC), 12 had gallbladder carci- intervention to prevent liver failure. noma (GBC), 3 had ampullary carcinoma (APC), and 19 had pancreatic carcinoma (PAC). Results: The confirmed long-term survivors (60 months after hepatic resection) were 9. 3 ICC, 2 ECC, GBC, and EP01C-046 APC patients respectively. None of PAC patients survived THE ANALYSIS OF PREDICTIVE long-term. Interestingly, out of the 3 APC patients, 2 were FACTORS OF MORBIDITY AFTER long-term survivors without recurrence (69, 111 months), HEPATECTOMY IN ELDERLY and the rest died without recurrence for 20 months. There PATIENTS are 2 relatively long-term survivors (30months) of PAC, who were high responders to chemotherapy. We divided T. Kato, M. Inagaki, K. Kitada, N. Tokunaga, them into two groups, a biliary tract group (BG; including Y. Tsunemitsu and H. Iwagaki ICC, ECC, GBC APC) and a pancreatic group (PG). The Gastroenterological Surgery, National Hospital Organi- mean survival time of BG was 19.6 months and PG was zation Fukuyama Medical Center, Japan 12.3 months (p=0.017). In the PG, univariate analysis Introduction: It is controversial whether hepatectomy can revealed that variable predictors of better prognosis were be indicated safety for aged patients. In this study, we the size ( 3 cm) of a tumor, number of tumors ( 3) and analyzed risk factors of morbidity and the prognosis metachronous recurrence. Multivariate analysis revealed focusing on the age. that number is the predictor. (p=0.012). Methods: We reviewed hepatectomy patients who were Conclusions: Hepatic resection in the selected BG patients, over 75 years old and had a diagnosis of hepatic or gall- especially APC patients may improve survival. For PAC bladder tumor at our institution between 2010 and 2017. patients, hepatic resection should not be recommended We retrospectively evaluated the morbidity according to except for high responders to chemotherapy. Clavien-Dindo classification (more than IIIa) and the prognosis. Factors were compared between 75-79 years old patients (Group I) and over 80 years old patients EP01C-048 (Group II). Results: 83 patients were enrolled. Forty patients (48%) THE LEARNING CURVE OF were classified in Group II. Female cases were higher and LAPAROSCOPIC LIVER RESECTION: the preoperative platelet and albumin level were lower in SMOOTH AND IDEALIZED WITH Group II. Meanwhile, there were no significant difference CONTINUOUS IMPROVEMENT OR with performance status, the number of comorbidities, TRUE? surgical procedure, blood loss, operating time, hospitali- 1 1 1  2 zation and the proportion of delirium. The complications A. Ivanecz , B. Krebs , B. Ilijevec , A. Stozer and 1 with over grade IIIa were found in 10 cases. Age, origins S. Potrc 1Department of Abdominal and General Surgery, Univer- of hepatobiliary tumors, surgical procedure, operating 2 time and blood loss were risk factors of morbidities in sity Medical Center Maribor, and Institute of Physiology, univariate analysis. Moreover, the age was the only in- Faculty of Medicine, University of Maribor, Slovenia dependent risk factor in multivariate analysis (odds ratio: Introduction: The aim of this study was to evaluate the 7.76, 95% CI=1.27-47.1, P=0.026). Mortality was 2.4%. learning curve of LLR in a tertiary referral center. Both cases were over 80 years old. No significant corre- Method: The first 90 patients undergoing pure LLRs be- lation was detected between overall survivals of two tween 2008 and 2017 were analyzed. LLR were divided groups. into 3 consecutive groups of 30 patients each (groups 1, 2 Conclusion: The factor of elder age affected the morbidity and 3) to compare their characteristics. of hepatectomy. The prognosis of aged patients was equal Results: Of 624, 90 (14%) patients underwent LLR. Pro- with younger patients. Appropriate careful perioperative portion of LLR progressively increased (5%, 12% and care should be demanded in over 80 years old patients. 27%). Conversion to open surgery was required in eleven patients (conversion rate, 12.2%). The overall major

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S417 morbidity rate (Clavien-Dindo 3) was 7% (7/90), and Conclusion: This study clarified conversion in laparo- there was no 90-day postoperative mortality. The 60% (54/ scopic hepatectomy did not influence RFS and OS of pa- 90) of the resected tumors were malignant and the R0 tients with hepatocellular carcinoma. resection rate were 96% (52/54). Comparing groups, results fi ˃ of LLR signi cantly improved in terms of operating 1 EP01C-050 tumor (6.6%, 30.0%, and 23.3%, P = 0.04) larger in diameter (24, 45 and 38 mm, P = ˂ 0.05) in difficult, LOCAL ONCOLOGICAL RESULTS OF posterosuperior locations (3.3%, 23.3%, and 23.3%, P = LAPAROSCOPIC LIVER SURGERY 0.02) and performing a major hepatectomy (0%, 16.6%, G. Beldi1, M. Dosch2, J. Gerber2, A. Lachenmayer1 and 13.3%, P = 0.05). However, results significantly changed in D. Candinas1 terms of major blood loss ˃500 mL (0%, 23.3%, 13.3%, P = 1Universitätsklinik für Viszerale Chirurgie und Medizin, 0.02), consequently laparoscopic pedicle clamping was Inselspital Bern, and 2Department for BioMedical more used over time (0%, 36.6%, 26.6%, P = ˂ 0.05) and for Research (DBMR), Group of Visceral Surgery, University longer durations (0, 45, and 60 minutes, P = ˂ 0.05). of Bern, Switzerland Conclusions: The true learning curve for LLR is more Background: Laparoscopic liver resection has been shown appropriately described as alternating periods of improvement to be technically feasible and is associated with excellent and regression. Surgeons should understand the increased risk short term outcomes. Oncological safety and efficiency, they assume by taking on more complex procedures. however, needs to be ensured. Methods: Monocentric review of 208 patients that underwent a total of 217 laparoscopic liver surgeries since 2012 was EP01C-049 performed. In order to assess efficiency of oncological local CONVERSION IN LAPAROSCOPIC control by laparoscopic resection 37 patients converted to open HEPATECTOMY DOES NOT INFLUENCE surgery and patients who underwent surgery for benign dis- RECURRENCE-FREE AND OVER - ALL ease and non-resectional therapies such as microwave ablation were excluded. A total of 45 patients with hepatocellular car- SURVIVALS OF PATIENTS WITH cinoma (HCC), 44 patients with colorectal metastasis (CRLM) HEPATOCELLULAR CARCINOMA and 15 patients with other malignancies were analysed. X. Long, Q. Cheng, S. Xiang, Y. Pei, J. Zhao, P. Zhu, Results: A total of 148 tumors were resected in 104 pa- B. Zhang, W. Zhang and X. Chen tients including 15 major segment-oriented or formal hep- Hepatic Surgery Center, Tongji Hospital, Tongji Medical atectomies. Median operative time was 112 min (range 43- College, Huazhong University of Science and Technology, 360) and median length of stay was 4 days (range 1-18). China Length of stay was 26% shorter when compared with the Introduction: Although risk factors and surgical conse- Swiss average as assessed by the representative DRG. quences of conversion in laparoscopic hepatectomy have been Local recurrence at the site of resection was observed in 3 reported, the impact of conversion on oncologic outcomes (7%) patients with HCC, 1 (2%) patient with CRLM and 2 remains unclear. This study aims to further identify inde- (13%) patients with other malignancies after a median pendent predictive factors of conversion and investigate the follow-up of 446 days (range 0-1956). In this population, impact of conversion on overall survival (OS) and recurrence- the incidence of hepatic or extrahepatic tumor progression free survival (RFS) of patients with hepatocellular carcinoma was observed in HCC in 25 (56%) , in CRLM 14 (32%) and (HCC) in laparoscopic hepatectomy. other malignancies in 6 (40%) patients up to now. Methods: 107 patients with HCC, 21 (19.6%) of who Conclusion: In a selected population, laparoscopic liver underwent conversion, received laparoscopic hepatectomy resection allows high rates of local tumor control. between 2011 and 2014. Independent predictive factors for conversion were determined with univariable and multi- EP01C-052 variable regression analyses. OS and RFS between con- version group and non-conversion group were compared OUTCOMES OF SIMULTANEOUS AND using Kaplan-Meier curves with log rank test and Cox- STAGED RESECTION FOR regression analysis. SYNCHRONOUS COLORECTAL LIVER Results: The reasons for conversion were bleeding, inad- METASTASES (CLM) equate surgical margin and unsatisfied vision, accounting Y. Liu1, H. L. R. Chen2, R. Radhakrishnan1, for 42.9% (9), 33.3% (7) and 23.8% (5) respectively. S. Sumarli2 and J. Y. Teo2 Multivariable regression analyses revealed, compared to 1Yong Loo Lin School of Medicine, National University of non-conversion group, patients receiving conversion were Singapore, and 2Department of Hepato-Pancreato-Biliary associated with inadequate surgical margin (19.0% versus and Transplant Surgery, Singapore General Hospital, 1.2%, P=0.047), increased use of Pringle maneuver (33.3% Singapore versus 12.8%, P=0.026), longer operation time (258.9 42.7 minutes versus 220.468.6 minutes, P=0.021) and Introduction: Although hepatic resection is the only hospital stay after surgery (12.03.1 days versus 9.83.9 curative treatment for patients with CLM, the surgical days, P=0.043). No significant difference of 1, 3, 5-OS and treatment for synchronous liver metastases remains 1, 3, 5-RFS were found between conversion group and non- controversial. This study aims to compare the outcomes conversion group. After Cox-regression analysis, conver- between patients who underwent simultaneous and staged sion was not associated with increased risks of OS (HR: colectomy and hepatectomy. 1.379, 95% CI: 0.373-5.097, P=0.630) and RFS (HR: Method: From January 2001 to December 2013, all pa- 0.533, 95%CI: 0.187-1.521, P=0.240) in the whole cohort. tients who had surgery for synchronous CLM at Singapore

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General Hospital were analyzed retrospectively. Patients Methods: From January 2015- June 2017, 12 patients were with extrahepatic metastases were excluded. included. 7 patients were females and 5 patients wre Results: 112 patients underwent surgery for synchronous male.The cause of NCPH— EHPVO-9, NCPF- 3. The in- CLM; 96 (85.7%) and 16 (14.3%) patients underwent dications of surgery were portal hypertension in 9 patients, staged and simultaneous resections respectively. growth retardation in 2 and abdominal discomfort due to Total median operative time for simultaneous is 280 huge splenomegaly in 1 patient. (95% CI 75 - 400) minutes, longer than 197.5 (95% CI 75 - Results: All 12 patients had undergone proximal sple- 480) minutes for staged resection (p = 0.0072). Median norenal shunt (PSRS).2 patients had shunt thrombosis with blood loss was 250mL (95% CI 0 - 2500) in staged development of oesophageal varices for which medical resection, higher than 25mL (0 to 1500) in simultaneous management and endoscopic variceal ligation were carried (p = 0.056). Median length of stay was 14 (95 % CI 5 - 74) out with continuation of anticoagulat therapy.1 patient died and 12 (95% CI 7 - 29) days for staged and simultaneous of myocardial infarction 6 months following surgery. resections respectively (p = 0.115). Conclusion: Surgery in NCPH is reserved for patients with Complication rates were similar between both groups: 15 portal hypertension related complicationswho fail medical of 96 patients (15.6%) from staged resection experienced and endoscopic treatment.Results after shunt surgery de- 17 complications vs. 6 of 16 (37.5%) from simultaneous pends on the specific disease(EHPVO showing the best resection experienced 6 complications (p = 0.076). No long term patency), preoperative liver function status and mortality was observed. post operative patency of the shunts. There were no statistical differences in overall and recurrence free survival between both groups. Conclusions: Simultaneous resection results in similar EP01C-054 perioperative and oncological outcomes compared to INTRAOPERATIVE ICG TEST staged resection and is an acceptable alternative for patients with resectable synchronous CLM. PREDICTS POSTOPERATIVE COMPLICATIONS IN PATIENTS Table 1[Complications] UNDERGOING A STAGED HEPATIC Outcomes Staged Simultaneous p-value RESECTION (n[96) (n[16) K. Horisberger1, F. Roessler1,2, D. Raptis1, C. Oberkofler1, Complications, n C. Tschuor1, P. Sanchez Velazquez1, H. Petrowsky1 and Yes 15 6 0.076 P. -A. Clavien1 No 81 10 1University Hospital Zurich, and 2Cantonal Hospital Wound Infections 1 2 ns Baden, Switzerland Pulmonary 4 0 Introduction: Sufficient function of the future liver remnant Cardiac 3 1 ns is requisite to avoid post-hepatectomy liver failure (PHLF). Different diagnostic tools help to estimate the volume and Hepatic Abscess/ 22 ns Fluid function. However, a tool to evaluate reliably the functional capacity of future liver remnant (FLR) is missing. Hepatic Failure/ 30 Insufficiency Methods: Between September 2015 and May 2017, all consecutive patients undergoing staged hepatectomies Others 4 1 ns received MRI or CT-scans to assess sFLR; 99mTc-Iodida scan was performed to assess the functional capacity. Pre- and intraoperative Indocyaningreen tests (ICGTest) were EP01C-053 performed to compare the different tests and with the ROLE OF SURGICAL SHUNTS IN NON outcome. Postoperative complications were graded and CIRRHOTIC PORTAL HYPERTENSION calculated according to Clavien-Dindo and Comprehensive Complication Index (CCI). IN THE ERA OF ADVANCE GASTRO- Results: 15 patients were included, median age 57. 9 pa- INTESTINAL ENDOSCOPY tients hat major complications ( grade III); median CCI D. Bora was 22.6. One patient died postoperatively. Gastro-Intestinal and Hepato-Biliary Surgery, Apollo Median preoperative R15 was 5 [IQR 2.2 - 8.8]. No sig- Hospital, India nificant correlation was found between sFLR, 99mTc-Iodida 99m Introduction: Non cirrhotic portal hypertension (NCPH ) scan and R15. Preoperative R15, Tc-Iodida scan and sFLR is a heterogenous group of vascular diseases that lead to did not correlate to CCI. Intraoperative R15 was median 11.4 portal hypertension with normal or mildly elevated Hepatic [IQR 5.3 - 17]; it correlated to end-of hospitalization CCI venous pressure gradient and preserved liver synthetic (p=0.05) and to 90 day CCI (p=0.0036). ROC curve analysis function.It is a common cause of portal hypertension in revealed that a cutoff value of 11.4 for intraoperative R15 was children (upto 70%)and young adults in India and other able to identify postoperative major complications. developing countries. Morbidity is mainly related to vari- Discussion: Intraoperative ICGtesting allows real-time ceal bleeding, hypersplenism, growth retardation and portal monitoring of the functional capacity of future remnant fl biliopathy.The main disease producing NCPH are EHPVO liver by clamping of arterial and porto-venous in ow of and NCPF.The main indication for surgery in NCPH is the part to be resected. We herewith propose a cutoff of prevention of variceal bleeding, growth retardation, portal intraoperative ICG that will be validated in a larger biliopathy, symptomatic hypersplenism and abdominal cohort. It could help to prevent disastrous postoperative discomfort due to massive splenomegaly. consequences.

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EP01C-055 (NELM). However, high recurrence rate has been reported from the Western centers, and cure has been rarely LAPAROSCOPIC REPEAT LIVER achieved. In Asian countries, the tumor biology and patient RESECTION AFTER OPEN LIVER demographics are widely different from those in the RESECTION IS SAFE AND FEASIBLE Western series, and little has not documented in terms of COMPARED WITH LAPAROSCOPIC the surgical outcomes for NELM. PRIMARY LIVER RESECTION: A Methods: This was a retrospective, multicenter, cohort study. The clinical data of initial hepatic resections for COMPARATIVE STUDY FROM A NELM were retrospectively collected. The variables SINGLE CENTER examined included patient characteristics, tumor factors, T. Wakabayashi1, Y. Abe1, O. Itano2, M. Shinoda1, operative outcomes, and postoperative recurrence and M. Kitago1, H. Yagi1, G. Oshima1, T. Minagawa3 and survival. Y. Kitagawa1 Results: Thirty affiliations registered 222 cases. The primary 1Surgery, Keio University School of Medicine, 2Hepato- tumor site was pancreas in 130 cases (59%), rectum in 28, Biliary-Pancreatic and Gastrointestinal Surgery, Interna- duodenum in 19, and ileum in 10. The NELM was syn- tional University of Health and Welfare School of Medi- chronous in 140 cases (63%) and metachronous in 82, and cine, and 3Shizuoka Cancer Center, Japan hepatic resection was performed concomitant with the Background: Technological innovations and accumu- resection of the primary tumor in 94 cases (42.3%). The lating experience have made it possible to use laparoscopic hepatectomy procedure was limited resection in 115 cases liver resection cases with re-existing adhesions or cicatri- (51.8%), lobectomy in 51 (23.0%) and segmentectomy in 33 cial changes. This study aimed to clarify the outcomes of (14.9%). Major complications occurred in 28 cases (13%) laparoscopic repeat liver resection (LRLR) among cases of including 2 operative deaths. R0 resection was achieved in recurrent liver cancer after open liver resection. 63.1%, but tumor recurrence was found in 83.4% after R0/1 Methods: There were 157 patients who underwent lapa- resections. The median recurrence-free and overall survival roscopic liver resection for liver tumors at our institution period was 14 and 113 months, respectively. during September 2012-September 2016. Sixty-two pa- Conclusions: This survey confirmed acceptable safety of tients were included in analysis and were retrospectively concomitant resection of the primary site and NELM. divided into an LRLR group (n = 13) and a laparoscopic Recurrence was frequent after hepatic resections, as re- primary liver resection group (LPLR; n = 49), and the ported from the Western series, and therefore, effective groups were compared in term of patient demographics, adjuvant treatment strategies are urgently needed. surgical procedures, and short-term surgical outcomes. Recurrence-free survival and overall survival were compared for patients with hepatocellular carcinoma and EP01C-057 with colorectal liver metastases. QUANTIFICATION OF THE fi Results: There was a signi cant inter-group difference in PERMISSIBLE LIVER RESECTION the hepatitis virus background (p= 0.036), but other patient demographics were comparable between the two groups. RATE USING A NEW The two groups had similar values for extent of resection, POSTHEPATECTOMY LIVER FAILURE operative time, estimated blood loss, transfusion require- PREDICTION SCORE ment, conversion to laparotomy, postoperative complica- N. Honmyo, T. Kobayashi, S. Kuroda, K. Ide, M. Ohira, tions, surgical margins, time to oral intake, and hospital H. Tahara, S. Shimizu, M. Hamaoka, S. Okimoto and stay. Furthermore, there were no inter-group differences in H. Ohdan recurrence-free or overall survival in the LRLR and LPLR Department of Gastroenterological and Transplant Sur- groups when we compared patients with hepatocellular gery, Hiroshima University Hospital, Japan carcinoma and patients with colorectal liver metastases. Introduction: A novel strategy for hepatectomy is required Conclusion: The LRLR and LPLR groups had equivalent since advances in image simulation systems, such as CT short-term outcomes. Furthermore, LRLR does not volumetry, have allowed quantitative assessment of liver compromise oncological outcomes compared to LPLR. volume. We present a prediction scoring system for post- hepatectomy liver failure (PHLF). Methods: A total of 232 patients who underwent hepa- EP01C-056 tectomy between 2013 and 2016 were enrolled. We retro- SURGICAL OUTCOMES FOR spectively analyzed each characteristic data multiplied with NEUROENDOCRINE LIVER resection or remnant liver rate as risk factors for severe, METASTASES: A RETROSPECTIVE, grade-B or -C, PHLF. We constructed a new PHLF pre- diction score from 154 cases by 2015, and investigated its MULTICENTER SURVEY IN JAPAN utility using validation cohort of 78 patients in 2016. 1,2 2 2 2 2 T. Aoki , N. Kokudo , J. Arita , T. Masui , A. Kudo , Results: Severe PHLF occurred in 21/154 patients 2 2 2 2 I. Komoto , T. Ito , R. Y. Osamura , M. Unno and (13.6%). The results of univariate and multivariate analyses 2 S. Uemoto identified three independent risk factors: ICGR-15 (%) 1 Second Department of Surgery, Dokkyo Medical Uni- resection rate 3.11, Platelet (103/ml) remnant rate 2 versity, and The Japan Neuroendocrine Tumor Society 130.3, and PT (%) remnant rate 70.62 (P< 0.05). We (JNETS), Japan decided cut-off values for each factor (3.0, 130, and 70.0, Background and aim: Surgical resection has been the respectively) and constructed Volume-associated ICG- treatment of choice for neuroendocrine liver metastases Platelet-PT score (VIPP score: 0-3), the sum of above

HPB 2018, 20 (S2), S333eS504 S420 Electronic Posters (EP01A-EP01E) - Liver conditions after each is converted to one point. The inci- Introduction: Liver resection represents a curative option dence of severe PHLF in patients with VIPP score of 0, 1, 2, in diffuse liver metastatic disease. ALPPS (Associating and 3 was 0.0% (0/27), 1.8% (1/56), 16.7% (8/48), and Liver Partition and Portal Vein Ligation for Staged Hepa- 52.2% (12/23), respectively. The AUROC curve of VIPP tectomy) is possible when the estimated future liver rema- score for severe PHLF was 0.871. In the validation cohort, nent (FLR) is 25-30% in a healthy liver. This technique is the usefulness of VIPP score was confirmed (the AUROC associated up to 12% mortality and a 53 to 85% morbidity. curve=0.809). Method: We reviewed 13 patients with irresectable colo- Conclusion: VIPP score can predict critical PHLF. We rectal liver mestastases who underwent ALPPS between propose that this score is useful for procedure selection by 2012 and 2017. First ALPPS stage included metastases quantitatively calculating the permissible liver resection rate. resection in FLR, ligation of corresponding portal branch and liver partition. A CT-Volumetry was performed to assess the new FLR/TLV relation. Second ALPPS stage EP01C-058 included completion of hepatectomy. DUODENAL HEM-O-LOK CLIP Results: Serious morbidity (Clavien 4-5) happened in 15.4% patients and 30-day postoperative mortality was MIGRATION AFTER LAPAROSCOPIC 7.7%. Overall survival at 6 months was 61.54% and 50% at CHOLECYSTECTOMY 50 months. After first stage, prothrombin activity (PA), M. Barabino, M. Giovenzana, E. Andreatta, M. Polizzi, albumin and bilirubin levels were not related to hospital R. Santambrogio and E. Opocher stay, morbidity or mortality, whilst creatinine levels at 72h HPB Surgery, San Paolo Hospital, Italy were associated with early complications in postoperative Introduction: Post-cholecystectomy clip migration (PCCM) period. After second stage, FLR below 35%, bilirubin is a rare late complication, with only 13 cases of clips found levels and PA at 72h were associated with liver failure in duodenum, of whom 2 attributable to Hem-o-Lok. incidence and creatinine levels at 24 and 72h were asso- Methods: We present the case of a 77 years old male, ciated with early mortality. admitted with a history of epigastric pain and vomiting over Conclusion: ALPPS provides best oncological outcomes the previous 3 days. Medical history included a laparo- to those patients with unresectable colorectal liver metas- scopic cholecystectomy performed for chronic cholecystitis tases. ALPPS technique was associated with lower three months earlier. A CT scan showed a suspect of a morbidity and mortality than described in bibliography. covered perforation of peptic ulcer close to a surgical clip, Creatinine levels are a predictor of mortality. FLR below thus inducing mild abdominal symptoms but inflammatory 35%, bilirubin levels and PA at 72h are associated with high occlusion. After failure of conservative treatment liver failure. (PPI), patient underwent an esophagogastroduodenoscopy that confirmed a duodenal ulcer with an outcropping hem- o-lok, thus a Roux-en-y gastro-jejune anastomosis (GJA) was performed, with regular post- operative course and discharge on POD 4. Results: Etiology of PCCM is an open issue. Three inconclusive and feeble randomized trials and few case reports ruled out the central role of different methods of cystic duct stump (CDS) closure. PCCM mainly based on the following points: anatomic proximity of the CDS to the duodenum, an underlying inflammatory course, and a pre- existing ulcer. The clinical onset is really variable, ranging between 3 days to 15 years. Conservative treatment (PPI and/or endoscopic removal) is effective in 80% of cases, while gastrectomy or GJA are rarely performed. Conclusions: The central issue is not the method of CDS closing but the proper way to do it (circumferential dissection of the duct). Use of Hem-o-Lok is justified by its Figure [ALPPS: Overall Survival] efficacy despite the rarity of migration. EP01C-060 EP01C-059 OUTCOMES FOLLOWING ALPPS FOR IRRESECTABLE IMPLEMENTATION OF AN ENHANCED COLORECTAL LIVER METASTASES: RECOVERY PROGRAMME IN LIVER OUTCOMES AFTER FIVE-YEAR SURGERY: 6-YEAR EXPERIENCE EXPERIENCE E. Martinou, R. Kumar, A. Riga, C. Jones, T. Worthington and N. Karanjia M. T. González-Nicolas Trébol, S. J. Genzor Rios, Hepatobiliary Surgery, Royal Surrey County Hospital, A. Perez Zapata, E. Laviano Martínez, C. Vallejo Bernad, United Kingdom M. Serradilla Martín and A. Serrablo Requejo Introduction: In our unit an enhanced recovery after liver Cirugía General y del Aparato Digestivo, Hospital surgery (ERAS) protocol was successfully implemented in Universitario Miguel Servet, Spain

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2011. The purpose of this study was to evaluate the effects increased significantly (P=< 0.0001). The count of the and present post-operative outcomes after liver surgery in systemic leukocyte (8.2 0.9 (x109/l)) and after (10.9 1.4 the age of ERAS. (x109/l)) the surgery also increased significantly (p=0.0002). Methods: Patients who underwent liver resection from Conclusions: The leukocytes in the micro- and macro- 2011 until 2015 were identified. Major liver surgery was circulation both increased. Monitoring the microcirculatory defined as the resection of 3 Couinaud’s segments. Major rolling leukocytes directly at the bedside can potentially morbidity was defined as the percentage of Clavien-Dindo assess the inflammatory status of the surgical patient. grade III/IV post-operative complications. Analyse-it v4.92.4 software was used for statistical analysis. Values EP01C-063 are presented as median(IQR). IS SURGICAL RESECTION JUSTIFIED Results: Liver resection was performed in 490 patients FOR HEPATOCELLULAR CARCINOMA with age of 64.4(17.2) years old and ASA status 2(0). Minor to major surgery ratio was 1:1. Estimated blood loss, WITH PORTAL VEIN TUMOR operating time, ITU and hospital stay were significantly THROMBUS? A SYSTEMATIC REVIEW higher in the major surgery group, (p< 0.0001). Overall AND META-ANALYSIS length of stay (LoS) was 5(3) days. In the first half of the L. Liang1, T. H. Chen2,C.Li1, H. Xing1, J. Han1, study, LoS was significantly higher than the second half M. D. Wang1, H. Zhang1, W. Y. Lau1,3, F. Shen1 and [6(2) vs 5(3), p< 0.0001]. Major morbidity was 7.1% and T. Yang1 in-hospital mortality was 0.6%. Subgroup analysis ac- 1Department of Hepatobiliary Surgery, Eastern Hepato- cording to age showed no difference in major complica- biliary Surgery Hospital, Second Military Medical Uni- tions and mortality, whereas minor morbidity was versity, 2Department of General Surgery, Ziyang First significantly higher in the elderly patients (>70 years old), People’s Hospital, and 3Faculty of Medicine, Chinese (1% vs 22%, p=0.018). Uni and multivariate analysis University of Hong Kong, China showed that advanced age was associated with increased Introduction: The prognosis of hepatocellular carcinoma < LoS (rs=0.325, 95%CI: 0.224-0.419, p 0.0001). (HCC) with portal vein tumor thrombus (PVTT) stays very Conclusions: ERAS following liver surgery is feasible, safe poor. According to the BCLC treatment recommendations, and effective in high volume liver centers. Further optimisa- sorafenib or other palliative treatment (PT) is recommended tion of the ERAS protocols is suggested especially regarding as the first-line therapy when HCC occurs with PVTT. In the elderly population and reducing minor morbidity. real world, however, a significant number of selected pa- tients with HCC and PVTT are treated with surgical EP01C-062 resection (SR). THE ROLLING LEUKOCYTES IN THE Methods: PubMed, Embase, Medline and Cochrane library SUBLINGUAL MICROCIRCULATION were used to search the studies comparing SR with PT DURING MAJOR LIVER RESECTION: A (including TACE, sorafenib, etc.) for HCC with PVTT, NEW POTENTIAL PARAMETER FOR which were published before September 2017. THE MONITORING OF THE Results: 4,810 patients from 7 studies were enrolled in this meta-analysis, which were divided into the SR group (n = INFLAMMATORY STATUS? 2,344) and the PT group (n = 2476). When compared with Z. Uz1, C. Ince2 and T. M. van Gulik1 the PT group, the pooled hazard ratio (HR) for the 1, 3 and 1Surgery, and 2Translational Physiology, Academic Med- 5-year OS rates of the SR group were 0.56 (95% CI 0.52- ical Center, The Netherlands 0.60, P = 0.03), 0.56 (95% CI 0.53-0.59, P < 0.001) and Introduction: Systemic inflammatory response is a 0.55 (95% CI 0.54-0.57, P < 0.001). For subgroup anal- complication that occurs frequently in major liver resection ysis, when compared with the mere TACE group, the patients. The surgical trauma and ischemia reperfusion pooled HR for the 1, 3 and 5-year OS rates of the SR group injury due to the Pringle manoeuvre are the most important were 0.54 (95% CI 0.43-0.67, P = 0.81), 0.75 (95% CI factors for triggering the inflammatory system. Aim of this 0.65-0.87, P = 0.25) and 0.76 (95% CI 0.67-0.88, P = 0.25). study is to show the activation of the leukocytes in the Conclusion: This meta-analysis demonstrated SR had better microcirculation during surgery in order to introduce a new OS than TACE or other palliative therapy for HCC with potential parameter; the rolling leukocytes. PVTT. SR may be suitable as the first-line treatment for Methods: In this prospective observational study videos of selected patients with resectable HCC and removable PVTT. the sublingual microcirculation were recorded using Cytocam, a handheld microscope which uses incident dark- field imaging technique. Two time points are measured, the EP01C-064 baseline (T0) after induction of anesthesia, and the second CHARACTERISTIC AND OUTCOME OF time point (T1) at the end of the surgery. 14 patients were DOUBLE EXTRA-LARGE (XXL) recruited, 12 are included, after undergoing evaluation using quality criteria in order to identify at least one post HEPATOCELLULAR CARCINOMA IN capillary venule (PCV) where focus is primarily important. CIPTO MANGUNKUSUMO HOSPITAL Three clips for each time point with duration of 4 seconds T. Lalisang1,2, W. Jeo1,2, Y. Mazni1,2 and A. N. Lalisang1,2 (25 frames/sec) in different spots are captured. Identifying a 1Digestive Surgery Division, Department of Surgery, PCV to count the activated leukocytes: sticking and rolling Universitas Indonesia, and 2Cipto Mangunkusumo Hos- leukocytes in the wall of the PCV. pital, Indonesia Results: The count of the activated leukocytes from Introduction: Liver resection remains the main curative T0 (6.2 1.7 (L/PCV/4s)) to T1 (15.6 0.9 (L/PCV/4s)) therapy for hepatocellular carcinoma (HCC). However,

HPB 2018, 20 (S2), S333eS504 S422 Electronic Posters (EP01A-EP01E) - Liver several guidelines interdict surgery for tumor >5cm 231 [IQR 190 - 301] min. for open cases (p=0.668). Median despite its resectability or operability, probably due to lack blood loss was 200 [IQR 100 - 400] mL versus 300 [IQR of published series regarding HCC with large size nodule. 125 - 750] mL, respectively (p=0.212). In the robotic group Here, the prevalence and management of double extra-large one patient (3%) had a major complication, versus three HCC (larger than 15 cm) are reported. patients (10%) in the open group (p=0.612). Readmissions Methods: We performed a descriptive retrospective study were similar, 10% in the robotic group versus 6% in the on patients treated in Cipto Mangunkusumo Hospital from open group (p=1.000). There was no mortality in either 2010 until 2017. group. Results: There were 70 cases of HCC, 51 (72.9%) of them Conclusion: Minor robotic liver resections of the poster- are male and the mean age is 51.3 years. The cases are osuperior segments are safe, feasible and display a shorter classified into four categories: length of stay than open resections in selected patients at (1) Double Extra-large (diameter >15 cm), expert centers. (2) Extra-large (diameter 10-15 cm), (3) Large (diameter 5-< 10 cm), and (4) Small (diameter < 5 cm). EP01C-066 There were 22.9%, 14.3%, 25.7% and 37.2% cases in PRESURGICAL FUNCTIONAL LIVER each group, consecutively. Range of diameter was 3 to 25 cm, mostly singular and located on the left liver. CAPACITIY ASSESSMENT BEFORE Hepatitis B was detected on 90% cases and 9 cases of MAJOR LIVER RESECTIONS: A non-B and C. Mean blood lost was 2000 ml. Overall COMPARISON OF 99MTC- operative mortality was 18,6%. Each category’s mortality MEBROFENIN HEPATOBILIARY was 5.7% (XXL), 10% (XL and L each). The XXL oper- SCINTIGRAPHY AND LIMAX TO ative mortality were 23.1% compared to 76.9% in the XL and L HCC. Prolonged ascites, pneumonia and relaparot- PREDICT POSTHEPATECTOMY LIVER omies occurred as operative morbidity. Range of length of FAILURE stay was 14 to 44 days. A. Jud Conclusion: Double Extra-Large HCC were common and University of Freiburg, Department of General- and not contraindicated for resection. Visceralsurgery, Germany Introduction: Posthepatectomy liver failure (PHLF) is a severe problem after major liver resections and is linked EP01C-065 with higher morbidity and mortality. Our goal must be to ROBOTIC VERSUS OPEN MINOR LIVER implement a presurgical routine to measure the current liver RESECTIONS OF THE function and to calculate future remnant liver function for further individual therapeutic decisions. POSTEROSUPERIOR SEGMENTS: A This study investigates postoperative outcome by MULTINATIONAL, PROPENSITY comparing 99mTc-mebrofenin hepatobiliary scintigraphy SCORE MATCHED STUDY and maximum liver function capacity test (LIMAx). C. Nota1, Y. Woo2, M. Raoof2, T. Boerner3, Methods: We performed a full presurgical liver ca- I. Borel Rinkes4, G. H. Choi5, P. Kingham3, Q. Molenaar4, pacity assessment in 13 patients before major liver re- Y. Fong2 and J. Hagendoorn4 sections because of hepatobiliary malignancies. We 1Surgery, University Medical Center Utrecht, The compared the results of the hepatobiliary scintigraphy Netherlands, 2City of Hope, 3Memorial Sloan Kettering to the LIMAx-Test to detect posthepatectomy liver Cancer Center, United States, 4University Medical Center failure (50-50 criteria, peak-bili 7, ISGLS-criteria) and fi Utrecht, The Netherlands, and 5Yonsei University College postoperative complications (Dindo-Clavien Classi ca- of Medicine, Republic of Korea tion, CCI). Results: 9 patients showed critical levels in the 99mTc- Introduction: Minor liver resections of posterosuperior mebrofenin hepatobiliary scintigraphy (< 2.7 %/min/ segments (1, 4A, 7, 8) are challenging to perform lapa- m2) and 4 patients in the LiMAx-Test (< 100 mg/h/kg). roscopically and are mainly done open. We determine the PHLF appeared in 3 patients according to the ISGLS- feasibility of robotic resections of posterosuperior segments criteria (1 ISGLS-A, 2 ISGLS-B). In total 4 patients met and compare short-term outcomes with the open approach. the requirements of the Peak-Bili-7 criteria including Methods: Data on open and robotic minor ( 3 segments) the above-mentioned 3 patients. Two of the 4 patients liver resections including the posterosuperior segments, were not recognized as critical by preoperative func- performed between 2009-2016, were collected retrospec- tional liver assessment, neither by scintigraphy nor by tively from four hospitals. Robotic and open liver re- LiMAx. The Evaluation of postoperative complications sections were compared, before and after propensity score based on the Dindo-Clavien Classification (IIIb or matching. higher) occurred in 3 patients. The 90-day mortality was Results: In total, 51 robotic resections were included and 0%. 145 open resections. After matching, 31 robotic resections Conclusion: Both methods, 99mTc-mebrofenin scintig- were compared to 31 open resections. Median hospital stay raphy and LiMAx, can be used to improve the prediction of was 4 [IQR 3-7] days for the robotic group, versus 8 [IQR 6 posthepatectomy liver failure. For better accuracy and - 10] days for the open group (p< 0.001). Median operative reliability further investigations are necessary. time was 222 [IQR 164 - 505] min. for robotic cases versus

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EP01C-067 protocol included periodical assessments of cysts by ul- trasound as per WHO-IWGE classification. Surgical can- ROBOTIC LEFT-SIDE HEPATECTOMY: didates are also evaluated with CT-scan. Data were INITIAL EXPERIENCE OF 12 CASES analyzed by multivariate analysis. G. Park and J. H. Lee Results: Twenty-three patients had active cysts (8%), 147 Division of Hepatobiliary and Pancreatic Surgery, had transitional cysts (51,2%), while 117 had inactive cysts Department of Surgery, Asan Medical Center, University (40,8%). Overall, 46 patients had surgery (16%). Signifi- of Ulsan College of Medicine, Republic of Korea cant factors were the onset of clinical symptoms (p< 0.01) Introduction: Robotic hepatectomy has been suggested as and imaging demonstrating compression of major liver fi a safe and effective management of liver disease including structures (vascular or biliary) or evidence of biliary stula < malignancy. In current study, we report our initial experi- (p 0.01). Our post-surgical complication rate was of 30% ence with robotic left side hepatectomy. Clavien grade I-II and 15% Clavien III-IV. Mortality rate Methods: A retrospective review of a prospective database was 0%. Radical surgery (total pericystectomy n=17; liver fi of 24 consecutive patients who underwent robotic hepa- resection n=13) was performed as the rst choice (65,2%), tectomy at a single institution by single surgeon was con- leaving conservative procedures (subtotal pericystectomy ducted. Twelve consecutive patients who underwent n=13; drainage only n=3) to cases where the anatomical robotic left-side hepatectomy from June 2016 to January situation was deemed too risky (34,8%). 2018, were identified and we analyzed their perioperative Conclusions: While most of our patients can avoid surgical outcomes. treatment thanks to a careful assessment and a strict follow- Results: The disease included 4 hepatocellular carcinoma up program, a number is likely to develop complications. (HCC), 4 metastatic cancer to liver, 1 combined HCC and Surgery is a reasonable radical option in such cases and can cholangiocarcinoma(CCC), 2 intrahepatic CCC and 1 be performed safely. intraductal papillary neoplasm of the bile duct (IPNB). The procedure included 6 left hemi-hepatectomies and 5 left lateral sectionectomies (two including single site incision). EP01C-069 The median tumor size was 32.5 (range, 12-81) millimeters CLINICAL IMPACT OF except 1 IPNB case and all patients had tumor free resec- STANDARDIZATION OF OPEN tion margin. The median totally operative time (skin to HEPATECTOMY PROCEDURE skin) of all patients was 206 (range, 105-295) minutes and each median totally operative time of left hemi-hepatec- A. Takahashi and the department of general surgery tomy and left lateral sectionectomy was 263 and 165 mi- Juntendo University Nerima Hospital, Japan nutes, respectively. The median postoperative hospital stay Introduction: The aim of this study was to assess the was 6 (range, 5-10) days. None of patients had transfusion. clinical impact of standardization in open hepatectomy There is no open conversion and also no any postoperative from surgical outcomes viewpoints. in hospital complications and mortalities. Methods: Since October 2015, we standardized the Conclusion: Our initial experience confirms the feasibility techniques of procedure in open hepatectomy. Liver and safety of robotic left side hepatectomy. transection was performed in all patients by the traditional Péan clamp-crushing methods. After dividing paren- chyma, the remaining large vessels were ligated and EP01C-068 divided with scissors, and small vessels were divided CYSTIC ECHINOCOCCOSIS OF THE using Liga-Sure. We conducted a retrospective analysis of 134 patients who underwent open hepatectomy. Of the LIVER: WHEN IS SURGERY AN 134 patients, 38 after standardization were assigned to INDICATION? group A and remaining 96 patients before standardization G. Lionetto1, T. Manciulli1,2, G. Costantini1,3, E. Monti1, were assigned to group B. The two groups were compared A. Broglia1,3, A. Peloso4, S. Zonta3, T. Dominioni3, with respect to the backgrounds, operative results, and E. Brunetti1,2 and M. Maestri1,3 morbidity. In the present study, we defined postoperative 1Department of Surgical - Clinical, Diagnostics and complication worse than grade 1by Clavien-Dindo clas- Paediatric Sciences, University of Pavia, 2Tropical and sification, as major complication. Infectious Disease Unit, 3General Surgery, IRCCS San Results: No in-hospital death occurred in this study. Major Matteo Pavia, Italy, and 4Division of Abdominal and complications (worse than grade 1by Clavien-Dindo clas- Transplantation Surgery, Geneva University Hospitals, sification) occurred in 13 patients (9%; 6 as grade II and 7 Switzerland as grade IIIa). The Group A was superior to Group B in < Introduction: Cystic Echinococcosis is a zoonosis caused terms of morbidity (0% vs. 14%; p 0.05), the drainage < by E. granulosus. The liver is commonly involved by the period for hepatic stump (median 6 days vs. 8days; p formation of cysts that while benign, have a potential for 0.01) and postoperative hospital stay (median 10 days vs. < slow progression to severe complications and could 14days; p 0.01). Other parameters, including diagnosis, become a technical nightmare for surgeons. We present a preoperative liver functions, type of hepatectomy, opera- fi retrospective, single-center study to assess the indications tion time, intraoperative blood loss did not differ signi - for surgical treatment. cantly between the two groups. Methods: We reviewed clinical and surgical records from Conclusion: Standardization of surgical procedure 287 patients with hepatic CE followed at our center from might improve the postoperative courses of patients in January 2012 to July 2017. Our standard follow-up hepatectomy.

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EP01C-070 located in the central portion or the remaining remnant liver volume is small, there is a risk of complications such as POSTOPERATIVE PHARMACOLOGIC hepatic failure after surgical treatment. Transarterial radi- THROMBOPROPHYLAXIS WITH oembolization (TARE) is a radiosurgical technique using ENOXAPARIN AND THROMBOTIC Y90 to induce primary tumor necrosis and hypertrophy of COMPLICATIONS AFTER LIVER remnant liver to reduce the risk of liver failure and enable SURGERY safe hepatic resection. In this study, we report a case of patients with hepatic resection after TARE. M. Hoshikawa, T. Tsunenari, T. Kato, M. Nishikawa, Method: Between January 2017 and December 2017, we T. Einama, T. Noro, S. Aosasa, H. Tsujimoto, H. Ueno and performed hemihepatectomy in 5 patients who had unre- J. Yamamoto sectable causes like central located, small remnant liver National Defense Medical College, Japan volume, vascular invasion to major vessel. We performed Introduction: Patients after liver surgery are classified into TARE 3 month before surgical resection. Then we check the high-risk group for deep vein thrombosis (DVT) and tumor volume and remnant liver volume after surgical pulmonary embolism (PE) according to the Japanese resection. Re-evaluating of liver function test, CT scan 4 guidelines. However, few reports have mentioned about weeks after TARE, and ICG test for patient safety, then we pharmacologic thromboprophylaxis and postoperative performed surgical resection. thrombotic complications after liver surgery. Results: None of the 5 patient had recurrence during Methods: From September 2015 to August 2017, 113 observation period. There was no hepatic failure after patients underwent postoperative pharmacologic thrombo- resection. 5 cases underwent Rt. hemihepatectomy. The prophylaxis with enoxaparin after liver surgery. Of these, mean operative time was 160 minutes. Mean hospital day 60 patients with postoperative enhanced CT during the was 7.5 days and mean blood loss 120 cc. Mean tumor hospital stay were included and estimated about thrombotic shrinkage rate was -21.1 % and mean remnant liver hy- complications. pertrophy rate was 39.5%. Only 1 case had wound Results: The patients were 44 males and 16 females with a complication, but the others had no postoperative median age of 72 years. Enoxaparin was administered in 49 complication. patients (82%), heparin in 1 patient (1.7%) and none in 10 Conclusion: Surgical resection after TARE is feasible patients (17%). 10 patients (17%) had postoperative technique for surgically unresectable cases of hepatocel- thrombotic complications (DVT/PE in 1 patient, throm- lular carcinoma. bosis of the internal jugular vein in 1 patient, inferior vena cava in 1 patient and portal vein in 7 patients) with no clinical symptoms. Postoperative pharmacologic thrombo- EP01C-072 prophylaxis reduced thrombotic complications (P=0.083). On the other hand, 4 patients had adverse events (bleeding PREOPERATIVE through placed abdominal drains in 3 patients, thrombo- THROMBOCYTOPENIA MAY PREDICT cytopenia in 1 patient) and all were improved after stopping POOR SURGICAL OUTCOME AFTER administration. Assessing perioperative factors, preopera- EXTENDED HEPATECTOMY tive chemotherapy increased the risk (P=0.083) and pre- M. Golriz1, O. Ghamarnejad2, E. Khajeh1, M. Sabagh1, operative serum albumin, intraoperative blood loss, K. H. Weiss3 and A. Mehrabi1 postoperative total bilirubin were significantly higher 1General, Visceral, and Transplantation Surgery, 2Gen- (P=0.02/0.037/0.066) and prothrombin percentage activity eral, Visceral, and Transplantation Surgery, and 3Hei- was significantly lower (P=0.0006) in patients with delberg University, Germany thrombotic complications. Antithrombotic drugs were administered and thrombosis regressed in all complicated Introduction: It is a novel idea that platelet counts may patients. predict the postoperative outcome following liver surgery. Conclusion: Further investigation in more patients will This may help in planning an extended hepatectomy (EH), reveal individual appropriate prevention and treatment for which is a surgical procedure with high morbidity and thrombotic complications after liver surgery. mortality. The aim of this study was to evaluate the pre- dictive potential of platelet counts on the outcome of EH. Methods: A series of 213 consecutive patients underwent EH (resection of five liver segments) between 2001 and EP01C-071 2016. The postoperative surgical outcomes were evaluated BRIDGING AND DOWNSTAGING ROLE and compared between patients with a normal preoperative OF TRANSARTERIAL platelet count. The ability of preoperative platelet counts to RADIOEMBOLIZATION (TARE) FOR predict posthepatectomy liver failure (PHLF), morbidity fi EXPECTED SMALL REMNANT (based on Clavien-Dindo classi cation), and 30-day mor- tality was evaluated using multivariate analysis. VOLUME AFTER LIVER RESECTION IN Results: A total of 213 patients who underwent EH were HEPATOCELLULAR CARCINOMA included in our analyses. PHLF were detected in 26.3% of J. -M. Lee, K. -S. Suh, S. K. Hong, K. C. Yoon, patients, complications in 26.8% of patients, and 30-day J. -H. Cho, N. -J. Yi, K. -W. Lee and H. Y. Woo mortality in 11.3% of patients. Multivariate regression Department of Surgery, Seoul National University Hospi- analysis revealed that the preoperative platelet count is an tal, Republic of Korea independent predictor of PHLF (odds ratio [OR] 4.4, 95% Introduction: Hepatectomy is the best treatment to confidence interval [CI] 1.3-15.1, p=0.019) and 30-day improve survival in liver cancer. However, if the tumor is mortality (OR 6.3, 95% CI 1.4-27.9, p=0.015).

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Conclusion: Preoperative platelet counts correlated with Introduction: The number of elderly people with hepato- PHLF and mortality following extended liver resection. biliary pancreatic diseases who require surgery has recently This predictive role was independent of other related pa- increased. Elderly patients are often treated with aspirin for rameters. Prospective studies are needed to further evaluate the secondary prevention of ischemic stroke and cardio- this predictive role and to determine the impact of preop- vascular events. Perioperative aspirin therapy is continued erative correction of platelet count on postoperative out- for patients who undergo liver resection at our institution. comes after EH. We evaluated the safety and feasibility of liver resection with continued antiplatelet therapy using aspirin. Methods: We retrospectively evaluated the outcomes of EP01C-073 570 patients who underwent liver resection between META-ANALYSIS OF THE January 2010 and December 2017. Patients were grouped according to whether they received preoperative aspirin PROGNOSTIC ROLE OF therapy (users, n = 50) or not (non-users, n = 520). Pre- PERIOPERATIVE PLATELET COUNT IN operative variables, intraoperative factors, and post- POSTHEPATECTOMY LIVER FAILURE operative outcomes were compared between the two AND MORTALITY groups. Results: The preoperative factors of more advanced age (P O. Ghamarnejad1, M. Golriz1, E. Khajeh1, P. Probst1, < 0.001) and a higher proportion of males (P< 0.002), K. H. Weiss2 and A. Mehrabi1 frequency of history of hypertension (P = 0.03), diabetes 1General, Visceral, and Transplantation Surgery, and mellitus (P < 0.001), and ASA classification (P < 0.001) 2Heidelberg University, Germany significantly differed between the two groups. Surgical Introduction: Posthepatectomy liver failure (PHLF) and duration, type of procedure, blood loss, and blood trans- mortality remain challenging issues in liver surgery, espe- fusion rate did not significantly differ between the two cially following extended hepatectomy. Emerging evidence groups. No significant difference in 90- day mortality rates suggests that the perioperative platelet count (PLT) can was evident between groups (users, 2.0%; non-users, predict PHLF. In this meta-analysis, we evaluated the 0.96%). None of the patients treated with aspirin developed impact of perioperative PLT on PHLF and mortality. uncontrollable excessive intra-operative bleeds or post- Methods: The literature in MEDLINE and Web of Science operative hemorrhage. was systematically searched. All studies comparing the Conclusions: Aspirin can be safely continued in patients outcomes of PHLF or mortality in patients with low and undergoing liver resection without risk of increasing high perioperative PLT were included. Mantel-Haenszel intraoperative bleeding or postoperative hemorrhagic tests with a random-effects model were used for meta-an- morbidity. We suggest that aspirin should be continued alyses and presented as odds ratios (OR) with corre- perioperatively for patients at high risk of developing car- fi sponding 95% con dence intervals (CI). diovascular events. Results: Thirteen studies containing 5260 patients were included. The cut-off PLT value was 150/nL in five studies with 1627 patients and 100/nL in seven studies with 1536 patients. One study evaluated both cut-off levels in 2097 EP01C-075 patients. Patients with a perioperative PLT < 150/nL had FEASIBILITY AND SAFETY OF higher PHLF (OR 4.79, 95% CI 2.89-7.94) and mortality BISEGMENTECTOMY 7e8 rate (OR 3.78, 95% CI 1.48-9.62) than patients with a PRESERVING HEPATIC VENOUS perioperative PLT >150/nL. Similarly, patients with a PLT OUTFLOW < 100/nL had a significantly higher risk of PHLF (OR 4.65, H. S. Jo1, Y. I. Yoon1, S. R. Kim1,Y.D.Yu1, 95% CI 2.60-8.31) and mortality (OR 5.34, 95% CI 3.49- 1 2 > D. -S. Kim and H. Han 8.16) compared with patients with a PLT 100/nL. 1 Conclusion: A low perioperative PLT correlates signifi- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University College of cantly with higher PHLF and mortality after liver resection. 2 However, the analyzed studies were either retrospective or Medicine, and Division of HBP Surgery and Liver included minor hepatectomy. Therefore, further prospec- Transplantation, Department of Surgery, Korea University tive observational studies with a priori hypotheses, College of Medicine, KU ANSAN Hospital, Republic of focusing on extended hepatectomy are needed to conclude Korea the prognostic role of the PLT in PHLF. Introduction: Preserving maximal future liver remnant is one of most important goals to be achieved in liver resec- tion. When tumor is located between segment 7 and 8, it is EP01C-074 hard to decide optimal extent of resection. This study aimed to evaluate the feasibility and safety of bisegmentectomy 7- SAFETY OF LIVER RESECTION 8 with thick inferior right hepatic vein (IRHV) or with right WITHOUT INTERRUPTION OF hepatic vein (RHV) reconstruction. ANTIPLATELET THERAPY WITH Method: Twenty Patients undergoing bisegmentectomy 7- ASPIRIN FOR HIGH-RISK PATIENTS 8 between 2010 and 2017 were eligible for the study. Perioperative profile and surgical outcomes of these pa- K. Monden, H. Sadamori, M. Hioki, M. Yoshimoto, tients were compared with 22 patients undergoing right C. Kobatake and N. Takakura posterior sectionectomy (RPS) that is the resection of Department of Gastroenterological Surgery, Fukuyama similar volume with bisegmentectomy 7-8 without hepatic City Hospital, Japan

HPB 2018, 20 (S2), S333eS504 S426 Electronic Posters (EP01A-EP01E) - Liver vein resection. In the bisegmentectomy 7-8 group, 14 pa- EP01C-077 tients with obvious IRHV (median 6 mm, range 3.6-8.8 mm) underwent bisegmentectomy 7-8 without hepatic vein NON HEPATIC SURGERY IN PATIENTS reconstruction. On the other hand, RHV reconstruction was WITH LIVER CIRRHOSIS: IS THE performed for 6 patients who had no IRHV to retain venous NIHILISM WARRANTED? fl out ow of remnant liver. A. Yadav, H. Ramesh, V. Lekha and S. Bains Results: Liver cirrhosis was more frequent in the biseg- Surgical Gastroenterology and Liver Transplant Unit, mentectomy 7-8 group than RPS group (55.0% vs. 18.2%, Lakeshore Hospital, India p=0.023). Baseline characteristics, besides liver cirrhosis, Background: Patients with Liver cirrhosis (LC) frequently did not differ between the groups. Two patients undergoing require non hepatic abdominal surgery. Surgery in these RHV reconstruction experienced anastomosis obstruction patients is looked at nihilistically even today. in early postoperative period and eventually metallic stent Aims: To analyze our experience of non-hepatic surgery in was inserted. They recovered without sequellae. No dif- patients with LC in respect to the morbidity and mortality ferences in surgical characteristics and outcomes were and try and identify the factors which affect the outcomes. observed between the two groups. Methods: Retrospective analysis Between March 2000 to Conclusions: Bisegmentectomy 7-8 can be performed December 2016. safely in selected patients who had thick IRHV. If there is Results: 278 patients with LC underwent non hepatic no obvious IRHV, alternatively, RHV reconstruction can abdominal surgery .Of these 176 underwent an intra- be considerable to preserve maximal future liver remnant. abdominal procedure and 102 were operated on for abdominal wall pathologies. 190 had a planned surgery vs 88 patients had surgery in emergency setting.The distri- EP01C-076 bution of patients according to child score was Child A- ENHANCED RECOVERY PROGRAM 132, Child B-100, and Child C-46.The mean MELD score AFTER OPEN AND LAPAROSCOPIC was 17.8 +/- 1.1. The overall mortality rate was 8.7% and LIVER RESECTION: MAY IT ENHACE the incidence of major morbidity was 23%. The mortality rate according to Child class was 4.8%, 7.3% and 12.4% in THE ADVANTAGES OFFERED BY THE Child class A, B, &C respectively p=NS. On subgroup MINIMALLY INVASIVE APPROACH? analysis, presence of ascites (n=102), emergency surgery, F. Giovinazzo, A. Rawashdeh, S. Barbaro, A. Jayyusi, surgery requiring bowel resection and alcohol as an M. Alzoubi, A. Takhar, T. Armstrong, Z. Hamady, ethology of liver disease (n=137) were markers of worse J. Primerose and M. Abu Hilal prognosis in this group of patients. Department of Surgery, Southampton University Hospital Conclusions: Surgery in patients with LC can be under- NHS Foundation Trust, United Kingdom taken with morbidity and mortality rates much lower than Introduction: The present study aimed to determine and that reported in literature, also the MELD score is a more compare the impact of enhanced recovery program (ERP) accurate marker of prognosis than the Child score. We after open and laparoscopic liver resection. identified a subgroup of patients who do worse than the Methods: Four standardized perioperative care pathways others, which could be a useful tool for prognosticating were developed and implemented in patients undergoing patients prior to surgery. liver resection (major open or laparoscopic, minor open or laparoscopic). Perioperative outcomes were compared be- tween the groups of patients operated before and after the EP01C-079 introduction of the ERP. TRANS-FISTULO-INTERNAL Results: Between December 2008 and December 2016, DRAINAGE FOR THE TREATMENT OF 787 patients underwent liver resection. Open resection were 315 (40%) and 472 (60%) Laparoscopic. In the open group, HYDATID CYST OF THE LIVER hospital stay (LOS) stay was significantly shorter in the WIDELY OPENED IN THE BILIARY ERP group (142 patients) when compared to the control TRACT group (173 patients) (median 6, IQ 5 to 8 and 7, IQ 6 to 12 F. S. Ftériche1, R. Rhaiem1, A. Sebai1, H. Maghrebi1, days, respectively, p=0.05). Patients undergoing ERP N. Maamouri2, A. Haddad1, W. Rebai1, A. Makni1, minimal invasive liver resection (233 patients) had similar R. Ksantini1 and Z. Ben Safta1 LOS compared with the control group (239 patients) (3 IQ 1Digestive Surgery A, and 2Gastroenterology and Hepa- > 2 to 4 versus 3 IQ 2 to 4 days, p 0.69). Clavien-Dindo tology B, University Hospital La Rabta, Tunisia Grade II complications were significantly (p< 0.0001) Introduction: Angiocholitis is a common complication of lower and no 90-day mortality was observed in both open liver hydatid cyst communicating with the biliary tract. The and Laparoscopic ERP groups. surgical treatment could be complex with a high risk of Conclusion(s): The impact of ERP on patients undergoing postoperative morbidity and mortality. liver resections has not been clarified yet, especially when Methods: We report a retrospective study showing the considering the expansion of laparoscopic liver surgery. In results of a surgical technique that allow trans-fistulo-in- our experience ERP reduced LOS after open liver resection, ternal drainage (TFID). Surgery requires emptying the cyst although after laparoscopic liver resection LOS was and exploring the choledocus. similar. However the minor rate of major complications, Results: From 2006 to 2018, 68 patients had surgery for such as have been equally witnessed in both groups sug- hydatic cyst communicationg with the biliary tract. Among gests ERP may further enhance the advantages of the them, 14 patients had TFID. Mean age was 45 (18-82) laparoscopic approach.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S427 years. Sex ratio (F/M) was 1.8. Seven patients (50%) EP01C-083 presented with acute angiocholitis. The cyst was located in the right liver in 60% of cases. Mean size was 6 cm (3-10). HYPOPHOSPHATEMIA AS AN EARLY Intraoperative cholangiography was performed in all cases. POSTOPERATIVE INDICATOR OF In 3 patients, a large cysto-biliary fistula was found without DECREASED MAJOR COMPLICATIONS migration of cystic material into the biliary tract allowing us RATE AFTER LIVER RESECTION FOR to avoid choledocotomy. Mean operative time was 210 mn COLORECTAL LIVER METASTASES (160-270). No intraoperative transfusion was recorded. Postoperative mortality was nul. Morbidity rate was 29%. Y. Berger, E. Nesher, R. Haddad, S. Tamir, N. Goldberg, No bilary fistula occurred during the postoperative course. D. Aranovich, D. Benchimol, H. Kashtan and E. Sadot Mean hospital stay was 12 days (7-19). External biliary Rabin Medical Center, Israel drainage was clamped after a mean time of 14 days (7-31). Background: Hypophosphatemia is commonly observed Ablation was performed after a mean duration of 50 days after liver resection, however the pathophysiology and its (23-100). Mean follow-up was 29 months (1-95). Only one clinical correlates remain poorly understood. We hypoth- patient had a cystic recurrence (7%). esized that hypophosphatemia is a surrogate for adequate Conclusion: TFID is simple operation, safe and efficient liver regeneration and may be correlated with post-hepa- for the treatment of hydatic liver cyst largely opened in the tectomy complication rate. biliary tract. Methods: Patients who underwent hepatectomy for colo- rectal liver metastases at Rabin Medical Center were analyzed. Postoperative serum phosphate levels and other EP01C-081 recognized risk factors for perioperative complications were assessed. Hypophosphatemia was defined as < PROPENSITY SCORE ANALYSIS OF 2.5mg/dl and major complications were defined as COSTS AND OUTCOMES OF grade>3. Logistic regression and standard statistics were LAPAROSCOPIC VERSUS OPEN LIVER used. RESECTION Results: From 2005-2017, 290 cases were included. The median age was 66 years (IQR:58-72), 113 (39%) J. Buell1, D. Wei2, L. Goldstein3, S. Johnston2 and were female, 120 (41%) underwent major hepatectomy, A. Patkar3 and 30-day and 90-day mortality rates were 2.8% and 1Tulane Transplant Institute, Tulane University School of 5.2%, respectively. Hypophosphatemia on postoperative Medicine, 2Epidemiology, Medical Devices, Johnson & day 2 (OR=0.2;CI:0.1-0.8;P=0.02) and female gender Johnson Co., and 3Global Health Economics and Market (OR=0.2;CI:0.05-0.09:P=0.04) were found to be pro- Access, Ethicon, United States tective factors for 90-day mortality, while intraoperative Objective: Laparoscopic liver resection (LLR) has been transfusion> 2units (OR=3.1;CI:1.1-9.6;P=0.04) was adopted as a safe and effective alternative to open liver found to be a risk factor. Long operative time resection (OLR). This study compared total hospital costs, (OR=1.01;CI:1-1.05;P=0.05) demonstrated a trend to- length of stay (LOS), and selected in-hospital complication wards increased 90-day mortality risk. Similarly, rates of LLR vs. OLR in the United States. hypophosphatemia on postoperative day 2 (P=0.01) and Methods: Analysis of liver resection outcomes in the intraoperative transfusion< 2units (P=0.01) were Premier Healthcare Database, which comprises hospital correlated with decreased major complication rates (Fig. > billing data from 700 hospitals in the U.S. in patients aged 1). On multivariate analysis, hypophosphatemia on ’ 18 years undergoing liver resection between Oct 15 and postoperative day 2 (OR=0.2; CI:0.1-0.5;P=0.001) and ’ Jun 17. Patients undergoing LLR were 1:1 propensity intraoperative transfusion< 2units (OR=0.3;CI:0.1- score matched to those undergoing OLR based on de- 0.8;P=0.02) remained significantly associated with mographics, hospital characteristics, and comorbidities. decreased major complication rates. Multivariable regression analyses were used to estimate the Conclusion: Early postoperative hypophosphatemia was difference in total hospital costs LOS, and the odds ratios of associated with lower 90-day mortality rates and was an peri-operative complications between the matched LLR independent predictor of decreased major complication and OLR groups, adjusting for hospital-level clustering. rates. These data may help identify those patients most Results: Before matching, sample included 363 LLR pa- likely to benefit from enhanced postoperative recovery tients (age: 59.4) and 1,246 OLR patients (age: 59.3); after protocols (ERAS). matching, there were 342 patients in each group (684 total; Table). LLR had $12,219 lower hospital costs than OLR (42.2% lower, p< 0.0001), and 3.5 days shorter LOS (48.7% lower, p< 0.0001). Unadjusted rates of the selected in-hospital complications were lower in LLR: bleeding (7.9%, 17.5%), respiratory failure (4.4%, 10.2%), intestinal obstruction (2.6%, 7.3%) and pleural effusion (1.5% and 5.8%); the corresponding adjusted odds ratios were 0.37 (95%CI: 0.21, 0.64), 0.37 (0.18, 0.74), 0.28 (0.11, 0.77), and 0.19 (0.06, 0.62), respectively(p< 0.05). Conclusion: This study confirms LLR was associated with significantly lower hospital costs, shorter LOS, and lower Figure 1 risk of in-hospital complications than OLR.

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EP01C-084 mortality was 3.8% and morbidity 36.4%. Ascites (25.6%), post hepatectomy liver failure (11.9%), bile leak (7.7%) EVOLUTION OF LAPAROSCOPIC and SSI (7.1%) were the most common non-hemorrhagic HEPATECTOMY IN THE SURGICAL complications. Disease specific surgical mortality was 3.6 MANAGEMENT OF LIVER DISEASE % for CRLM and 1.7% for HCC. Morbidity was also M. Baltatzis, P. Stathakis, A. Mirza, A. Tyurkylmaz, slightly higher in CRLM (38.1%) versus studies of HCC fi S. Jamdar, A. Siriwardena and A. Sheen alone (30.9%). The speci c transfusion rate for CRLM was Department of Hepatobiliary and Pancreatic Surgery, 29.4% and for HCC 19.7%. Manchester University Hospitals, NHS Foundation Trust, Conclusions: Bleeding, bile leak, ascites, and PHLF United Kingdom remain prominent complications in liver resection proced- ures and contribute to a mortality rate of approximately 4%. Aim: Since the first reports of laparoscopic hepatectomy in Findings from this study may challenge traditional beliefs the early 1990s there has been a gradual increase in the use that cirrhosis is the most important contributor to mortality of the technique. Consensus conferences in Louisville USA and transfusion after liver surgery; that rates of transfusion and Morioka Japan have provided guidance on case se- are greater in the Asia Pacific region; and that cirrhosis lection. This study reports the adoption of the laparoscopic (HCC) is associated with worse surgical outcomes than approach by predominantly one attending (consultant) CRLM. surgeon in this regional liver surgery service. Methods: Laparoscopic liver surgery was initially adopted by the lead surgeon in 2009. All operations were under- taken using a two-surgeon approach until individuals had EP01C-086 achieved competence. Demographic data are presented as INCIDENCE OF SPLANCHNIC VEIN median (range) where appropriate and non-parametric tests THROMBOSIS FOLLOWING are used for comparison accepting significance at the P < ABDOMINAL SURGERY, A 0.05 level. Patients were allocated to one of two temporal SYSTEMATIC REVIEW AND META- cohorts. Results: The total number of patients in this cohort were ANALYSIS 400 (2006-2017) (197 [49%] male; median [range] age 68 P. Serrano1, B. Zhang2, M. Kim2 and E. Duceppe3 [30-88]). In the initial cohort from 2006 to 2011 the total 1Surgery, 2McMaster University, and 3Centre Hospitalier number of liver resections undertaken were 173 with 10 de L’Université de Montréal (CHUM), Canada (5.8%) undertaken laparoscopically. From 2012 to 2017 Background: Splanchnic vein thrombosis (SVT) is an there were 227 liver resections with 67 (29.5%) undertaken uncommon but potentially life-threatening condition. laparoscopically. The difference in the proportion of lapa- Abdominal surgery increases the risk of SVT; however, its roscopic cases was significant (P< 0.001). In the overall incidence is not clear. Our objective was to determine the series of 400 there were 4 (1%) post-operative deaths. SVT incidence following open and laparoscopic abdominal There were no deaths after laparoscopic liver surgery and surgery and evaluate groups at risk. no conversions. Methods: We searched Medline and Embase for clinical Conclusion: Laparoscopic hepatectomy can be safely and studies evaluating the incidence of post-operative SVT. uneventfully incorporated into modern liver surgical Study selection, data abstraction, risk of bias and quality of practice. the evidence assessment were carried out in duplicate. Statistical heterogeneity was calculated using the Chi squared and I2 tests and clinical heterogeneity was explored EP01C-085 with subgroup analysis. IS HCC ASSOCIATED WITH WORSE Results: Of 5549 abstracts screened, 74 full text articles were fi SURGICAL OUTCOMES COMPARED TO reviewed, and 46 met inclusion criteria (33 speci ctoHPB surgery). The proportion of SVT in all abdominal surgery, CRLM? including colorectal and bariatric surgery, was 2.36%, 95% J. Amaral1,2, M. Guitierrez2, L. Goldstein2 and S. Ghosh2 CI: 1.96-2.77; with high heterogeneity (I2=95%). In HPB 1Surgery, Brown University, and 2Ethicon Inc, United surgery was 4.93% 95%CI: 4.14-5.72. The proportions of States highest risks of SVT after HPB procedures were 24.17% in Purpose: The purpose of this study is to understand the splenectomy with devascularisation, 8.76% in hepatectomy incidence of complications associated with open liver re- for malignancy in patients with cirrhosis, and 4.56% in sections for liver tumors with respect to regional variation pancreatectomy with venous resection. Subgroup analysis and disease specific incidence. explained the heterogeneity. Mortality secondary to post- Methods: A systematic literature review of the incidence operative SVT included irreversible thrombosis, bowel (weighted average) of complications and correlating factors ischemia, hepatic failure and gastrointestinal bleed. during open liver resection published during the past five Conclusion: Incidence of SVT after abdominal surgery is years were analyzed. low but remains a relevant complication, particularly Results: In total, 139 manuscripts and 29 abstracts met the among patients undergoing HPB surgery. Patients under- study criteria providing data on 540,397 [MG1] liver re- going procedures involving mechanical manipulation of the sections. 46% of studies were conducted in Asia Pac, 27%- venous system and splenectomy are at the highest risk. Europe, and 23%-North America. 78% of studies focusing Given the life-threatening risks associated with SVT, close on HCC were from Asia Pacific whereas 77% of focusing post-operative monitoring may be beneficial for certain on CRLM were from Europe/North America. The average surgery.

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EP01C-087 Radio-frequency Assisted Liver Partition with Portal vein embolization in Staged liver resection (RALPPS). POSTOPERATIVE COLLECTIONS Methods. From January 2016 to August of 2017 - 31 AFTER LIVER SURGERY: patients with different malignancies of liver and bile ducts PREDICTORS, AND LONG-TERM included in the study for assessment of liver function who OUTCOMES underwent PVE (17 patients) and RALLPS (14 patients) to increase future liver remnant (FLR) before major liver F. Fleres1, R. Brustia2, E. Tamby1, T. Piardi1, F. Perdigao2, resection. Index of hepatic uptake (IHU) and scintigraphic O. Scatton2, R. Kianmanesh1 and D. Sommacale1 liver volume was assessed before and after PVE and 1Reims University Hospital, and 2Pitié Salpêtrière Hospi- RALPPS. tal, Sorbonne Université, France Results: The mean IHU of FLR was increased by 0,6 Introduction: Postoperative collection (PC) can occur (range 0-1,56) and mean liver volume increased up to 73% after liver surgery (LS), but little is know on their impact on (range 23-171%) from 14 to 30 days after PVE alone. The short and long-term outcomes. The aim of this study was to mean IHU of FLR increased by 0,2 (range 0-1,15) and analyze factors predicting the occurrence of PC, the need of mean volume increased up to 85% (range 25-264%) from 9 drainage and their impact on oncologic outcomes. to 14 days after PVE combined with RALLPS. Methods: . This prospective, single-center, cohort-study Conclusion: Hepatobiliary scintigraphy assessment included all patients undergoing LS from 2008 to 2017. A showed that FRL function improved markedly in patients systematic postoperative CT scan was realized on day7. with PVE alone than after RALPPS but in longer (more 1-2 The primary outcome was to determine variables associated weeks) period of time. We suggest that hepatobiliary fi fl with PC, de ned as the presence of a uid collection, and scintigraphy assessment should be performed in all patients infected in case of positive bacterial culture. Secondary considered for surgical increase of FLR. outcomes were to determine factors predicting drainage requirement, and the impact of infected PC on 5-y overall (OS) survival. Results: We included 254 patients: 45% (n=114) experi- EP01C-089 enced PC. LAPAROSCOPIC VERSUS OPEN LEFT In the multivariate analysis, variables associated to PC LATERAL HEPATIC SECTIONECTOMY: occurrence were BMI (25-30=OR1.56(95%IC:0.78,3.13), A META-ANALYSIS 30-35=OR1.99(95%IC:0.67,5.89) p=0.002) and surgical D. Magouliotis1,2, V. Tasiopoulou3, A. Svokos4, resection (anatomic=reference, nonanatomic=OR1.22(95% K. Svokos5, G. Christodoulidis1 and D. Zacharoulis1 IC:0.52,2.85), combined=OR2.09(95%IC:0.72,6.07), 1Department of Surgery, University Hospital of Larissa, p=0.014). 2Pharmacology, Faculty of Medicine, 3Faculty of Medi- In the PC subgroup (n=114), variables predicting cine, University of Thessaly, Greece, 4Riverside Regional drainage requirement were antibiotic use OR14.01(95% Medical Center, and 5Warren Alpert Medical School of CI:1.25,157 p= 0.015) and C-reactive protein (CRP) Brown University, United States OR1.02(95%CI:1,1.05 p=0.043). The AUROC (0.71, 95% CI:0.59,0.83 p=0.002) found 152 mg/L as the optimal CRP Introduction: This study aimed to assess the perioperative cutoff value associated with PC drainage. parameters and outcomes of laparoscopic left lateral In the malignant disease subgroup with PC (n=96), we sectionectomy (LLLS) compared with an open (OLLS) observed lower 5-y OS among patients with infected vs approach. non-infected PC (33% vs 56%, Log-Rank=0.03). Materials and methods: A systematic literature search Conclusions: In this cohort study we observed how was performed in PubMed, Scopus and Cochrane library, in nonanatomic or combined LS and BMI are associated to PC accordance with the PRISMA guidelines. The Odds Ratio after LS, and those with CRP higher than 152 mg/L may (ORs), the weighted mean difference (WMD) and 95 % fi require drainage. Moreover, the presence of an infected PC con dence interval (95 % CI) were evaluated, by means of negatively impact 5-y OS. Random-Effects model (Mantel-Haenszel or Inverse Vari- ance statistical method). OR< 1 or WMD< 0 denoted outcome was more frequent in the OLLS group. Results: Nine articles met the inclusion criteria and EP01C-088 incorporated 2,602 patients. This study reveals comparable HEPATOBILIARY SCINTIGRAPHY mean operative time, mean operative margin and rate of ASSESSMENT OF LIVER FUNCTION R1 resection between LLLS and OLLS. The intraoperative AFTER PORTAL VEIN EMBOLIZATION mean blood loss, mean length of Intensive Care Unit stay, mean hospital stay were significantly increased in the AND RALPPS < 1 2 OLLS group (p 0.05). Complications were assessed R. Alikhanov , P. Kim , L. Bondar, O. Melekhina, according to the Clavien-Dindo classification. The inci- Y. Kulezneva, I. Kazakov, A. Vankovich, dence of grade I, II, III and IV complications was similar D. Akhaladze, S. Iskhagi, V. Tsvirkun and between the two groups. The incidence of grade V com- M. Efanov plications was increased in OLLS group (p< 0.05). The 1 2 fi HPB Surgery, and Moscow Clinical Scienti c Center, mean perioperative cost was similar between the two Russian Federation techniques. Background: The aim of this study was assessment the Conclusion: These outcomes should be treated with real liver function by using hepatobiliary scintigraphy in caution given the small number of the included compara- patients after portal vein embolization (PVE) alone and tive studies. Well-designed, randomized controlled studies,

HPB 2018, 20 (S2), S333eS504 S430 Electronic Posters (EP01A-EP01E) - Liver comparing LLLS to OLLS, are necessary to assess further concomitant extra-hepatic procedures were excluded. their clinical outcomes. Wedge/segmentectomy was divided into anterolateral (Couinaud’s segments 2, 3, 4b, 5, and 6) and poster- osuperior (segments 1, 4a, 7, and 8) segments. Eleven EP01C-090 OLRs were divided into 3 groups according to scores based CLASSIFICATION OF OPEN LIVER on less (score 0) or more (score 1) than median/mean values of operative time, blood loss, and CCI. RESECTION BASED ON OPERATIVE Results: Of 3,707 OLRs, 2,047 were selected. Median TIME, BLOOD LOSS, AND operative time, median blood loss, and mean CCI were 145 COMPREHENSIVE COMPLICATION min, 200 ml, and 10.4, respectively. Group I (0 point) INDEX included wedge resection and left lateral sectionectomy. Group II (1 points) included anterolateral segmentectomy Y. Kawaguchi, E. Simoneau, Y. S. Chun, C. Conrad, and left hepatectomy. Group III (2-3 points) included C. -W. D. Tzeng, T. A. Aloia and J. -N. Vauthey posterosuperior segmentectomy, right hepatectomy, right Department of Surgical Oncology, University of Texas MD posterior sectionectomy, central hepatectomy, and Anderson Cancer Center, United States extended left/right hepatectomy (Table 1). The 90-day fi Introduction: A classi cation system is needed to stratify mortality rates (Groups I, II, and III: 0.5%, 1.3% and 2.9%) patients undergoing open liver resection (OLR). The pre- and major complication rates (4.1%, 8.3%, and 15.2%) sent report aimed to evaluate OLR procedures based on a were associated with increase from Groups I to III (all P< fi previously-described laparoscopic liver resection classi - 0.001, trend test). cation (Ann Surg.2018), using operative time, blood loss, Conclusions: This classification provides three-level step- and comprehensive complication index (CCI). wise OLR difficulty: Group I (low), Group II (intermedi- Method: Consecutive 3707 patients who underwent OLR ate), and Group III (high). This can be useful for surgical were included. Patients who underwent multiple wedge/ education and to benchmark surgical procedures. segmentectomy, vascular/biliary reconstruction, and

EP01C-090 Table 1Perioperative outcomes by Procedures Wedge- Wedge- Left Seg- Left Seg- Right Ex- Right Right Colini Ii-LeA Tttit AL† PS‡ lateral AL† Hep PS‡ Hep Hep posterior Hep Hep Number 196 72 121 253 206 108 607 316 25 17 126 2047 OR time, min Median 117 133 110 152 120 198 140 196 250 320 246 145 IQR 78-145 108-194 80-143 99-2011 84-200 146-270 108-235 120-295 233-315 251-375 148-330 105-236 Blood loss, mL Median 100 110 125 100 200 200 300 300 225 250 300 200 IQR 50-200 56-250 88-200 75-250 100-313 100-300 200-500 200-600 150-525 150-500 200-470 100-400 Morbidity CCI§ Mean 5.2 5.7 5.4 7.4 7.5 8.0 12.8 16.6 9.2 10.3 11.7 10.4 SD 12.4 11.3 13.1 15.3 14.5 16.1 20.5 21.8 7.1 10.9 11.6 18.1 A1I 18.9 25.0 20.7 26.5 26.3 30.6 43.2 56.0 28.0 35.3 40.9 36.0 complication Major 4.1 4.2 4.1 5.9 11.2 9.2 13.2 19.0 16.0 23.5 18.39 11.5 complication 90-day 0.5 0 0.8 1.2 1.5 0 3.1 4.1 4.0 0 1.6 2.1 mortality Score¶ 00011223 2 23 Group I II III

Abbreviations; Wedge-AL, wedge resection of anterolateral segment; Wedge-PS, wedge resection of posterosuperior segment; Left lateral, left lateral sectionectomy; Seg-AL, anterolateral segmentectomy; Left Hep, left hepatectomy; Seg-PS, posterosuperior segmentectomy; Right Hep, right hepatectomy; Ex-Right Hep, extende right hepatectomy; Right posterior, right posterior sectionectomy; Central Hep, central hepatectomy; Ex-Left Hep, ectended left hepatectomy; IQR, interquartile range; CCI, comprehensive complication index; SD, standard deviation. † ‡ Couinaud’s segments 2, 3, 4b, 5, and 6; Couinaud’s segments 1, 4a, 7, and 8 §Defined by Slankamenac et al. ¶One point was allocated as follows; either operative time (145 min and more), the amount of blood loss (200 mL and more), or CCI (10.4 and more).

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EP01C-091 categories: before and after ERAS. The primary outcome was LOS after surgery. Secondary outcomes included BOWEL NECROSIS ASSOCIATED WITH postoperative infection, transfusion, liver failure, UTI, EARLY POSTOPERATIVE ENTERAL sepsis, and readmission. Categorical variables were TUBE FEEDING: A CASE REPORT compared using Fischer exact or Pearson Chi-Square test. F. Lisboa Freire Junior1, W. Vieira da Mota2, LOS was compared using Mann-Whitney U test. Statistical fi fi < R. Melo Campos2, R. de Lima França1, signi cance was de ned as p value 0.05. S. Hulliane Freitas Pinheiro1, A. Alves Sobrinho1, Results: 101 patients underwent major hepatectomies (52 J. Medeiros Santos1, I. Godeiro de Oliveira Maranhão1 and traditional and 49 ERAS cases) and 288 patients underwent A. de Araújo Lima Liguori1 minor hepatectomies (186 traditional and 102 ERAS fi 1Hospital Universitario Onofre Lopes, HUOL/UFRN, and cases). There was no signi cant difference in LOS 2Universidade Potiguar, Brazil following major hepatectomy after implementation of ERAS (6.5 vs. 6 days, p=0.25). There was an increase in the Introduction: Intestinal ischemia can be caused by a pro- rate of postoperative liver failure (3.8% vs. 14.3%, p=0.09). cess that reduces the intestinal blood flow. Postoperative In contrast, there was a significant decrease in LOS for enteral tube feeding may sometimes be responsible for patients undergoing minor liver resection after the imple- severe complications such as bowel necrosis. mentation of ERAS (5 vs. 3 days, p=0.008) with no dif- Methodology: Case report and literature review. ference in secondary outcomes. Case report: A 66-year-old female, with systemic arterial Conclusion: The implementation of a liver ERAS pathway hypertension and diabetes controlled was admitted with notably decreased LOS for minor hepatectomies. We sus- jaundice and itching, associated with weight loss, nausea pect that the higher rate of liver failure and unchanged LOS and anorexia. Radiological findings evidenced a nodule in for major liver resections is likely due to increase case the topography of the common bile duct and duodenal complexity and more aggressive oncologic resections. papilla, with a suspicious aspect and expansion of intra and extrahepatic bile ducts and gallbladder distension. Results: A duodenopancreatectomy was realized and then was initiated the enteral tube feeding on the first post- EP01C-093 operative day. In the seventh postoperative day, the patient ACCELERATED LIVER HYPERTROPHY was presenting abdominal distension, nauseas and vomit- IS ASSOCIATED WITH RECURRENCE ing and it was performed a Computed Tomography (CT) IN PATIENTS WITH COLORECTAL scan which showed diffuse distension of the jejunoileal loops, without caliber transition points, with stasis of in- LIVER METASTASES 1 1 1 2 testinal contents and some regions with hydroaeal level. K. Joechle , M. Okuno , E. A. Vega , B. Odisio , 3 1 1 1 This patient presented in the nineth day a significant S. A. Lang , Y. S. Chung , C. -W. D. Tzeng , J. E. Lee , 1 1 leukocytosis and a new CT scan of the abdomen showed J. -N. Vauthey and C. Conrad 1 diffuse distension of jejunoileal loops, with signs of loop Sugical Oncology, UT MD Anderson Cancer Center, 2 distress, suggesting bowel necrosis. Afterwards she was United States, Interventional Radiology, UT MD Ander- 3 submitted to exploratory laparotomy, resection of terminal son Cancer Center, United States, and General and ileum with cecal region and colostomy by Mikulicz. The Viceral Surgery, Medical Center Freiburg, Germany mesenteric arteriography did not evidence athero- Introduction: While concerns exist regarding an associa- thrombotic causes, thus it is an atypical case-report of a tion between rapid liver hypertrophy and tumor progres- patient without significant risk factors for bowel necrosis. sion, published data are controversial. This study aimed to Conclusion: Through this case report, it is seen the investigate whether extensive liver regeneration after portal importance of this complication after set up an enteral tube vein embolization (PVE) was associated with recurrence or feeding. long-term outcome for patients with colorectal liver me- tastases (CRLM). Methods: Patients who underwent PVE before hepatec- EP01C-092 tomy for CRLM between 2000 and 2015 were evaluated SHORT-TERM OUTCOMES AFTER retrospectively. Patients with extrahepatic disease, post- hepatectomy liver failure and 90-day mortality were IMPLEMENTATION OF ERAS IN LIVER excluded. Kinetic Growth Rate (KGR) was defined as SURGERY degree of hypertrophy at initial liver volumetry divided by K. Landa1, K. Shah1, J. Thacker1, W. Lane2, S. Knechtle1, the weeks elapsed after PVE. Receiver operating charac- K. Ravindra1, A. Barbas1 and S. Zani1 teristic (ROC) analysis was performed to determine the 1Duke University Medical Center, and 2Surgery, Duke KGR cut-off value that predicted recurrence. Survival University Medical Center, Department of Surgery, United analysis was performed using log-rank statistic and Cox States regression. Introduction: Enhanced recovery pathways have previ- Results: The study included 99 patients. Based on ROC fi ously proven to reduce length of hospital stay (LOS) in analysis, a KGR 2.7 %/week was identi ed as predicting many types of surgeries. Their use in liver surgery remains tumor recurrence (AUC 0.67, p=0.039). Oncological limited and formal guidelines have not been published. characteristics were comparable between patients with < Methods: Using our institutional NSQIP data, we con- higher ( 2.7 %/week) and lower ( 2.7 %/week) KGR. fi ducted a retrospective review of patients who underwent Patients with higher vs. lower KGR had signi cantly worse hepatectomies from 2013-2017. The liver ERAS program recurrence-free (RFS) (5-year rate 7.9% vs. 39%, was implemented in 2015. Subjects were stratified into two p=0.0002) and overall survival (OS) (5-year rate 34.1% vs.

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48.9%, p=0.016). Multivariate analysis revealed higher evaluation of liver function. This modality has better KGR as the only factor significantly associated with RFS versatility and spatial resolution compared with 99mTc- (HR 2.37, p=0.002) and OS (HR 2.03, p=0.035). GSA scintigraphy. We assessed whether functional Conclusion: KGR identifies a subset of patients with worse remnant liver volumetry (FRLV) using EOB-MRI predic- survival. Understanding the growth factor and cytokine ted post hepatectomy liver failure (PHLF). interplay following PVE that may promote tumor growth Method: We retrospectively analyzed 114 cases performed may allow for the identification of novel therapeutic angles. hepatectomy of more than one segment (MOS). Signal intensity (SI) of remnant liver were measured by putting region of interest in T1WI image. SI of spinal erector EP01C-094 muscle and spleen were calculated for standardization of SI EXPRESSION OF OATP1B3 IN CASES value. Functional remnant liver score was derived in divi- sion of average SI of liver by average SI of muscle (or WITH INDOCYANINE GREEN spleen) as liver-muscle ratio(LMR) and liver-spleen EXCRETORY DEFECT ratio(LSR), respectively. Future remnant volume was M. Tanimoto, T. Kokudo, J. Arita, Y. Inagaki, calculated by volume analyzer, then FRLV was calculated N. Akamatsu, J. Kaneko, Y. Sakamoto and K. Hasegawa by multiplying LMR(or LSR) and remnant volume. Stan- Hepato-Biliary-Pancreatic Surgery Division and Artificial dardized FRLV(sFRLV) was calculated by dividing FRLV Organ and Transplantation Division, Graduate School of by body surface area. Definition of PHLF is used ISGLS Medicine University of Tokyo, Japan classification. Background: The indocyanine green (ICG) retention rate Results: LMR correlated with ICG-R15(p=0.004), but not is widely used for preoperative evaluation of patient’s liver LSR, FRLV or sFRLV. PHLF( GradeB) occurred in 5 function. However, there are a few patients showing ICG patients (4.4%). In univariate analysis, predictive factors of excretory defect, and the absence of organic anion trans- PHLF were operative time(p=0.010), blood loss(p=0.013), porting polypeptide 1B3 (OATP1B3) has recently been FRLV(LMR) (p=0.021), sFRLV(LMR)(p=0.015), reported in these patients. FRLV(LSR)(p=0.040), and sFRLV(LSR)(p=0.044). In Methods: Since October 2006 to March 2015, 103 patients multivariate analysis, only sFRLV(LMR) was independent underwent 99mTc-GSA hepatic scintigraphy (GSA scin- predictive factor of PHLF(p=0.042). ROC analysis revealed that cut-off value of sFRLV(LMR) predicting tigraphy) in our department. Among those, the value of 2 ICG retention rate at 15min (ICGR15) were over 40% in 27 PHLF was 599ml/m (AUC: 0.913). In analysis of PTPE patients, and 11 patients who underwent liver resection cases (n=17), 10 cases over cut-off of sFRLV did not occur were analyzed. Immunohistochemistry analysis of the PHLF, but 7 cases lower than cut-off occurred PHLF in 4 normal liver tissue was performed for OATP1B3. Ten pa- patients (57%) (p=0.019). tients with hepatocellular carcinoma and one patient with Conclusion: sFRLV using EOB-MRI predicts PHLF in colorectal liver metastasis were included. hepatectomy of MOS. Result: The median value of ICGR15 was 48.9% (range 40.1-75.3).In 6 cases, OATP1B3 expressions were not detected. GSA scintigraphy showed normal liver function EP01C-096 in 4 patients, moderate to severe liver damage in 2 patients. SHORT-TERM RESULTS OF In 3 cases, low OATP1B3 expressions were observed. Two MINIMALLY INVASIVE LIVER cases showed normal OATP1B3 expression, and GSA RESECTION FOR BENIGN TUMORS. scintigraphy showed moderate to severe liver damage. Postoperatively, 2 patients suffered from pleural effusion SINGLE CENTER EXPERIENCE and ascites. There was no case of liver failure nor mortality. M. Efanov, R. Alikhanov, V. Tsvirkun, A. Vankovich, Conclusion: OATP1B3 measurement may be useful to I. Kazakov, P. Kim, N. Elizarova, E. Zamanov and diagnose ICG excretory defect. K. Grendal HPB Surgery Department, Loginov Moscow Clinical Sci- entific Center, Russian Federation EP01C-095 Aim: The aim of the study was to evaluate the short-term USEFULNESS OF FUNCTIONAL results of minimally invasive liver resections (MILR) for REMNANT LIVER VOLUME benign tumors. Materials and methods: During four years (2014-2017) ASSESSMENT USING EOB-MRI TO the total number of all liver resection was 525 with 175 PREDICT POSTHEPATECTOMY LIVER (33%) MILR. Benign liver tumors were the indication for FAILURE IN HEPATECTOMY OF MORE liver resection in 54 (10%) patients for hemangioma (31), THAN ONE SEGMENT adenoma (8), FNH (9) and cystadenoma (6). MILR were performed in 49 (91%): 39 lap and 10 robotic resections. K. Araki1, N. Harimoto1, N. Ishii1, M. Tsukagoshi1, Open approach was applied in 5 patients. Indications for T. Igarashi1, A. Watanabe1, N. Kubo1, H. Kuwano2 and resection were giant (>10 cm) growing lesions with clinical K. Shirabe1 signs and suspicion for malignancy. 1Department of Hepatobiliary and Pancreatic Surgery, Results: Major hepatectomy was performed in 7 (13%) and 2Department of General Surgical Science, Gunma patients. Partial resection of postero-superior segments and University, Japan caudate lobe was performed in 17 (31%) patients with ro- Introduction: Several reports described Gd-EOB-DTPA- botic system in 6 of them. enhanced MRI (EOB-MRI) can be potentially used for

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Major morbidity after MILR was observed in one (2%) treatment has been shown to have protective properties and patient (IIIA, Clavien-Dindo). There was no mortality. Bile to stimulate liver regeneration. This study aims to investi- leakage revealed in 3 of 5 patients after open resections gate the effect of preoperative EPO on survival following (IIIA). Mean operation time of MILR and open resection major hepatic resection in a cirrhotic rat model. was comparable: 280 (105-605) min and 290 (260-385) Methods: Cirrhotic liver was induced by intraperitoneal min, respectively. The mean blood loss for MILR and open injection of thioacetamide (200 mg/kg/ml) in 72 Lewis rats. procedures was 377 ml and 810 ml, respectively. The mean Each 36 rats received EPO (1 IU/g, every second day, 5 postoperative hospital stay after MILR and open resection times preoperatively) or saline (control) and major hepa- was 73 and 135 days, respectively. tectomy (removal of the left and half of the median lobe) Conclusion: MILR is the safe option for treatment of giant was performed. Biochemical and immunohistochemical symptomatic benign tumors and may be considered as the parameters, cytokines and overall survival were compared first choice approach if surgery is indicated. Difficult-to-reach following surgery. liver segments lesions is not a contraindication for centers Results: Rats that received preoperative EPO had with high volume of minimally invasive liver surgery. decreased hepatic aspartate aminotransferase, alanine aminotransferase, and interleukin (IL)-1b expression, 48 EP01C-097 hours following surgery. They had increased hepatocyte COMPARATIVE STUDY OF growth factor and vascular endothelial growth factor ESOPHAGEAL DEVASCULARISATION expression at 1 hour, increased IL-6 expression at 24, 48, and 120 hours, and increased Ki-67, 120 hours following WITH SPLENECTOMY VS PROXIMAL surgery. Overall survival was significantly improved SPLENORENAL SHUNT IN NON among EPO-treated rats (P = 0.034). CIRRHOTIC PORTAL HYPERTENSION Conclusion: Preoperative EPO treatment has a protective P. Gopal, S. Devakumar, A. Anbazhagan, effect and stimulates liver regeneration, leading to R. Shanmugasundaram and O. L. Naganath Babu improved overall survival following major hepatectomy in Madras Medical College, India a cirrhotic rat model. Background: Shunt surgery is preferred in patients with non cirrhotic portal hypertension (NCPH) for control of EP01C-099 variceal bleeding. However, for patients with non shuntable AN ASSESSMENT AND OUTCOME OF vein devascularisation procedure with splenectomy is the HEPATO-BILIARY-PANCREATIC only option. In this study , we retrospectively analyse the SURGERY FOR A ELDERLY PATIENT efficacy of devascularisation procedure versus Proximal Y. Katsuki, Y. Sakurai and K. Arai splenorenal shunt ( PSRS) in control of variceal bleed. Surgery, Shonan Tobu Medical Hospital, Japan Materials and methods: This is a retrospective study done from 2011-2017 at institute of Surgical Gastroenterology, Purpose: In recent years, there has been an increase in the Madras medical college, Chennai, India. Data were number of elderly patients undergoing hepato-biliary- collected from prospectively analysed electronic database. pancreatic surgery for malignant tumor of hepato-biliary- There were totally 36 patients who underwent surgery for pancrease(HBP). The purpose of this study was to report bleeding esophageal varices, after failed endotherapy in the outcome and assessment of hepato-biliary-pancreatic sur- background of NCPH. Among these 36 patients, 24 pa- gery in elderly patients with malignant tumor of HBP. tients underwent Devascularisation with splenectomy Methods: A total of 58 patients with malignant tumor of (group I), 12 patients underwent PSRS HBP underwent hepato-biliary-pancreatic surgery at our (group II) hospital from January 2015 to December 2017. Patients < Results: We compared the results of morbidity, mortality, were divided into elderly ( 75 years) and nonelderly ( 75 operative time, intraoperative blood loss, variceal rebleeding, years) groups based on age at the time of surgery. Groups residual varices and recuurent varices in both the groups. were compared with regard to general preoperative data, Rebleed rate was similar in both the groups with higher intraoperative data, postoperative 30-day complications operative time and intaoperative blood loss in Group II. and their severity, pathological result, and short-term out- Conclusion: Devascularisation procedure with splenec- comes (recurrence, overall survival (OS), and disease-free tomy is equally effective as PSRS for control of variceal survival (DFS) rates). bleeding with comparable results in terms of less morbidity Results: The elderly group was characterized by higher > , less operative time, less blood loss in NCPH. Charlson Comorbidity Index 2 and American Society of Anesthesiologists (ASA) grade. Comparisons of other fi EP01C-098 general preoperative data showed no signi cant differ- ences. In addition, there were no significant differences in PREOPERATIVE ERYTHROPOIETIN short-term outcomes except for postoperative 30-day TREATMENT IMPROVES SURVIVAL complication rate. Although 30-day postoperative compli- FOLLOWING MAJOR HEPATIC cation rate was higher in the elderly group compared with RESECTION IN A CIRRHOTIC RAT the nonelderly group, the incidence of major complications MODEL was similar between groups. Cancer recurrence, OS, and DFS rates also were similar between groups. Conclusion: S. -W. Suh and Y. S. Choi Although elderly patients with tumor of HBP had higher College of Medicine, Chung-Ang University, Republic of Charlson Comorbidity Index and ASA grade, they could Korea achieve short-term outcomes of hepato-biliary-pancreatic Aim: Major hepatic resection of a cirrhotic liver may result surgery similar to those of nonelderly patients. in a fatal clinical course. Preoperative erythropoietin (EPO)

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EP01C-100 Objectives: Analysis of the implementation of ERAS protocols (Enhanced recovery after surgery) in our center in PRE-OPERATIVE NOMOGRAM laparoscopic liver surgery (LLS). INCORPORATING INDOCYANINE Patients and methods: All LLS procedures performed in GREEN TEST TO PREDICT 90-DAY our Unit from January 2014 to October 2016 were MAJOR COMPLICATIONS AFTER analyzed. Dindo-Clavien and Iwate classifications were fi MAJOR HEPATECTOMY (MH) FOR used for complications and dif culty scoring, respectively. We defined: “Super fast-track” for patients discharged prior VARIOUS HEPATOBILIARY DISEASES to 24- and 48-hours in low-intermediate and advanced re- IN A WESTERN COHORT sections, respectively; and “Fast-track” for patients M. Rajakannu, D. Cherqui, O. Ciacio, N. Golse, G. Pittau, discharged in less than 48- and 72-hours in low-interme- M. A. Allard, A. Sa Cunha, D. Castaing, R. Adam and diate and advanced resections, respectively. E. Vibert Results: A total of 95 laparoscopic hepatectomies were Centre Hepato Biliaire, Hopital Paul Brousse - Université performed. The “super fast-track” protocol was completed Paris Sud, France in 43% and 37,5% patients in minor and major resections Background: Incidence of serious complications after MH respectively. A total of 67% and 56,3% patients completed has remained high despite considerable improvement in the “fast-track” protocol in the minors and majors re- mortality rates over last two decades and it has significant sections respectively. The percentage of overall complica- negative impact on post-operative survival and quality of tions was 15,2% with a CCI (Comprehensive Complication life in patients undergoing MH. No risk model is currently Index) of 2,085,8. There was one readmission (2,1%). available to identify those patients at higher risk of major The complications according to Dindo-Clavien classifica- complications after MH. tion were: I: 5(10,9%) and IIIa: 2(4,3%) -one biliary Methods: Prospective recruitment of patients undergoing leakage and 1 intraabdominal collection treated by CPRE MH for various indications was performed. Pre-operative and percutaneous drainage, respectively. None of the clinical and laboratory data including liver stiffness and complications was related with early discharge protocols. indocyanine green retention at 15 min (ICG-R15) were Conclusions: Excluding technically difficult cases, con- analyzed to identify independent risk factors for major versions and patients with BMI>35 and ASA IV, more complications, defined as >Grade II complications ac- than 50% of laparoscopic liver resections could be included cording to Clavien-Dindo classification during the 90-day in protocols for early or very early discharge. In highly post-operative period. A nomogram was built with only selected patients, liver surgery protocols can be performed pre-operative predictors and validated by Heat map plot. with hospital stay lower than 24 hours. The safety of our Results: Complications observed after 164 MHs (56.7% “fast-track” and “super fast-track” protocol is very high. men, median age-62 years) were Grade I (12.8%), Grade II (39%), Grade IIIa (9.8%), Grade IIIb (17.1%), Grade IVa (0.6%), Grade IVb (0%) and Grade V (2.4%) with 49 pa- EP01C-102 tients (29.9%) developing major complications. Three pre- COMBINED LAPAROSCOPIC ’ operative parameters: patient s age, ICG-R15, and extent of COLORECTAL AND LIVER RESECTION liver resection, were identified and internally validated by bootstrap as independent predictors of major complications FOR PATIENTS WITH SYNCHRONOUS after MH. A nomogram (Figure1) built with these three LIVER METASTASES OF COLORECTAL factors demonstrated a good discriminatory performance ORIGIN: A RETROSPECTIVE, with area under receiver operating curve of 0.76 and an MULTICENTER, PROPENSITY SCORE excellent Goodness-of-fit in Heat map plot. MATCHED STUDY Conclusions: This novel and simple nomogram accurately M. J. van der Poel1, P. J. Tanis1, A. M. Rijken2, predicts major complications in a patient undergoing MH. 3 4 3 This allows pre-operative identification of patients at risk and E. C. Gertsen , S. Ovaere , M. F. Gerhards , 3 1 ’ 4 may influence decision making for surgical intervention. H. A. Marsman , M. G. Besselink ,M.DHondt and P. D. Gobardhan2 1Academic Medical Center Amsterdam, The Netherlands, 2Amphia Hospital, The Netherlands, 3OLVG, The EP01C-101 Netherlands, and 4AZ Groeninge Hospital, Belgium IMPLEMENTATION OF ERAS Background: Laparoscopic simultaneous colorectal and PROTOCOLS (ENHANCED RECOVERY liver resection (LSCLR) is an option with potential benefits, AFTER SURGERY) AND CORRELATION but there are concerns whether SCLR could increase the WITH IWATE DIFFICULTY SCORING risk of morbidity compared with staged resections. This SYSTEM IN LAPAROSCOPIC LIVER study aimed to identify the impact on postoperative morbidity of adding a liver resection to a colorectal resec- SURGERY tion using a laparoscopic approach. 1 1 1 1 R. Ciria , I. Gómez-Luque , M. D. Ayllon , A. Padial , Methods: A retrospective, multicenter, propensity score 2 2 2 J. Gómez-Serrano , C. Garcia-Gaitán , C. Ruiz-Villen , matched study was performed comparing LSCLR (2009- 1 1 1 A. Luque , P. Lopez-Cillero and J. Briceño 2016; four centers) with laparoscopic colorectal resection 1 Unit of HBP Surgery and Liver Transplantation, and alone. Data from the Dutch ColoRectal Audit of two 2 Unit of Anaesthesia, University Hospital Reina Sofía, participating centers were used to match control patients Spain based on propensity scores in a 1:1 ratio. Propensity scores

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S435 were calculated based on 7 pre-operative variables. Pre-, EP01C-104 intra- and post-operative outcomes were compared using paired test. HEMODYNAMIC AND CLINICAL Results: A well-balanced cohort of 122 patients was EFFECTS OF SHUNT DIAMETER IN analyzed (61 patients undergoing LSCLR and 61 patients PORTACAVAL SHUNT: A SYSTEMATIC undergoing laparoscopic colorectal resection alone). Liver REVIEW resections consisted of minor resections only. LSCLR was E. Khajeh, M. Golriz, P. Fathi, O. Ghamarnejad and associated with a small increase in operating time (206 A. Mehrabi (166-308) vs 197 (148-231) minutes, p=0.057) and General, Visceral, and Transplantation Surgery, Heidel- increased blood loss (200 (100-700) vs 75 (5-200) ml, berg University, Germany p=0.011). Conversion rates were 5 and 8%, p=0.687. The incidence of severe complications (Clavien-Dindo grade 3 Introduction: Portacaval shunts (PCS) were used to fl or higher) (15% vs 21%), anastamotic leakage (8% vs 7%) decrease the portal vein ow (PVF) and pressure (PVP). and mortality (0% vs 2%) specifically did not differ be- However, the proper shunt diameter to optimize PVF and tween LSCLR and colorectal resection alone. PVP is still controversial. Our aim was to systematically Conclusion: In selected patients, LSCLR can be safely review the effects of different PCS diameters reported, to fi performed without increasing the risk of postoperative determine the ef cient shunt with lower complication rates. morbidity compared to laparoscopic colorectal resection Methods: A systematic literature search was performed to fi alone. nd studies reporting diameter of H-Graft PCS in patients with cirrhosis, portal hypertension and gastrointestinal varices. Articles reporting hepatic hemodynamic changes and outcomes with specified PCS diameters were included EP01C-103 and reviewed. MODERN APPROACH TO THE Results: Our search results identified 360 articles. After TREATMENT OF PATIENTS WITH screening, 12 studies with 440 patients were included in the ISOLATED LIVER TRAUMA study. Mean postoperative PVP was 19.35.5 in 8mm diameter and 16.73.8 in 10mm (p=0.0022). PVP A. Shabunin, M. Tavobilov, D. Grekov and P. Drozdov decreased 33.9% after 8mm PCS and 44.3% after 10mm City Clinical Hospital named by Botkin S.P., Russian (p=0.1242). PVF was prograde in 92.0% of patients with Federation 8mm and 74.9% with 10mm PCS (p=0.0002). Variceal Objective: To improve the results of treatment of patients rebleeding occurred in 3.1% of 8mm and 4.5% of 10mm with liver injury by applying a differentiated approach. PCS (p=0.5759). Shunt thrombosis occurred in 6.5% of Material and methods: From January 2008 to December 8mm group and 6.3% of 10mm (p=0.9502). Chronic en- 2017, there were 282 patients with liver injury in the cephalopathy was diagnosed in 3.6% of 8mm PCS and department of liver and pancreatic surgery. According to 13.4% of 10mm PCS (p=0.0060). fi the AAST classi cation, the distribution of patients was Conclusion: Diameter of a shunt plays an important role on as follows: class I -71 (25.2%), grade II -87 (30.9%), its efficacy. In patients with cirrhosis, portal hypertension grade III -79 (28.2%), grade IV -36 (12.8% ), V class - 8 and variceal bleeding, 8mm PCS comparing to 10mm PCS (2.9%). Laparotomy/laparoscopy was performed in 220/ was associated with higher prograde PVF, more efficient 282 patients (78%). Until May 2014, a diagnosed liver decrease in PVP, lower variceal rehemorrhage, and chronic injury with hemoperitoneum was an indication for encephalopathy. Further studies are necessary to compare prompt intervention, regardless of the degree of hemor- the role of shunt diameter on its efficacy. rhage. Since May 2014, an algorithm based on the prin- ciples of nonoperative management (NOM) in the abdominal trauma has been applied. The 62/282 pa- tients (22%) were applied to the NOM, of which 26/62 EP01C-105 patients (41.9%) underwent angiography with selective LIVER RESECTION IN ELDERLY embolization. PATIENTS Results: When comparing the results of surgical treatment A. Laurenzi, G. Maximiliano, M. D’Oliveira, G. Pittau, (group 1), conservative therapy (group 2) and selective O. Ciacio, R. Adam, E. Vibert, D. Castaing, embolization (group 3), we obtained the following data: the A. Sa Cunha and D. Cherqui average bed-day was 20.3; 7.4; 12,2 (p = 0,092), the Paul Brousse Hospital - Université Paris Sud, France average bed-day in the intensive care unit was 3.5, Introduction: The proportion of old people has risen over respectively; 0; 2.8 (p = 0.01), postoperative complications the past 50 years. Nevertheless such population presents were respectively: 16.9%; 0%; 6.4% (p = 0.01), lethality, an increased rate of comorbities; this can negatively respectively: 6.15%, 0%, 0% (p = 0.01), the average cost of impact on postoperative course after elective surgery. treatment: 6170.2 USD, 4 698 USD, 1081.5 USD (p = Liver surgery has gained an important role in the treatment 0.002). of liver tumors over the last 20 years, however overall Conclusion: Conducting strict NOM indications with morbidity and mortality rate are estimated at 22.6% and isolated liver trauma is effective, safe and economically 2.6% respectively. feasible.

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The aim of this study is to evaluate the impact of liver associated with shorter operating time (150 (108-224) vs surgery in elderly patients in order to identify patient that 198 (125-324) minutes, P=< 0.001), less blood loss (100 can benefit from liver resection. (50-305) vs 300 (105-600) ml, P=< 0.001) and a shorter Methods: We reviewed our prospective database of liver postoperative hospital stay (4 (3-6) vs 7 (5-9) days, P=< resections between April 2012 and December 2016. All 0.001). Post-operative severe morbidity (8% vs 6%, patients aged 65 years were collected. Patients were P=0.132) and mortality (0% vs 2%, P=0.157) were com- divided into 4 groups according to their age: group 1 (65- parable. Incisional hernias within 1 year follow-up were the 69yrs), 2 (70-74yrs), 3 (75-79yrs), 4 (80yrs). Preopera- same in both groups (2%). tive, intraoperative and postoperative data were analyzed. Conclusion: This international, propensity score matched Results: Four-hundred four patients underwent liver study supports the implementation of laparoscopic LLS as resection in the study period. Laparoscopic approach was standard procedure and emphasizes the advantages in terms used in 13.1% of the patients, while 37.6% of the patients of operating time, blood loss and postoperative hospital underwent major hepatectomy. Liver cirrhosis was present stay compared to open LLS. in 21% of the patients. Median hospital stay was 9 days. Overall morbidity (Clavien-Dindo 3a) was 15.8%, liver- related 12%, while extra-hepatic complications were 7.2%. EP01C-107 ’ Ninety-days mortality was 3.2%. Patient s age did not SURVIVAL OUTCOMES AFTER negatively impact on morbidity and mortality. At multi- variate analysis major hepatectomy, increased preoperative HEPATIC RESECTION FOR bilirubin and pedicle clamping >60’ were predictive fac- HEPATOCELLULAR CARCINOMA AND tors of postoperative morbidity while intraoperative trans- COMPARISON OF THERAPEUTIC fusions, insulin-dependent diabetes and cirrhosis were MODALITIES FOR RECURRED predictive of 90-days mortality. HEPATOCELLULAR CARCINOMA: A Conclusions: Liver resection is safe and feasible in selected elderly patients. SINGLE CENTER EXPERIENCE FOR 10 YEARS Y. Koh, C. Cho, H. Kim, Y. Hur and E. Park EP01C-106 Chonnam National University Hwasun Hospital, Republic SHORT-TERM OUTCOMES OF of Korea LAPAROSCOPIC VERSUS OPEN LEFT Introduction: Surgical resection is undoubtedly the stan- dard modality for resectable hepatocellular carcinoma LATERAL SECTIONECTOMY: AN (HCC). The aim of this study was to evaluate survival INTERNATIONAL PROPENSITY SCORE outcomes after hepatic resection for HCC and to compare MATCHED STUDY outcomes of various modality for recurred HCC. R. Fichtinger1, M. van der Poel2, B. Gorcek3, C. Verhoef4, Methods: Between 2004 and 2013, surgically resected M. de Boer5,M.D’Hondt6, M. Abu Hilal7, T. Terkivatan4, 500 cases for HCC at CNUHH were reviewed. For R. van Dam1 and M. Besselink3 calculation of cumulative survival, the Kaplan-Meier 1Maastricht University Medical Center+, 2Surgery, 3Aca- method was used. Comparisons were made with the uni- demic Medical Center, 4Erasmus Medical Center, Rotter- variate log-rank test. dam, 5University Medical Center Groningen, The Results: Male was predominant (Male: Female = 85.6 %: Netherlands, 6Groeninge Hospital, Belgium, and 7Uni- 14.4%) and Median age was 59.0 (range: 29-53). The mean w versity Hospital Southampton, United Kingdom follow up of all patients was 62 (48 120 months) months. The postoperative mortality rate was 2% (n=10). Overall 1-, Introduction: Laparoscopic left lateral sectionectomy 3-, and 5-year survival rates were 94.1%, 84.1%, and (LLS) is considered superior to open LLS and should be a 77.8%, respectively (mean, 90.2 months). Disease-free 1-, standard procedure in every liver surgery center. A suc- 3-, and 5-year survival rates were 69.1%, 46.6%, and cessfully completed RCT to support these statements is 36.8%, respectively (mea, 49.0 months). Recurrence was lacking. The aim of this study was to increase the level of observed in 254 patients (50.8%) during observation evidence supporting the advantages of laparoscopic LLS period. 30 patients underwent repetitive resection for using propensity score matching. recurred HCC. RFA, TACE, and chemotherapy or radio- Methods: We performed an international, retrospective therapy were performed in 78, 111, and 22 patients, cohort study including all patients undergoing open or respectively. Overall 1-, 3-, and 5-year survival rates were laparoscopic LLS between January 2000 and January 2017. 98.1%, 87.8%, and 83.6% (mean, 96.4 months), in radical Open and laparoscopic LLS were matched based on pro- intended treatment (repetitive resection and RFA) group, pensity scores in a 1:1 ratio. Propensity scores were 87.4%, 66.5%, and 53.8% (mean, 66.0 months) in TACE calculated based on 12 pre-operative variables. Pre-, intra-, and other treatment group, and, 69.2%, 18.5%, and 0% in and post-operative outcomes were compared using paired no-treatment group, respectively. tests. Conclusion: Hepatic resection was a safe and effective Results: A total of 560 patients were included in 6 centers therapeutic modality for HCC. Recurrence rate was high, in 3 countries. Out of 218 laparoscopic LLS, 117 were however, survival rate could be improved with active and matched with 117 open LLS. Baseline characteristics were proper treatment for recurred HCC. well balanced after matching. Laparoscopic LLs was

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5 EP01C-108 Hepatology, KU Leuven, Belgium, and Department of Surgery, Academic Medical Center, Amsterdam, The EMERGENCY PROXIMAL Netherlands LIENORENAL SHUNT(LRS) FOR Introduction: To evaluate the results of the first 250 VARICEAL BLEEDING IN PATIENTS laparoscopic liver resections (LLR) performed by a single WITH EXTRAHEPATIC PORTAL surgeon trained in laparoscopic surgery and hepatobiliary VENOUS OBSTRUCTION(EHPVO) surgery,and to investigate whether a learning curve is present. S. Roy1, N. Dash2, S. Pal1, P. Sahni2, Methods: Retrospective review of a prospectively main- T. K. Chattopadhyay2 and S. Nundy2 tained database of all patients who underwent LLR between 1Department of Gastroenterology and Human Nutrition, October 2011 and November 2017 at a single center.Five AIIMS Delhi, and 2Department of Gastrosurgery and consecutive groups of equal size were evaluated to inves- Liver Transplantation, AIIMS, India tigate the presence of a learning curve. Introduction: LRS is safe and effective (95%,15 year Results: During 73 months,379 liver resections were survival) one-time procedure for variceal bleeding in pa- performed, of which 251 procedures (66%) were tients of EHPVO. Endotherapy is favoured in acute bleed performed by a pure laparoscopic approach.From the but on failure, requires emergency surgery. We analysed first year to the most recent year, the percentage of LLRs our results of emergency LRS in this cohort. increased from 45% to 69.2%.Overall, 111 patients were Methods: All patients with EHPVO with acute variceal operated in semiprone position for resections in the bleed who had undergone emergency LRS after failed posterosuperior segments. Malignancy was present in endotherapy were included. 217(86.8%) of patients (colorectal liver meta- Results: Between 1975 and 2010 we operated 965 patients stases(CRLM) in 136 cases (54%)).Thirty-two patients with EHPVO of whom 50 underwent emergency LRS. The (12.8%) underwent a repeat hepatectomy. Median blood demogarphic variables were comparable. 3(6%) had loss was 100ml (IQR:50-250ml). Median operative time gastropathy and 3(6%) had biliopathy. Pre-operative was 135 minutes (IQR:90-180min).Conversion rate was endotherapy was done in 19 and 31 underwent direct LRS 2.4%.Peri-operative blood transfusion was needed in 5 due to massive bleed. 3(6%) died, 4 (8%) had early rebleed patients. Major complication rate (Clavien-Dindo and 1 late (2%) rebleed. 5 were re-explored,1 for rebleed grade III) was 3.2% (8 patients).R0 resection rate was and 4 for other surgical complications. The mean post 94.8%(238 cases).There was no 30-day mortality. In operative hospital stay was 12 days and none of them had patients with CRLM, 5-year survival rate was 65%.There encephalopathy over a mean follow up for 109 months were no significant differences,apart from a shorter (range 24-364). Liver functions were normal. hospital stay (p< 0.001) during the 5 consecutive In comparision to elective setting, emergency rescue periods. LRS carried higher mortality (1.1 vs 6%)), re-bleed rate Conclusion: Trained laparoscopic surgeons with an addi- (7.6% vs 10%), need for transfusion (6.5 vs 18.96%) and tional hepatobilairy fellowship may enter practice directly need for further endotherapy (8.4% vs 10%). A total 1500 from training and perform LLR with short term and shunts have been done over last 30 years in our department oncologic outcomes in line with early adopters and most for bleeding EHPVO. However since 2010 not a single experienced laparoscopic liver surgeons. emergency LRS has been done in view of increased experience in endotherapy. Conclusion: Compared with our published experience with elective LRS, emergency LRS is an effective therapeutic option for acute variceal bleed after failed endotherapy.

EP01C-109 SHORT TERM AND ONCOLOGIC OUTCOMES OF THE FIRST 250 LAPAROSCOPIC LIVER RESECTIONS PERFORMED BY A LAPAROSCOPICALLY TRAINED LIVER SURGEON M. D’Hondt1, E. Willems1, I. Parmentier2, H. Pottel3, C. Verslype4, C. De Meyere1, F. Vansteenkiste1 and M. Besselink5 1Digestive and Hepatobiliary/pancreatic Surgery, 2Oncology and Statistics, Groeninge Hospital, 3Inter- disciplinary Research Center KU Leuven Campus Figure Kortrijk, Leuven University, 4Gastroenterology and

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EP01C-110 trials were reported. The aim of this study was to perform an update systematic review and meta-analysis of studies OUTCOMES OF LAPAROSCOPIC AND comparing perioperative outcomes of laparoscopic vs. open OPEN SURGERY FOR BENIGN LIVER LLS. TUMOURS, WITH EMPHASIS ON Methods: A systematic review was performed in Medline, SYMPTOMS AND QUALITY OF LIFE. A EMBASE, Cochrane Library Central and Scielo/LILACS. SYSTEMATIC REVIEW Randomized and observational studies comparing periop- 1 1 1 erative results between laparoscopic and open LLS were B. V. van Rosmalen , J. J. de Graeff , M. J. van der Poel , st 1 1 2 included. The latest date for the search was December 31 , I. E. de Man , M. G. H. Besselink , J. Verheij and 2017. Treatment outcomes, including conversion rate, T. M. van Gulik1 1 2 estimated blood loss, transfusion rate, operative time, Surgery, AMC, and Pathology, AMC, The Netherlands hospital stay, morbidity and mortality were evaluated. Background: Symptomatic benign liver tumours (BLT) Results: A total of 2566 articles were initially evaluated, may be an indication for surgery. Surgical treatment exists and 20 studies included in the meta-analysis (18 observa- of laparoscopic and open liver resection. However, surgical tional and 2 randomized trials). Conversion rate was 8.7%. outcomes have never been compared before in a systematic Laparoscopic LLS showed shorter hospital stay [mean review, as well as the influence of type of surgery on relief difference (MD)=-2.19days; 95%CI -2.70-(-1.67); I2=78%, of symptoms and quality of life (QOL). P=< 0.001; N=3116]; lower blood loss [MD=-119.81ml; Methods: Two independent reviewers performed a sys- 95%CI -127.90-(-111.72); I2=32%; P=< 0.001, N=618]; tematic literature search in Pubmed and Embase. All arti- lower transfusion rate [risk difference [RD]=-0.06; 95%CI cles on surgery for symptomatic BLT were abstracted. -0.08-(-0.04); P=< 0.001; I2=12%; N=2924]; marginal Methodological quality was evaluated using the MINORS decrease in overall morbidity [RD=-0.03; 95%CI -0.06- tool. Outcomes were divided in open and laparoscopic. (-0.00); P=0.07; I2=0%; N=3224]; and lower perioperative Results: A total of 69 articles were analysed, including mortality [RD=-0.02; 95%CI -0.02-(-0.01); P=0.01; 4913 patients receiving surgery for BLT. 3749 patients I2=0%; N=3288]. There was no difference regarding received open surgery and 1164 laparoscopic. A total of operative time, cardiac and pulmonary complications and 1022 major resections were performed: 581 open and 33 reoperation rate between the groups. laparoscopic. Blood loss, operative time and length of Conclusion: Laparoscopic had better perioperative results hospital stay were respectively 457ml, 183min and 8,2days than open approach and should be recommended as the for open surgery, versus 124ml, 146 min and 6,4days for gold-standard approach for LLS. laparoscopic. The most common indication for surgery was symptoms: 61,9%. Overall, symptoms decreased from 69% preoperative to 16% postoperative. 2 out of 14 studies EP01C-112 using a validated QOL questionnaire reported an advantage for laparoscopy, 12 didn’t report differences. A total of 309 MAJOR HEPATECTOMIES FOR complications were reported: (7,2%) open and (3,7%) ADVANCED LIVER ECHINOCOCCOSIS: laparoscopic. A SINGLE CENTER EXPERIENCE Conclusion: Blood loss, operative time, length of hospital L. Lauka, I. Jelovskis, S. Gerkis and A. Sivins stay and complications were less for laparoscopic surgery, Soft Tissue and Abdominal Surgery, Riga East Clinical which can be explained by the majority of minor resections. University Hospital, Latvia Oncology Center, Latvia However, as the percentages of complications are still far Introduction: Liver echinococcosis is a disease that in apart, it could be considered to perform more extensive advanced cases requires excessive surgical treatment and laparoscopic surgery for BLT in selected patients. by its nature can resemble a malignant disease, especially in a case of alveolar echinococcosis. Latvia is an area with low prevalence, nevertheless, surgical treatment mostly require EP01C-111 major hepatectomies. Latvia Oncology Center is a leading LAPAROSCOPIC VS. OPEN LEFT liver surgery center in Latvia with approximately 60 hep- LATERAL SECTIONECTOMY: AN atectomies performed a year. UPDATE SYSTEMATIC REVIEW AND Methods: From 2014 to 2017 thirteen surgeries were performed for liver echinococcosis in Latvia Oncology META-ANALYSIS OF RANDOMIZED Center. In 10 cases it was major hepatectomy - hemi- AND NON-RANDOMIZED hepatectomy (n=2) or extended hemihepatectomy (n=8) CONTROLLED TRIALS without or with biliodigestive reconstruction (n=3). Nine R. L. Macacari, F. F. Coelho, W. M. B. Bernardo, patients had received medical treatment; only in 1 case J. A. P. Kruger, V. B. Jeismann, G. M. Fonseca, regression was observed. Average operation time was 5 D. M. Cesconetto, I. Cecconello and P. Herman hours and 50 minutes. There were 2 men and 11 women. Department of Digestive Surgery and Coloproctology, São Average age was 54 years (range 25-80). Paulo University / School of Medicine, Brazil Results: Of 10 patients after major hepatectomies, eight Background: Left lateral sectionectomy (LLS) is consid- developed complications, half of them grade III or more ered the most suitable anatomical liver resection to be (Clavien-Dindo). The most often complication was liver fi performed laparoscopically. Laparoscopic LLS has been insuf ciency (n=6). Three patients underwent percutaneous increasingly performed, however studies specifically abdominal collection drainage and/or thoracostomy. Two comparing laparoscopic and open LLS are mostly retro- of them were discharged with drains in place; both had fi spective with small sample size. Only recently prospective external bile ducts resection due to in ltration of lesions.

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One patient died on operation day due to excessive 7Niguarda Ca’ Granda Hospital, Milan, 8Loreto Nuovo bleeding, this patient had an excessive spread of disease Hospital, Naples, 9Università degli Studi di Parma, and with partial infiltration of vena cava, previous multiple 10Vimercate Hospital, Italy surgeries and stenting of IVC. Postoperative course was Introduction: Increased expertise with minimally invasive uneventful for patients undergoing minor hepatectomies. liver surgery (MILS) may justify an extension of in- Conclusions: Advanced liver echinococcosis is a disease dications to benign disease resection. Aim of this study was that often requires major surgery and is related with sig- to evaluate operative risk of MILS for benign disease and if nificant risk of postoperative complications. MILS has widened indications for resection. Method: Prospective study including centers with >6 MILS for benign disease, enrolled in the I Go MILS reg- EP01C-113 istry from January 2015 to October 2016. Cysts fenestra- SHORT-TERM OUTCOMES OF tions were excluded. LAPAROSCOPIC HEPATECTOMY IN Results: 173 MILS were performed in 15 centers. Con- version rate was 6.9%. Postoperative mortality and EXTREMELY ELDERLY PATIENTS morbidity rates were 0 and 13.9%. During the same period, R. Marukuchi, S. Onda, J. Yasuda, K. Haruki, H. Shiozaki, 3713 liver resections were performed, of which 818 MILS. T. Hata, T. Gocho, H. Shiba, Y. Ishida and K. Yanaga Rate of MILS for benign disease did not increase during the Surgery, The Jikei University School of Medicine, Japan years (24.1% in the first period vs. 22.0% in the last period; Introduction: In developed countries, Laparoscopic hep- p=ns). Overall indication for benign disease (open+MILS) atectomy has been widely performed in recent years. was 11.0%, significantly higher in low-volume centers (< However, few studies have reported the outcome of lapa- 100 resections/year) than in high-volume (100 resections/ roscopic hepatectomy in elderly patients. Herein we report year) (15.4% vs. 10.2%; p< 0.001). Rate of laparoscopic short-term outcomes of laparoscopic hepatectomy in approach for benign disease was 42.5%, significantly extremely elderly patients. higher in low-volume centers than in high-volume (63.9% Methods: From July 2006 to August 2017, 71 patients vs. 37.5%; p< 0.001). Major and posterior segments re- underwent laparoscopic hepatectomy at Jikei University sections rates were significantly lower in MILS group than Hospital. Of these, seven patients (10 %) were older than 80 in the open (15.0% vs. 34.2% and 11.6% vs. 30.3%; p< years at surgery. We compared the short-term outcomes of 0.001) but not significantly different between low- and laparoscopic hepatectomy in extremely elderly patients ( high-volume centers. 80 years of age; (group A, n=7) and non-extremely elderly Conclusions: MILS for benign disease was feasible and patients (< 80 years of age; (group B, n=64), as well as safe. Low-volume centers resected more benign disease extremely elderly patients undergoing open minor hepa- than high-volume centers, but without showing any in- tectomy during the same period (group C, n=13). crease during the years. Rate of difficult and major MILS Result: The mean age of Group A, B, and C were 82.6, was not significantly different between low- and high- 59.7 and 83.9 years, respectively. The preoperative ASA volume centers. score (1/2/3) was 0/6/1 in group A, 11/46/7 in group B, and 0/12/1 in group C. The indications (primary cancer/meta- static/others) in group A, B, and C was 3/4/0, 32/18/14, and EP01C-115 8/5/0, respectively. The conversion rates from laparoscopy BUDD-CHIARI SYNDROME e to laparotomy, and the postoperative hospital stay were OUTCOMES OF SURGICAL PORTAL comparable between group A and B (14% versus 16%, p=1.000; 9.7 days versus 8.8 days, p=0.802). The in- DECOMPRESSION AND LIVER cidences of postoperative complications among three TRANSPLANTATION groups were comparable {14%, 8% versus 15%, p (A V. Gunasekaran, T. S. Chandrasekar, versus B) =0.559, p (A versus C) =0.948}, and there was no T. -M. Ahmed Shaikh, R. Rajalingam, G. Narasimhan, in-hospital mortality in these three groups. M. S. Reddy and M. Rela Conclusion: Laparoscopic hepatectomy seems to be safe Institute of Liver Disease and Transplantation, Gleneagles and acceptable in extremely elderly patients. Global Health City, India Introduction: Budd-Chiari syndrome (BCS) is charac- terised by hepatic venous outflow obstruction. We present EP01C-114 the management outcomes of BCS patients. LIVER RESECTION FOR BENIGN Methods: The records of 55 patients who presented with DISEASE: HAVE THE INDICATIONS BCS between 2011 and 2017 to were retrospectively INCREASED IN THE ERA OF reviewed. Management plan was based on severity of symptoms, underlying liver function, level of outflow MINIMALLY INVASIVE APPROACH? obstruction and patency of retrohepatic cava. Patients were AN IGOMILS-BASED STUDY accordingly managed by non-operative procedures, F. Ardito1, L. Aldrighetti2, A. Guglielmi3, E. Jovine4, decompressive shunt surgery and liver transplantation. U. Cillo5, A. Ferrero6, L. De Carlis7, G. Belli8, Results: The median age at presentation was 24.8 years(1- R. Dalla Valle9, A. Slim10 and Italian Group of Minimally 43 years). Seven patients had underlying haematological Invasive Liver Surgery disorder.There were 35 male and 20 female patients. One 1Catholic University, Rome, 2San Raffaele Hospital, patient presented with acute BCS. Nonsurgical Interven- 3University of Verona, 4Maggiore Hospital, Bologna, tional procedures were done in 11 patients with Cavoplasty 5Policlinico Universitario, Padua, 6Mauriziano Hospital,

HPB 2018, 20 (S2), S333eS504 S440 Electronic Posters (EP01A-EP01E) - Liver alone in 8, Hepatic venoplasty with RHV stenting in 2 and safe minimally invasive variant of ALPPS for rapid FLR TIPS in 1 patient. hypertrophy in patients with h-CCA and i-CCA. Twenty nine patients underwent surgery for BCS. Sur- gical procedures performed were Liver transplantation in 15 patients (Living donor-13;Deceased donor-2),Portal EP01C-117 decompression in 12 patients(Porto-caval shunt-5,Meso- BENEFITS OF HEPATECTOMY caval shunt-7),Retro-caval cyst excision in 1 and Denver shunt in 1 patient. COMBINED WITH SPLENECTOMY IN Morbidity in patients with transplantation included bile PATIENT WITH HEPATOCELLULAR leak in 3, chyle leak in 2, MHV thrombosis in 1 patient and CARCINOMA AND CHILD B LIVER mortality rate was 0.6% (1/15). Median hospital stay was FUNCTION: A CASE-MATCHED STUDY 24 days(11 - 182 days). Mean follow-up was 16 months. Y. Pei, X. Chen and W. Zhang In patients with portal decompression, morbidity Hepatic Surgical Center, Tongji Hospital, Tongji Medical included chyle leak in 2 and shunt thrombosis in 1 patient College, Huazhong University of Science and Technology, and 1 death with mean follow-up of 10.3 months. China Conclusion: Budd Chiari syndrome is a challenging clin- fi ical problem affecting young patients. Management should Objective: To explore the bene ts of hepatectomy com- be tailored to the anatomy of the obstruction and underlying bined with splenectomy for patients with hepatocellular liver function. carcinoma (HCC) and Child B liver function through a case-matched study. Methods: We identified 245 patients underwent hepatec- tomy for HCC and Child B liver function. Among these EP01C-116 patients, 116 patients performed simultaneous hepatectomy RADIO-FREQUENCY ASSISTED LIVER and splenectomy (the HS group); other 129 patients just PARTITION WITH PORTAL VEIN underwent hepatectomy (the H group). The one-to-one EMBOLIZATION IN STAGED LIVER matching produced 95 paired patients, survival analysis RESECTION (RALPPS) IN PATIENTS was compared and liver function one year later was WITH HILAR AND INTRAHEPATIC reassessed. Results: The postoperative liver failure rates were 7.37% CHOLANGIOCARCINOMA and 6.15% (P=0.95), the postoperative mortality rates were M. Efanov, R. Alikhanov, V. Tsvirkun, Y. Kulezneva, 6.15% and 4.6% (P=0.86) in the HS group and H group, O. Melekhina, P. Kim, I. Kazakov, A. Vankovich, respectively. The 1-, 3-, and 5-year overall survival (OS) E. Zamanov and N. Kulikova rates were 94.8%, 56.2% and 24.9% in the HS group, and HPB Surgery Department, The Loginov Moscow Clinical 82.1%, 38.5% and 10.5% in the H group, respectively (P< Scientific Center, Russian Federation 0.001). After multivariable analysis, tumor size, tumor Objective: Estimation of the short-term results of Radio- number, postoperative liver failure, and Child-Pugh score frequency Assisted Liver Partition with Portal vein embo- were independent risk factors for OS. The proportion of liver lization in Staged liver resection (RALPPS) compared with function turned to Child A one year after surgery was 95.4% Portal Vein Embolization (PVE) and subsequent major in the HS group, while only 83.3% in the H group (P=0.02). liver resection in patients with hilar (h-CCA) and intra- Conclusions: Compared with non-splenectomy, hepatec- hepatic (i-CCA) cholangiocarcinoma. tomy combined with splenectomy for patients with HCC Summary background data: Unsatisfactory immediate and Child B liver function showed no different periopera- outcomes of associating liver partition and portal vein tive outcomes but achieved significant survival benefit. ligation for staged hepatectomy (ALPPS) in surgery of Splenectomy is a beneficial factor for patients with HCC cholangiocarcinoma suggested that patients with biliary and Child B liver function; liver function improved cancer should not be treated by ALPPS. Short-term results significantly at one year after splenectomy. of ALPPS variants with reduced surgical trauma on the first Keywords: Hepatocellular carcinoma, Child B liver func- stage in patients with cholangiocarcinoma were not yet tion, hepatectomy, splenectomy. estimated. Methods: RALPPS and PVE were applied in 10 and 18 EP01C-118 patients respectively. Future liver remnant (FLR) was OPERATIVE OUTCOMES OF LIVER estimated by CT. The propensity score matching method RESECTION: A 9-YEAR EXPERIENCE was used in compared groups. AT THE MEDICAL CITY Results: The mean rate of FLR hypertrophy after RALPPS/ PVE before and after matching was 42%/32% and 49%/ R. Maddumba, V. de Villa, D. Ang and M. Sumo 31%, respectively. The mean duration of hypertrophy after Surgery, The Medical City, Philippines RALPPS/PVE before and after matching was 16/20 days Hepatectomy, once high-risk and resource-exhaustive and 14/17 days, respectively. Major morbidity rate (IIIa surgery, has evolved to be a routine and safe procedure. A grade, Clavien-Dindo) after the stage 1 was significantly liver center was established in our hospital in 2008 and larger for RALPPS before matching. There were no dif- hepatectomies have since been increasingly performed. ferences in morbidity of stage 1 after matching as well as This is a review of our operative outcomes for 9 years. for stage 2 before and after matching. Data of hepatectomies performed between July 2008 and Conclusions: According to preliminary short-term results June 2017 were collected retrospectively and reviewed with estimation RALPPS may be considered as an effective and attention to patient demographics, intraoperative data, and

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S441

30-day operative outcomes. There were 135 liver resections Conclusion: This study describes the profile of BF after performed during the study period. The median patient age hepatectomies. The threshold of 12 days defines the was 56 years and majority were males (67%). Fifteen persistency of the BF. percent had cirrhosis, the majority caused by Chronic Hepatitis B. The indication for surgery was malignancy in 73%, mostly HCC followed by colorectal liver metastasis. EP01C-120 Living donor hepatectomy was the most common non- EARLY EXPERIENCE FROM A malignant indication for surgery (7%). Major resection ( 4 segments) comprised 31% of cases, mostly right hepa- HEPATOBILIARY CENTER DURING A tectomies. Median blood loss was 625 ml. The majority TIME OF NATIONAL FINANCIAL (70%) had no blood transfusion. Complication rate was CRISIS 16%, the majority due to pneumonia. There were two A. Tooulias1, S. Chatziisaak1, A. Prionas1, reoperations: one for abdominal compartment syndrome V. Papagiannis2, G. Tsoulfas1 and V. N. Papadopoulos1 (ACS) and the other for partial gut obstruction due to 11st Surgical Department, Aristotle University of Thessa- malrotation. Three patients (2.2%) expired within 30 days loniki, and 2Intervational Radiology, G.H. Papageorgiou, of surgery due to post-operative liver failure in a cirrhotic, Greece sepsis from fungemia, and ACS. Introduction: The goal is to record and evaluate the early Major liver resections can be safely performed in our steps of a tertiary hepatobiliary center during a time of hospital with a relatively young HPB program. The national financial crisis. operative outcomes were acceptable with low mortality Method: Prospective cohort of patients (N=101) between (2.2%) and morbidity (16.4%) rates. Good outcomes can 2011 until 2017. Patients undergoing liver surgery or trans- be achieved by adequate preoperative preparation, arterial chemoembolization (cTACE or DSM-TACE) or meticulous surgical technique and optimum perioperative ablation (RFA, MWA) and combination of the above, were management. considered eligible. Demographics, risk factors, histopa- thology and outcomes were recorded. Child-Pugh and MELD were used for classification of HCC patients. EP01C-119 Management decisions were made according to BCLC CAN THE PERSISTENCY OF BILIARY criteria. FISTULAS BE PREDICTED AFTER A Results: Among the total of 101 patients with a mean age HEPATECTOMY ON HEALTHY LIVER? of 64 years old (37-87), 71 were males. Histopathological fi BI-CENTER STUDY ON 139 PATIENTS nding revealed that 75 of our patients suffered from pri- mary liver neoplasias (56 HCC, 15 CCA, 1 GIST, 1 NET, 1 1 1 1 C. Maulat , D. Dousse , M. Lallement , Focal Nodular Hyperplasia). The risk factors for patients 1 1 1 A. Hantoush Al Ali , T. Tuyeras , G. Tuyeras , with HCC included HBV (21), HCV (2), HBV and ETOH 2 1 2 1 L. Chiche , B. Suc , C. Laurent and F. Muscari (4), HCV and ETOH (1), ETOH (11), NASH (2), primary 1 Chirurgie Digestive et de Transplantation, CHU bile cirrhosis (1), hemosiderosis (1) and idiopathic (13). 2 Toulouse, and CHU Bordeaux, France Overall, 54 patients underwent surgical resection, 20 Introduction: The biliary fistula (BF) is one of the major TACE, 11 ablation, 6 combination of resection and TACE, complications after hepatectomy. This study permits to 2 of surgery and ablation, 5 of TACE and ablation and 3 define the persistent BF and to isolate its predictive factors. were treated with both resection, TACE and ablation. Method: All patients included in this bi-center study from Kaplan-Meier analysis revealed a survival deficit in patients 2004 to 2016 had a BF after hepatectomy. This study undergoing one type of operation over the patients that included the duration distribution of BFs in order to were managed with combination of procedures. determine when a BF was considered to be persistent. Conclusion: Our results suggest that a multidisciplinary Univariable and multivariable analysis were performed on approach of patients with primary liver disease has signif- 65 variables to research predictive factors for persistent icant clinical benefits. Future high quality studies are biliary fistula (pBF). necessary in order to confirm or oppose our observations. Results: The study included 139 patients, 59% had he- patic resection for CRLM (Colorectal Liver Metastases) and 27% had biliary-digestive anastomosis. BF were EP01C-121 fi diagnosed by biloma (49%), external stula (43%), and RISK FACTORS OF BILE LEAK AND ITS choleperitonitis (8%); respective time frame of appear- e ance were 10 days, 3 days and 6 days. The threshold for CONSEQUENCE SINGLE CENTER pBF was 12 days. Bilomas resulted in more pBF, the STUDY OF 501 CONSECUTIVE LIVER daily flow rates were more significant for the pBF from RESECTIONS fi the rst day. In the pBF group, the median drying-out V. Spetzler1, M. Schepers1, H. Pinnschmidt2, M. Koch1, duration was 33 days (13-141) vs. 10 days. Five pre- E. -G. Achilles1, U. Herden1, L. Fischer1, B. Nashan1 and dictive factors were isolated: BMI 27, extended hep- J. Li1 atectomy, ALAT Day 1 415, Total bilirubin 25, BF 1Department of Hepatobiliary Surgery and Transplantat Day 1 100 ml. A predictive score was developed and it Surgery, and 2Institute of Medical Biometry and Epide- > showed that the BF would be persistent when it was miology, University Medical Center Hamburg-Eppendorf fi 0.5 with a sensibility of 93%, a speci city of 60%, a VPP (UKE), Germany of 92% and a VPN of 64%.

HPB 2018, 20 (S2), S333eS504 S442 Electronic Posters (EP01A-EP01E) - Liver

Bile leaks are one of the most common complications patients (17%) had an ablation site recurrence [median in- after liver resection. The International Study Group of Liver terval 9 months (7, 17)] and 15 patients had a liver-only Surgery (ISGLS) established a uniform bile leak definition recurrence without ablation site. 6 patients underwent a including a severity grading. The goal of our analysis was liver transplantation after HCC ablation. Although no im- to assess risk factors discriminatingly for the three ISGLS aging of tumour recurrence, liver histology was positive in bile leak grades. 3 patients. The study included a total of 501 liver resections be- Conclusion: Local control after ablation of liver tumours tween July 2012 and December 2016. The total rate of bile remains a delicate issue and should be followed closely leaks was 14.0% (grade A/B/C, 2.8/8.0/3.2%). Univariate although iconographic interpretation post-ablation is not and a multivariate regression analyses were performed for unequivocal. risk factor assessment. Patients that had had chemotherapy recently before liver resection suffered more often from grade A and B bile EP01C-123 leaks. Patients with a biliary disease (gall-bladder carci- LAPAROSCOPIC VERSUS OPEN LIVER noma, cholangiocarcinoma or benign biliary diseases) and patients who had required biliary interventions (ERC or RESECTION OF RIGHT POSTERIOR PTC) before the operation and who usually received a bilio- SEGMENTS e A SINGLE CENTRE digestive reconstruction, had an increased risk for grade C COMPARATIVE STUDY leaks. Major liver resections were associated with increased M. Papoulas1, E. Kontis1, S. Majid1, M. Pizanias1, rates of all three grades. In univariate but not in multivariate A. Gupta2, N. Heaton1 and K. Menon1 analysis, staged hepatectomies (ALPPS) were a risk factor 1Institute of Liver Studies, and 2Anaesthesiology, King’s fi for bile leaks and liver brosis had a protective effect on the College Hospital NHS Foundation Trust, United Kingdom occurrence of bile leaks. Patients with all three grades of Introduction: Patients with lesions in the right posterior bile leaks had on average an increased length of hospital- segments of the liver have been considered poor candidates stay. Mortality and surgical site infections were signifi- for laparoscopic liver resection (LLR). To compare short- cantly increased in grad C leaks, only. term outcomes of LLR and open liver resections (OLR) of Grad C bile leaks are clinically most relevant and are the right posterior segments. associated with malign and benign biliary diseases and Methods: Retrospective review of patients undergoing preoperative biliary interventions as well as bilio-digesitve resection of the right posterior segments of the liver from anastomoses. Especially these patient groups require June 2016 to December 2017 in our tertiary centre. increased awareness peri-operatively. Results: Nineteen and 17 patients underwent LLS and OLR, respectively. The mean age and gender distribution were comparable between groups. In three patients EP01C-122 (15.8%), a conversion to open surgery was indicated. The SURGICAL MICROWAVE ABLATION max tumour diameter was comparable between the groups OF PRIMARY AND SECONDARY LIVER (4.04 2.52cm in LLR versus 3.88 2.26 in OLR, TUMOURS: ICONOGRAPHIC FOLLOW- p=.876). Similar operating times were found in LLR and UP AND LOCAL CONTROL OLR (244.66 79.42min and 220.75 102.35min respectively) (p=0.187). There was no difference in intra- L. F. Abreu de Carvalho, S. Sagaama, H. Maes, S. Laurent, operative blood loss (p=0.539), duration of Pringle M. De Man, A. Geerts, K. Geboes, manoeuvre (p=0.157) and resection margins (p=0.114). H. Van Vlierberghe and R. I. Troisi Postoperative complications were comparable with similar Ghent University Hospital, Belgium Dindo-Clavien (DC) score. Length of stay (LOS) was Introduction: Microwave ablation allows the treatment of shorter following LLR (4.8 1.72 versus 9.0 3.9 days, small hepatic tumours with limited morbidity but local p< 0.0005). recurrence is a known pitfall. Conclusion: Shorter LOS with similar short-term out- Methods: A prospectively gathered monocentric database comes place LLR as an attractive alternative to OLR for was reviewed for the assessment of the local control after selected patients with lesions in the right posterior sector. hepatic ablation. Results: Between January 2013 and December 2016, 121 patients underwent a hepatic ablation. Combined proced- EP01C-124 ures were excluded, remaining 54 patients with 78 lesions QUALITY OF LIFE IN PATIENTS WHO in total. 32 patients (60%) had hepatocellular carcinoma (HCC), 18 patients (33%) had colorectal liver metastases UNDERWENT LIVER RESECTION FOR and 4 patients (7%) had other metastases. There were only 3 BOTH BENIGN AND MALIGNANT open procedures. Median operating time was 121 (104, DISEASES: A SINGLE CENTRE STUDY 155) minutes and median hospital stay was 3 (3, 4) days. E. Uy Magadia1, C. Teh1,2 and A. Casupang2 Major morbidity (Clavien-Dindo grade 3 and 4) occurred in 1General Surgery, and 2Liver Center, National Kidney and 4 patients (7%). An incomplete ablation was diagnosed in 9 Transplant Institute, Philippines patients (17%). The findings were sometimes incongruent Background/aim: Hepatic resection has evolved into a between CT and MRI or in time. Retrospective analysis common surgical procedure for a wide range of benign and was necessary to differentiate an incomplete ablation from malignant indications. Despite the complexity of resections local recurrence. A total of 32 patients (60%) had a recur- and the co-morbidities of patients increasing, reported rence after a median follow-up of 24 months (9, 37). Nine morbidity rates have remained relatively stable over time.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S443

Patient-centred outcomes that look beyond short-term Median OS and RFS were similar among those with and mortality and disease-free survival should be part of quality without cirrhosis (p-values: 0.05,0.09 respectively). Pres- outcomes in a hepatic resection. Quality of Life (QoL) ence of vascular invasion has a negative influence on OS studies have shown to be an important marker in deter- (p=0.007) and RFS (p=0.005). Resection margin of < 5mm mining outcomes in patients who underwent hepatectomy. is a negative predictor of RFS (p=0.01). Therefore, studies on the QoL after liver resection will be Conclusions: Similar recurrence rates among those with evaluated in this study. cirrhotic and non-cirrhotic liver could indicate an under- Methodology: From 2009 to 2017, all patients screened lying chronic inflammatory pathology in the background with liver tumors who underwent liver resection were ’normal’ liver and would warrant appropriate surveillance included in the study. QoL was assessed using the Quality for both groups. Careful pre-operative evaluation of liver of Life Assessment Forms (Functional Assessment of function might allow major resection to obtain clear mar- Cancer Therapy - Hepatobiliary Version 4) which will be gins and achieve longer RFS. given at first visit prior to surgery, 30 and 90 days post-op. The questionnaire consisted of multi-item scales, which consists of Physical, Social/Family, Emotional, Functional EP01C-126 and other additional concerns of the patient. SURGICAL RESECTION OF GALL Results: A total of 48 patients underwent liver resection from 2009-2017. Quality of life was significantly improved BLADDER CANCER AMONG PATIENTS 90 days after hepatectomy. Those who underwent hepa- PRESENTING WITH JAUNDICE: A tectomy via laparoscopic approach had significant better SYSTEMATIC REVIEW AND META- outcomes, QoL scores returned to baseline immediately 30 ANALYSIS days post-operatively compared with an open approach. B. Dasari1, M. Ionescu1, T. Pawlick2, J. Hodson3, J. Isaac1, Conclusion: Liver resections significantly improved the P. Muiesan1, K. Roberts1, R. Sutcliffe1, QoL of patients who underwent hepatectomy. Sex, age, co- R. Marudanayagam1 and D. Mirza1 morbidities, tumor size and complications were significant 1Queen Elizabeth Hospital Birmingham, United Kingdom, determinants for the quality of life in these patients. 2Ohio State University, Wexner Medical Center, United States, and 3Medical Statistics, Queen Elizabeth Hospital Birmingham, United Kingdom EP01C-125 Introduction: Preoperative jaundice has been considered a SURGICAL RESECTION OF relative contraindication to radical resection of gall bladder HEPATOCELLULAR CARCINOMA cancer (GBC) due to poor prognosis and high postoperative AMONG PATIENTS WITH CIRRHOTIC morbidity. However, recent reports have suggested that AND NON-CIRRHOTIC BACKGROUND aggressive surgery may improve long-term survival among LIVER: A COMPARATIVE ANALYSIS OF patients with advanced GBC and obstructive jaundice. We sought to compare the post-operative outcomes among POST-OPERATIVE OUTCOMES patients with resectable GBC presenting with and without B. Dasari1, J. Hodson2, K. Roberts1, R. Sutcliffe1, jaundice based on a systematic review and meta-analysis. M. Ionescu1, P. Muiesan1, D. Mirza1, Methods: An electronic search of Medline, EMBASE, R. Marudanayagam1, J. Isaac1 and S. Kamarajah3 CINAHL, and Pubmed was performed using the following 1Queen Elizabeth Hospital Birmingham, 2Medical Statis- MeSH terms: ’cholecyst’, ’gallbladder’, ’tumour’, ’cancer’, tics, Queen Elizabeth Hospital Birmingham, and 3Queen ’carcinoma’, ’adenocarcinoma’, ’neoplasia’, ’neoplasm’, Elizabeth Hospital, United Kingdom ’jaundice’, ’icterus’. Overall survival following surgery Introduction: Hepatocellular carcinoma (HCC) usually was the primary outcome; resectability and post-operative develops in the background of chronic inflammation. In morbidity were the secondary outcomes assessed. about 15-20% of the patients, HCC could be arising in Results: Eight non-randomised studies met inclusion normal background liver. The current study is aimed at criteria. Among the 2,089 patients with GBC, 33.6% had comparing the histological evaluation of the background preoperative jaundice. Patients with jaundice were more liver and outcomes among the patients with HCC devel- likely to have advanced disease (OR:5.87,95% CI:2.41- oping in the liver with and without cirrhosis. 14.33,p< 0.001). In turn, the odds of death long-term was Methods: Patients who underwent liver resection for HCC markedly higher among patients who presented with between 2004-2017 were included. Pre-operative evalua- jaundice (HR:2.21,95% CI:1.64-2.97,p< 0.001). tion of background liver was performed based on the Following surgery, patients who had GBC and jaundice had clinical history, biochemical, radiological assessments and a higher risk of post-operative morbidity (OR:3.54,95% liver biopsy in selected patients. Post-hepatectomy liver CI:2.47 - 5.06,p< 0.001), bile leak (OR:2.15,95% CI:1.24- insufficiency (PHLI), recurrence-free (RFS) and overall 3.71, p=0.006) and post-hepatecomy liver failure survival (OS) were compared. Univariate analyses were (OR:6.67,95% CI:2.61-17.02, p< 0.001) than patients who performed to identify predictors of survival. did not have preoperative jaundice. Results: 179 patients who underwent liver resection for Conclusions: Radical surgical resection of GBC among HCC. Variations existed in the pre-operative vs. post- patients presenting with obstructive jaundice was associ- operative evaluation of background liver: normal (69% vs. ated with more advanced disease, increased perioperative 48%), cirrhotic (19.5%vs.15.6%), fibrotic (10.6%vs.9.5%). morbidity, as well as markedly worse long-term survival. The incidence of PHLI was similar among the groups Patients with GBC presenting with jaundice should be (p=0.815), with a tendency to select parenchymal preser- carefully evaluated and counselled before considering ving surgery for those with abnormal liver (p< 0.001). extensive surgical resection.

HPB 2018, 20 (S2), S333eS504 S444 Electronic Posters (EP01A-EP01E) - Liver

EP01C-127 Method: Retrospective analysis of patients undergoing liver resection between 2010-2016. Patients without ASSESSMENT OF LIVER available perioperative weight were excluded. Primary INFLAMMATION AND FIBROSIS AFTER outcome was postoperative major morbidity according to WEIGHT LOSS SECONDARY TO Clavien classification defined as Clavien III-V. Secondary BARIATRIC SURGERY IN PATIENTS outcomes were overall complications, Comprehensive WITH NONALCOHOLIC FATTY LIVER Complication Index (CCI) and length of hospital stay (LoS). DISEASE Results: A total of 181 patients were analyzed. Major and M. Alsharidah, F. A. Alghamdi, H. Aldosri, A. Alharbi, overall postoperative complications were reported in 25 A. Alwarthan, F. Bamihrez, H. Alkhaldi, A. Alsharabi, (14%) and 87 (48%) patients, respectively. LoS was 8 days F. Alsaif and M. Hassanain (6-12). On POD2, median POGW was 2.6 kg (1.1-4.0). Surgery, King Saud University, Saudi Arabia Perioperative weight gain correlated with duration of sur- Background: Non-alcoholic fatty liver disease (NAFLD) gery (r=0.36, p< 0.001), CCI (r=0.267, p< 0.001) and LoS is characterized by fatty infiltration and marked activation (r=0.215, p< 0.001). Area under ROC (AUROC) was 0.74, of inflammatory cells and cytokines. In obese patients, identifying an ideal cutoff of 3.5kg, which yielded a bariatric surgery has been shown to reduce effectively liver sensitivity and specificity of 72% and 70.5%, respectively, steatosis and inflammation with controversy when it comes to predict major complications. On multivariable analysis, to liver fibrosis. In this study we examined the effect of cirrhosis (OR, 6.45; 95% CI, 1.35-30.81; p =0.02) and bariatric surgery on systemic inflammation in patients with weight gain (OR, 4.73; 95% CI, 1.51-14.80; p=0.008) were NAFLD. The samples were collected prospectively as part independent predictors for major complications. of prospective study (number: NCT01619215). Conclusions: Perioperative weight gain >3.5kg is an in- Objective: The present study aims to assess the correlation dependent and modifiable predictor for major complica- between liver function, systemic inflammatory markers, tions after liver resection. and liver histological changes in NAFLD patients under- going bariatric surgery. Methods: Blood samples were obtained at two time points: EP01C-129 just prior to surgery and 3 months post-operatively. Sam- SALVAGE HEPATECTOMY FOR HCC ples obtained to evaluate liver function, selected metabolic, and inflammatory markers. RECURRENCE AFTER FAILED RFA, Results: total of 51 patients (16 male, 35 female) with a TACE OR PEI: AN UNLOCK GATEWAY mean age of 33.6 (SD=9.5), The median body mass index TO THINK OF changed from 43.9 8.7kg/m2 to 37.4 11.6kg/m2 (p- G. Petracca, M. Iaria, L. Ferrara, A. Spotti, G. Bianchi, < value 0.0001). ALT dropped from 36 23.3 to 34 13.6 G. Missale and R. Dalla Valle (p-value=0.03), IL1 decreased from 3.2 331 to 3.2 431 Parma University Hospital, Italy (p-value< 0.0001), MCP1 decreased also from 611.9393 Introduction: Outcomes of salvage hepatectomy for local to 550.4443 (p-value=0.01), microvascular steatosis recurrent hepatocellular carcinoma (HCC) after loco- percentage dropped from 312 to 110 (p-value=0.0003) regional or percutaneous treatments are still unclear. and macrovesicular steatosis percentage changed from Methods: We conducted a retrospective analysis of 92 1524 to 218 (p-value< 0.0001). consecutive patients with HCC who underwent either pri- Conclusion: Our result revealed that liver function and mary liver resection (group 1, 65/92) or salvage hepatec- systemic cytokines are improved along with histopatho- tomy for recurrent HCC after failed percutaneous or loco- logical changes in NAFLD patients 3 months following regional treatments (group 2, 27/92). bariatric surgery. Further work is needed to study the long- The two cohorts were compared in terms of perioperative term effects on these markers. mortality and morbidity and long-term disease-free and overall survival rates were analized. Results: Group 2 patients were previously submitted to a EP01C-128 different range of treatments such as: RFA (17 cases), RFA PERIOPERATIVE GAIN OF WEIGHT IS + PEI (4 cases), TACE (4 cases), RFA + TACE (2 cases). A PREDICTOR OF MAJOR HCC average size was comparable between group 1 and 2 COMPLICATIONS AFTER (27.6 mm vs. 27.5 mm, respectively). In 6/60 (group 1) and 11/27 (group 2) liver resections were performed lapa- HEPATECTOMY roscopically. Perioperative mortality rate was nihil in both I. Labgaa, G. -R. Joliat, G. Jarrar, F. Grass, N. Halkic, groups and morbidity rate was comparable. The median N. Demartines and M. Hübner progression-free survival was 16 months [CI 95% 12.3- Visceral Surgery, Lausanne University Hospital CHUV, 19.6] for group 1 and 43 months [CI 95% 22.5-63.4] for Switzerland group 2 (p=0.013). The median overall survival was 68 Introduction: Major complications after hepatectomy are months [CI 95% 32.4-103.5] for group 1 and 81 months responsible for a considerable clinical and financial burden. [56-106.9] for group 2 (p=0.015). Preliminary data suggested that early perioperative gain of Conclusions: Salvage hepatectomy for HCC recurrence in weight may be associated with adverse outcomes after patients not resected upfront, whose HCC relapsed after abdominal surgery. The present study aims to investigate failure of loco-regional or percutaneous procedures, ap- the predictive value of perioperative weight gain for major pears to be safe and effective. In our limited series, it complications after hepatectomy. provided optimal outcomes in terms of disease-free and

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S445 overall long term survival, being a reasonable option in complications and Comprehensive Complication Index such patients. (CCI). Secondary endpoint was length of hospital stay (LoS). Area under ROC (AUROC) analysis was used to determine a predictive cut-off value for DAlb. EP01C-130 Results: A total of 155 patients were analyzed. Serum al- HYDATID LIVER CYSTIC DISEASE bumin showed a rapid decrease after liver surgery (POD0, 4-6 hours after surgery), with a mean DAlb of 13.5 mg/L ( WITH PORTAL VEIN INVASION: A 6.4). Overall complications were reported in 90 (58%) RARE COMPLICATION AND patients. Median CCI and LoS were 20.9 (0-29.6) and 9 TREATMENT days (7-15), respectively. DAlb correlated with blood loss (r=0.377, p< 0.001) and CCI (r=0.277, p< 0.001). M. Linhares, L. Silva, C. Maeda, R. Moura and R. Fuziy D Universidade Federal de São Paulo, Brazil AUROC of Alb for overall complications was 0.71 and ideal cutoff was determined at 13 mg/L. On multivariable Introduction: Hydatidosis is an endemic zoonosis, caused analysis, DAlb was the only independent predictor for by the parasite Echinoccocus granulosus. The liver is the overall complications (OR, 2.12; 95% CI, 1.03-4.39; most commonly affected organ. The disease is slowly p=0.042). progressive and may remain asymptomatic for several Conclusions: DAlb is an early predictor for complications years. When symptomatic, the clinical presentation may after liver surgery. A cutoff of 13 mg/L identifies patients at vary from abdominal pain, jaundice and even anaphylactic higher risk. shock in extreme cases. One of the most common com- plications of disease is the fistulization of a hydatid cyst into the biliary tree. However, other intrahepatic structures may be rarely involved. The purpose of this study is to EP01C-132 report a case of liver hydatid cyst with direct portal vein IMPACT OF BILE LEAKAGE ON invasion, an unusual complication of this condition. PERIOPERATIVE AND LONG-TERM Methods: case report. ONCOLOGICAL OUTCOME Results: A 62-year-old man comes to the outpatient clinic referring abdominal pain in the right hypocondrium for 3 E. Braunwarth, F. Primavesi, B. Cardini, R. Oberhuber, months. He denies jaundice and weight loss. He claims to T. Resch, M. Maglione, C. Margreiter, S. Schneeberger, have been travelling in South America for several months. D. Öfner and S. Stättner CT scan shows multiple confluent cysts in segments VII Department for Visceral-, Transplantation- and Thoracic and VIII, with heterogeneous content and parietal calcifi- Surgery, Medical University Innsbruck, Austria cations, measuring about 13 x 6.5 cm. Two other cystic Background: Bile leakage is a frequent and severe images with the same characteristics are present in segment complication following liver surgery. This study aims to V. There is thrombosis of the right portal branch. The evaluate risk factors and related outcome parameters. thrombus has attenuation similar to the cystic lesions Methods: All hepatic resections performed at the Medical described above, corresponding to the portal extension of University Innsbruck between 2005 and 2016 were retro- the hydatid cyst. The patient underwent an open right spectively analysed. Perioperative risk factors related to hepatectomy and gross examination of the surgical spec- postoperative bile leakage were identified using univariate imen confirmed the presence of hydatid material inside the and multivariate analysis. Kaplan-Meier method was used right portal branch. for survival analysis. Conclusion: Although rarely, hydatid cysts may directly Results: Bile leakage (according ISGLS definition) involve the portal vein. occurred in 52 of 498 liver resections (10%), excluding bilioenteric-anastomosis (7%). The incidence of bile leakage was higher in patients after major hepatectomy (15 < EP01C-131 vs. 6%, p 0.001), whereas there was no difference be- tween benign and malignant diseases (7 vs. 12%, p=0.193). EARLY POSTOPERATIVE DECREASE Postoperative 90-day-mortality (11 vs. 4%, p=0.411) and OF SERUM ALBUMIN: A BIOMARKER 90-d-morbidity excluding bile leakage (37 vs. TO PREDICT COMPLICATIONS AFTER 29%,p=0.231) was not significantly different within both LIVER SURGERY? groups. Portal vein embolization, bilioenteric-anastomosis, regional lymphadenectomy, vascular reconstruction and I. Labgaa, G. -R. Joliat, G. Jarrar, N. Halkic, M. Schäfer, intraoperative T-drainage were significant factors in uni- N. Demartines and M. Hübner variate analysis for developing bile leakage. Only Visceral Surgery, Lausanne University Hospital CHUV, lymphadenectomy (HR:2.43) and bilioenteric-anastomosis Switzerland (HR:4.99) remained significant in multivariate analysis. Introduction: There is growing evidence that post- D Postoperative renal failure and surgical site infections were operative decrease of serum albumin ( Alb) might predict more common in patients with bile leakage. Median sur- complications after major abdominal surgery. This study D vival in the entire cohort (42 vs. 65mo, p=0.14) and among aimed to study Alb in liver surgery and to determine a cut- malignant disease (39 vs. 54mo, p=0.23) was not statisti- off value to discriminate patients with and without post- cally affected by bile leakage. Moreover, disease-free sur- operative complications. vival (12.0 vs. 10.0mo, p=0.88) was comparable in both Method: Retrospective analysis of patients undergoing groups. liver surgery between 2010-2016. Patients with missing Conclusion: Bile leakage is a frequent complication pre- and postoperative albumin values were excluded from following major liver resection, whereby bilioenteric- the analysis (n=120). Primary endpoints were overall

HPB 2018, 20 (S2), S333eS504 S446 Electronic Posters (EP01A-EP01E) - Liver anastomosis and regional lymphadenectomy are significant Methods: All consecutive cases of LLR between risk factors. However, neither short-term postoperative November 2007 and May 2017 and 1:1 case matched OLR mortality nor long-term oncological outcome is affected by during same period were enrolled in this retrospective this specific complication. cohort study. All surgical procedures were performed by one surgeon(KH Kim). The LLR and OLR groups were compared in terms of demographics, clinical perioperative EP01C-133 outcomes. IS THE IWATE SCORE REALLY USEFUL Results: A total of 61 cases of LLR were performed in patients over 70 years of age during the study period, IN PREDICTING THE COMPLEXITY OF including 36 cases of HCC, 5 cases of intrahepatic chol- LAPAROSCOPIC LIVER RESECTION? angiocarcinoma, 5 cases of liver metastasis of colorectal C. Muñoz, A. Hessheimer, V. Molina, J. Fuster, cancer, 7 cases of IHD stone, 3 cases of biliary cystade- J. C. Garcia-Valdecasas and C. Fondevila noma, 2 cases of biliary IPMN, 2 cases of hemangioma, and HPB and Transplant Surgery, Hospital Clínic de Barce- 1 case of liver cyst. LLR group (n=61) had a significantly lona, Spain shorter postoperative hospital stay than the OLR group < Laparoscopic liver resection (LLR) is a technically (n=61) (9.1 2.3 vs 12.3 2.1 days, p 0.001) and less demanding undertaking; scoring systems have been estimated blood loss than OLR group (153.4 67.5 vs < developed to help predict surgical complexity in LLR. 260.4 89.2mL, p 0.001). Aim: To evaluate the utility of the Iwate Score Index (ISI) in Conclusions: LLR is a well considered operation in pa- predicting perioperative events indicative of surgical diffi- tients over 70 years of age who have no abnormality in culty and risk for failure using the laparoscopic approach. pulmonary and cardiac function. The authors suggest that Methods: We retrospectively analyzed all LLR performed LLR could be a reasonable operative option for selected old at our center between 01/2009 and 12/2017. Important aged patients. perioperative outcomes were evaluated as a function of the ISI score in each case. EP01C-135 Results: 201 LLR were performed, including 40 major and VON WILLEBRAND FACTOR 161 minor liver resections (3segments).MedianISIwas5 ANTIGENE IS ASSOCIATED WITH (IQR 2-11). According to the ISI, 70% of the lesions were ONKOLOGICAL OUTCOME IN localized in a favorable segment of the liver for LLR, 58% PATIENTS UNDERGOING MAJOR were >3cm in diameter, 88% were not proximal to major vascular structures, and 87% were undertaken via a purely LIVER RESECTION laparoscopic approach. Diverse surgical procedures were P. Starlinger1, D. Pereyra1, P. Bräuer1, S. Hägele1, performed: 30% non-anatomical (local) resection, 23.4% left C. Brostjan1 and T. Grünberger2 lateral sectionectomy, 22.9% segmentectomy, 23.4% more 1Department of Surgery, Medical University of Vienna, than segmentectomy. While there was no significant correla- and 2Department of Surgery, Rudolfstiftung Hospital tion between ISI and perioperative blood loss, there were Vienna, Austria significant positive correlations between ISI and operative Background and aims: While we recently reported on the time (r=0.37, p< 0.001) and conversion to open surgery (2.8% association of von Willebrand factor antigene (vWF-Ag) when ISI < 6 pts and 12.9% when ISI >6pts,p< 0.001). and poor postoperative outcome in patients undergoing Conclusion: In our experience, the ISI is an accurate pre- liver resection, this highly complex protein was also set in dictor of operative time and risk for conversion to open context with cancer development and metastasis. However, surgery. While prospective validation is necessary, it appears available experimental data is not conclusive on whether to provide useful guidance to help avoid futile attempts at vWF-Ag acts as a pro- or as an anti-tumorigenic agent. LLR when the surgeon does not have enough experience. Thus, we aimed to clarify the role of vWF-Ag on onco- logical outcome after major liver resection. Methods: 76 patients undergoing major hepatectomy were EP01C-134 prospectively included in this study. vWF-Ag was assessed COMPARATIVE STUDY OF preoperatively and patients were followed up for disease recurrence. LAPAROSCOPIC LIVER RESECTION Results: Significantly elevated levels of vWF-Ag were found AND OPEN LIVER RESECTION IN in patients with disease recurrence at 6, 12 and 24 months PATIENTS OVER 70 YEARS OF AGE after liver resection (p=0.038,p=0.011,p=0.016, respec- H. -D. Cho, K. -H. Kim, D. -H. Jung, G. -C. Park, tively). ROC-analysis was performed to assess the predictive T. -Y. Ha, C. -S. Ahn, D. -B. Moon, S. -H. Kang and potential and showed a good discriminatory potential be- S. -G. Lee tween patients with and without disease recurrence within the Division of Hepatobiliary Surgery and Liver Trans- first 6 months for preoperative vWF-Ag (AUC=0.699). A plantation, Department of Surgery, Ulsan University and cut-off at 157% was found to detect patients at risk for early Asan Medical Center, Republic of Korea disease recurrence after 6 months (3.6%vs26.3%, p=0.014), Introduction: Laparoscopic liver resection(LLR) tends to 12 months (7.7%vs38.9%, p=0.006) and 24 months (39.1% fi be preferred by young patients because of its cosmetic vs70.6%, p=0.018). Ultimately, patients identi ed by this fi effect. The aim of this study was to compare the results of cut-off showed a signi cantly reduced disease free survival laparoscopic liver resection and open liver resection(OLR) (1.3 years vs. 2.6 years, p=0.007). Conclusion: to evaluate the safety and efficacy of laparoscopic liver vWF-Ag seems to be associated with resection in patients over 70 years of age. early disease recurrence after liver resection. Indeed,

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S447 preoperative vWF-Ag was found to be a reliable predictor Introduction: The ability to predict 30-day readmission for for recurrence even within the first 6 postoperative months patients following liver resection can improve health out- and thus might be useful in preoperative decision making comes and equity. for high-risk patients. Methods: A case-control retrospective study was con- ducted for readmission in a large single center including EP01C-136 743 liver resection patients from 2000-2016. Multivariate INFLUENCE OF PERIOPERATIVE propensity score (PS)-adjusted regression was conducted SELECTIVE SEROTONIN REUPTAKE for causal inference to determine the most predictive comorbidities and clinical variables. Regression analysis INHIBITOR THERAPY ON included age, sex, race, ASA (American Society of Anes- POSTOPERATIVE OUTCOME IN thesiologist) score >2, body mass index (BMI), major PATIENTS UNDERGOING LIVER resection, cirrhosis, hypertension (HTN), diabetes (DM), RESECTION obesity, tumor size and margin, prior abdominal surgery, 1 2 3 4 and the likelihood of undergoing laparoscopic versus open B. Rumpf , D. Pereyra , P. Jonas , A. Assinger , 1 3 1 surgery. C. Brostjan , T. Grünberger and P. Starlinger 1 Results: Department of Surgery, Medical University of Vienna, The mean age in the study was 57.22 (standard 2Department of Surgery, Medical University of Vienna, deviation [SD] 13.61), 452 (43.88%) were female, and 100 General Hospital Vienna, 3Department of Surgery, (13.46%) were readmitted. Patients who were readmitted fi Rudolfstiftung Hospital Vienna, and 4Institute of Physi- were signi cantly more likely to be African American and > ology, Medical University of Vienna, Austria have American Society of Anesthesiologist scores 2, Medicare or Medicaid instead of commercial insurance, Background and aims: fi Previously, modi cation of intra- hypertension, and diabetes (all p< 0.01) . In multivariate platelet serotonin was hypothesized as a potential interven- regression, laparoscopic versus open surgery had no asso- tion to improve liver regeneration in patients undergoing liver ciation with readmission. The top readmission predictors resection. However, within a recent study our group showed a were hypertension (OR 8.56, p< 0.001) followed by Af- potential adverse effect of high intra-platelet serotonin in rican American race (OR 2.77, p< 0.001). terms of oncologic outcome. Within this study, exploratory Conclusions: Our analysis identified significant racial and data on the use of selective serotonin reuptake inhibitors insurance disparities in readmission following liver resec- (SSRI) was collected. Still, the number of patients with SSRI tion, in addition to specific comorbidities and clinical var- therapy was limited. Thus, we now aimed to evaluate the use iables. This analysis suggests efforts to reduce health of selective serotonin reuptake inhibitors (SSRI) in a large disparities and target patients with particular risks factors cohort of patients undergoing liver resection. may produce more effective, equitable care. Methods: 333 patients were included out of our prospec- tively maintained institutional data base. Intake of SSRI during the perioperative period was recorded. Patients were followed up for postoperative liver dysfunction (LD) and EP01C-138 morbidity. HOW GOOD LAPAROSCOPIC LIVER Results: In total, 37 patients (9.1%) were perioperatively RESECTIONS ARE? A PROPENSITY treated with SSRI. Patients with SSRI intake showed a SCORE-MATCHED ANALYSIS OF higher incidence of morbidity (40.9% in no SSRI vs 48.6% PERIOPERATIVE OUTCOMES in SSRI, p=NS) and a significantly increased incidence of LD (10.5% in no SSRI vs 21.6% in SSRI, p=0.047). Ulti- V. B. Jeismann, F. F. Coelho, J. A. P. Kruger, mately, logistic regression analysis was computed and G. M. Fonseca, D. M. Cesconetto, R. L. Macacari, showed a significantly increased risk for postoperative LD I. Cecconello and P. Herman in patients using SSRI (p=0.039,OR=2.939). Gastroenterology, University of Sao Paulo Medical Conclusion: The present study is the first one to present School, Brazil solid data on an association between SSRI intake and poor Introduction: Laparoscopic liver resection is considered postoperative outcome in patients undergoing liver resec- one of the last frontiers of laparoscopic surgery. The tion. This association might be due to an impairment of experience with this approach is growing, however, good liver regeneration as a result from decreased intra-platelet quality comparative data remains scarce. In this study, we levels of serotonin. compared perioperative results of patients undergoing open and laparoscopic liver resections. EP01C-137 Methods: Consecutive patients undergoing liver resection DO CO-MORBIDITIES, CLINICAL between July 2008 and January 2016 were studied. Study VARIABLES, OR SURGICAL APPROACH groups were compared after propensity score matching (PSM). PREDICT READMISSION POST LIVER Results: Five hundred ninety liver resections were included RESECTION? in the comparative analysis: 470 open and 120 laparoscopic. D. Monlezun1, P. McLaren2, J. Sulzer2,C.Li1, A. Volk1, After PSM, 120 patients were included in each group. M. Mvula1, K. -V. Van Anh1, M. Darden3, G. Parker4 and Laparoscopic technique had shorter operative time (286.83 J. Buell1 133.42 352.44 141.5 minutes, P < .001), shorter 1Surgery, Tulane University School of Medicine, 2Surgery, hospital stay ( 5.813.89 9.99.29 days, P < .001), and Louisiana State University Health New Orleans, 3Public lower morbidity (19.2% 35%, P = .008). There was no Health, George Washington University, and 4Dartmouth difference regarding estimated blood loss, transfusion rate College, United States or mortality.

HPB 2018, 20 (S2), S333eS504 S448 Electronic Posters (EP01A-EP01E) - Liver

Conclusion: Laparoscopic liver resection presented better Background: Hepatocellular carcinoma (HCC) is perioperative outcomes, mainly shorter hospital stay and frequently associated with varying degrees of liver lower morbidity. Experience with the laparoscopic tech- cirrhosis. This study investigated how the histological nique should be encouraged in specialized centers. cirrhotic severity affects the surgical outcomes of HCC patients after curative liver resection (LR). EP01C-139 Methods: A series of 1524 patients with HCC who SEVERE POSTOPERATIVE MORBIDITY received curative LR between 1999 and 2015 was reviewed RELATED TO MAJOR retrospectively. Liver cirrhosis was histologically staged as mild, moderate, or severe based on the Laennec grading HEPATECTOMIES PERFORMED FOR system. Surgical outcomes between the groups was LIVER BENIGN TUMOR: A BI-CENTRIC compared. RETROSPECTIVE STUDY Results: Mild, moderate, and severe cirrhosis were iden- M. Chetboun1, T. Piardi1, R. Rhaiem1, A. Cayeux1, tified in 575 (37.7%), 597 (39.2%), and 132 (8.7%) pa- P. Pessaux2, R. Kianmanesh1 and D. Sommacale1 tients, respectively, and 220 (14.4%) patients were non- 1HPB, General and Endocrine Surgery, University Hos- cirrhotic. The patients in the severe cirrhosis group pitals of Reims, and 2HPB Surgery, University Hospital of exhibited significantly higher morbidity and mortality rates Strasbourg, France than those with mild, moderate or non-cirrhosis. The 5-year recurrence-free survival (RFS) and overall survival (OS) Introduction: Liver benign tumors (LBT) are rare lesions rates were 36.8% and 64.5% in the non-cirrhotic group; that may be managed by surgical resections. The present 34.8% and 60.4% in the mild cirrhosis group; 17.3% and study reports on major hepatectomies performed for LBT 43.4% in the moderate cirrhosis group; and 6.1% and with a special focus on severe postoperative morbidity. 24.1% in the severe cirrhosis group, respectively. RFS and Methods: Patients who underwent major hepatectomies for OS rates did not differ significantly between the non- LBT were included retrospectively from two HPB expert cirrhotic group and the mild cirrhosis group; however, centers in a cross-sectional study. long-term survival was significantly worse as cirrhotic The primary endpoint was the 90 postoperative days (90- severity increased. Based on multivariate analysis, moder- POD) severe morbidity (Clavien grade III). ate and severe cirrhosis were independent risk factors for Results: From 1999 to 2016, among 277 liver resections, decreased RFS and OS. 71 patients underwent major hepatectomy performed for Conclusions: More histologically severe cirrhosis signifi- LBT. Patients were mostly young (44 15 years) females (75%;n=53). cantly worsens the short-term and long-term outcomes of Right (83%;n=59) and left (17%;n=12) hepatectomies HCC patients who receive LR. Evaluating the histological were performed for unique (73%;n=52) or multiple cirrhotic severity should be emphasized as an important fi (27%;n=19) LBT. Tumor mean size was 100 60 mm. novel parameter for determining the safety and ef cacy of Intraoperative injuries occurred in 17% (n=12) mainly LR to treat HCC. represented by hepatic veins or vena cava injuries (6%;n=4). 90-POD mortality was 1.4%, one patient died from acute liver failure without access to liver transplantation. EP01C-141 Overall 90-POD medical or surgical complications SMALL FOR SIZE SYNDROME (SFSS) occurred in 58% (n=41). Surgical complications occurred AND HYPOXIA: LESSONS LEARNED in 23% (n=16), while medical complications occurred in FROM THE ASSOCIATED LIVER 51% (n=36) of the patients. Severe 90-POD medical or surgical complications PARTITION AND PORTAL VEIN happened in 18% (n=13) of the patients. Medical compli- LIGATION FOR STAGED cations (11%;n=8) were significantly higher than surgical HEPATECTOMY (ALPPS) PROCEDURE complications (9%;n=6) (p=0.05). One patient needed an IN RATS emergency liver transplant for acute liver failure. A. Dili1, V. Lebrun2, C. Bertrand3 and I. Leclercq2 In multivariate analysis, intraoperative injury was an in- 1Surgery & Laboratory of Hepato-Gastroenterology, CHU dependent risk factor of severe postoperative complications. UCL Namur/ UCL/Istitut de Recherche Expérimentale et Conclusion: Major hepatectomies for LBT are rare pro- Clinique, 2Laboratory of Hepato-Gastroenterology, UCL/ cedures leading to significant postoperative complications. Institut de Recherche Expérimentale et Clinique, and The over-risk of non-surgical life-threatening complica- 3Surgery, CHU UCL Namur, Belgium tions should not be ignored in the surgical decision. Excessive portal hypertension with compensatory arte- rial constriction of the future liver remnant (FLR) is EP01C-140 considered the main cause of SFSS after major hepatec- HISTOLOGICAL SEVERITY OF LIVER tomy. ALPPS combines portal vein ligation and paren- CIRRHOSIS: AN IGNORED KEY chymal transection to obtain rapid hypertrophy of FLR for PLAYER IN THE SURGICAL patients needing marginal hepatectomy, with high risk of TREATMENT OF HEPATOCELLULAR postoperative SFSS. This procedure sets the FLR in the same hemodynamic portal conditions as in SFSS, and yet, CARCINOMA patients survive, and obtain boosted FLR hypertrophy. B. Liang, Z. Huang and X. Chen This study analyzes the role of hepatic hemodynamics in Hepatic Surgery Center, Tongji Hospital, Tongji Medical liver regeneration and differences between SFSS and College, Huazhong University of Science & Technology, ALPPS. China

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S449

Mortality, FLR mass recovery assessment (ALPPS vs Conclusions: MELD score of 13mg/dl preoperatively SFSS). Flow analysis of portal trunk and hepatic artery per was significantly associated with increased risk for any FLR perfused (Qpv/FLR, Qha/FLR) (Sham, ALPPS, postoperative complications, 30-day mortality and SFSS). Immunohistochemistry and ELISA on hypoxia increased length of hospital stay. TAB score did not prove markers performed. to be helpful in correctly identifying the patients at risk for Seven-day mortality: ALPPS:29.41%, SFSS: 77,78% developing complications or mortality. (p< 0,0001). 7-day FLR mass recovery improved in ALPPS vs SFSS (p=0,02). ALLPS and SFSS proved similar increase in shear stress (Qpv/FLR) compared to EP01C-143 < Sham (p 0.0001). However, FLR arterial perfusion (Qha/ IMPACT OF SURGICAL MARGIN FLR) in ALPPS was decreased compared to SFSS (p=0,0007). A higher percentage of hypoxia in ALPPS was ACCORDING TO AFP RATE BEFORE confirmed by pimonidazole immunostaining (p=0,0002), as HEPATECTOMY FOR well as HMGB1, HIF1a and HIF2a. When hypoxia was HEPATOCELLULAR CARCINOMA induced in SFSS by dimethyloxaloglycine (DMOG) mor- F. Marques1, E. Boleslawski2, O. Ciacio1, D. Cherqui1, tality decreased (DMOG-SFSS: 16,6%, SFSS: 77,78%) M. A. Allard1, N. Golse1, R. Adam1, O. Farges3, < fi (p 0,0001). No signi cant difference in FLR regeneration J. Y. Mabrut4 and E. Vibert1 between ALPPS and DMOG-SFSS. 1Centre Hépatobiliaire, Hôpital Paul Brousse, 2Chirurgie fi Our study suggests that liver insuf ciency in SFSS is not Digestive et Transplantation, CHRU Lille, 3Chirurgie related to parenchymal desarterialisation; adversely, Hépato-pancréato-Biliaire, Hopital Beaujon, and 4Service reduction of arterial liver perfusion, observed in ALPPS, de Chirurgie Générale, Digestive et Transplantations may protect the FLR from hepatocellular failure and stim- Hépatiques et Intestinales, Hospices Civils de Lyon, France ulate regeneration, as proved in hypoxia induced SFSS. Introduction: Surgical margins in hepatocellular carci- noma (HCC) are required to remove potential satellite nodules and microvascular invasion. The aim of this study EP01C-142 was to assess if preoperative tumors with high AFP (>100 DETERMINANTS OF OUTCOME ng/ml) required wider margins than tumors with low AFP. FOLLOWING HEPATECTOMY BY Methods: Between April 2012 and January 2016, all pa- EVALUATING PROGNOSTIC tients (n=397) who underwent a first hepatectomy without SIGNIFICANCE OF DIFFERENT macroscopic remnant disease (R2) were analyzed in eHPBChir Group (5 centers). Preoperative prognostic fac- SCORING SYSTEMS tors for time to recurrence were analyzed in univariate and D. Zirpe1, C. Gopakumar2, S. Swain2, S. Das2, multivariate analysis. The impact of surgical margins ( 1 B. Vibhute1, A. Khakhar2 and A. Ramamurthy2 cm or not), in patients with AFP rate inferior or superior to 1Liver Transplantation & GI Surgery, Sahyadri Speciality 100 ng/ml on the time to recurrence (TTR) and the overall Hospital, and 2Liver Transplantation & GI Surgery, survival (OS) were studied. Apollo Hospital, India Results: Preoperative high AFP rate (> 100 ng/ml) was Introduction: Present study evaluated factors mentioned in observed in 98/397 (25%) patients and resection margin < scoring systems such as Child Turcott Pugh (CTP) score, 1cm was retrieved in 247/397 (62%) patients. The com- Model of End Stage Liver Disease (MELD) score.A parison of low and high AFP patient groups was summa- modified score based on CTP scoring system but elimi- rized in table 1. In multivariate analysis, the only prognostic nating two subjective parameters (encephalopathy and as- factor for TTR was a combination of AFP > 100 ng/mL cites) and including proThrombin time, Albumin, serum and resection margin < 1cm (HR=2.438; IC95% [1.709- total Bilirubin : TAB score with similar scoring system was 3.478]; p< 0.001). In patients with high AFP rate, surgical formulated. margin highly impacted TTR contrary to patients with low Methods: Present study was conducted prospectively at a AFP rate where surgical margin had no impact on TTR tertiary care hospital from October 2015 to August 2017. (graph 1). There is a trend for better OS according to AFP All patients were evaluated with the same preoperative and margin that did not reach significance. evaluation protocol. Post operative morbidity was Conclusion: Surgical margins 1 cm highly impacted measured by using the Clavien-Dindo Classification of recurrence in patients with AFP>100 but not in patients Surgical Complications. Duration of follow up was 30 days with AFP100. from the date of surgery. Results: Total 51 patients were included in the study. Median MELD, TAB and CTP score values were 7.86 EP01C-144 (6-18) and 3.20 (3-6), 5.24 (5-8) respectively. Overall PROGNOSTIC SCORE IN PATIENTS morbidity associated with hepatic resection was 43.2%. WITH PYOGENIC LIVER ABSCESS-OUR Univariate analysis showed that jaundice at presentation (p=0.029), intra operative blood loss (p=0.009) and RESULTS IN SURGICAL OUTCOME duration of surgery (p=0.001) were significantly associ- AND LETHALITY PREDICTING ated with post operative complications leading to signif- P. Marinova1, D. Stoykov2, P. Tonchev2, I. Dekova2 and icant increase in total hospital stay (p =0.002). Post T. Sabotinov2 operative hepatic failure (PHF) was seen in 4 (7.8%) 1Hepato-pancreato-Biliary Surgery, and 2Hepato- patients. Post operative mortality was observed in two pancreato-Biliary Surgery, Medical University of Pleven, (3.92%) patients. Bulgaria

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Introduction: Pyogenic liver abscess (PLA) is a disease Kaplan-Meier analysis was 35,9 months (%95 CI: 27-44 with formation of inflammatory isle in the liver parenchima months) vs 29,4 months (%95 CI: 22-36 months) p:=0.8 with cavity with purulent collection. Aim The purpose of (figure 1) this study is to analyze the lethal cases in patients with PLA Conclusion: According to our experience, outcomes of and create a prognostic index , which could provide the non-CRCLM patients who underwent ALPPS surgery were final outcome of treatment. similar with outcomes of CRCLM patients. Materials and methods: In our study we included 89 cases of PLA. We performed retro - prospective study in the period 2004-2009- we had 51 patients, and a prospective part - the period 2010-2017 with proven 38 patients. Results: We have 6 fatal cases - overall mortality rate of 7.6 %. Based on the SOFA Score (Septic Organ Failure Assessment score) we try to predict lethality in patients with PLA. After analyzing the lethal cases, we found that in 5 of 6 cases have a high SOFA score total> 10 points. Regarding the aim to create a prognostic index to assess the severity of the disease and treatment outcome "we used cross- tabulations and chi-square to match SOFA index and any of the following values: I value “ Immune deficiency”, II-Risk pathogenesis of abscess, III- Positive blood culture. Conclusion: The evaluation of the "critical point ” showed that the index > 9.5 sensitivity 80% and specificity was 87% ( 1-0129 = 87.1% ) Keywords pyogenic liver abscess, Figure[ALPPS Kaplan-Meier Survival Graph] lethality, SOFA score. EP01C-146 EP01C-145 FACTORS THAT DICTATE OUTCOMES OF ALPPS SURGERY POSTOPERATIVE ICU ADMISSION COMPARING COLORECTAL LIVER AFTER PERFORMANCE OF HEPATIC METASTASIS WITH OTHER RESECTIONS IN GREECE ETIOLOGIES G. C. Sotiropoulos, I. D. Kostakis, Z. Garoufalia, A. Prodromidou and N. Machairas D. Balci1, E. O. Kirimker1, E. Ustuner2, C. Uzun2, 2nd Department of Propaedeutic Surgery, National and G. Utkan3, A. Azap4, A. Demirkazik5 and E. Gecim1 Kapodistrian University of Athens, Medical School, 1Surgery, 2Radiology, Ankara University School of Medi- Greece cine, 3Medical Oncology, Ankara University, 4Infectious Diseases, and 5Medical Oncology, Ankara University Introduction: The scarcity of available intensive care unit School of Medicine, Turkey (ICU) beds in Greek hospitals prohibits performance of major surgical procedures and leads to repeated post- Introduction: Associating liver partition and portal vein ponement of operations. The objective of our study was to ligation (ALPPS) offers resectability for bilobar malignant investigate risk factors that constitute admission to the ICU lesions of the liver with a two stage operation. In this mandatory following liver resection. presentation we compared the outcomes of our ALPPS Methods: Patients undergoing liver resection by one senior procedure series regarding to the primary disease. hepatobiliary surgeon during a 6-year period were pro- Patients and methods: Thirty-two ALPPS procedures spectively sampled and retrospectively analyzed for the were performed in Ankara University Hospitals between purposes of this study. Nominal logistic analyses were December 2012 and January 2018. Patients were grouped performed. according to etiology iinto two groups: Colorectal cancer Results: ICU coverage was requested for the perfor- liver metastasis (CRCLM) and other etiologies(non- mance of liver resections in 14 of 222 cases (6%). Patient CRCLM). Groups compared in terms of mortality and age (p=0.0164; cutoff at 65 years), estimated surgery recurrence. duration (p< 0.0001; cut-o at 260 min), open liver Results: Eighteen patients were operated for CRCLM and resection (vs laparoscopic; p=0.0065), scheduled major thirteen patients were operated with the diagnosis of he- liver resection (p=0.0281), and performance of lympha- patocellular carcinoma (3), cholangiocarcinoma (7), a denectomy (p=0.0368) and of biliodigestive anastomosis neuroendocrine tumor, a sarcoma metastasis and a gastric (p=0.0224) were statistically significant parameters for cancer metastasis. postoperative ICU bed demand in the univariate analysis. Recurrence was seen in 3 of 13 non-CRCLM patients Patient age (p=0.0061) and liver resection duration and 9 of 18CRCLM patients. within a median follow up (p=0.0075) retained their statistical significance in the of 28 months. Surgical margin positivity was found in multivariate analysis. Patient age and operative duration one patient in each group. There were two patient deaths represented the most important prognostic factors that in non-CRCLM group (20%) and 5 deaths were occurred can prevent postoperative ICU treatment in patients un- in CRCLM group and was not significantly different dergoing liver resection. between groups (p> 0.05). Estimated mean survival with

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Conclusion: Diligent and individualized preoperative pa- Surgery, Tokyo Medical and Dental University, 3Depart- tient evaluation could enable liver resections to be ment of Surgery, Keio University, 4Department of performed without the need for ICU coverage. Such Gastroenterological Surgery, Yokohama City University approach would increase the amount of responsibility for Graduate School of Medicine, and 5Division of Gastro- surgeons and anesthesiologists, and require a detailed and enterological and General Surgery, St. Marianna Uni- sincere patient consent. versity School of Medicine, Japan Background: Surgical outcomes in hepatocellular carci- EP01C-147 noma (HCC) patients with high-signal-intensity in the PERFORMANCE OF LIVER hepatobiliary (HB) phase of gadoxetic acid disodium (Gd- RESECTIONS IN GREECE: FACTORS EOB-DTPA)-enhanced magnetic resonance imaging THAT DICTATE POSTOPERATIVE ICU (MRI) have not been evaluated in detail. Methods: Between 2008 and 2013, 21 HCC patients ADMISSION showed high-signal-intensity in the HB phase and under- G. C. Sotiropoulos, I. D. Kostakis, Z. Garoufalia, went curative hepatectomy at five medical university hos- A. Prodromidou and N. Machairas pitals. Surgical outcomes were compared among the 21 Second Department of Propaedeutic Surgery, National patients with high-signal-intensity HCC and 194 patients and Kapodistrian University of Athens, Medical School, with low-signal-intensity HCC. Greece Results: After propensity score matched analysis, the Background: The scarcity of available intensive care unit Child-Pugh class A did not differ between 21 patients with (ICU) beds in Greek hospitals prevents major surgical high-signal-intensity HCC and 21 patients with low- procedures and leads to repeated postponement of opera- signal-intensity HCC, nor did the size of HCC or the tions. The aim of our study was to evaluate risk factors that number of HCCs. The 5-year survival rate was signifi- constitute admission to the ICU mandatory following cantly higher in patients with high-signal-intensity HCC hepatectomy. (83%) than in patients with low-signal-intensity HCC Methods: Patients undergoing heptectomy by one senior (61%, p = 0.0177). The 5-year recurrence-free survival hepatobiliary surgeon during a 6 year period were pro- rate was significantly higher in patients with high-signal- spectively sampled and retrospectively analyzed for the intensity HCC (54%) than in patients with low-signal- purposes of this study. Nominal logistic analyses were intensity HCC (39%, p = 0.047). Multivariate analysis performed. showed high-signal-intensity HCC to be a significant in- Results: ICU coverage was requested for the performance dependent prognostic factor for survival and recurrence- of hepatectomy in 14 of 222 cases (6%). Patient age free survival in HCC. (p=0.0164; cutoff at 65 years), estimated surgery duration Conclusions: High-signal-intensity in the HB phase is a (p< 0.0001; cut-o at 260 min), open hepatectomy (vs novel prognostic factor for favorable surgical outcomes in laparoscopic; p=0.0065), scheduled major liver resection patients with HCC. (p=0.0281), and performance of lymphadenectomy (p=0.0368) and of biliodigestive anastomosis (p=0.0224) were statistically significant parameters for postoperative EP01D - Electronic Poster: 1D - Liver Technical ICU bed demand in the univariate analysis. Patient age Surgery (p=0.0061) and hepatectomy duration (p=0.0075) retained EP01D-001 their statistical significance in the multivariate analysis. Patient age and operative duration represent the most ROBOT-ASSISTED LIVER SURGERY IN important prognostic factors that can prevent postoperative A GENERAL SURGERY UNIT WITH A ICU treatment in patients undergoing hepatectomy. “REFERRAL CENTRE HUB&SPOKE Conclusion: Individualised preoperative patient evaluation LEARNING PROGRAM”. EARLY could enable hepatectomies to be performed without the OUTCOMES AFTER OUR FIRST 70 need for ICU beds. Such approach would increase the amount of responsibility for surgeons and anesthesiolo- CONSECUTIVE PATIENTS 1 2 2 3 gists, requiring detailed and sincere patient consent. A. Giuliani , E. Andolfi , A. Fontani , F. Calise , A. Rocca1 and G. Ceccarelli2 EP01C-148 1Department of Medicine and Health’s Sciences ’V. 2 HIGH SIGNAL INTENSITY IN THE Tiberio’, University of Molise, General and Robotic Surgery Unit, San Donato Hospital, and 3Hepato-Biliary HEPATOBILIARY PHASE OF Surgery Unit, P.O. Pineta Grande Hospital, Italy GADOXETIC ACID DISODIUM- Background: The aim of this study was to evaluate safety, ENHANCED MRI IS A NOVEL feasibility and short-term outcomes of our first 70 consec- PROGNOSTIC FACTOR FOR utive patients treated by robotic-assisted liver resection FAVORABLE SURGICAL OUTCOMES after a reversal proctoring between a high HPB volume OF HCC centre and our well-trained centre in minimally invasive General Surgery. Six surgeons were involved in this S. Ariizumi1, D. Ban2, Y. Abe3, T. Kumamoto4, Hub&Spoke learning program. S. Koizumi5, M. Tanabe2, O. Itano3, I. Endo4, T. Otsubo5, Methods: From September 2012 to December 2016, 70 M. Yamamoto1 and Association for Clinical Research on patients underwent robotic-assisted liver resections. We Surgery (ACRoS) treated 18 patients affected by colorectal and gastric cancer 1Dept. of Gastroenterological Surgery, Tokyo Women’s with synchronous liver lesions suspected for metastases in a Medical Univ., 2Department of Hepato-Biliary-Pancreatic

HPB 2018, 20 (S2), S333eS504 S452 Electronic Posters (EP01A-EP01E) - Liver fi one-stage robotic-assisted procedure. For the rst 20 pro- EP01D-003 cedures we had a tutor in the operatory room, who was present also in the next most difficult procedures. LOCAL MODIFICATION SUPPORTING Results: The 30- and 90-day mortality rate was zero with LIVER SURGERY IN INDONESIAN an overall morbidity rate of 10.1%. Associated surgical HOSPITAL procedures were performed in about 65,7% of patients. The A. Nugroho1, R. Saunar1 and E. Frana2 fi observed conversion rate was 10%. The results of the rst 1Digestive Surgery, and 2Nursing Department, Fatmawati 20 cases were similar to the next 50 showing a shortned General Hospital, Indonesia learning curve. A safe liver surgery is feasible and widely performed Conclusion: Minimally invasive robot-assisted liver around the world. With the high number of large size and resection is a safe technique; it allows overcoming many advanced tumor, open surgery is still the preferred method. limits of conventional laparoscopy. This innovative, time- However, several local modifications are necessary to enduring Hub&Spoke may allow patients to undergo a overcome technical problems due to lack of sophisticated proper standard of care also for complex surgical proced- and expensive instruments. Our modifications include ures, without the obligation of reaching specialized centres. exposure techniques using a local hand made retractor, vessel loop apparatus using a small size feeding tube and a modified waterjet instruments for parenchymal transection. EP01D-002 Various open liver resections have been performed with CHEN’S SIMPLE TECHNIQUE this modification during 2 years time. We believe that we LIGATING THE CORRESPONDING have to do what we can do in the right way whenever INFLOW AND OUTFLOW VESSELS possible. DURING HEPATECTOMY: A PROSPECTIVE RANDOMIZED EP01D-004 CONTROLLED TRIAL AND ANIMAL AN INTRAOPERATIVE ULTRASOUND- STUDY BASED NAVIGATION APPROACH FOR B. Zhang, B. Zhang and X. Chen LAPAROSCOPIC ABLATION OF LIVER Department of Surgery, Tongji Hospital of Huazhong University of Science and Technology, China TUMORS 1 1 2 Objectives: We have devised a simple bleeding control I. Paolucci , M. Schwalbe , G. A. Prevost , 2 2 1 technique (Chen’s Technique) ligating the corresponding A. Lachenmayer , D. Candinas , S. Weber and 2 inflow and outflow vessels without hilus dissection P. Tinguely 1 before the parenchyma transection during hepatectomy. ARTORG Center for Biomedical Engineering Research, 2 The main objective of this study is to investigate the role and Department of Visceral Surgery and Medicine, of Chen’s technique on postoperative metastasis and Inselspital, Bern University Hospital, University of Bern, survival. Switzerland Methods: During the past 10 years, 330 patients with pri- Introduction: Limitations of navigation systems aiming to mary HCC were performed hepatectomy with the new augment precision in laparoscopic ablation of liver tumors, hemorrhage control technique, and prospective randomized are inaccuracies due to organ deformation and technical controlled trial was applied. Circulating tumor cells (CTC) complexity. We evaluated accuracy and efficiency of a were detected in 24 hours postoperatively. We further novel approach for laparoscopic tumor ablation based on applied a mice model ligating the pedicle of the lesion- electromagnetic tracked laparoscopic ultrasound (ELUS). located hepatic lobe before hepatectomy to imitate the Methods: The proposed navigation approach combines clinic practice, and evaluated the role of the new technique intraoperative 2D ELUS-based planning for navigated on postoperative metastasis and survival. positioning of ablation probes, with immediate 3D ELUS- Results: Chen’s technique prolonged postoperative overall based validation of intrahepatic probe position. Using a and disease-free survival for patients with primary HCC, laparoscopic liver phantom model, accuracy of ablation and reduced the number of circulating tumor cells (CTC) probe positioning (measured as target positioning error, postoperatively, when compared with the conventional TPE), the number of probe repositionings necessary to hit hepatectomy. In the animal model, hepatectomy with the tumor target and time efforts of ELUS were measured Chen’s technique showed lower metastasis, and longer and compared to conventional laparoscopic ultrasound survival when compared with conventional surgery. (LUS) guidance. Human specific-AFP expressed at a high level in the serum Results: Sixty targeting attempts were conducted by three of the metastasis bearing mice, but not expressed in surgeons (10 targetings using ELUS and LUS each). metastasis-free mice. Median time for target definition was 48.5 seconds. Median Conclusion: Chen’s technique ligating the inflow and TPEs and times for targeting using ELUS and LUS were outflow vessels of the lesion-located hepatic lobe before 4.2 mm (IQR 2.9 - 5.3 mm) versus 6mm (IQR 4.7 - 7.5 hepatectomy reduces postoperative metastasis and prolongs mm), and 39 seconds (IQR 24 - 47 seconds) versus 76 survival of primary HCC. These results also indicate a seconds (IQR 47 - 121 seconds), respectively (p < 0.01 potential mechanism that Chen’s technique prevents he- each). No ablation probe repositionings were needed when matogenous metastasis owing to its coincidence to princi- using ELUS compared to required repositionings in 59% ples of oncological surgery to avoid the intraoperative (17/30) of LUS targetings. spread of tumour cells during hepatectomy.

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malignancies as it provides good surgical outcomes and oncological adequacy.

EP01D-006 A STUDY OF THE SEQUENTIAL RELATIONSHIP BETWEEN THE INCREASE OF THE FUTURE REMNANT LIVER VOLUME AND THE FUNCTIONAL TRANSITION AFTER PREOPERATIVE PORTAL VEIN EMBOLIZATION Y. Tsuruga1, T. Kamiyama2, A. Nagatsu2, S. Shimada2, K. Wakayama2, T. Orimo2, H. Yokoo2, H. Kamachi2 and A. Taketomi2 1Gastroenterological Surgery, JCHO Hokkaido Hospital, 2 [Probe repositionings required to hit the tumor] and Gastroenterological Surgery I, Graduate School of Medicine, Hokkaido University, Japan Conclusions: The proposed approach allows accurate and Background: Preoperative portal vein embolization (PVE) efficient targeting of liver tumors in a laparoscopic model. is a widely used strategy to enable major hepatectomy with As a dynamic navigation approach relying on intra- insufficient liver remnant. PVE induces hypertrophy of the operative imaging only, it yields a simple technique for future remnant liver (FRL) and shift of the functional accurate and efficient laparoscopic ablation of liver tumors. reserve to FRL. In this study, we investigated the sequential relationship between the increase of the FRL volume and the functional transition after preoperative PVE using 3D EP01D-005 fused image of CT and 99mTc-galactosyl-human serum 99m ROBOTIC-ASSISTED LEFT albumin ( Tc-GSA) single-photon emission computed HEPATECTOMY: OUR INITIAL tomography (SPECT). Methods: Thirteen patients who underwent major hepa- EXPERIENCE tectomy following PVE were enrolled. CT and 99mTc-GSA M. V. Marino1 and A. L. Komorowski2 SPECT scintigraphy were performed at pre-PVE, one week 1Emergency and General Surgery, Azienda Ospedaliera and two weeks after PVE. Functional Volume (FV) of FRL Villa Sofia-Cervello, and 2Surgical Oncology, Maria was defined as total liver volume (FRL volume counts/ Skłodowska-Curie Memorial Institute of Oncology Cancer total liver volume counts) of 99mTc-GSA SPECT from 3D Centre, Poland fused image with CT. Introduction: Firstly described in 2002, the robotic liver Results: The average increase rate of the volume of FRL surgery has been considered as a unique opportunity to and FV of FRL at one week after PVE were 31.7 (16.6) overcome the traditional limitations of laparoscopy. % and 41.2 (31.0) % (mean (SD)) respectively. Those of Despite some potential benefits, the number of robotic the volume of FRL and FV of FRL at two weeks after major hepatectomies reported in literature for now remains PVE were 43.5 (20.4) % and 52.4 (26.7) % respectively. limited. Herein we analyse our initial results of evaluating In three of 13 cases, the FVs were especially lower than the potential advantages of the robotic approach to liver CT volumes of FRL at two weeks after PVE. One of the interventions. three cases progressed microsteatosis more than 30% by Methods: We retrospectively reviewed our database of biopsy, and this steatosis improved to 10% 13 weeks robotic liver surgeries. From April 2015 to May 2016, 12 after PVE. patients consecutively underwent fully robotic-assisted Conclusions: The functional transition lagged behind the laparoscopic left hepatectomy. increase of the FRL volume after PVE because of Results: The mean operative time was 315 min (200-445 progressing steatosis. min) and the mean estimated blood loss was 245 ml (125- 628 ml). Only in one case, we performed a Pringle manoeuvre. The indications for surgery in all patients was EP01D-007 malignancy (8 colorectal cancer metastases, 4 hepatocel- CORONARY-RENAL SHUNT COMBINED lular carcinomas). The mean number of lesions was 1.85 WITH SPLENECTOMY FOR SELECTIVE (range 1-4 lesions) and the mean lesion size was 38 mm (15-85 mm). The average length of hospital stay comprised VARICEAL DECOMPRESSION 6.5 days (5-14 days) while the acceptable morbidity rate 2/ M. Tian, Y. Yang, P. Du, D. Jia and M. Liu 12 (24%) was obtained. None of the patients underwent Hepatobiliary Surgery, People’s Hospital of Ning Xia conversion to open surgery. The 90-day mortality rate was Autonomous Region, China nil. The mean surgical resection margin was 12 (7-22) mm, Instruction: Selective shuns for gastroesophageal varices and we achieved the R0-resection rate in all cases. including distal splenorenal shunt and coronary-caval shunt Conclusions: The robotic left hepatectomy is a safe and may not solve the problems of the giant spleen with serious feasible technique also for the management of liver hypersplenism or deep location of the left gastric vein

HPB 2018, 20 (S2), S333eS504 S454 Electronic Posters (EP01A-EP01E) - Liver behind the pancreas. A new selective shunt procedure reconstructed with a patch, two MHV were replaced with should be explored. PTFE graft, 2 RHV were reconstructed with termino-ter- Methods: Coronary-renal shunt combined with splenec- minal anastomosis. In 5 cases HV was exposed at the cava- tomy was performed on 16 patients with gastroesophageal confluence. Overall morbidity occurred in 10 (55%) pa- varices and serious hypersplenism due to posthepatitic tients: grade IIIb-IV in 2 (11%). Median hospital stay was cirrhosis. The patients had the dilated left gastric vein 10 days and 90-day mortality was 0%. After median 19- entering the splenic vein by preoperative CT angiorgraphic month follow-up (range: 5-86) we observed one spared- evaluation. After splenectomy, the proximal part of the liver and one liver-cut surface recurrence, both associated splenic vein with a length of 3-5cm and the left gastric vein with extra-hepatic recurrence. were freed from the pancreas. The freed splenic vein was Conclusions: Lesser-volume hepatectomies are feasible for divided at the distal side with the proximal orifice anaso- tumours of 10 or more cm when planned by surgeon and mosed to the left renal vein. Ligation or division between radiologist with expertise in interpreting pre-operative im- sutures was applied to the splenic vein between portal vein aging accurately. and left gastric vein. The right gastric and gastro-epiploic vessiles were divided to occlude the back flow from the portal vein. EP01D-009 Results: There were no operative motality and no pro- THE LIVER TUNNEL: IS THERE A cedure-relative complications. Post-operative CT and endoscopy showed the shunts were patent with reduced or PLACE FOR VASCULAR AND BILIARY obliterative varices in all sixteen patients. There were no RECONSTRUCTION FOR THIS NEW recurrent variceal haemorrhage nor encephalopathy by 6-36 PARENCHYMA SPARING months’ follow-up. HEPATECTOMY? Conclusion: This procedure can reach the aim of selective L. Urbani1, R. Balestri1, S. Signori1, N. Roffi1, variceal decompression when splenectomy is required. P. G. Vacca1, G. Licitra2, P. Colombatto3, P. Boraschi4, Keywords: portal hypertension; coronary-renal shunt; se- M. Castagna5 and P. Buccianti1 lective variceal decompression; splenectomy 1General Surgery, 2Anestesiology, 3Hepatology, 4Radi- ology, and 5Pathology, Azienda Ospedaliero-Universitaria Pisana, Italy EP01D-008 Introduction: Liver Tunnel (LT) is a new parenchyma LESSER VOLUME HEPATECTOMIES sparing hepatectomy (PSH) for deep centrally located liver FOR TUMORS OF 10 OR MORE CM lesions, which relies on tumor-vessel detachment and on USING PARENCHYMA SPARING presence of communicating veins (CV) when middle-he- TECHNIQUES patic-vein (MHV) resection is required. Recently, we showed the possibility to perform PSH with vascular re- 1 1 1 fi1 L. Urbani , R. Balestri , S. Signori , N. Rof , constructions using also polytetrafluoro-ethylene-graft P. G. Vacca1, G. Licitra2, P. Colombatto3, P. Boraschi4, 5 1 (PTFE-based PSH). We describe the techniques allowing M. Castagna and P. Buccianti LT in our series of patients. 1General Surgery, 2Anestesiology, 3Hepatology, 4Radi- 5 Methods: We analysed all patients with deep centrally ology, and Pathology, Azienda Ospedaliero-Universitaria located tumors and eligible for LT. Pisana, Italy Results: Sixteen consecutive patients met the inclusion Introduction: Parenchyma sparing hepatectomy (PSH) criteria: 13 for CRLM, 1 for non-CRLM, 1 for HCC and 1 techniques assure adequate future liver remnant (FLR), for symptomatic FNH. Fourteen patients underwent to LT. since lesser-volume hepatectomies are feasible preserving Median resected lesions number was 2 (range: 1-10) with in/out-flow by exposure of first/second order glissonian median largest diameter of 38 mm (range: 12-80). We pedicles and by vascular reconstructions. Applicability of performed 5 MHV-resection (3 CV-based PSH, 1 PTFE- PSH for huge tumors was analysed. based PSH, 1 MHV-RHV anastomosis), 5 MHV-raffia, and Methods: We considered all consecutive patients with 2 MHV-exposure. In one V2-MHV tunnel the left-hepatic- tumors of 10 or more cm. vein was replaced with PTFE graft. In both PTFE-based Results: Twenty-one consecutive patients were identified. PSH, CVs were inadequate for spared liver outflow. One Lesser-volume hepatectomy was performed in all 18 pa- LT was a re-do hepatectomy (previous right upper trans- tients eligible for PSH based on preoperative imaging, for 7 versal with t-t RHV anastomosis) with partial resection of primary, 9 metastatic and 2 benign tumors with median cava vein. In one case the left biliary duct was reconstructed larger diameter of 106 mm (range: 100-168) and median with a “trans-tunnel” hepatico-jeujunostomy. Morbidity number of 1 (range: 1-18). FLR in-flow preservation was observed in 7 (50%) patients: grade IIIb-IV in 2 (14%). required first/second order glissonian pedicles exposure in Median hospital stay was 11 days and 90-day mortality was 12 cases. Hepatic vein (HV) was resected at the cava- 0%. After median 39-month follow-up (range: 3-68) 1 confluence in 9 cases. FLR out-flow preservation was liver-cut surface and 1 spared-liver recurrence were through pre-existing communicating veins (CV-based observed, both successfully re-operated. PSH) in 1 case and through the middle-hepatic-vein (MHV- Conclusions: LT is a feasible new PSH and can be asso- based PSH) draining segments V-VI in 3 cases. Vascular ciated to vascular and biliary reconstructions. reconstruction was needed in 5 cases: one MHV was

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EP01D-011 at Couinaud segment VIII adjacent to major intrahepatic vessels. APPLICATION OF A THREE- Methods: Between July 2015 and June 2017 thirty-six DIMENSIONAL RECONSTRUCTION patients underwent robotic curative hepatectomy for HCC TECHNIQUE IN SAFETY ASSESSMENT in our hospital. Two patients who had deep-seated tumor at OF HEMIHEPATECTOMY FOR HUGE segment VIII adjacent to major intrahepatic vessels un- fi HEPATIC TUMOR derwent robotic unroo ng hepatectomy. During operation the overlying liver parenchymal was removed and the S. Dong, L. Chen, B. Zhang, X. Luo and X. Chen tumor was peeled-off from wall of exposed major vessels. Hepatic Surgery Center, Tongji Hospital, Tongji Medical The clinicopathological profiles and surgical outcomes College, Huazhong University of Science and Technology, were retrospectively reviewed. China Results: The first patient was a 63-yr-old male who had a Introduction: The purpose of this study was to determine tumor deep-seated at segment VIII between the middle and the clinical value of three-dimensional computer recon- right hepatic veins. The tumor diameter was 2.8 cm and struction technique in preoperative safety assessment of resected liver weighed 130gm with a safe margin of 0.1 cm. hemihepatectomy for huge hepatic tumor. The hepatectomy time was 180 mins and blood loss was Methods: 108 patients who underwent hemihepatectomy 2800 cc. The postoperative recovery was smooth and pa- of two groups (tumor diameter 10cm vs.< 10cm) were tient discharged at 9th postoperative day. The second pa- subjected to preoperative hepatectomy simulation by tient was a 48-yr-old male. The tumor diameter was 2.0 cm IQQA-Liver software. Liver volume (LV), standard liver and resected liver weighed 55 gm with a safe margin of 1.5 volume (SLV), tumor volume (TV), functional liver cm. The hepatectomy time was 150 mins and blood loss volume (FLV=LV-TV), excised liver volume (ELV), was 150 cc. The postoperative course was uneventful and excised functional liver volume (EFLV) and residual liver patient discharged at 8th postoperative day. Follow-up volume (RLV) were calculated. The ratio of total liver image of two patients after operation showed no recurrence resection as ELV/LV, the ratio of functional liver resection at 28th and 8th month respectively. as EFLV/FLV, and the relative amount of future liver Conclusion: We concluded robotic unroofing hepatectomy remnant as RLV/FLV and RLV/SLV were compared be- is feasible for curative resection of deep-seated HCC at tween two groups. Couinaud segment VIII adjacent to major intrahepatic Results: Simulation showed high correlation (r = 0.994, p< vessels. 0.001) and accuracy between ELV and actual ELV. The EFLV/FLV was significantly smaller (p< 0.01) in the < group of tumor 10cm than that 10cm, either in the right EP01D-013 hemihepatectomy subgroup or in the left hemihepatectomy subgroup. However, the RLV/FLV was significantly lager FINGER FRACTURE TECHNIQUE WITH (p< 0.01) in the group of tumor 10cm than that < 10cm, GLISSONIAN PEDICAL APPROACH IN and RLV/SLV was not different (p>0.05). 25 patients had LIVER RESECTION e OLD IS STILL RLV/LV < 30%, but only one patient had RLV/SLV < GOLD 30%. Majority of the patients had RLV/FLV and RLV/SLV B. Vasavada and H. Patel >40% (97.2% and 98.1%, respectively). No patients suf- Hepatobiliary and Liver Transplantation, Shalby Hospi- fered postoperative liver failure or death in both groups. tals, India Conclusion: Our results indicated in the same extent of anatomical hepatectomy, the lager the tumor is, the less Introduction: In modern world there are many devices functional liver tissue will be resected, and greater tumor available for liver transection with clamp crushing method free residual volume will be remained. is still god standard. Finger fracture technique is rarely used recently. We use finger fracture technique with glssonian pedical technique to reduce operative time and anesthetic related complications. EP01D-012 Methods: We performed liver resection using glissonian ROBOTIC UNROOFING pedical approach and parenchymal transection using finger HEPATECTOMY IS FEASIBLE FOR fracture technique. Average operatime time, blood loss, bile CURATIVE RESECTION OF DEEP- leaks and any other complication noted and compared with fi SEATED HEPATOCELLULAR standard literature. Major liver resection de ned as resec- tion of two adjacent segments. CARCINOMA AT COUINAUD SEGMENT Results: 12 patient were under went liver resection with VIII ADJACENT TO MAJOR above techniques two patients under gone left trisegmen- INTRAHEPATIC VESSELS tectomy for hilar cholangio carcinoma, two patient under M. -C. Lin1,2, C. -M. Peng1, Y. -K. Yang1, W. -H. Chen1, went right posterior sectorectomy for hepatocellular carci- C. -L. Hsieh1 and H. -C. Liu1 noma, one patient left hepatectomy for hepatocellular car- 1Division of General Surgery, Department of Surgery, cinoma, two patients underwent right hepatectomy for Chung Shan Medical University Hospital, and 2Depart- hepatocellular carcinoma,one patient segment 8 resection ment of Surgery, Faculty of Medicine, National Yang-Ming for liver metastasis, one patient left lateral segment resec- University, Taiwan, Republic of China tion for liver trauma and 3 patient underwent segment 4b5 Introduction: The purpose of this study is to evaluate resection for ca GB. Mean operative duration was 3 hrs feasibility of robotic unroofing hepatectomy for curative compared to 4-5 hours by literature in other techniques. resection of deep-seated hepatocellular carcinoma (HCC) Mean blood loss was 270 ml. two patient developed minor

HPB 2018, 20 (S2), S333eS504 S456 Electronic Posters (EP01A-EP01E) - Liver bile leaks -which settled down with conservative treatment of the jejunal veins(JVs) around the superior mesenteric at 2 weeks. One patient expired due to post operative MI artery (SMA) has yet been detailed. diagnosed by echo,ecg and cardiac markers. Methods: Anatomy of first jejunal vein(JVT) in 200 Conclusion: Figure fracture technique with glissonian consecutive patients who underwent AF-PD regarding and pedical approach is rapid method for liver resection with the procedure in dissecting mesojejunal vessels were comparable outcomes to all other techniques. reviewed by preoperative computed tomography (CT) and operative records. We defined a venous branch crossing the cut line during mesojejunum division as dangerous branch EP01D-015 (DB), which often causes unexpected bleeding. DB appears IMPACT OF RADIOFREQUENCY- if there is difference between the territory of jejunal arteries (JAs) resected and that of JVs resected. We compared pa- ASSISTED TRANSECTION ON LOCAL tients according to following criteria; I. The root of JVT HEPATIC RECURRENCE AFTER was preserved or not, II. The number of JAs which JVT RESECTION OF COLORECTAL LIVER covering was few(JVT-F;1-2) or many(JVT-M;3-), III. The METASTASES number of JAs resected was few(JA-F;0-1) or many(JA- M;2-4). F. Burdio1, I. Poves2, L. Grande2 and R. Quesada2 Result: I.JVT was preserved in 93/200(46.5%), and 1Surgery, and 2Hospital del Mar, Spain ligated/resected in 107/200(53.5%), II. Number of JVT-F/ Resection is the gold standard in the treatment of liver JVT-M was 130/70.DB was divided in 86%(60/70) in JVT- metastases from colorectal cancer. An internal cooled M and 40%(49/130) in JVT-F. III. Number of JA-F/JA-M radiofrequency electrode was shown to achieve tissue in preserving JVT was 64/29.Number of JA-F/JA-M in coagulation to a greater margin width. The aim of this study ligated JVT was 43/64. DB in preserving JVT was divided is to determinate if a RF-assisted transection device in (66/66) %, and in ligated JVT was divided in (40/70) %. (RFAT) has any effect on local hepatic recurrence (LHER) Conclusion: Profound understanding of JV anatomy based compared to conventional technologies. on preoperative CT findings and intraoperative strategy A study population of 103 patients who had undergone a could facilitate a safe dissection around the superior hepatic surgical resection was retrospectively analysed. mesenteric artery. Patients were classified into two groups according to the device used: a RF-assisted device (RFAT group; n = 45) and standard conventional devices (control group; n = 58). LHER was defined as any growing or enhancing tumour in EP01D-017 the margin of hepatic resection during follow-up. Cox ROBOTIC VERSUS OPEN LIVER proportional models were constructed and variables were RESECTIONS: A RETROSPECTIVE eliminated only if p > 0.20 to protect against residual COMPARATIVE STUDY confounding. To assess the stability of Cox’s regression S. Goja and S. K. Yadav model and its internal validity, a bootstrap investigation Institute of Liver Transplantation and Regenerative Med- was also performed. icine, Medanta-The Medicity, Gurgaon, India Baseline and operative characteristics were similar in both groups. With a mean follow-up of 28.5 months (range Background: The authors present their experience of ro- 2-106), in patients with positive margins, we demonstrated botic liver resections in comparison with open technique. 0% of LHER in RFAT vs. 27% in control group (p = Methods: Retrospective review of liver resections done 0.032). In the multivariate analysis five factors demon- robotically from February 2015 to June 2017 compared to strated significant influence on the final model of LHER: matched control cohort of open cases from January 2012 to RFAT group, size of the largest metastases, number of December 2016. resected metastases, positive margin and usage of Pringle- Results: Seventeen patients in the study group were manoeuvre. compared with matched control of 34 open cases (1:2 This study suggests that parenchymal transection using a ratio). The type of procedure were similar in both groups, fi RFAT able to create deep thermal lesions may reduce there were ve left lateral hepatectomy, two left hepatec- LHER especially in case of margin invasion during tomy, and one left hepatectomy with hepatico-jejunostomy, transection. one right hepatectomy, one right posterior sectorectomy, four bisegmentectomy and three mono-segmentectomy. Mean operative duration was 442 135 minutes in the robotic compared to 357 127 minutes in control group EP01D-016 (p = 0.03). Mean blood loss was 270 311 ml in the THE SAFE DISSECTION BASED ON robotic compared to 451 330 ml in control group (p = JEJUNAL VEINS ANATOMY e 0.06). Minor complications developed in 17% of robotic DISCLOSURE OF FINAL BLACK BOX cases compared to 41% in open surgery OF PANCREATICODUODENECTOMY (p = 0.5), while major complications occurred in 5.8% of robotic cases compared to 8.8% of open S. Irie (p = 0.3). Mean hospital stay was 5.35 0.8 days for the Gastroenterological Surgery, Japanese Foundation robotic group and 7.7 4.2 days for open group (p = 0.02). Cancer Research Hospital, Japan Conclusion: This study highlights the utility of robotics for Background: Pancreaticoduodenectomy(PD) is performed liver resections with equivalent outcomes and decreased safely due to anterior first approach (AF). But the anatomy length of stay compared to open surgery.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S457

EP01D-018 The primary outcome was intraoperative blood loss. Sec- ondary outcomes were postoperative liver function, post- PERIOPERATIVE OUTCOMES OF 857 operative morbidity and mortality, and duration of hospital CONSECUTIVE RADIOFREQUENCY- stay after surgery. ASSISTED LIVER RESECTIONS Results: After propensity score matching, there were 124 I. Reccia, M. Sodergren, K. Jayant, T. Kusano, P. Retsas, patients in the IPVBO group and the HIO group, respec- fi X. Zhao, D. Spalding, L. Jiao, M. Pai and N. Habib tively. There were no signi cant differences between the HPB Surgery, Imperial College London, United Kingdom two groups regarding intraoperative blood loss, blood transfusion requirement, operating time, postoperative Introduction: Radiofrequency (RF) assisted liver resection morbidity and mortality, and duration of hospital stay after allows non-anatomical liver resection to be performed with surgery (P > 0.05).However, The IPVBO group was limited blood loss and offers the opportunity for a combi- associated with significantly lower peak in postoperative nation of resection and ablation at the same surgical pro- ALT level than the HIO group (P < 0.05). cedure. In this study, we analyse the rate of perioperative Conclusions: The results indicated that IPVBO did not complications, focusing on the incidence of post-hepatec- lead to more intraoperative blood loss compared with HIO, tomy liver failure (PLF) and infective complications (bile and it decreased the peak of postoperative ALT level. In leak and abscess), and examine its impact on morbidity and terms of postoperative morbidity and mortality, duration of mortality. hospital stay after surgery, IPVBO was also equal to HIO. Methods: Single institution case series of consecutive pa- Thus, IPVBO could be an alternative method of hepatic tients undergoing RF-assisted liver resection between 2001 inflow occlusion. and 2015 for benign and malignant liver tumours. Periop- erative outcomes were analysed retrospectively from a prospectively maintained clinical database. EP01D-021 fi Results: Eight hundred and fty seven RF-assisted liver LEARNING CURVE IN LIVER resections were performed (468 males: 389 females). The median age was 61 years (range 19-89). Median intra- RESECTION: DOES INTRAOPERATIVE operative blood loss was 130 mL, with 9.8% (n=84) of ULTRASOUND HELP? patients requiring blood transfusion. Intra-abdominal col- F. Botea1, D. Nicolaescu1, A. Barcu1, N. Picu1, G. Droc2, lections developed in 10.6% of patients with 8.7% of pa- D. Tomescu2, A. Croitoru3, V. Herlea4 and I. Popescu1 tients requiring percutaneous drainage, while bile leak at 1Center of General Surgery and Liver Transplantation, resection margin developed in 2.8% of the cases. Major 2Department of Anesthesia and Intensive Care, 3Depart- liver resection was performed in 34% (n=292) of patients ment of Oncology, and 4Department of Pathology, and the incidence of PLF was 1.5% (n=13) with a single Fundeni Clinical Institute, Romania directly related mortality (0.1%). The overall 30-day mor- Introduction: Liver resection (LR) remains a difficult tality was 1.5%. surgical procedure, with a long learning curve (LC). Conclusion: Radiofrequency-assisted liver resection has Intraoperative ultrasound (IOUS) helps understanding liver evolved into a feasible and safe technique of liver resection anatomy, the relationship between focal lesions and the with an acceptable incidence of perioperative morbidity main vessels, and guides the LR plane. The paper analyses and a low incidence of PLF and related mortality. the influence of IOUS on LC in LR for a surgeon trained both in LR and IOUS guidance. Method: The first 150 consecutive IOUS guided LRs EP01D-020 performed in 138 patients performed between January 2013 A PROPENSITY SCORE ANALYSIS OF and July 2017 were included in a retrospective study. The TWO METHODS OF HEPATIC group was divided into 3 consecutive subgroups of 50 LRs each. The parameters used for LC evaluation were related VASCULAR OCCLUSION IN to the patient (Charlson comorbidity index CCI), procedure HEPATECTOMY (technically-difficult LR, operating time, blood loss), and X. Luo, L. Chen, W. -H. Liu, S. -L. Dong, H. -P. Luo, its results (major morbidity, reinterventions, 90-day mor- B. -X. Zhang and X. -P. Chen tality, length of hospital stay). Tongji Hospital, Tongji Medical College, Huazhong Uni- Results: The parameters for the 3 subgroups were: median versity of Science and Technology, China CCI of 6, 7, and 7points; technically-difficult LR rate of 54, Introduction: The key points in hepatectomy are reducing 56, and 70%; median operating time of 320, 345, and blood loss and preservation of hepatic function. The aim of 355min; median blood loss of 650, 900, and 800ml; major this study was to compare the perioperative outcomes of morbidity rate of 2, 6, and 12%; reintervention rate of 0, 2 partial hepatectomy using two techniques of hepatic and 2%; 90-day mortality of 0, 4, and 2%; median length of vascular inflow occlusion. hospital stay of 9, 8, and 9 days, respectively. The results of Method: A total of 1817 patients were selected from our the first subgroup were not inferior to the other 2 sub- multi-institutional hepatectomy database in China and groups, except in terms of technically-difficult LR rate, and classified into two groups: the hemihepatic inflow occlu- were comparable to the literature. sion (HIO) group (n =1693) and the ipsilateral portal vein Conclusions: The inclusion of IOUS in the training, both branch occlusion (IPVBO) group (n =124). Propensity for tumor mapping and resection guidance, leads to a steep score matching of patients in a ratio of 1:1 was conducted. LC in LR.

HPB 2018, 20 (S2), S333eS504 S458 Electronic Posters (EP01A-EP01E) - Liver fi EP01D-022 Background: Objective assessment of the dif culty of laparoscopic liver resection (LLR) pre-operatively is key in COMBINED HPB WITH MULTI- improving its uptake. Difficulty scores are proposed but are QUADRANT, MULTI-VISCERAL not used routinely in practice. We identified and appraised RESECTION WITH ROBOTIC XI : OUR predictive models to estimate LLR difficulty. EARLY EXPERIENCE Methods: We systematically searched the literature for tools predicting LLR difficulty. Two independent reviewers A. K. H. Chiow1,E.W.C.Eu1, L. S. Lee1, S. S. Tan1, selected studies, abstracted data, and assessed methodol- S. K. Lim2,F.C.Ng2 and C. Y. Ngu3 ogy. We evaluated tools’ quality and clinical relevance 1HPB Unit, Department of Surgery, 2Department of using the Critical Appraisal and Data Extraction for Sys- Urology, and 3Department of Surgery, Changi General tematic Reviews of Prediction Modelling Studies Hospital, Singapore (CHARMS) guidelines. Introduction: Earlier iterations of the Robotic Da Vinci Results: From 1,037 citations, we included 5 studies system (S, Si) had been limited by bulky robotic arms and reporting on 4 predictive tools using data from 2003 to need for repositioning of the robotic cart for multi-quad- 2016 in Asia. In 2 development studies, tools were rant, multi-visceral surgery. The introduction of the Da designed to predict difficulty as assigned by experts using a fi Vinci Xi with its slimmer arm pro le, longer reach and 10-level difficulty index or operative time. Neither internal fi rotating boom mounted arms has simpli ed the docking validation nor performance metrics were reported. In 3 procedure allowing for single docking even for complex validation studies, one LLR tool was subjected to 3 external multi-quadrant surgery. We present our early experience validations using the Da Vinci Xi for various hepato-pancreatico- (1 independent and geographic), and 2 open surgery biliary (HPB) surgeries combined with other sub-special- tools were validated in a LLR population. Validations ities for multi-visceral resection. compared post-operative outcomes (operative time, blood Methods: A retrospective review of a prospectively loss, transfusion, major morbidity, and conversion) be- maintained database of robotic surgeries performed in CGH tween the risk categories. One study validated discrimina- since February 2015 to November 2017 was done. All tion (AUROC 0.53). Calibration was not assessed. cases involving combined multi sub-speciality synchro- Conclusions: The very few existing tools cannot be used nous surgery was reviewed and anonymised data was confidently to predict LLR difficulty. Consistent objective extracted for analysis. clinical outcomes defining LLR difficulty should be Results: 360 robotic cases had been performed in CGH established, and better-quality tools developed and vali- during the study duration covering colorectal, urology, dated in a wide array of populations and clinical settings, HPB and upper gastrointestinal surgery. 11 cases were following best practices for predictive tools development multi-visceral, multi-quadrant surgeries of which 4 were and validation. This will contribute to broader uptake of HPB combined with another specialty. 2 were left lateral LLR and risk-stratification for future trials. sectionectomies of liver with anterior resection for meta- static colorectal cancer, 1 Whipple operation for peri- ampullary carcinoma with right partial nephrectomy for renal cell carcinoma(RCC) and lastly cholecystectomy EP01D-024 with partial nephrectomy for RCC. All margins were EVALUATION OF THUNDERBEAT FOR clear. There was no 90 day/inpatient mortality in the entire PARENCHYMAL TRANSECTION IN cohort of 11 patients. OPEN HEPATECTOMY Conclusion: Complex multi-quadrant, multi-visceral sur- T. Komokata, B. Aryal, D. Kamiimabeppu, N. Tada, geries are feasible and safe with the Da Vinci Xi. More K. Yoshikawa and M. Kaieda comparative studies with larger cohorts are needed to Department of Surgery, Kagoshima Medical Center, Na- confirm the benefit of this modality versus conventional tional Hospital Organization, Japan laparoscopic surgery. Introduction: THUNDERBEAT (TB) is a novel device that uses both ultrasonic and advanced bipolar energies. It has been sometimes applied to various surgical specialties, EP01D-023 but its use in liver surgery has not been well recognized yet. CRITICAL APPRAISAL OF PREDICTIVE In this pilot study, the applicability and efficiency of TB TOOLS TO ASSESS THE DIFFICULTY was evaluated in non-anatomical open liver resection. OF LAPAROSCOPIC LIVER Method: TB was used as a single device, assisted by RESECTION: A SYSTEMATIC REVIEW Pringle maneuver with or without infra-hepatic IVC 1 2 3 1 clamping, in 9 major and 8 minor hepatectomies from Apr. J. Hallet , A. Mahar , K. Beyfuss , S. Jayaraman , 2016 to Dec. 2017. We retrospectively evaluated the intra- P. Serrano4, G. Martel5, N. Coburn1, T. Piardi6 and 7 and immediate post-operative results, while including P. Pessaux video clip of our liver resection technique with TB in a case 1 2 ’ 3 University of Toronto, Queen s University, Sunnybrook of left lobectomy. Research Institute, 4McMaster University, 5University of 6 7 Results: Interpretation of the intra- and immediate post- Ottawa, CHU de Reims, and IHU Strasbourg, France operative results of the cohort was noted in Table 1.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S459

EP01D-024 Table 1 Resection type Variables Parenchymal Resected Transfusion Clavien-Dindo Postoperative liver resection time liver weight avoidance >or[ IIIa dysfunction (min, mean±SD) (g, mean±SD) rate (%) Major hepatectomy 14.7±5.3 min. 572±216 g 44.4 % Bile leak (n=1)Bleeding (n=1) 0 (n=9) Hepatico-jejunostomy failure (n=1) Minor hepatectomy 8.6±1.6 min. 87.5 % 0 0 (n=8)

Conclusions: Use of TB during non-anatomical open liver Medicine/Kyungpook National University Hospital, resection made the procedure simple and substantially Republic of Korea rapid. It also avoided multi-device use. Concerns on Decreased blood loss, less postoperative pain, and bleeding and bile leakage in major hepatectomy need to be excellent cosmetic outcome have well been validated as the addressed in future trials. advantage of laparoscopic hepatectomy. However, donor safety is the most important issue in living donor hepa- EP01D-025 tectomy. Hence, pure laparoscopic right lobe donor hepa- LAPAROSCOPIC LIVER RESECTION OF tectomy has been applied in donors with favorable hepatic THE SEGMENTS 7 AND 8 vascular and biliary anatomy. We present the experiences for totally laparoscopic right A. Maeda, Y. Kaneoka, Y. Takayama, Y. Fukami, hepatectomy in living donors with bile duct anomalies. T. Takahashi and M. Uji From May 2016 to November 2017, totally laparoscopic Department of Surgery, Ogaki Municipal Hospital, Japan right lobe donor hepatectomy for adult-to-adult living Introduction: Laparoscopic liver resection (LLR) of the donor liver transplantation was performed in 24 cases. fi Segments 7 and 8 (S78) is still dif cult. The present study Among them, right hepatic ducts with more than 2 orifices elucidates safety and appropriate approach of LLR for S78 were demonstrated in 11 patients. tumors. By Nakamura classification, type 2 anomaly was Methods: Between June 2010 and December 2017, 170 identified in 5 patients, type 3a in 3 patients, and type 3b in patients underwent LLR at our hospital, and 57 (33.5%) 3 patients, respectively. All donors were recovered hepatectomies were for S78 tumors. These were divided in without vascular or biliary complication. Biliary compli- 2 groups: those patients with subsegmentectomy or more cations occurred in four cases of 24 recipients. Anasto- (Group S, n=37) and partial or limited resection (Group P, mosis site stricture of hepatic duct was confirmed in 3 n=20), and analyzed retrospectively. cases (1 case in type 1, 1case in type 2, and 1 case in type Results: Indicated diseases were HCC in 44, metastases in 3b). And bile leakage from anatomosis site was identified 11, cholangiocarcinoma in 1 and benign tumor in 1. in one case (type 3a). All complicated recipients was Median age (Group S, 69 years vs. Group P 68.5 years), improved by biliary stents by endoscopic retrograde male: female ratio (25:12 vs. 12:8), BMI (22.9 vs.24.2 kg/ cholangiopancreatography, or percutaneous transhepatic m2), history of abdominal surgery (48.6% vs.55.0%), biliary drainage. tumor size (2cm vs. 1.5cm, p=0.092), number of tumors (1 Conclusively, totally laparoscopic living donor right vs. 1), and ICG R15 rate (12.5% vs. 17.5%, p=0.081) were hepatectomy is feasible and acceptable in donors with bile not different. Surgical duration (217 min vs. 178 min, duct anomaly. But, to become a routine procedure, further p=0.192), blood loss (215 g vs. 300g, p=0.632), number of evaluation and long-term results by highly experienced ports (6 vs. 6), wound length (5cm vs. 5cm), morbidity surgeons should be demanded. (>Clavien-Dindo classification,Grade 2) (8.1% vs. 25%, p=0.081), and hospital stay (13 days vs. 12.5 days) were not different. However, open conversion rate (2.7% vs. 15%, p=0.031) and positive surgical margin (0% vs. 20%, EP01D-028 p=0.026) were significantly different. LAPAROSCOPIC LIVER RESECTION Conclusion: LLR for S78 tumors is feasible with accept- USING VR SIMULATION TECHNIQUE able morbidity and mortality rates. Anatomical subseg- Y. Seyama1, K. Mori1, T. Koseki1, Y. Shimizu1, mentectomy or more extensive liver resection is preferable T. Maeshiro1, S. Miyamoto1 and M. Sugimoto2 when liver function reserve is in a tolerable range. 1Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, and 2International University of Health and EP01D-026 Welfare School of Medicine, Japan SHORT TERM OUTCOMES OF Background: The surgical field from the caudal side is TOTALLY LAPAROSCOPIC LIVING specific to laparoscopic hepatectomy and is useful to DONOR RIGHT HEPATECTOMY IN approach to the hepatic vein during liver transection. BILE DUCT ANOMALIES Simulation of the surgical anatomy is important because we are not familiar with the caudal view. However, ordinary 3D H. T. Ha, Y. S. Han, J. R. Han, J. M. Chun and analysis is observed on a two-dimensional monitor, so there Y. J. Hwang is a disadvantage of lack of reality. We present laparoscopic Hepato-Biliary-Pancreas Surgery and Liver Trans- hepatectomy simulation using VR technology which attracts plantation, and Kyungpook National University School of attention in medical treatment in recent years.

HPB 2018, 20 (S2), S333eS504 S460 Electronic Posters (EP01A-EP01E) - Liver

Method: A case was 77-year-old female with three hilar lymphadenectomy. But further trials comparing robot metastasis from rectal cancer, and resection of segment 7 to laparoscopy are required. was conducted. A 3-dementional virtual hepatectomy simulation with real-time deformation (Liversim) and VR Table[Clinic, operative and postoperative data (n=11)] observation by a head mount display was clinically applied Characteristics Overall Distribution - especially to get images of hilar portal systems and hepatic mean / median vein anatomy. Age 56.5 ± 13 Results: Preoperative 3D virtual hepatectomy was Gender (Female) 63.7 % performed repeatedly on a personal computer, and we could get images of the branch of P6 and P7 in hilum and the right BMI 30.2 ± 4.4 hepatic vein on the raw surface with deformation of the Largest lesion size - cm (n = 8) 2.8 ± 1.1 liver parenchyma. Head mounted display provides us with Iwate difficult score (range) 5 (2 - 7) immersive 3D simulation. During the operation, we iden- Operative time - min 325 ± 103 tified and taped the root of P7 Glisson capsule. The right Estimated Blood Loss - ml 203 ± 186 hepatic vein was also identified on the raw surface from the caudal view. Laparoscopic anatomical resection of segment Intensive Care Unit - days (range) 2 (1 - 4) 7 was successfully performed. Length of Stay - days (range) 3 (3 - 7) Conclusion: Simulation using VR technology is useful for laparoscopic hepatectomy from the caudal view.

EP01D-032 EP01D-030 RECURRENT PYOGENIC ROBOTIC LIVER SURGERY e INITIAL CHOLANGITIS WITH EXPERIENCE OF 11 CASES IN A SINGLE HEPATOLITHIASIS e 10 YRS CENTER SURGICAL EXPERIENCE IN R. L. C. Araujo, M. A. Sanctis, F. Felippe, D. Burgardt and BANGLADESH D. Wohnrath 1 2 3 2 Department of Upper GI and HPB Surgery, Barretos H. Rabbi , M. M. Rashid , H. N. Hakim , A. T. Ahmed , 3 3 2 Cancer Hospital, Brazil A. Q. Chowdhury , M. M. Sarder , M. Ali , M. A. Islam3 and A. N. Azam3 Introduction: Robotic liver surgery is feasible, but it re- 1BIRDEM General Hospital, 2Hepato-Biliary-Pancreatic mains a work in progress when compared to laparoscopic Surgery, BIRDEM General Hospital, and 3Surgery, Dhaka approach. We report our initial experience with robotic Medical College Hospital, Bangladesh liver surgery. Methods: Consecutive patients undergone liver resection Introduction: Recurrent pyogenic cholangitis (RPC) is by daVinciÒ SI robot, and by the same team were reported. recurring cholangitis associated with intrahepatic stones For posterior and upper segments, and right hepatectomy, and biliary obstruction. Sepsis is the grave sequel. Delin- patients were positioned in oblique left lateral position and eating extent of disease were key to management strategy. reverse Trendelenburg. For left lateral or IV/V resections, Method: This prospective study includes 461 cases of RPC only reverse Trendenlenburg was used. All cases used 3 surgically treated at BIRDEM & other hospitals of Dhaka trocars of 8mm and 2 of 12mm were used. The surgical city, during January 2007 to July 2017. The study designed specimens were removed through Pfannestiel incisions or at outcome of ductal clearance and removal of diseased slight enlargement of trocar site. segment in RPC. Hepatolithitomy, hepatic resections with Results: From April 2016 to December 2017, 11 cases of T-tube or bilioenteric drainage were main modality of robotic hepatectomy were performed. Clinicopathological, treatment. operative and postoperative data are summarized in the Result: Patients presented between 20-76 yrs, 281 male table. Briefly, 6 (54.5 %) patients presented colorectal liver and 180 were female. We found 354 patients (76.78%) metastases (CRLM), 3 (27.3 %) incidental gallbladder from south eastern part of Bangladesh. 28.5% patients cancers (IGBC), and 2 (18.2 %) hepatocellular carcinomas presented with. Recurrent abdominal pain, Jaundice and (HCC) in cirrhotic livers. One right hepatectomy 1 (9.1 %), fever. Isolated left duct stone found in 42.95%, right duct 2 left lobectomies (18.2%), 3 IVb/V resections with stone in 20.82%, bilateral stones in 25.59% cases and Intra- lymphadenectomy (27.3%), and 5 upper posterior re- extrahepatic litihiasis in 24.72%. Left Lateral Segmentec- sections (45.5 %) were performed. Intraoperative ultra- tomy was the most common procedure in 307 cases. T-tube sound was used for CRLM and HCC. No intraoperative drainage required in 154 cases, hepaticojejunostomy in 307 blood transfusions were necessary. Two patients (18.2%) patients, Access loop was made in 14 patients. Post-oper- presented complications: pulmonary embolism (grade 2) ative complications were in 16% cases. and biliary fistula (grade 3). Conclusion: Treatment of RPC is tailored according to Conclusion: In our series, robotic surgery seemed to be presentation, extent of disease and remnant liver volume. safe even for cirrhotic livers. Moreover, the putative ben- We found, in bilateral disease, Left duct approach efits of its articulate arms can help to access non-laparo- following left lateral segmentectomy with biliary drainage scopic segments (posterior and upper) and also facilitate offers better ductal clearance and prevents recurrence.

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EP01D-033 occurred in three patients. Estimated blood loss was 100ml (range100-500) and Pringle maneuver was carried out on ROLE OF THE ANTERIOR FISSURE seven(15%) patients. No blood intra-operative transfusions VEIN IN VENTRAL OR DORSAL were performed. R0 resection was obtained in all patients. RESECTION OF THE SUPERIOR Morbidity was 12,7% and the median hospital stay was 4 ANTERIOR SEGMENT OF THE LIVER days. (SEGMENT VIII) Conclusion: Our results show that liver resections with robotic technique can be performed safely even without N. Taniai, J. Ueda, H. Takata, Y. Aoki and H. Yoshida systematic Pringle maneuver. However, prophylactic Surgery, Nippon Medical School, Japan isolation of the hepatic pedicle with the predisposition Background: The vein that runs between ventral and to the clamping should be desirable in all possible dorsal Segment VIII is called the anterior fissure vein cases. (AFV). AFV is sometimes needed as a boundary for subsegmental resection of Segment VIII. Methods: We analyzed data from 151 patients who had EP01D-035 undergone abdominal computed tomographic (CT) exam- inations. The position of the AFV is identified by deter- REAL-TIME FLUORESCENCE IMAGE- mining whether the AFV drains flows into the proximal, GUIDED GURGERY FOR SAFE AND medial, or distal portion of the middle hepatic vein (MHV) PRECISE LEFT HEPATIC or right hepatic vein (RHV). Furthermore, the proximal TRISECTIONECTOMY region is divided into 2 halves; the proximal portion is E. Hatano1, M. Tada1, S. Hai1, H. Nishino2, S. Seo2, designated as P1 and the distal portion is designated as P2. S. Uemoto2 and J. Fujimoto1 Results: The AFV could be identified in 78.8% (119/151) 1Department of Surgery, Hyogo College of Medicine, and of the patients. The AFV flowed into the MHV in 84.9% of 2Department of Surgery, Kyoto University Graduate the patients and into the RHV in 15.1%. Among the former, School of Medicine, Japan the AFV flowed into the proximal MHV in 69.7% of the patients. Background: Left hepatic trisectionectomy (LHT) is still a Conclusions: Although the AFV might not be easily challenging procedure. Nationwide surgical database in identifiable, the AVF can be used to determine the border Japan showed 90-day in-hospital mortality of LHT was between the ventral and dorsal portions of Segment VIII. 14.6%. To secure the future remnant liver volume, the The AFV should thus be used as a landmark for precise resection is necessary. However, the right hepatic subsegmentectomy. vein (RHV) was not always along the right intersectional plane. According to virtual LHT, 45.5 % of patients exhibited partial exposure of the RHV on the transected plane (Sato F et al. World J Surg, 2014). In such cases, full EP01D-034 exposure of the RHV may lead to the unnecessary resection PRINGLE MANEUVER IN ROBOTIC of segment VI or full exposure may be impossible. To LIVER SURGERY: OUR EXPERIENCE perform safe and correct anatomical resection, we intro- fl B. Pesi1, M. Annecchiarico1, F. Tofani1, L. Bencini1, duced a uorescent indocyanine green (ICG)-based imag- L. Moraldi1, E. Gia2 and A. Coratti1 ing technique. 1Careggi University Hospital, and 2Oncology, Careggi Patient and results: Anatomical LHT was performed in University Hospital, Italy the patient with perihilar cholangiocarcinoma after portal embolization of left branch and anterior branch. After Introduction: The most feared complication in liver ligation of left and anterior branch of hepatic artery, fluo- resection is intraoperative hemorrhage, sometimes massive. rescent imaging was obtained with near-infrared light Negative peri-operative events and poor long-term survival camera system (LIGHTVISION, Shimadzu Co, Kyoto, are associated with blood loss and consequent need for Japan) by injecting 0.25mg of ICG into peripheral vein. blood transfusions. Pringle maneuver is the most used The parenchymal dissection during LHT using the fluo- technique to reduce intra-operative bleeding, however, this rescent imaging was shown. maneuver has the problem of the duration of ischemia, especially on diseased liver. Robotic surgery thanks to magnified view and three-dimensional visualization asso- ciated with fine movement of reticulating endowrists allow to perform precise parenchymal dissection, with good identification and coagulation of vascular structure. Aim of study is to evaluate blood loss and the need to perform Pringle maneuver in patients underwent robotic liver resection. Methods: Fourty-seven patients underwent robotic cura- tive liver resections were analysed. Eight(17%) patients had benign lesions and thirtynine(83%) had malignant tumor. Results: Twenty-one(45%) patients had anatomical re- sections (4right hepatectomy, 2left hepatectomies, 8biseg- mentectomies, 7segmentectomies), while twentysix(55%) Figure patients had non anatomical resection. Median operative time was 270 minutes (range150-540). Open conversion

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The dissection line was the boundary between the radiological images. Such recognition often differs be- colored and non-colored area. The RHV was partially tween operator and assistants. To conquer difference exposed only on the cranial side of the transected plane. of anatomical recognition, we are going to develop Furthermore, we developed the Medical Imaging Projec- three-dimensional (3D) model navigation for open tion System (MIPS), which uses ICG emission signal and hepatectomy. active projection mapping, to identify anatomical land- Material and methods: Digital segmentation of anatom- marks for parenchymal dissection (Nishino H et al. Ann ical structures from multidetector-row computed tomogra- Surg, 2017), providing an option for real-time navigation phy images utilized the original software “PLUTO”, which system for LHT. was developed by Graduate School of Information Science, Nagoya University. After changing the final segmentation data to the stereolithography files, a 3D printed liver at a EP01D-036 70% scale was produced. The support material was washed THE ROLE OF INDOCYANINE GREEN and mold charge was removed from 3D printed hepatic veins. The surface of 3D printed model was abraded and (ICG) IN ROBOTIC LIVER SURGERY coated with urethane resin paint. After natural drying, 3D D. Ng, E. Eu, L. S. Lee, A. Chiow and S. S. Tan printed hepatic veins were colored by injection of a dye. CGH, Singapore The 3D printed portal veins were whitish because mold Introduction: The ability of ICG to provide a fluorescence charge remained. All procedures after 3D printing were appearance under infrared light enables its wide usage in performed by hand work. We used 3D print of a liver to surgical oncology. It is capable of identifying hepatic le- hepatectomies for 14 patients. sions intraoperatively and identifies anatomic sections in Results: In all study patients, hepatectomy was performed real time. The purpose of this study is to describe the referring to 3D printed model. The planned resections were technical aspects of its use and to evaluate the diagnostic successful with histologically negative surgical margins. value of ICG fluorescence in robotic liver surgery in a Conclusions: Application of 3D printed liver to hepatec- single-center. tomy is easy and suitable procedure. In the future, diffusion Methods: Patients who underwent robotic liver resection at of 3D printing technology in hepatectomy requires further Changi General Hospital for primary liver cancer and improvement and automatization of hand work after 3D colorectal liver metastases (CLM) were included. All cases printing. were completed robotically with daVinciXi. For identifi- cation of liver tumor, 5mg of ICG was given intravenously 1-3 days prior to surgery. For identification of anatomical EP01D-038 segments, negative staining method was used by giving PURE LAPAROSCOPIC RIGHT AND 5mg of intravenous ICG after clamping of the segmental LEFT HEPATECTOMY WITH inflow. Firefly fluorescence imaging was used for illumination. UMBILICAL ZIGZAG SKIN INCISION Results: A total of 9tumors were resected in 8patients. Of T. Shikano the 9 tumors, ICG was used for tumor identification in 4 Surgery, Yokkaichi Municipal Hospital, Japan and negative staining for anatomical resection in 6. All 4 Introduction: Laparoscopic hepatectomy is gradually tumors were successfully identified with ICG fluorescence. gaining acceptance as an alternative to open resection in The anatomical resection performed were right posterior selected patients for its less invasiveness and high cosm- sectionectomy (n=4), right anterior sectionectomy (n=1), esis. To achieve higher cosmesis, we performed hepatec- and right hepatectomy (n=1). Negative staining was clearly tomy with umbilical zigzag skin incision. identified in 4 patients; however it was not demonstrated in Methods: Between June 2010 and January 2018, 75 two patients due to failure to tightly control the hepatic laparoscopic hepatectomy with umbilical zigzag skin inci- inflow. sion were performed in our hospital. We performed pure Conclusion: Robotic ICG fluorescence can provide clear laparoscopic major hepatectomy with umbilical zigzag skin identification of tumors on liver surface. Tight control of incision in 8 patients, 5 right lobectomy and 3 left lobec- the inflow is crucial to obtain a successful real time negative tomy. In an abdominal approach, after marking a zigzag staining for anatomical resection. skin incision, the skin was incised along this line. After the peritoneum was opened, camera port was inserted through zigzag skin incision. After multiport hepatectomy was EP01D-037 done, the specimen was delivered to outside body through APPLICATION OF A THREE- the zigzag skin incision. DIMENSIONAL PRINT OF A LIVER IN Results: Intraoperative blood loss was 135ml mean. Operation time was 430 minutes mean. The length of post- HEPATECTOMY operative hospital stay was 7 to 8 days. There were no T. Igami, H. Tanaka, Y. Toyoda, T. Ebata, Y. Yokoyama, morbidities and no mortalities. The umbilical zigzag skin T. Mizuno, J. Yamaguchi, S. Onoe and M. Nagino incisions were so small and beautiful that the patients were Division of Surgical Oncology, Department of Surgery, very happy. Nagoya University Graduate School of Medicine, Japan Conclusion: The case result confirms that pure laparo- Background: Hepatectomy is performed according to scopic right hepatectomy with umbilical zigzag skin inci- the recognition of liver anatomy obtained by preoperative sion can be safely performed with high cosmesis.

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EP01D-039 for the study. Data from a prospectively collected data- base were analysed. THE STAND OF PORTAL VEIN Results: Tumour types were 7 colorectal metastases ARTERIALIZATION IN (CRLM), 4 intrahepatic cholangiocarcinoma and 1 Klatskin HEPATOBILIARY SURGERY: A Tumour. Hepatectomies were major in 41.6% of cases. Six SYSTEMATIC REVIEW patients required associated resection: 4 biliary recon- struction, 1 colorectal resection and 1 splenopancreatec- A. Majlesara, M. Golriz, O. Ghamarnejad, E. Khajeh and tomy. Seven patients had hepatic vein resection and 5 portal A. Mehrabi vein resection. In all cases venous involvement could be General, Visceral, and Transplantation Surgery, Heidel- managed with lateral resection. Venous reconstruction berg University, Germany enabled resection in 5(41.6%) patients otherwise non- Introduction: Hepatic artery (HA) reconstruction during resectable. Among CRLM the venous reconstruction fi liver resection can be impossible due to arterial in ltration allowed to avoid major resection in 5(71.4%) cases. or anatomical limitations. Portal vein arterialization (PVA) Median operative and clamping time were 456min(270- is discussed to improve the hepatic oxygenation and pro- 960) and 30min(8-95), blood loss were 445cc in vide a new chance for the patients with dearterialized liver. median(40-1500). At pathological examination, venous The aim of this study is to review the clinical application of infiltration was confirmed in 8(66.7%) patients. No PVA in hepatobiliary surgeries. vascular complications related to the patch were registered. Methods: The systematic review was performed according One patient died because of liver failure without vascular to the PRISMA guidelines. MEDLINE, Embase, and Web thrombosis and one due to biliary fistula complicated by of Science databases were systematicly searched. Experi- arterial bleeding. Postoperative major (Dindo III/IV) com- mental studies, review articles, letters, and also articles plications were observed in 2(16%) patients, median published in languages other than English were excluded. comprehensive complication index was 10.45(0-100). Results: A total of 20 studies, involving 57 patients, were Blood transfusions were required in 3 patients. Median included. According to the anatomical location, hilar lesions hospital stay was 9 days(5-46). (38 patients, 70.4%) were the most common indication of Conclusions: Venous reconstruction with PP during hep- the surgery. The reasons for performing PVA were excision atectomy is feasible allowing resection of otherwise un- of lesions abutting HA (32 patients, 56.1%), HA ligation (11 resectable patients and decreasing of major resection rate. patients, 19.3%), HA thrombosis (six patients, 10.5%), iat- rogenic injury (four patients, 7.0%), and failure of HA reconstruction (four patients, 7.0%). An end-to-side anas- tomosis between celiac trunk branches and portal vein (PV) EP01D-042 was the main performing technique for PVA (35 patients, COMPARETIVE ANALYSIS OF 59.3%). The most common complication of PVA was portal LAPAROSCOPIC-ASSISTED AND OPEN hypertension (12 of 57, 21.1%). Thirty-five patients (61.4 LIVER RESECTION FOR LARGE %) survived during the follow-up period of 1 to 87 months. HEPATIC TUMORS Conclusion: PVA may provide a chance of cure for pa- tients with the unresectable lesions. To prevent portal hy- R. Alikhanov, M. Efanov, P. Kim, I. Kazakov, pertension and liver injuries due to thrombosis or over- A. Vankovich, D. Akhaladze, S. Iskhagi, K. Grendal, arterialization, calibrating and timely closure of PVA E. Zamanov and V. Tsvirkun fi should be considered. HPB Surgery Separtment, Moscow Clinical Scienti c Center, Russian Federation Background: This study aimed to assess outcomes of EP01D-041 Laparoscopic-Assisted Resection(LAR) and Open Liver Resection(OLR) for large ( 8 cm) liver tumors. VASCULAR RESECTION DURING Methods: A prospectively collected database of 350 liver HEPATECTOMY FOR LIVER resection was reviewed from January of 2015 to August MALIGNANCIES: RESULTS FROM A 2017. The data for patients undergoing LAR comparing TERTIARY CENTER USING with OLR for large liver tumors were analyzed. AUTOLOGOUS PERITONEAL PATCH Results: During the period studied, 30 LARs and 43 OLR were performed (females, 54 %; mean age, 55.4 years) for FOR VENOUS RECONSTRUCTION large tumors. Patients with benign tumors were 20 in LAR S. Langella, F. Menonna, M. Casella, N. Russolillo, and 27 in OLR group. Patients with malignant tumors were R. Lo Tesoriere and A. Ferrero 10 in LAR and 16 in OLR group. The mean diameter of General and Oncological Surgery, Mauriziano Hospital, tumor in LAR group was 126 mm and in OLR - 120 mm Italy (p>0,05). The median operative time was 382 min in LAR Introduction: To evaluate early outcomes of venous and 350 min in OLR group(p>0,05), and the blood loss reconstruction with peritoneal patch (PP) during resection was 310 ml for LAR and 790 ml for OLR group(p< 0,05). for hepatic malignancies. The Clavien-Dindo complications IIIa-b were 10% in LAR Methods: Since 05/2015 PP was considered as first and 11,6% in OLR (p>0,05), and no mortality occurred option for venous reconstruction. From 05/2015 to 12/ during a 90-day period. 2017 357 consecutive hepatectomies for malignancies Conclusion: The findings showed that LAR is feasible and were performed at our institution. Among 15 patients safe for large liver tumors, has less blood loss and can be requiring venous resection, PPwasusedin12included performed with acceptable morbidity.

HPB 2018, 20 (S2), S333eS504 S464 Electronic Posters (EP01A-EP01E) - Liver fl EP01D-043 The hepatic blood ow was blocked by Pringle method with an incidence of 72.37% (55/76). The mean operative UTILITY OF THE GORETEX AND THE time was 266.0487.44min. The intraoperative blood LEFT RENAL VEIN AS A SUBSTITUTE transfusion rate was 10.53% (8/76) and intraoperative GRAFTS FOR LIVER RESECTIONS IN blood loss was 330.21163.51ml. There were 6 cases TUMORS WITH SUPRAHEPATIC AND undergoing open surgery. Thus, the transfer rate was 7.89% INFERIOR CAVA VEIN INVASION (6/76).As for postoperative complications, the post- operative bile leakage rate was 2.63% (2/76).There was no L. A. Martinez Insfran, R. Robles Campos, R. Brusadin, perioperative death and re-operation case occurred within V. Lopez Lopez, T. Nicolas Nicolas, A. Lopez Conesa, 30 days. After the operation, the average time for hospital P. Parrilla Paricio and P. Gil stay were 7.143.39 days. All patients were followed up Department of General Surgery, Hospital Universitario and the follow-up time lasted from 6 to 36 moths. Patients Virgen de la Arrixaca, Spain checked for their condition every 3 to 6 months after Introduction: The invasion of the Inferior Cava Vein leaving the hospital. The average tumor-free survival time (IVC) and/or suprahepatic veins (SHV), represent a chal- was 18.386.80months, and there was no patient dead lenge for a R0 resection, achieved by vascular resections during the follow-up period. that often require reconstruction with grafts, both biological Conclusion: Laparoscopic right hepatic posterior lobec- as prosthetics. The main objectives were the analysis of tomy is safe and effective, which is worthy of clinical postoperative results (morbidity and mortality) at 90 days promotion. and overall and disease-free survival at 1 and 5 years. Keywords: Laparoscopy, Right hepatic posterior lobec- Methods: Retrospective study on a prospective database of tomy, Hepatoma approximately 1500 patients operated until September 2017. There was variability in the amount of resected pa- renchyma and about total or partial hilar occlusion, as well EP01D-045 as in the SHV. LAPAROSCOPIC ANATOMICAL Results: From the 13 patients who underwent liver re- HEPATECTOMY VIA HEPATIC VEIN sections with vascular reconstructions, 8 of them under- APPROACH went IVC resection with replacement of a goretex graft, and W. Cheng and X. Yin 5 patients with invaded SHV underwent resections with Hunan Provincial People’s Hospital, China placement of a 3 cm long LRV graft. The average age was Introduction: To investigate the clinical outcomes on 58 years (range 46-71). Hepatic volumetry was performed, laparoscopic anatomic liver resection via hepatic vein getting an insufficient remnant liver volume in 7 cases, approach. performing the ALPPS-TORNIQUETE technique. A hilar Methods: 130 cases of laparoscopic anatomic liver resec- and IVC clamping test was performed and veno-venous tion through hepatic vein approach were retrospectively bypass was never required. One patient died post- reviewed between Jan 2013 and Jun 2017. operatively (7.7%), and Clavien morbidity higher than IIIa Results: The mean operative time was 304.4146.1min, was found in 5 cases. The actuarial survival at 1, 3 and 5 the mean blood loss was 133.3188.9ml. 4 cases years was 87, 67 and 45% respectively. conversed to open surgery. In the postoperative period, Conclusions: In cases of IVC or SHV invasion by a tumor, 4 cases showed pleural effusion, 2 case showed bile leaks if there is a small remnant liver parenchyma, with prosthetic and 1 case showed wound infection, which resolved on graft or autologous left renal vein replacement should be treatment. There was no case went reoperation and no death considered as a valid alternative when resections and occurred. The mean duration of the patients’ stay in hos- complex vascular reconstructions are needed. pital was 17.45.6 days. Conclusions: Laparoscopic anatomic liver resection EP01D-044 through hepatic vein approach can be implemented effi- CLINICAL ANALYSIS OF ciently and effectively with the insurance of instrument, method and surgical manipulation. LAPAROSCOPIC RIGHT HEPATIC Keywords: laparoscopic liver resection, anatomic liver POSTERIOR LOBECTOMY FOR resection, through hepatic vein approach HEPATOMA (WITH 76 CASES REPORT) Y. Xinmin, L. Yi and L. Sheng EP01D-046 Department of Hepatobiliary Minimally Invasive Surgery, ANATOMICAL RESECTION OR People ’s Hospital of Hunan Provincial, China ENUCLEATION FOR LIVER Objectives: To explore the clinical value of laparoscopic right hepatic posterior lobectomy for the safety and efficacy HEMANGIOMA of the treatment of right hepatic posterior lobe tumor. V. Boyko, R. Smachylo, O. Tyshchenko, Method: We collected patients’ clinical data for summary M. Chernyayev and Y. Mushenko review, those who underwent laparoscopic right posterior Institute of General and Urgent Surgery, Ukraine lobectomy in our hepatobiliary department from November Introduction: Liver hemangioma is not rare benign hepatic 2013 to February 2017. Then, we evaluated the safety and tumor. Various strategies were proposed. We compared efficacy of laparoscopic right posterior lobectomy for the two surgical approaches aimed to remove hemangioma - treatment of right posterior lobe tumor. anatomical resection of affected segments and enucleation. Result: In this study, 76 patients were included and 70 Materials and methods: Since 2010 till 2017 130 patients patients underwent laparoscopic subtotal lobe resection. were operated in the Institute for liver hemangioma.

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Indications for surgery were hemangiomas more than 5 cm significantly shorter in 3D-LRH group (101 vs 123 min, P in diameter, complicated and symptomatic tumors. 59 and = 0.003). Liver parenchyma transection time was also 71 patients underwent anatomical resections and enucle- shorter in 3D-LRH group (138 vs 151 min, P = 0.089), ations. The age and gender of patients, comorbidities, size although not significant. There was no significant differ- and location of hemangiomas were comparable in both ence in liver mobilization time, intraoperative bleeding/ groups. We used clamp crush technique and LigasureÔ transfusion, and postoperative complications. sealing technology (during last years ValleylabÔ LS10 Conclusions: 3D vision with maintenance of pneumo- Generator). Duration of surgery, blood loss, postoperative peritoneum facilitates hepatic vascular isolation/division, morbidity and mortality were assessed. and may contribute to the development of LRH. Results: The duration of surgery was comparable in both groups 14412,6 and 138,614,4 minutes in resection and enucleation group. Blood loss was higher in anatomical EP01D-048 resections - 356,8 18,6 ml compared with 240,4 14,2 ml TECHNIQUE OF EXTENDED in enucleation group. There was no postoperative bleeding in any group, but bile leaks occurred in 6 patients after HEPATECTOMY WITH STAPLER IN anatomical resection and only in 2 patients after enucle- PORCINE MODEL ation. One patient died in liver resection group due to A. Majlesara, M. Golriz, E. Khajeh, O. Ghamarnejad and th pulmonary embolism on 6 postoperative day. A. Mehrabi Conclusions: Enucleation of hemangioma is preferable General, Visceral, and Transplantation Surgery, Heidel- intervention compared with anatomical liver resection berg University, Germany taking into consideration rate of intraoperative blood loss Introduction: Notwithstanding the recent advances in and and postoperative bile leak. surgical techniques and perioperative care, extended hep- atectomy (EH) is still a high risk procedure with relatively high rates of morbidity and mortality. Experimental models EP01D-047 of large animals are advantageous in the study of post- 3D VISION AND MAINTENANCE OF hepatectomy liver failure (PHLF) and liver regeneration STABLE PNEUMOPERITONEUM: A due to similarities to human anatomy and physiology. We NEW STEP IN THE DEVELOPMENT OF aimed to report methods of different extents liver resection up to left EH in pigs using stapler. LAPAROSCOPIC RIGHT Methods: All resection methods including resection of left HEPATECTOMY lateral lobe (LLL, segments II and III), left hemi- T. Kawai1,2, C. Goumard1, F. Jeune1, S. Komatsu1,3, hepatectomy (segments II, III, and IV), left EH (II, III, IV, O. Soubrane4 and O. Scatton1 V, and VIII) were described. 1Department of HPB Surgery and Liver Transplantation, Results: After anesthesia and midline laparotomy, we Pitié Salpêtrière Hospital, Sorbonne Université, France, prepared the surrounding ligaments and mobilized the liver. 2Department of Surgery, 3Department of Surgery, Grad- Then we resected LLL of the liver. In next step, we resected uate School of Medicine Kobe University, Japan, and the left medial lobe (LML) to perform left hemi- 4Department of HPB Surgery and Liver Transplantation, hepatectomy. For left EH, after resection of LLL and LML, Beaujon Hospital, University Paris VII Denis Diderot, we resected the right medial lobe (RML). Finally, we France described the method of resection of segment VII following Background: Although laparoscopic liver resection is left EH. All steps of resection were performed under widely performed, many technical difficulties remain, such Pringle maneuver to prevent massive bleedings. After re- as accurate isolation/division of hepatic vessels in laparo- sections, we controlled the bleeding with hand-suturing. scopic right hepatectomy (LRH). Innovative surgical de- Conclusion: As has been noted, owing to simplicity and vices, such as three-dimensional (3D) laparoscopy and rapidity of performance, stapler hepatectomy is an appro- priate model to investigate outcomes of EH. optimized carbon dioxide (CO2) insufflation system, may help to overcome technical difficulties in LRH. The pur- pose of this study was to analyze the efficacy of 3D vision associated to active pneumoperitoneum maintenance in EP01D-049 LRH. LIGAMMENTUM VENOSUM AS AN Methods: In our prospectively maintained database from ANATOMICAL LANDMARK DURING 2006, 75 consecutive LRH from May 2011 to June 2017 PURE LAPAROSCOPIC LEFT were included in this study. All LRH were performed with HEPATECTOMY 2D vision and standard CO2 insufflator (2D-LRH group, 45 cases) or 3D vision with optimized CO2 insufflator (3D- J. -W. Choi LRH group, 30 cases). Preoperative clinical characteristics, Chungbuk National University College of Medicine, Re- surgical data including operation time of separate steps public of Korea within the procedure, and postoperative complications were Background: Maintaining an anatomical orientation is compared between the two groups. more difficult using the laparoscopic approach because of Results: Clinical and pathological factors were comparable the lack of a complete hepatic overview and tactile feed- between two groups. Total operative time was significantly back. Laparoscopy-specific anatomical landmarks help shorter in 3D-LRH group than in 2D-LRH (360 vs 390 min, surgeons maintain a proper anatomic orientation when P = 0.029). Right hepatic pedicle dissection time was performing laparoscopic surgery. This study describes the

HPB 2018, 20 (S2), S333eS504 S466 Electronic Posters (EP01A-EP01E) - Liver use of the ligamentum venosum (LV) as an anatomical Conclusion: Solo SILC had comparable postoperative landmark during laparoscopic left hepatectomy. complications and feasibility in the aspect of operation time Methods: The LV passes from the left portal vein to the left and hospital stay compared with conventional MULS for a hepatic vein and is easy to identify and access the dorsal favorable located single HCC. surface of the liver. Its anatomic features facilitate the approach to the left hepatic vein and achieve safe inflow control of left hemiliver via an individual ligation or the EP01D-051 Glissonean approach. Following exposure of the middle RESULTS OF LAPAROSCOPIC hepatic vein, parenchymal transection is curved toward the LV, which serves as a landmark for dissection. The tran- DEROOFING WITH CHEMICAL section point of the left bile duct is determined by the ABLATION BY ETHANOL location of the LV, especially if there is bile duct variation. DISPERSAL FOR SYMPTOMATIC After completing parenchymal transection up along the LV LIVER CYST with the exposure of the middle hepatic vein, the left he- T. Koseki, Y. Seyama, K. Mori, H. Kanomata, Y. Shimizu, patic vein was reached and ligated. T. Maeshiro and S. Miyamoto Results: Between February 2013 and September 2017, 21 Surgery, Tokyo Metropolitan Bokutoh Hospital, Japan consecutive patients underwent pure laparoscopic left hepatectomy. The median operation time was 240 min Introduction: For treatment of symptomatic liver cyst, fi (range: 180-350 min), and the median intraoperative blood deroo ng of the cystic wall is most commonly performed fl loss was 200 ml (range: 80-600 ml). Major postoperative treatment. However, reaccumulation of uid is a problem. complications occurred in one patient (4.8%). Median We introduced ethanol dispersal combined with laparo- fi postoperative hospital stay was 8 days (range: 5-15 days). scopic deroo ng to reduce the risk of reaccumlation. We Conclusions: The LV should be considered as an anatomic report the short- and long-term results of laparoscopic fi landmark during laparoscopic left hepatectomy. deroo ng with ethanol dispersal. Methods: Between 2011 and 2017, eight patients under- went laparoscopic deroofing and ethanol dispersal (ethanol group), and eight patients underwent only laparoscopic EP01D-050 deroofing (former period; historical control). In deroofing FEASIBILITY OF SOLO SINGLE- and ethanol dispersal, 100-ml of absolute ethanol was INCISION LAPAROSCOPIC SURGERY sprayed on the internal surface of cyst after fenestration of IN NON-ANATOMICAL MINOR LIVER cyst. Short- and long-term results were evaluated and RESECTION FOR FAVORABLE compared the two groups. LOCATED SINGLE HEPATOCELLULAR Results: The medial operative time and postoperative hospital stay were 138 minutes and 130 minutes, 4 days and CARCINOMA 4.5 days, in ethanol group and in control group respec- Y. Choi, H. -S. Han, Y. -S. Yoon, J. Y. Cho, S. Kim, tively. The serum AST levels in ethanol group showed mild K. H. Kim and I. G. Hyun elevation as 50.5IU/L and were 28IU/L in control group Surgery, Seoul National University Bundang Hospital, (p=0.066). But the AST level in ethanol group normalized a Republic of Korea month after surgery (median, 21.5 IU/L). The medial size Introduction: We introduced solo surgery using a lapa- of cyst before surgery was 16.5cm in ethanol group, and 17 roscopic scope holder to wide an operator’s activity range cm in control group (p=0.920). The medial size 9 to 12 and reduce instrument crowding and clashing in single months after surgery was 3 cm in ethanol group and 8.5cm incisional surgery. This study aimed to compare the sur- in control group, which showed significant difference gical outcomes of solo single incision laparoscopic surgery (p=0.046). (SILS) and conventional multiport laparoscopic surgery Conclusion: Laparoscopic deroofing and chemical ablation (MULS) for hepatocellular carcinoma (HCC). by ethanol dispersal for symptomatic liver cyst is safe and Methods: A retrospective analysis for solo SILS (n=20) useful to prevent reaccumulation of the liver cyst. compared to accumulated data of conventional MULS (n=152) in non-anatomical minor liver resection for pa- tients with a single HCC in the favourable location at a EP01D-052 single center was performed between 2003-2017. Baseline IMMEDIATE RECOGNITION OF characteristics, operative outcomes, and postoperative IATROGENIC VASCULAR INJURIES complications were compared. Results: No significant differences in baseline character- ALLOWS FOR EMERGENCY istics and pathologic stage were found between the two RECONSTRUCTION IN MAJOR LIVER groups. Open conversion, postoperative complication RESECTIONS (Clavien-Dindo I/II/IIIa/IIIb) and recurrence rate were not M. Kalisvaart, A. Schlegel, R. Marudanayagam, different (0 vs. 12 (7.9%), P=0.364, 1(5%)/0/0/0 vs. 3(2%)/ J. Isaac and P. Muiesan 4 (2.6%)/8(5.3%)/1 (0.7%), P=0.650, 6 (30%) vs. 55 Liver Unit, Queen Elizabeth Hospital, United Kingdom (36.2%), P=0.587, respectively in SILS and MULS). Here we describe two cases of emergency vascular However, operative time and hospital stay were signifi- reconstruction in major hepatectomies. cantly shorter in SILS (110.2 57.1 vs 204.5 108.4 Patient A: A 44-year old female underwent laparoscopic mins, 2.5 1.9 vs 6.8 3.7 days, both P < 0.001,) right hemihepatectomy for a large adenoma. Bleeding compared to MULS.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S467 occurred after transection and stapling of the right he- EP01D-053 patic vein. This was controlled with sutures through a midline-laparotomy. However, at closure, the infrahe- SHORT AND LONG-TERM OUTCOMES patic inferior vena cava (IVC) was found tense and AFTER LAPAROSCOPIC OR ROBOTIC engorged. After further dissection, it became clear the LIVER RESECTION IN PATIENTS WITH IVC was completely divided intrahepatically with the HCC LOCATED IN POSTEROSUPERIOR fl stapler inferior to the hepatic venous con uence. The SEGMENTS: COMPARISION WITH IVC was bypassed with an iliac vein graft and anti- coagulation was initiated (Figure 1A). Patient recovery OPEN LIVER RESECTION was uneventful. J. U. Chong, G. H. Choi, D. H. Han and J. S. Choi Patient B: A 65-year old male underwent extended right Department of Surgery, Yonsei University College of hemihepatectomy + SII-NAR for colorectal liver metasta- Medicine, Republic of Korea ses. After resection, the left lateral segment seemed Introduction: Hepatocellular carcinoma located in post- congested and cut-surface inspection of the SII-NAR erosuperior segemtents, especially segments VII and VIII, revealed complete division of the left hepatic vein (LHV). are considered to be difficult for minimally invasive liver Cadaveric iliac vein grafts were used for an emergency resection (MLR) because of limited visualization, the risk portocaval-shunt and reconstruction of the LHV (Figure of major bleeding and difficulty in bleeding control. This 1B). The splenic artery was ligated and the portocaval- study compared outcomes after laparoscopic or robotic shunt was left open to further decrease portal pressure. liver resections for HCCs located in segments VII or VIII Patients’ condition deteriorated on POD-4 and an emer- with open liver resections. gency laparotomy was performed, showing a pale and Methods: Between January 2005 to December 2016, 497 congested liver. The LHV was patent but compressed by patients underwent liver resections for HCCs located in haematoma at the NAR-site. The portocaval-shunt had segments VII or VIII. Among them, 63 patients underwent thrombosed and a thrombectomy was performed, resulting minimally invasive liver resection (MLR), which included in decongestion. Patient experienced a very slow, but full 48 patients in laparoscope approach and 15 patients in ro- recovery. botic approach. We retrospectively evaluated perioperative Conclusion: Immediate repair of major venous injuries can and oncologic outcomes between the groups. result in good outcomes. Such challenging procedures Results: In terms of perioperative outcomes, operative time require a surgeon with both, experience in major HPB- was longer for MLR group than open group (421 min. vs, surgery and transplantation. 274 min., p< 0.001). While intraoperative blood loss was higher for open group (334 ml vs. 773ml, p< 0.001) and postoperative stay was longer (8.3 days vs. 17.5 days, p=0.001), there were no significant differences in post- operative complication rates (20.6% vs. 17.3%, p=0.596), In terms of oncologic outcomes, 5-year overall survival (85.5% vs. 79%, p=0.085) and 5-year disease survival (45.3% vs. 64.3%, p=0.489) rates did not show significant difference between MLR group and open group. Conclusion: MLR for HCC located in segments VII or VIII may be more time-consuming compared to open, but ben- efits of lower hospital stay and lower blood loss with same oncologic outcomes should make it a more attractive option in deciding operative procedure.

EP01D-054 UNILATERAL Y90 RADIOEMBOLIZATION INCREASES FUNCTIONAL CAPACITY OF THE CONTRALATERAL LIVER LOBE ALONG WITH VOLUMETRIC HYPERTROPHY (THE RADIOEMBOLIZATION, VOLUMETRY, AND LIVER FUNCTION e REVOLUTION STUDY) B. Garlipp1, M. Seidensticker2, D. Kupitz3, S. Kropf3, O. Großer3, J. Jürgens4, J. Omari3, J. Ricke2, M. Pech3 and H. Amthauer5 1General Surgery, Otto von Guericke University, 2Ludwig Figure 1 Maximilian University, 3Otto von Guericke University, 4Universitätsklinikum Hamburg Eppendorf, and 5Charité - Universitätsmedizin Berlin, Germany

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Background: Portal vein embolization (PVE) is the stan- compared among the groups using fluorescence imaging dard of care when preoperative induction of hypertrophy of system (PDE-NEO, Japan). the future liver remnant (FLR) is needed prior to major liver Result: Of the 82 patients, 154 lesions were assessed after resections. Unilateral Yttrium-90-Radioembolization (RE) excluding deeply-located 30 lesions (>10mm). There were also induces contralateral liver hypertrophy and may be a no significant differences on tumor identification rates: useful alternative to PVE or in-situ split (ALPPS) as it 82.1% (ICG-test), 72.7% (1.25 mg), 86.5% (2.5 mg), and provides simultaneous anti-tumor treatment of ipsilateral 85.3% (3.75 mg), P=0.320. New fluorescing lesion rates lesions. However, FLR volumetry is poorly correlated with were significantly different among the groups: 8% (ICG- FLR metabolic function measurements following PVE or test) vs. 11% (1.25mg), 25.6% (2.5mg), and 31.0% ALPPS. FLR metabolic function has not been previously (3.75mg), P=0.037. investigated after RE. Conclusion: ICG administration (2.5 mg) one day before Method: 99mTc-mebrofenin hepatobiliary scintigraphy surgery may be reasonable because of comparable identi- (HBS) with single-photon emission computed tomography fication rate with the conventional method (0.5mg/kg (SPECT) was used to determine left-lobar volume (LLV) within 14 days as ICG-test). It is important to note that new and left-lobar metabolic function (LLFct) prior to and 6 fluorescing lesions including false positive is higher than weeks after right-hepatic RE in non-cirrhotic patients with the conventional method. predominantly right-hepatic secondary liver malignancies. Results: Twenty-two subjects were enrolled. Mean LLV increased from 397 mL before RE to 461 mL after RE. EP01D-056 Mean relative LLV change after RE was +22.1%. Mean INTRAOPERATIVE 3D-IMAGE LLFct as measured by 99mTc mebrofenin uptake increased from 1.42%/m2/min before RE to 1.57%/m2/min after RE. GUIDANCE IN LAPAROSCOPIC AND Mean relative LLFct change after RE was +27.7%. No OPEN LIVER RESECTION. INITIAL significant difference was noted between increase in LLV EXPERIENCE vs. increase in LLFct (p=0.659). E. Herrero, M. I. García Domingo, J. Camps, Conclusion: Contralateral volumetric liver hypertrophy L. Martinez de la Maza, J. Tur, M. Galofré and E. Cugat after unilateral RE is associated with a similar increase in Hospital Universitari Mutua Terrassa, Universitat de metabolic function of the contralateral liver lobe. This Barcelona, Spain finding warrants further investigation of RE as a method for Introduction: Image-guided systems have recently been preoperative FLR hypertrophy induction prior to extended introduced for their application in liver surgery. However, liver resections. its use is not widespread and the experience in liver surgery, especially by laparoscopic approach is very limited. Our aim is to show our initial experience in 2 cases of liver EP01D-055 resection surgery (one laparoscopic and one open surgery) TUMOR IDENTIFICATION USING using a navigation and planning system with 3D and FLUORESCENCE IMAGING: augmented reality technology. COMPARISON OF TIMING AND Methods: The first case was a woman with an of hepato- DOSAGE OF INDOCYANINE GREEN cellular adenoma in segment III and a laparoscopic resec- tion of the segment III was decided. The second case was a 1 1 1 K. Kobayashi , Y. Kawaguchi , Y. Kobayashi , male patient with liver cirrhosis who presented a hepato- 1 1 1 1 M. Matsumura , J. Arita , N. Akamatsu , J. Kaneko , cellular carcinoma in segment IV and a resection was 1 2 1 Y. Sakamoto , N. Kokudo and K. Hasegawa planned by open surgery. 1 Hepato-Pancreatico-Biliary Surgery Division, Depart- The navigation system used was the Cas One Liver ment of Surgery, Graduate School of Medicine, The Uni- (Cascination AG, Bern, Switzerland), and the 3D re- 2 versity of Tokyo, and National Center for Global Health constructions of images were obtained with MeVis Distant and Medicine, Japan Services (MeVis Medical Solutions AG, Bremen, Background: Fluorescence imaging using indocyanine Germany). green (ICG) intraoperatively visualizes malignant hepatic Results: All the steps of the procedure are described. tumors as fluorescence. ICG was reportedly used as a Since the preoperative study (initial MRI study, 3D fluorophore for tumor identification when the liver function reconstruction and surgery planning) to the intraoperative test was performed within 14 days preoperatively. How- setting (instrument calibration and landmark adquisition) ever, ICG administration method remains unclear when the and the surgery itself (determination of the transection test was done more than 14 days before surgery. The aim of line, liver transection and evaluation of the resection this report is to evaluate optimal dosage of ICG adminis- margins). This technique allowed a complete resection of tered one day before surgery. segments III and IV respectively with vascular control of Method: Between 2016 and 2017, 82 patients underwent the segmental branches. Both patients had an uneventful liver resection for malignant tumors of the liver. One day postoperative course. before surgery, 1.25 mg, 2.5 mg or 3.75 mg of ICG was Conclusion: Clinical application of image guidance is intravenously injected. In contrast, additional ICG was not feasible. Intraoperative navigation systems provide pre- administered when patients underwent ICG (0.5mg/kg) cise, real-time information to the surgeon, improving the liver function test (ICG-test) within 10 days preoperatively. decision-making process and the accuracy of the The rates of tumor identification with fluorescence were resection.

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EP01D-057 Parenchymal dissection was fast (only 15 minutes). Blood loss was 100 cc. R0 resection was achieved. Post-operative SINGLE INSTITUTE EXPERIENCE OF course was uneventful, with patient discharge on POD 6. ROBOTIC HEPATECTOMY: 12 To date, no cases have been reported on the use of laser CONSECUTIVE CASES system for liver resection. Our initial experience is J. H. Lee1, H. S. Lee2, G. H. Choi3 and K. H. Kwon2 extremely promising, showing the safety and reliability of 1Surgery, 2Surgery, National Health Insurance Service this instrument during liver resection, even in case of Ilsan Hospital, and 3Surgery, Yonsei University College of cirrhosis. A favorable parenchymal transection speed was Medicine, Republic of Korea achieved, without increasing the risk of biliary leak or bleeding. Additionally, this device helps decreasing the Background: Laparoscopic liver resection is a challenging number of tools to use during hepatic resection, combining procedure. However, the robotic surgery system enable to the role of coagulation and dissection in the same instru- minimal invasive liver resection even for beginners. ment. Larger experiences are surely needed in this field. Method: Seven consecutive patients underwent robotic liver resection from August 2016 to December 2017. We investigate of short term perioperative outcomes for feasi- bility and safety of robotic liver resection for beginner. EP01D-059 Results: There were nine female patients and three male PURE LAPAROSCOPIC LIVER patients. Among them five patients were diagnosed by RESECTIONS IN THE hepatocellular carcinoma and three were biliary cystade- POSTEROSUPERIOR SEGMENTS IN noma, three was intrahepatic duct stone, one was colon cancer liver metastasis. And there was one central bisec- SEMIPRONE POSITION: A SINGLE tionectomy and one caudate lobectomy, six left hepatec- SURGEON EXPERIENCE OF 111 tomy, three right hepatectomy (including one ALPPS case), CONSECUTIVE CASES one segment 4 segmentectomy. The mean operation time M. D’Hondt1, E. Willems1, I. Parmentier2, H. Pottel3, were 505minutes and mean estimated blood loss was 319ml C. Verslype4, C. De Meyere1 and F. Vansteenkiste1 and mean length of hospital day was 7.8days. And there 1Department of Digestive and Hepatobiliary/Pancreatic was no case of intraoperative transfusion. And there was no Surgery, 2Oncology and Statistics, Groeninge Hospital, major perioperative complication. 3Interdisciplinary Research Center KU Leuven Campus Conclusion: Robotic liver resection appears to be a feasible Kortrijk, Leuven University, and 4Gastroenterology and and safe procedure even in beginner. The robotic systems Hepatology, KU Leuven, Belgium can expand the indications of laparoscopic liver resections, Introduction: Pure laparoscopic liver resections in the especially for more complex major hepatectomies for posterosuperior (PS) segments remain technically chal- beginner. lenging. Exposure is limited. Installation of the patient in semiprone position may lead to a better exposure and may limit blood loss. EP01D-058 Methods: Retrospective review of a prospectively FIRST APPLICATION OF HIGH POWER collected database of all patients who underwent a laparo- DIODE LASER IN HEPATIC RESECTION scopic liver resection for lesions in the PS segments be- FOR HEPATOCELLULAR CARCINOMA tween September 2011 and December 2017. Results: One hundred and eleven patients underwent a ON CIRRHOSIS laparoscopic liver resection in the PS segments. Multiple F. Melandro, F. Giovanardi, M. Garofalo, A. Consolo, resections were performed in 36 patients. Median age was R. Hassan, M. Castrovillari, P. B. Berloco and Q. Lai 68 years (IQR:60-75). Indication for resection was colo- Sapienza Universita’ di Roma, Italy rectal metastases in 70 patients (63.0%) and hepatocellular Recently, an exponential growth in the use of diode carcinoma in 20 patients (18.0%). Conversion occurred in 3 lasers has been observed in several areas of surgery (i.e., patients (2.7%). Median operative time was 150 minutes urology, gynecology, thoracic surgery). During liver (IQR:120-180min). Median operative blood loss was resection, parenchymal transection is still challenging, 150ml (IQR:100-350ml). Transfusion was necessary in 3 although several devices are available on the market. We patients (2.7%). Six patients (5.4%) presented with severe present our initial experience with a high power diode laser postoperative complications (Clavien-Dindo grade III). for hepatic resection. Median hospital stay was 5 days (IQR:4-7). R0 resection A 59 year-old man affected by NASH-related cirrhosis rate was 96.4%. There was no 90-day mortality. Analysis of and a 5-cm hepatocellular carcinoma on segment III was two consecutive groups showed no significant differences referred for surgery. MELD score was 12. An open left in operative time (140min (IQR:120-180) VS 165min lateral sectionectomy with trans-parenchymal approach (IQR:130-190), p=0.092) or blood loss (150ml (IQR:50- was done. Liver transection was performed using Biolitec 300) VS 150ml (IQR:100-375), p=0.72), indicating the LeonardoÒ Dual 200 diode laser system. Laser character- absence of a steep learning curve. istics were: output power= 40 W; wavelength= 980-1470 Conclusion: Pure laparoscopic liver resections in the PS nm; working speed= 5 mm/s. During the transection, he- segments in semiprone position are safe and feasible. Using mostasis of the small vessels (< 2 mm), preservation of the the semiprone position enables this approach through large ones and biliostasis were efficaciously performed. improved visualisation, and avoids a steep learning curve.

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significative difference in terms of complications, blood loss, transfusion, operation time, hospital stay. Conclusion: LLR is a safe and feasible for elderly patients. However, perspective randomized studies are needed to validate this thesis.

EP01D-061 LAPAROSCOPIC LIVER RESECTION FOR LIVER TUMORS IN PROXIMITY TO MAJOR VASCULATURE: A SINGLE- CENTER COMPARATIVE STUDY E. Willems1, M. D’Hondt1, I. Parmentier2, H. Pottel3, C. Verslype4, C. De Meyere1, F. Vansteenkiste1 and M. Besselink5 1Department of Digestive and Hepatobiliary/Pancreatic Surgery, 2Department of Oncology and Statistics, Groe- ninge Hospital, 3Interdisciplinary Research Center KU Leuven Campus Kortrijk, Leuven University, 4Gastroen-

FIGURE terology and Hepatology, KU Leuven, Belgium, and 5Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands Introduction: Only small case series have been published regarding laparoscopic liver resection (LLR) for tumors in EP01D-060 proximity to major vessels(MVs).The aim of this study is to LAPAROSCOPIC LIVER RESECTION IN compare peri-operative outcomes of LLR for tumors < 20 ELDERLY PATIENTS: A SYSTEMATIC and 20mm from MVs. REVIEW AND METANALYSIS Method: Retrospective analysis of a prospectively M. Notarnicola, R. Memeo, S. Roselli, P. Panzera and collected database of consecutive LLR (October 2011- L. Lupo August 2017) performed by a single surgeon. Proximity to fi Università di Bari - Policlinico di Bari, Italy MVs was de ned as a distance of 20mm or less to the caval vein,hepatic veins and portal vein (main trunk and first Introduction: Laparoscopic liver resection (LLR) is branches). feasible and safe compared to open technique (OLR). Results: A total of 235 LLR were performed, of which 60 However, few data are available for elderly population patients (24%) had lesions in proximity to major vascula- (>70 years old). ture, median distance to MV 10 mm (range 0-17). Signif- The aim of this study is to assess the feasibility of LLR in icantly more patients in the close-to-major-vessels group elderly patients, throughout the comparison with the OLR (CTMV) received neo-adjuvant chemotherapy (36.7% and with nonelderly patients. vs24.2%,p=0.0094). In the CTMV group, the median Methods: The Cochrane Library, Embase, PubMed, Web Difficulty Score for LLR was significantly higher of Science were analyzed to identify relevant studies to (8.5(IQR:6.0-9.0)vs5.0(IQR:3.0-6.0),p< 0.001) as was the perform a systematic review and meta-analysis. use of CUSA (p< 0.001) and Pringle manoeuver (15% Nine studies met the inclusion criteria among 17 vs5.1%;p< 0.001). Operative time was significantly longer selected studies, and a total of 1413 patients were (180min(IQR:140-210)vs120min(IQR:75-150),p< 0.001) analysed. Two categories of papers were included: (1) and blood loss was significantly higher (190ml(IQR:100- comparisons between open and LLR in elderly and (2) 325)vs75ml(IQR:50-220), p< 0.001) in the CTMV comparisons between elderly and nonelderly who under- group.This did not result in a difference in perioperative went LLR. blood transfusion (5.0%vs2.8%,p=0.42) or postoperative Results: In group 1, 1025 patients were included; 640 morbidity (15.0%vs14.3%,p=0.89). There was no mortality underwent OLR and 385 LLR. LLR was associated with in both groups.There was no significant correlation be- minor blood loss (p=0.009), less transfusions (p=0.02) less tween the distance to MVs and blood loss (p=0.80); oper- post-operative Clavien-Dindo III-IV complications ative time(p=0.95).Correlation between central venous (p=0.002). No significative differences were evidenced in pressure drop and blood loss was borderline significant operation time, duration of hospital stay, bile leakage, as- (p=0.06). cites, mortality, liver failure, R0 resection, long-term Conclusion: In selected patients, LLRs of lesions in overall and disease-free survival. In group 2, 388 patients proximity to MVs is safe and feasible when performed by were included; 112 elderly patients and 276 nonelderly experienced surgeons working in an experienced team. patients underwent LLR. The meta-analysis showed no

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EP01D-063 MANAGING MEGA TUMORS OF LIVER e EXPERIENCE FROM AN EMERGING HBP UNIT OF A DEVELOPING COUNTRY H. Bari, M. Nasrullah and F. Hanif Surgical Oncology, Shaukat Khanum Cancer Hospital Lahore, Pakistan Background/aims: The aim of this study was to review our management for mega liver tumors, greater than or equal to 10 cm in size. Methods: Records of patients referred for evaluation of mega liver tumors on radiological investigation ( 10cm) Figure between October 2014 and December 2017 were retro- spectively analyzed. Results: Median age was 38.5 years. Five patients (62.5%) were male. Most of the lesions (62.5%) were involving EP01D-062 right lobe of the liver along with extension in segment IV. SELECTIVE CHEMOEMBOLIZATION Mean tumor size was 15.5 cm (SD 4.6). Hepatoblastoma OF LIVER ARTERIES AS A STAGE OF (25%), primary neurodendocrine tumor of liver (25%) and COMPLEX TREATMENT OF PATIENTS secondary liver tumors ((25% - adrenocortical tumors with liver invasion) were the most commonly observed pathol- WITH UNRESECTABLE CANCER ogy, followed by hemangioma (12.5%) and colorectal liver METASTASES (OWN EXPERIENCE) metastasis (12.5%). Preoperative chemotherapy was D. Astakhov1, D. Lebedev1, Y. Ivanov1, A. Kedrova2 and offered to patients with hepatoblastoma. Right portal vein D. Panchenkov1 embolization along with segment IV branches was 1Moscow State University of Medicine and Dentistry performed preoperatively in one patient with neuroendo- named after A.I. Evdokimov, and 2Oncology, Federal crine tumor. Research and Clinical Center of Specialized Types of Tri-sectionectomy was performed in four patients. Hemi- Medical Care and Medical Technologies of FMBA of hepatectomy, ALPPS and non-anatomical liver resection Russia, Russian Federation (for hemangioma) were performed in rest of the patients. Purpose: Chemoembolization is one of the methods of Mean duration for intraoperative pringle maneuver was local treatment. Due to hydrophilicity and biocompati- 37.5 19 minutes. Median intraoperative blood loss was bility with the tissues of microspheres filled with cyto- 525 mls (287-1775mls). Our mean duration of surgery was statics, one can achieve a long-term effect by controlling 325 127 minutes. Over all hospital stay was 10.3 6.5 tumor growth. The differentiation of the sizes of the days, including ICU stay of 2.5 1.6 days. Only two pa- microcatheter and the microspheres allows them to be tients developed postoperative morbidity. injected into the vessels associated with neoangiogenesis Conclusion: In conclusion surgery for mega tumors of and tumor progression. liver is challenging. However adequate planning with pre- Methods: Between January 2015 and December 2017, 17 operative portal vein embolization or staged procedure can patients underwent arterial chemoembolization with drug- lead to resection of these large liver tumors safely and saturated microspheres as a part of the treatment of meta- successfully. static cancer of various primary localizations. There were 8 men (age from 52 to 75 years, mean 63.6), and 9 women (age from 43 to 68 years, mean 55.3). In 9 cases, femoral EP01D-065 artery access was used, and in 8 cases, radial artery access LAPAROSCOPIC ANATOMICAL was used. In 15 patients, one vial of HepaSphere (in 6 cases POSTEROSUPERIOR saturated with 50 mg, and in 9 cases of 75 mg of Doxo- SEGMENTECTOMY WITH ICG rubicin) was co-administered in the hepatic arteries. Two patients required the introduction of two vials of FLUORESCENCE STAINING BY microspheres. ULTRASOUND GUIDED PORTAL Results: Partial reduction of tumor size was achieved in all BRANCH PUNCTURE APPROACH patients, that allowed to continue specialized treatment. In 1 X. Wang, Q. Gao, X. Zhu, J. Zhou and J. Fan case, there was complete regression of the tumor node. In 3 Department of Liver Surgery, Zhongshan Hospital, Fudan cases, arterial chemoembolization was performed twice at University, China an interval of 197, 329 and 371 days. Introduction: Anatomical hepatic resection could improve Conclusion: The method of arterial chemoembolization survival and limit complications from hepatectomy in of the liver with drug-saturated microspheres allows a HCC. Laparoscopic anatomical posterosuperior segmen- deep cytotoxic effect on the metastasis of cancer in the tectomy resection is technically difficult. The segment liver, improving the immediate results of treatment, identification technique used in open surgery is blue dye manifested in regression and stabilization of the tumor staining. However, it is difficult to reproduce this technique process.

HPB 2018, 20 (S2), S333eS504 S472 Electronic Posters (EP01A-EP01E) - Liver laparoscopically and is impossible to indentify the inter- 1oP(20%) to 3oP(15%). The complications were greater in segmental plane during division of the liver parenchyma. 3oP(26%). However, ClavienIII decreased in 2oP and Herein, we developed laparoscopic ultrasound guided 3oP(7.3%, 2.6%, 5.4%). There was no mortality. The portal branch puncture technique to injection ICG fluores- average stay was similar (1o-2o:3 days vs 3oP:4 days) cence dye to the visualization of posterosuperior segments Discussion: We found a significant increase in the number during pure laparoscopic anatomical segmentectomy. of RHL in our unit, expanding indications and types of Method: Preoperative 3D MDCT simulation was resections, mainly major resections, without this having performed. The portal branches of posterosuperior seg- produced an increase in serious complications. ments (S7,8,4a,2) were identified by laparoscopic ultra- sound and punctured with the 22-gauge PTCD needle through the abdominal wall under laparoscopic US guide. EP01D-067 ICG dye (0.025 mg in 10 mL of saline) was injected into VIDEO BASED INSTRUMENT POSE portal branches without clamping inflow. The target seg- ments started to fluoresce immediately after the injection of TRACKING IN NAVIGATED the ICG. Liver parenchyma was transected along the fluo- LAPAROSCOPIC SURGERY rescence boundary. A. Gupta1, I. Paolucci1, R. Sznitman1, S. Weber1 and Results: The intersegmental plane could be indentified D. Candinas2 clearly during division of the liver parenchyma. The hepatic 1ARTORG Center for Biomedical Engineering Research, vein and the origin of the Glissonean pedicles of poster- and 2Department of Visceral Surgery and Medicine, osuperior segment were present on the border of fluores- Inselspital, Bern University Hospital, University of Bern, cence (with video). The postoperative courses of all cases Switzerland were uneventful. Introduction: To overcome the challenges of depth loss fl Conclusions: ICG uorescence staining by ultrasound and limited field of view, image-guided surgery has been guided portal branch puncture approach has great value in introduced for intraoperative guidance in laparoscopic laparoscopic anatomical segmentectomy for S7,8,4a,2. surgery. Currently used navigation systems are based on This novel technique enable us to clearly identify poster- external instrument tracking systems (e.g. optical, electro- osuperior segments prior to and during parenchymal tran- magnetic). However, these systems face challenges like section, thus enhancing the accuracy of pure laparoscopic instrument bending, line-of-sight (optical systems) and anatomical segmentectomy. magnetic distortions (electromagnetic systems). Video based tracking represents a low-cost tracking method which would eliminate the need for external trackers and the EP01D-066 induced errors. LAPAROSCOPIC HEPATIC SURGERY: Methods: The proposed system uses the video from the EVOLUTION IN REFERENCE UNIT stereo laparoscope currently used in the liver surgeries. Visual markers, attached or engraved on the instruments, B. Sánchez1, F. J. Leon Diaz2, D. Cabaño2, 2 2 are then detected in the left and right image of the video. J. A. Perez Daga and J. Santoyo Santoyo Using the geometrical parameters of the camera, the pose of 1Hepatobilipancreatic Surgery and Transplantation Unit, 2 the instrument is calculated, which is then fed back to the SAS, and Hepatobilipancreatic Surgery and Trans- navigation system. plantation Unit, H. U. Regional, Spain Results: The first prototype of a video based tracking Introduction: Despite the existing evidence in laparo- system was implemented and integrated into a commer- scopic liver surgery, regarding safety, ease and similar re- cially available navigation system (CAS-One AR, CASci- sults in survival, less than 15% of liver resections are nation AG, Switzerland). The instruments were performed through this route. successfully detected in the 3D video and their location Objective: To analyze the evolution of laparoscopic he- displayed on the navigation screen. In a phantom setting, a patic resections (LHR) in the last 14 years (2004-2017) in a tracking frequency of 10 frames per second was achieved. unit of Hepatobiliopancreatic Surgery. Conclusions: Initial integration of video based tracking of Material and method: A descriptive study performed 152 instruments in a surgical navigation system was demon- RHL divided into three periods; 1st Period (1st P):2004- strated. By tracking the instruments in the laparoscopic 2009:41, 2nd Period (2nd P):2010-2014: 38 and 3rd Period video, the system eliminates the need for an external (3rd P):2015-2017:73. Variables: demographic, etiology, tracking system and might reduce setup time and inaccur- size-number of the lesion, location , type of resection, acies caused by bending. However, the tracking frequency surgical time, transfusion and / or conversion, use of drains, and the accuracy have to be improved and validated under histology, morbidity and mortality and postoperative stay. clinical conditions. Results: The average of RHL / year in 1oP and 2oP:6.8 and 7.6, while 3oP:24.3 RHL / year. We observed a progressive increase in middle age (1oP:54; 2oP:60; 3oP:62) and in EP01D-068 malignant pathology (Metastasis, CHC and chol- angiocarcinoma), 1oP:34%, 2oP: 60% 3oP:67%. The ANTE-SITUM WITH IN-SITU highest RH were 2.6%:2oP and 13.7%:3oP. The surgical HYPOTHERMIC HEPATIC RESECTIONS time has increased with the periods (1oP:173min, M. Chinthakindi 2oP:203min, 3oP:246min). The need for transfusion(14%) Surgical Gastroenterology, Osmania General Hospital, and the use of drainages(30%) have been similar between India periods. The conversion to open surgery decreased from

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S473

Introduction: The liver surgery for tumours that involve the geometrical changes caused by the tumor and the the IVC or the HV are a technical challenge and usually changes in liver tissues but also the relationship of neigh- need to be operated upon under total vascular exclusion to boring vascular structures could easily be manipulated from prevent massive blood loss. Ante-situm liver resections, different angles with the models. otherwise called "ex-situ in-vivo” resections is achieved Conclusion: Patient-specific models could provide an through externalization of the liver outside of the abdom- increased understanding of the complex vascular hepatic inal cavity by clamping and sectioning of the efferent anatomy of the tumor and allow surgeons to orient tumoral pedicles (suprahepatic veins) ("ex situ") without cutting the structure operation more effectively. These models also afferent vascular pedicle ("in vivo"), thus leaving the he- help them gain valuable experience in surgical techniques patic pedicle intact. Here we are presenting our experience without exposing patients to risks of harm. of ex-situ hepatic resections. Materials and methods: This is a retrospective data of “Ex-situ in-vivo” Hypothermic Hepatic Resections done at EP01D-070 Osmania General Hospital, Hyderabad in 8 years. In-situ LESSONS LEARNED FROM 40 MAJOR cooling of the liver was done with cold HTK Solution. Ante situm hepatic resections were done for liver tumours LAPAROSCOPIC HEPATECTOMIES involving the IVC/Hepatic veins. C. Muñoz, A. Hessheimer, V. Molina, D. Calatayud, Results: Total 4 male patients with median age of 44.5 R. Garcia, J. Ferrer, J. Fuster, J. C. Garcia-Valdecasas and years (range 22 to 65 years). The average total vascular C. Fondevila exclusion time was 120 minutes. The right extended hep- HPB and Transplant Surgery, Hospital Clínic de Barce- atectomy with IVC resection in 1case, Central hepatectomy lona, Spain with middle hepatic vein tumour thrombectomy in 1case, Major laparoscopic hepatectomy (MLH) is very chal- Ante situm hepatic and IVC reconstruction for Chronic lenging procedure and not many surgeons have experience BCS in 1 case and left hepatectomy with IVC and RA enough to be comfortable wit the procedure. tumour thrombectomy in 1case were done. Average blood Aim: To present our experience with 40 MLH, including lose was 1200ml.No operative mortality. The longest the evolution of these procedures in our center over time. follow up was 2 years. Methods: A retrospective analysis of prospectively Conclusion: Recent surgical innovations such as Ante collected data was performed for all MLH performed be- situm or ex vivo resections under total vascular exclusion tween 01/2009 and 12/2017. All operating surgeons had with in-situ hypothermia have improved the safety of extensive previous experience in open hepatectomy (>200 complex hepatic resections that involve the IVC/HV. cases per surgeon). Results: Median patient age was 62 yrs (IQR 35-76). Four patients had chronic liver disease and two cirrhosis. 83% of EP01D-069 MLH were undertaken for malignant pathology, including COMPREHENSIVE APPROACH TO 70% for metastases and for 10% HCC. Interventions ONCOLOGICAL LIVER SURGERY included 65% right hepatectomies, 35% left hepatectomies. Six patients (15%) underwent additional resection or radi- WITH 3D PERSONALIZED MODELS IN ofrequency ablation. Median operative time was 282min PREOPERATIVE PLANNING for the initial 20 cases (P1) and 270min for the subsequent A. Coker1, M. A. Ozer2, A. Uguz3, O. V. Unalp3 and 20 (P2) (p=NS); median blood loss was 190mL P1 and F. Govsa2 300mL P2. Seven patients (18%) experienced Clavien III 1Surgery HPB Unit, 2Anatomy, and 3Surgery, Ege Uni- morbidity, and two underwent reintervention for bile leak versity, Turkey (both during P1). There was one postoperative death fi Introduction: Increase in indications of primary hepatic to (massive pulmonary embolism on postoperative day ve). metastatic cancer operations require more detailed knowl- 85% of malignant lesions had R0 resection. Median follow- edge of the vascular, tumoral and organal anatomy. 3D up was 29months. Among patients operated for malignant printing liver models are used in new surgical approaches, lesions, median recurrence-free survival was 25months, innovative operative strategies and preoperative planning. and three-year patient survival was 29.6%. Our purpose to create life-like individual 3D patient models Conclusion: The results from this large single-center series is to aid hepatectomy process of the surgeon, to assess indicate that MLH is an effective treatment option, even for tumor extent, spread and liver arterial supply as well as patients with malignant lesions. With increasing experi- biliary structures, portal and hepatic venous drainage. ence, perioperative outcomes appear to improve Methods: 20 patients’ computed tomography scans were considerably. imported into DICOM imaging software to obtain 3D surface renderings of liver tumoral tissue and its vascular structures. 3D models of liver, tumoral tissue, portal veins, EP01D-071 hepatic veins, hepatic arteries and biliary system were LEARNING CURVE IN LIVER created using 3D modelling software. LAPAROSCOPIC SURGERY. RESULTS Results: 3D anatomosurgical models assist us to compre- OF A 215 LIVER RESECTION SERIES hend the spatial anatomy configuration of like-like models. 3D personalized liver models help to examine the location A. Navarro Barrios, R. Robles Campos, A. López Conesa, of the liver tumor in details with reference as well as its R. Brusadin, V. López-Lopez, F. Alconchel Gago, extension and neighboring relationship of vascular struc- B. Gomez Perez and P. Parrilla Paricio tures in patients suffering from hepatic carcinoma. Not only Hospital Virgen de la Arrixaca Murcia, Spain

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Objective: Our aim is to present the results of 215 lapa- Stage 2, PVF was > 17 cm/sec in 6 patients After ligation of roscopic liver resections in our HBP unit after 14 years of the right hepatic artery 11 patients (31%) presented a PVF > experience. 17 cm/sec, which was maintained until 30 minutes after Patients and methods: From January 2003 to December finishing the major hepatectomy (19 right trisectionectomy 2017, 1500 liver resections have been performed in our and 16 right hepatectomy). After starting somatostatin unit. 215 of them were performed via laparoscopic access. perfusion, PVF decrease below 17 cm/sec in 9 patients. In 2 We split our patients into two comparison groups: first 107 cases ligation of the splenic artery was necessary. vs. last 108 resections. We assessed the age, gender, 5 patients presented postoperative liver failure (POLF) diagnosis, liver state, laparoscopic approach: Hand Assis- (14.3%): 4 within the group of patients with high PVF ted Laparoscopic Liver Surgery (HALLS) or TLLS treated with somatostatin (2 of them died). (Totally Laparoscopic Liver Surgery) and the surgical Conclusion: Somatostatin could be useful to decrease outcomes, including morbidity and need of hemoderivative portal flow in major liver resections. transfusion. Results: Table 1. EP01D-073 LAPAROSCOPIC VERSUS OPEN LIVER Table[Results after 215 liver resections] RESECTIONS: LESSONS FROM A 1-107 108-215 p value DEVELOPING COUNTRY CENTRE Resections Resections D. Davila1, J. Aristizabal1, P. Sanchez2 and O. Palacios1 1 2 Primary Malignant 15.4% 29.6% 0.062 Hepato-Pancreato-Biliary Surgery, and Investigation Liver Tumours and Epidemiology Department, Clinca CES, Colombia Liver metastases 66.3% 50% 0.062 Introduction: Data regarding laparoscopic liver resec- HALLS 78.8% 53.7% 0.009 tion(LLR) in developing countries is scarce due to un- TLLS 20.6% 38% 0.009 availability of this technique, either because of cost issues or lack of skills.The aim of this study is to compare the Major resections 12.1% 12% 0.608 perioperatory outcome between laparoscopic and open Transfusion 5.7% 1.8% 0.254 liver resections in a Colombian centre. Pringle 39.2% 13% <0.001 Methods: Retrospective, cross-sectional study, comparing Surgical time 155 m 122 m 0.001 100 LLR versus 50 open liver resections (OLR) performed Morbidity 10.3% 13.9% 0.417 by the same HPB surgeons during a 4-years period. Either malignant and benign causes were included. Hepatectomies associated with bile duct reconstruction were excluded. Conclusions: Performing a higher number of liver re- Preoperatory, intra and postoperatory variables were included sections entails a lower need of Pringle manoeuvre, surgical in a multivariare analysis. T student, Chi2 and U-Mann time and hospital stay. More procedures were performed Whitney test and binary logistic regression were applied. via TLLS and on cirrhotic livers during the second period. Results: 60% of the LLR and 58% of the OLR were related to malignancy. OLR and LLR were divided in < 3 seg- EP01D-072 ments: 11.3% and 31.3% respectively. 3 segments: 2% PORTAL INFLOW MODULATION BY and 4% respectively. Left or right hemihepatectomy: 6% SOMATOSTATIN DURING and 12% respectively. Segment 4b and segment 5 resec- TOURNIQUET ALPPS tion: 15.3% and 8% respectively. There was statistical significance in intraoperatory bleeding (p= 0.047) and R. Brusadin, R. Robles Campos, V. López-López, global hospital stay (p< 0.05). There was no difference in A. López-Conesa, A. Navarro Barrio, F. Alconchel Gago, 30-days mortality (p=0.21), intraoperative and post- B. Gómez perez, T. Nicolas López, A. González Gil and operative complications (p=0.055) or oncological margins P. Parriila Paricio (p=0.2) between LLR and OLR. Conversion rate was 4%. ’ ’ Hospital Clinico Universitario Virgen de la Arrixaca , Conclusion: Even in a developing country, LLR may be Spain associated with less intraoperatory bleeding and shorter Introduction: Small for size syndrome (SFSS) is a serious hospital stay. Complications rate and resection margins are complication of extended hepatectomy. The relationship similar between LLR and OLR. However, surgical skills in between high portal pressure and SFSS has been clearly HPB surgery and laparoscopic surgery are mandatory to demonstrated insomuch that some authors refer to it as perform LLR. “small for flow” syndrome. We present our experience with portal inflow modulation by somatostatin in tourniquet EP01D-074 ALPPS MINIMALLY INVASIVE ALPPS-IS IT Methods: We calculated the portal vein flow (PVF) by intraoperative ultrasound during Tourniquet ALPPS pro- THE FUTURE? cedure. We established 2 groups: patients with portal flow C. Delimpalta lower than 17 cm/sec and those with flow higher than 17 James Paget Hospital, United Kingdom cm/sec. In the latter case we started portal inflow modula- Introduction: Associating liver partition and portal vein tion intraoperatively by intravenous administration of so- ligation for staged hepatectomy (ALPPS) represents a new matostatin and we maintained it for 3 days. technique to achieve resection in patients with predicted Results: The PVF was measured in 35 patients. At the end small volumes of future liver remnant (FLR). ALPPS leads of the stage 1, PVF was higher than 17 cm/sec in 6 cases to rapid hypertrophy of FLR but also high postoperative (17%) and somatostatin was initiated. At the beginning of mortality and morbidity. The feasibility and benefits of

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S475 minimally invasive liver surgery have been well docu- EP01D-080 mented, and such approaches might represent the solution to this complex issue. THREE-DIMENSIONAL ANATOMIC Method: Review of published literature. LOCALIZATION STAINING OF Results: The ALPPS procedure has been performed lapa- HEPATIC SEGMENTS IN ANATOMIC roscopically by stage or its entirety. Its great benefit seems HEPATECTOMY FOR PRIMARY to come in facilitating the second part of the operation. This fi HEPATOLITHIASIS stage is often complicated by brous adhesions, which 1,2 1 1 1 fi H. Tang ,W.Lv, J. Dong and S. Lu could be minimised with less invasive technique in the rst 1 2 stage. Laparoscopy reduces surgical stress and systemic Chinese PLA General Hospital, and The University of inflammatory reaction and both intra-operative blood loss Tokyo, China and bile leakage are less common. The portal vein flow Background: The clinical significance of anatomic hepa- reduces by 50% with pneumoperitoneum, and there is tectomy (AH) for the treatment of primary hepatolithiasis improved visibility of dissection planes. (PHL) is not clear. And there are certain limitations to the Multiple techniques such as round-the-liver ligation, current staining techniques in use with regard to the visu- microwave ablation and selective hepatic artery clamping alization of the affected areas. The aim of this study is to have all been implemented successfully laparoscopically. present a newly-established staining technique termed In all published series results were comparable to those “three-dimensional (3D) anatomic localization staining of of the open approach, and patients often benefited from hepatic segments” (3D ALSHS). lower complication rate and shorter hospital stay. Methods: Sixty-nine PHL patients who underwent hepa- Recently, ALPPS was completed robotically, opening tectomy between January 2009 and December 2013 were further possibilities for development. studied retrospectively. Demographic, operative and Conclusions: Minimally invasive ALPPS is feasible and follow-up data were collected prospectively and analyzed safe. Post-operative results compare to those of open pro- retrospectively. The patients were classified into the AH (n cedures, and early data suggest decreased complication = 33) and non-AH (n = 36) groups. AH with 3D ALSHS rate. However ALPPS technique is still nascent, and further was performed in the AH group. We evaluated the intra- studies need to establish appropriate indications, approach operative data, and the short-term and long-term outcomes. and guidelines. Results: The final stone clearance rate and stone recurrence rate were significantly better in the AH group than in the non-AH group (97.0% vs. 77.8%, P = 0.029; 6.7% vs. fi EP01D-077 35.7%, P = 0.025). The AH group had signi cantly less intraoperative blood loss (219 mL vs. 466 mL, P = 0.001) HOW TO REMOVE THE TUMOR and a significantly lower number of patients who received LOCATED IN S1 PARACAVAL PORTION blood transfusion (6.1% vs. 38.9%, P = 0.003). Further, the USING ICG FLUORESCENCE AH group patients recovered more quickly after surgery TECHNIQUE AND MAJOR PORTAL (median hospital stay: 22 days vs. 26 days, P = 0.001). FISSURE TRANSECTION Conclusion: This staining technique for AH had several advantages over the non-AH technique for PHL patients N. Takemura, F. Inagaki, F. Mihara, T. Kurokawa, and should be further evaluated clinically in PHL patients. M. Tokuhara and N. Kokudo Department of Surgery, Hepato-biliary-Pancreatic Sur- gery Division, National Center for Global Health and e Medicine (NCGM), Japan EP01E - Electronic Poster: 1E Liver Miscellaneous A hepatic tumor located in the S1 paracaval portion is difficult to remove because it is located deep part of the EP01E-003 liver and attached with the main vasculatures; right main HYPERAMMONEMIC Glisson sheath, right hepatic vein, middle hepatic vein ENCEPHALOPATHY IN FAST and inferior vena cava. Herein, we report a 34-year-old GROWING HEPATIC TUMORS: A NEW male patient who underwent the tumor resection in S1 PHYSIOPATHOLOGICAL PATHWAY paracaval portion using ICG fluorescence technique and major portal fissure transection. He has been suffered PROVED BY MOLECULAR BIOLOGY from chronic hepatitis B, CT done after tumor marker THAT RESULTED IN ADEQUATE elevation revealed small hepatocellular carcinoma in the TREATMENT AND FULL S1 paracaval portion attached with right main Glisson NEUROCOGNITIVE RECOVERY sheath. ICGR15 value which was done 2 weeks before the R. Surjan1, F. Ferrari Makdissi2, T. de Castro Basseres3, operation revealed 2%. Resection of the tumor in the S1 M. Autran Cesar Machado3 and E. Santana dos Santos4 paracaval portion concomitant with the ventral area of S8 1Surgery, University of São Paulo School of Medicine, was performed using the portal staining method with the 2Gastrointestinal Surgery Department, 3Surgery, Univer- ICG fluorescence imaging and with the major portal sity of São Paulo Medical School, and 4Oncology fissure transection. The ICG imaging also revealed the Department, University of São Paulo, Brazil tumor location during the parenchymal transection. The tumor was removed successfully with the ventral area of Ammonia is a nitrogen compund miscible with water. S8. The technique of the ICG fluorescence imaging and When ammonia blood level increases, it enter the central the major portal fissure transection will be shown in the nervous system in excessive quantities leading to astroglial presentation. cells swelling, astrocyte phenotipe transformation to

HPB 2018, 20 (S2), S333eS504 S476 Electronic Posters (EP01A-EP01E) - Liver

Alzheimer’s type II cells and increased oxidative stress, individual anatomy with comprehensive imaging, good leading to severe neurological toxicity and encephalopathy. perioperative care and meticulous surgical technique, as have Fast growing hepatic tumors and fibrolamellar hepatocel- been learned from the fellowship days. lular carcinoma hve been associated with hyperammonemic encephalopathy. Many physiopathological explanations were described and teatment options proposed, but they EP01E-006 were all based in suppositions and did not reach a MEASUREMENT OF PORTAL VENOUS consensus. We performed gene testing and RNA expres- sion analysis to demonstrate a new physiopathological PRESSURE PRIOR TO MAJOR LIVER pathway to hyperammonemia in patients with fast growing RESECTIONS: HOSPITAL BASED hepatic tumors that envolves c-Myc overexpression in the EXPERIENCE poliamine synthesis that results in ornithine decarboxylase H. Bari, F. Hanif, S. A. Akbar and U. Farooq and ornithine transcarboxylase dysfunctions that culmi- Surgery, Shaukat Khanum Cancer Hospital, Pakistan nates in urea cycle disorder and hyperammonemia. This Objective: Liver resections for Hepatocellular Carcinoma allows a different treatment option then previously reported (HCC), in patients with portal hypertension (PHT) has and full neurological recovery. All patients with hepatic increased morbidity. So assessment for presence of PHT is tumors that develop neurocognitive disorders should be important preoperatively. This can be done by non-invasive tested for serum ammonia level. This may allow prompt clinical-criteria (varices, splenomegaly or thrombocyto- and adequate treatment to a non-enherited urea cycle dis- penia) or invasive portal vein pressure assessment (with order and complete clinical recovery. Hepatic-Venous-Pressure Gradient measurements). We aimed to determine whether routine preoperative HVPG measurements are necessary in child’s A cirrhotic EP01E-005 patients, undergoing liver resection for HCC and also im- EARLY EXPERIENCES IN LIVER mediate post-operative liver dysfunction and 30-day mor- RESECTION: LESSON LEARNED FROM tality in these patients. LIVER SURGERY AND Methods: All Child’s class A patients with HCC and had TRANSPLANTATION FELLOWSHIP preoperative HVPG measurements were included. It was a 3-year, retrospective case series done at Shuakat Khanum PROGRAM AND ITS Hospital. Postoperative liver dysfunction was assessed by IMPLEMENTATION IN DAILY using the ’50-50 criteria on day-5. SURGICAL PRACTICE Results: Twenty patients met the inclusion criteria. None A. Nugroho1, M. Mayasari2 and R. Saunar1 of the patients had any clinical signs of PHT. Only two 1Digestive Surgery, Fatmawati General Hospital, and (10%) patients had raised HVPG (13 and 15 mm Hg). Right 2Surgery, St Carolus Hospital, Indonesia lobe lesions were observed in 80% of the patients. A total of fourteen patients underwent surgery. Mean duration of Introduction: Fellowship program in liver surgery and surgery and hospital stay was 222 82.5 minutes and 6.8 transplantation provide wide opportunities to learn and 3.2 days, respectively. Two patients were found to have experience in all aspects of liver resection and trans- unresectable disease intraoperatively. None of the patients plantation, including patient selections and perioperative had deranged Prothrombin-Time or Bilirubin on post- care. With extensive exposures in daily surgical practice of operative day-5, as per ’50-50’ criteria. Other parameters liver surgery, it is expected that fellow will be able to bring (Lactate, Albumin, INR and Platelets) were also within such expertise to his or her daily practices. After comple- normal range after surgery. tion of fellowship, despite several limitations in diagnostic Conclusion: In this study 90% of patients underwent an and therapeutic resources, we managed to start liver pro- unnecessary invasive test. Clinical signs of PHT are reliable gram and perform a series of liver resections with reason- and HVPG measurement can be avoided in early stage able outcomes. HCC. Methods: From May 2016 to 2017, fourteen liver re- sections were performed, all of which were reviewed in this study. EP01E-007 Results: There were 8 male and 6 female, with median age THE EFFECTS OF PNA/K-TIDE AND of 63 (range 17-74) years old. The indication of hepatec- SW033299 ON NASH ASSOCIATED tomy includes 8 primary liver cancers, 5 liver metastases (3 CIRRHOSIS IN THE RODENT colorectal cancer, 2 renal cell carcinoma) and 1 liver M. Shade1, J. A. Sanabria1, R. Aguilar1, M. Andryka1, trauma. There were 6 non anatomical resections and 9 1 1,2 anatomical resections, including Right hemihepatectomy, A. Mallick and J. Sanabria 1Surgery & Marshall Interdisciplinary Research Institute, Left Hemihepatectomy, Left lateral sectionectomy, Right 2 Posterior sectionectomy and Right Anterior sectionectomy. Marshall University School of Medicine, and Nutrition & Inflow occlusion technique, either Glissionean approach or Proteomic/Metabolomic Core Facility, Case Western selective individual occlusion, together with Kelly crushing Reserve University, United States technique for parenchymal transection was applied in all NAFLD/NASH and its complications ESLD/HCC have cases. become the most common cause for liver transplantation in Conclusion: In limited resources setting like ours, a safe liver the West. We tested the efficacy of two compounds resection can still be done with a proper patient selection developed by our group in reversing the liver disturbances and adherent to basic principles such as understanding of produced by NASH.

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C57Bl 6J mice (female: n=7, per each time point) were of shunt in 43% of patients with viral hepatitis and 62% - exposed to normal chow (NC group, Control -) or high fat with ethanol liver cirrhosis. Formation of SRVS in anhe- diet + fructose (HFD, Western diet). The mice on HFD was patic PH is a compensatory mechanism. In this situation non-treated (Control+) or treated with p-Na/K-tide, with splenectomy or application of splenorenal venous anasto- SW033299 or exposed to an exercise protocol. Body mosis can be fatal. composition was determined by MRI spectroscopy. Quantitative protein expression of genes involved in cell metabolism or cell senescence (p53, p21, p16, mTOR1, EP01E-010 STAT33, SIRT7, FOX01, Grb2) were determined by ADAPTIVE GROWTH CHANGES IN THE Western Blots. Metabolic profiles were measured on treated plasma by LC/MS-MS. Principal component analyses LIVER REMNANT ARE AFFECTED BY (PCA) were conducted. THE SIZE OF HEPATECTOMY IN RATS Total body weight and TBF corrected by aging increased M. Meier1, K. Jarlhelt Andersen1, A. Riegels Knudsen1, significantly in the HFD group (p< 005 by ANOVA). The J. Randell Nyengaard2, S. Dutoit-Hamilton3 and amount of liver fat accumulation, the number of cells in F. Viborg Mortensen1 senescence and the apoptotic index were significantly 1Department of Surgical Gastroenterology, Section for decreased in treated groups(p< 00.5 by ANOVA). In Upper Gastrointestinal and Hepato-Pancreatico-Biliary addition, the deposition of collagen was significantly lower Surgery, Aarhus University Hospital, 2Department of in the pNaK and SW groups. Glutathione ratio, mitochon- Clinical Medicine, Core Centre for Molecular drial ß-lipid oxidation function and Na/K-exchange pump Morphology, Section for Stereology and Microscopy, activity after censored for aging followed similar trends Aarhus University, and 3Institute of Pathology, Aarhus among groups (p< 0.05 by ANOVA). pNaK-tide and University Hospital, Denmark SW033299 appears to exercise their effects through To improve outcome after extended partial hepatectomy different signal pathways . Metabolic prints on interventions (PH) identification of processes involved in regeneration is groups showed reversal of metabolism disturbances. needed. We investigated dynamics of hepatocyte hyper- pNaK-tide/SW033299 not only prevent but reverse plasia and hypertrophy in rats subjected to increasing PH. NASH changes in the rodent model. 104 male Wistar rats subjected to 30%, 70%, or 90% PH; SHAM or no operation. Blood and liver tissue harvested at EP01E-008 post-operative day (POD)1, 3, and 5 (n=8 per group). ROLE OF ULTRASOUND DOPPLER Following main parameters were assessed: Mean hepato- cyte volume (hVOL) and number of proliferating hepato- EXAMINATION IN CHOICE OF cytes (hPROL) by stereology, liver regeneration rate (RR) SURGICAL TACTICS IN PORTAL by change in liver weight, liver function by serum HYPERTENSION proconvertin-prothrombin ratio (PP). fi M. Zarivchatskiy, G. Bogatyreva, I. Mugatarov and At POD1, hVOL increased signi cantly in all PH- E. Kamenskikh groups; followed by a decline to baseline-values. At POD3, Surgical Dept., E.A.Vagner Perm State Medical Univer- hPROL reached maximum in PH(70) and PH(90); hPROL sity, Russian Federation remained unchanged in PH(30). Maximal values of hVOL and hPROL were found in PH(90). RR increased signifi- Introduction: Сhoice of surgical tactics in complicated cantly with size of PH. Liver function was greatly reduced portal hypertension (PH) is actual.More than 400 exami- in PH(70) and PH(90) at POD1, increasing to baseline- nations of hepatic blood flow in patients with complicated values at POD5. PH, including 16 patients, operated by the method of liver tunneling, were fulfilled. Methods: One hundred protocols were chosen randomly. Comparison of distribution indices revealed different occurrence frequency of ultrasound symptoms of PH, having different etiology. Seventy patients with viral etiology of PH prevailed. Varix dilatation of cardia is revealed in 47% of patients. Splenorenal venous shunt (SRVS) is visualized in 43%, recanalization of umbilical vein - in 23% of patients. All types of anhepatic portosystemic shunts are visualized in majority of patients with cirrhosis of ethanol etiology. Liver is always enlarged in fatty hepatosis. In spite of low linear blood flow velocity in PV, its compensatory dilatation is not typical. Damage of PV architectonics is revealed in patients with subhepatic PH, enlargement of PV diameter is naturally absent, splenorenal venous shunt is always observed. Results: Ultrasound Doppler examination is the method of early diagnosis of PH type, its stage and prognosis of bleeding risk. It permits to choose optimal treatment method and evaluate its efficiency by comparison of indices Figure [Hyp Prolif Ratio] before and after treatment. Conclusion: Indications to application of splenorenal Figure: hVOL (red bar) and hPROL (blue bar) normal- venous anastomosis are doubtful due to natural formation ized to the maximum potential (PH(90) POD1 resp. POD3)

HPB 2018, 20 (S2), S333eS504 S478 Electronic Posters (EP01A-EP01E) - Liver in relation to RR (full line) and PP (dashed line) by size of assess role of prophylactic ES in reducing postoperative PH pre- and post-operative. bile leak in patients undergoing partial cystectomy. We found that early phase of rat liver regeneration is Methods: 54 patients with hepatic hydatid cyst met in- characterized by an increase in hVOL. Only after 70% and clusion criteria, 27 were excluded or declined to participate. 90% PH is hyperplasia superseded by hypertrophy; more 26 women and 28 men (mean age 44.610.1, range: 22-61 pronounced the larger PH. This dynamic pattern may reflect years) were randomly assigned to either group I with ES (n the differences in requirements and adaption in order for the = 27) or group II without ES (n = 27). future liver remnant to maintain body homeostasis and to Results: Demographics, clinical, laboratory and radiolog- regenerate. ical characteristics of cysts were not statistically different between two groups. Group I had significant decrease in bile leak rate compared to group II (11.1% vs. 40.7%, EP01E-011 P=0.013), with significantly shorter duration of hospital CLINICAL UTILITY OF SURGICAL stay (P< 0.0001). Biliary fistula in Group I had signifi- APGAR SCORE FOR PREDICTING cantly lower daily output (100 ml/day vs. 350 ml/day) with COMPLICATIONS AFTER gradual reduction till stoppage of leak in 3-4 days without fi fi HEPATECTOMY FOR intervention. Biliary stula in-group II had a signi cant higher need for biliary intervention through postoperative HEPATOCELLULAR CARCINOMA ERCP with ES compared to biliary fistula in group I 1 1 2 2 S. A. Park , Y. Tomimaru , K. Takada , T. Shirakawa , (FEP=0.002), with significantly longer mean time of fistula 1 1 1 1 K. Noguchi , S. Morita , H. Imamura , T. Iwazawa , closure (P=0.011) and longer time to drain removal (P< 1 1 K. Akagi and K. Dono 0.0001). Non-biliary complications were comparable be- 1 2 Surgery, and Anesthesiology, Toyonaka Municipal tween two groups. Hospital, Japan Conclusion: Prophylactic endoscopic sphincterotomy Introduction: Surgical Apgar score (SAS) has been provide significant reduction in postoperative bile leak rate recently proposed as a simple predictor of postoperative with shorter hospital stay after partial cystectomy of hy- complications. Some studies have shown utility of the datid cyst. Biliary fistula in patients with ES has signifi- scoring system in some kinds of surgeries. To date, how- cantly lower daily output with shorter time of drain removal ever, SAS has not been investigated in patients undergoing and shorter time to closure than patients without ES. hepatectomy for hepatocellular carcinoma (HCC). Methods: This study included 158 consecutive patients undergoing hepatectomy for HCC in our institution. As- EP01E-013 sociation between SAS and postoperative complications OPERATIVE TREATMENT OF HEPATIC was examined in the patients. The patients had post- operative morbidities classified as Clavien-Dindo grade II HYDATID CYSTS IN NON ENDEMIC or higher. Multivariate regression analysis was performed REGION: A SINGLE CENTER to identify independent factors that significantly influenced EXPERIENCE the development of postoperative complications. G. Marom, S. Abu Gazala, H. Merhav, D. Padawar, A. Id, Results: Postoperative complications developed in 28 G. Zamir, A. Pikarsky, L. Luques, Y. Demma and (17.7%) of the 158 patients. The proportion of cases with A. Khalaileh fi complications signi cantly inversely correlated with SAS Department of Surgery, Hadassah-Hebrew University fi (Spearman rank correlation 0.829). SAS was signi cantly Medical Center, Ein Kerem, Israel lower in cases with complications than those without Background: Hydatid cyst disease is a zoonosis caused by complications (5.6 1.3 points vs. 6.6 1.3 points, p = Echinococcus genera. While non-operative management 0.0004). Comparisons of patients with and without shows acceptable results, in selected patients, surgery re- complication showed that preoperative serum albumin level mains the mainstay of treatment for hepatic cyst (HHC). and operation time, as well as SAS, were associated with While Israel is considered a non-endemic area, our center complications. Multivariate analysis revealed that post- has gained experience in the surgical treatment of HHC. operative complications significantly correlated with SAS. Objective: We aimed to describe our centers’ experience in Conclusion: This study demonstrated the clinical utility of the surgical treatment of HHC. SAS in predicting the development of postoperative com- Methods: Data was collected from 70 patients treated plications after hepatectomy for HCC. operatively in Hadassah Medical Center between 1994- 2014. Results: 70 patients underwent surgical treatment for he- EP01E-012 patic hydatid cyst at the Hadassah Hebrew university PROPHYLACTIC ENDOSCOPIC medical center between 1994-2014. The group involved 45 SPHINCTEROTOMY FOR PREVENTION females and 25 males with an average age of 39.5 years OF POSTOPERATIVE BILE LEAK IN (range 6.5-74). Surgical procedure involved: hepatic lo- bectomy in 24 patients (left hepatic lobectomy in 14 pa- HYDATID LIVER DISEASE: A tients and right hepatic lobectomy in 10 patients), unroofing RANDOMIZED CONTROLLED STUDY (33 patients), pericystectomy (12 patients), marsupilization A. Elgendi, M. Elshafei and E. Bedewy (1 patient), distal pancreatectomy (1 patient). Average cyst University of Alexandria, Egypt size was 7.16 cm, multiple or bilobar cyst were noted in 23 Background: Bile leak is the main cause of morbidity and patients. There were noted 23 post op morbidity. According mortality after surgery for hydatid liver cysts. Aim was to to clavien- dindo classification: 8 patients had grade I, 8

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S479 patients had grade II, 4 patients graded as 3A, 2 patients Introduction: Auxiliary partial orthotopic liver trans- were graded as 3B. There was 1 case of mortality. plantation(APOLT) is an effective treatment for acute liver Conclusion: We have presented our 20 years’ experience failure(ALF). However, hepatic injury and regeneration in the surgical treatment for hydatid cyst. Hydatid cyst mechanism of native and donor liver is rare. disease in Israel is uncommon and is mostly seen in distinct Method: We created an ALF mouse model wherein about demographic groups. Although patients are mostly treated 82% liver tissue was resected with 25min total hepatic medically once decided on surgery the results are vascular exclusion. The lateral lobe was transplanted as a satisfactions. donor liver. The survival and hepatic injury and regenera- tion parameters in APOLT and ALF group were observed post transplantation. EP01E-014 Results: In the ALF group, most mice died within 48h SELECTIVE TRANSHEPATIC because of liver failure. Of the 33 mice in APOLT group, 27 lived more than 7d. The levels of transaminases, serum ELECTROPORATION MEDIATED BY ammonia, total bilirubin and hepatocyte apoptosis were HYPERSALINE INFUSION THROUGH significantly increased in ALF group, compared to APOLT THE PORTAL VEIN IN RAT MODEL. group. In addition, significant regeneration of the native PRELIMINARY RESULTS ON liver with and graft liver were observed in APOLT group. DIFFERENTIAL CONDUCTIVITY Conclusions: It was proved that APOLT could meliorate live function, reduce native hepatocyte apoptosis, and F. Burdio, C. Pañella, M. Cáceres, L. Grande and facilitate the native liver regeneration for ALF in mice, R. Quesada which was first reported in the world. Hospital del Mar, Spain Introduction: Spread liver tumours are not suitable for treatment either by surgery or conventional ablation EP01E-017 methods. The aim of this study was to evaluate feasibility and safety of selectively increasing the healthy hepatic COMPOSITE PARAGANGLIOMA WITH conductivity by a hypersaline infusion (HI) through the NEUROBLASTOMA IN RETROHEPATIC portal vein. We hypothesize this will allow simultaneous RETROPERITONEUM MIMICKING safe treatment of all nodules by irreversible electroporation HEPATOCELLULAR CARCINOMA (IRE) when applied in a transhepatic fashion. C. K. Cho Method: Sprague Dawley (Group A, n = 10) and Athy- Surgery, Chonnam National University Medical School, mic rats with implanted hepatic tumour (Group B, n = 8) Republic of Korea were employed. HI was performed (NaCl 20%, 3.8 mL/ Kg) by trans-splenic puncture. Deionized serum (40 mL/ Introduction: Paraganglioma is more common in the head Kg) and furosemide (2 mL/Kg) were simultaneously and neck region than in the retroperitoneum. Neuroblas- infused through the jugular vein to compensate hyper- toma is one of the derived from the embryonal sympathetic natremia. Changes in conductivity were monitored in the nervous system usually developed in children. Composite hepatic and tumour tissue. The period in which hepatic paraganglioma with neuroblastoma(CPN) consists of a conductivity was higher than tumour conductivity was neuroendocrine component mixed with a neural compo- defined as the therapeutic window (TW). Animals were nent, and has been reported occasionally in the children, but monitored during 1-month follow-up. The animals were extremely rarely in the adult. sacrificed and selective samples were used for histolog- Methods: A 62-year-old man visited complaining right ical analysis. upper abdominal pain. Abdominal CT and MRI demon- Results: The overall survival rate was 82.4% after the HI strated 11x11x16 cm sized multiseptated cystic mass that fl protocol. The mean maximum hepatic conductivity after HI contained hemorrhagic uid in right hepatic lobe. All fi was 2.7 and 3.5 times higher than the baseline value, in routine laboratory nding with tumor markers were within group A and B, respectively. The mean maximum hepatic normal range. The elective operation was planned under the conductivity after HI was 1.4 times higher than tumour impression of hepatocellular carcinoma in right lobe of tissue in group B creating a TW to implement selective liver with questionable retroperitoneal invasion. In opera- fi IRE. tion nding, there was about 20x15cm sized large mass was Conclusions: HI through the portal vein is safe when the detected in the area between posterior portion of right he- hypersaline overload is compensated with deionized serum patic lobe and retrohepatic retroperitoneum with invasion and it may provide a TW for focused IRE treatment on of right adrenal gland. Right hepatectomy and right adre- tumour nodules. nalectomy with resection of retroperitoneal tissue was performed. Results: The tumor was well marginated and demarcated from the liver, and was composed with both cystic and solid EP01E-016 component. Pathological result of cystic lesion was para- AUXILIARY PARTIAL ORTHOTOPIC ganlglioma with CD56(+), synaptophysin(+) and Ki-67(+, LIVER TRANSPLANTATION FOR 2-3%). On the other hand, the res solid component was ACUTE LIVER FAILURE IN MICE anaplastic neuroblastoma with CD56(+), synaptophysin(-), Ki-67(+, 10-15%). The final pathological diagnosis was Q. Cheng, D. Gao, X. Long, P. Zhu and X. -P. Chen confirmed by CPN in retroperitoneum. Hepatic Surgery Center, Tongji Hospital, Tongji Medical Conclusions: CPN of the retropeitoneum developed in College, Huazhong University of Science and Technology, the adult extremely rare. Here in, we report a case of China

HPB 2018, 20 (S2), S333eS504 S480 Electronic Posters (EP01A-EP01E) - Liver retroperitoneal CPN mimicking hepatocellular carcinoma effects upon the coagulation process, except Trisulfate developed in the adult. Disaccharide(TD). Aims: To evaluate and compare the effects of heparin fragments with different molecular weights in the cellular EP01E-018 protection in Wistar rats liver cells subjected to ischemia MANAGEMENT STRATEGIES OF and reperfusion. Materials and methods: Male Wistar Rats were subjected BLUNT HEPATIC AND SPLENIC to surgical ischemia of the median and lateral liver lobes for TRAUMA IN AUSTRIA: MULTICENTRE 60 minutes and reperfusion for 4 hours and divided in 4 SURVEY ANALYSIS Groups (n=6): Control: IV infusion of saline; Enox: M. Fodor, F. Primavesi, D. Morell-Hofert, E. Gassner, Enoxaparin (4200 Da) IV infusion (2mg/kg); Fond: B. Cardini, E. Braunwarth, M. Haselbacher, D. Öfner and Fondaparinux (3000 Da) IV infusion (0.03 mg/Kg); TD: S. Stättner Trisulfate Disaccharide (585 Da) IV infusion (0.2 mg/kg). Medical University of Innsbruck, Austria Saline or heparin fragments (0.4 ml) were injected into the penile vein, 10 minutes before reperfusion. Alanine Management of hepatic and splenic injuries has evolved Aminotransferase (ALT) and Aspartate Aminotransferase over the past 30 years. Non-operative management (NOM) (AST) were quantified after 4h of Reperfusion. rapidly gained standard of care. However, uncertainty still Results: There were decreases in ALT and AST in Enox, exists about patient selection and details of management as Fond and TD when compared with the control group (p < time to reinitiating oral intake, duration of restricted ac- 0.05). There was no difference between Enox and Fond tivity, or necessity of repeated imaging. This national groups, but TD group animals presented lower ALT levels multicentre questionnaire study aims to give a cross- compared to Enox and Fond groups. sectional overview of current management of blunt liver Conclusion: Decreased ALT and AST levels after admin- and splenic trauma in Austrian hospitals. istration of Enoxaparin, Fondaparinux and Trisulfate A multicentre questionnaire study was performed. Data Disaccharide in the animal model of liver I/R suggests collection involved electronic-based questionnaires hepatocellular protection with a greater effectiveness of the comprised of questions examining the selection criteria for smaller molecular weight fragment (TD). NOM and practical aspects of follow-up. The question- naires were addressed to all Austrian surgical departments and trauma units. After three months, responses were electronically and anonymously recorded, data were EP01E-021 analysed using descriptive statistics. HEPATIC ALVEOLAR In total, 60% response could be achieved, but 24 % ECHINOCOCCOSIS: THE completed the full questionnaire. A widespread shift to POSSIBILITIES OF NOM could be observed. More than 70 % of injuries were ULTRASONOGRAPHY IN THE treated conservatively. 40 % of hospitals actually follow a structured clinical algorithm. Further outcomes and details PLANNING OF SURGICAL OPERATION about the single questionnaire aspects will be presented. Y. Stepanova1,2 and O. Ashivkina2 NOM is the standard of care for blunt hepatic and splenic 1Radiology, А.V. Vishnevsky Institute of Surgery, and injuries in Austria. In clinical relevant questions there is 2Radiology, I.M. Sechenov First Moscow State Medical still a lack of consensus. Based on this experience, standard University, Russian Federation protocols may be generated for systematisation of care in Aim: To estimate the possibilities of US in the planning of blunt abdominal trauma. surgery in patients with alveolar echinococcosis (AE). Materials and methods: The data of 64 patients who were undergone complete liver resection or reduction surgery in EP01E-019 A.V. Vishnevsky Surgery Institute in January 2008 - THE MOLECULAR WEIGHT OF December 2017 we respectively analyzed. Specificity and HEPARIN FRAGMENTS INTERFERES sensitivity of US, CT and MRI were analyzed and ROC- curves were constructed. Statistical significance was WITH THE PROTECTION OF THE calculated using Chi-square. HEPATOCYTE SUBJECTED TO INJURY Results: US diagnostic value: porta hepatis [0,781; < BY ISCHEMIA AND REPERFUSION 0,05];vena cava [0,826; < 0.05]; hepatic veins [0,979; < < < E. R. Vasques1,2, J. E. M. Cunha1, A. M. Coelho1, 0,05]; liver arteries [0,833; 0,05]; vena porta [0,796; < H. B. Nader3, I. L. S. Tersariol3, M. Lima3, T. Rodrigues4, 0,05]. CT diagnostic value: porta hepatis [0,746; 0,05]; < < E. Chaib1 and L. A. C. D’Albuquerque1 vena cava [0,855; 0,05]; hepatic veins [0,771; 0,05]; > > 1Gastroenterology, University of Sao Paulo Medical liver arteries [0,633; 0,05]; vena porta [0,889; 0,05]. > School, 2Research Institute, Prevent Senior Corporate, MRI diagnostic value: porta hepatis [0,714; 0,05]; vena < < 3Infar, UNIFESP, and 4CCNH, UFABC, Brazil cava [0,787; 0,05]; hepatic veins [0,729; 0,05]; liver arteries [0,633; >0,05]; vena porta [0,852; >0,05]. Background: Calcium overload is responsible for hepatic The efficiency of US was significantly comparable to CT cell death after ischemia and reperfusion (I/R). Sodium- and MRI when we analyzed the involved of porta hepatis, calcium exchanger (NCX) decreases the cytoplasmic vena cava, hepatic veins. Assessment of involvement of calcium by acceleration of calcium extrusion. Heparin liver arteries and vena porta was not statistical significant fragments of different molecular weights interact with the and their confirmation requires further study. NCX decreasing calcium. However, they have adverse

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S481

Conclusion: Accumulated experience of A.V. Vishnev- Non-surgical management of blunt liver trauma skogo Surgery Institute shows the possibility of qualitative contributed to reduced mortality from liver trauma. Hepatic preoperation US evaluation of AE-lesion, which has to artery embolisation (HAE) has become a key part of the include assessment of distant dissemination and involve- treatment algorithm for treatment of hepatic trauma with ment of the liver main vessels. In a big surgical hospitals, arterial extravasation. However, significant complications which has an experience of AE treatment, pre-operative US can follow HAE. We aimed to identify the incidence of can become the method of choice in planning of surgical endoscopic or surgical intervention after HAE. operation. We performed a 10 year retrospective review of a pro- spectively maintained database of patients undergoing HAE for severe liver trauma (AIS >3). Demographics, site EP01E-022 of liver injury, vessel embolised and complications were THE DIAGNOSTIC VALUE OF THE recorded and analysed. There were 358 cases of severe liver trauma (AIS >3)in RECOMBINANT ANTIGEN B1 FOR THE the study period. Thirty one (8.6%) patients underwent SEROLOGICAL DIAGNOSIS OF HAE (10 grade III, 19 grade IV and 2 grade V). There HEPATIC CYSTIC HYDATID were no deaths in the patients undergoing HAE. The most A. Tuerganaili, Y. Shao, B. Ran, T. Jiang and H. Wen common mechanism was blunt trauma (n=27/31; 87%) The First Affiliated Hospital of Xinjiang Medical Univer- and segments V-VIII were more commonly injured (n=25/ sity, China 31; 81%). Fifty percent (11/22) of patients who underwent HAE with grade IV-V liver injuries developed a biloma Objective: Get echinococcus granulosus antigen B1 re- that required either percutaneous or endoscopic drainage combinant protein (rEgAgB1) by genetic engineering, Overall, of 31 patients undergoing HAE, 5 underwent discuss its’ serology diagnosis value for HCE, and analysis early hepatectomy for major hepatic necrosis following the relationship between its’ expression and clinical test. HAE and 8 underwent early ERCP and stenting to treat Methods: Construct rEgAgB1, then ELISA and Immuno- biloma formation. 5 patients also required percutaneous blotting method of serum samples were taken by recom- drainage. binant protein and HCF for 25 patients with HCE and 25 Severe liver trauma requiring HAE is associated with normal people respectively, retrospectively analyzed the intrahepatic biliary complications. Further intervention is clinical data of 25 patients with hepatic hydatid cyst, study required in a significant proportion of these patients and the relationship between age, sex, symptom,subtype,other represents a significant health care burden arising from organs affected or not, quantity of the cyst, size of the cyst HAE that should be anticipated and treated early. and the expression level of rEgAgB1 in serum. Results: Use rEgAgB1 as antigen, detect the IgG1 specific antibody in the serum of 25 patients with HCE, 19 of which were positive, serum positive rate is 76%. Use rEgAgB1 as EP01E-024 antigen, detect the IgG4 specific antibody in the serum of HELLP SYNDROME COMPLICATED BY 25 patients with HCE, 9 of which were positive, serum SUBCAPSULAR LIVER HEMATOMA. A positive rate is 36%. Analysis the clinical data of 25 pa- SURGICAL EMERGENCY tients with HCE, the result showed there is no correlation between age, ethnic, symptom, size of cyst and expression S. Alonso Batanero, J. Quiñones Sampedro, level of rEgAgB1 in serum. A. B. Sanchez Casado, J. A. Alcazar Montero, Conclusion: Serological diagnosis by rEgAgB1 has high T. Rubio and L. Muñoz Bellvis sensitiviy and specificity, The recombinant AgB indicates Complejo Asistencial Universitario de Salamanca, Spain the advantage of no cross-reaction with other parasite dis- Introduction: Spontaneous hepatic rupture associated with eases or nonparasite hepatic diseases. Recombinant antigen preeclampsia or HELLP syndrome is a rare event, the B can improve the specificity but decrease the sensitivity. incidence is 1 in 40.000-1 in 250.000 pregnancies. Case: A 35-year-old female G1P0A0 was admitted in our hospital at the 35th week of pregnancy presenting abdom- EP01E-023 inal pain, nausea and vomiting. Arterial pressure was normal as platelet count and there BILOMA FOLLOWING HEPATIC was no proteinuria. Likewise, elevated liver enzymes and a ARTERY EMBOLISATION (HAE) FOR lactate dehydrogenase of 307 U/L, led us to the diagnosis of MAJOR LIVER TRAUMA AT THE HELLP partial syndrome and decided to carry out urgent ALFRED - IS EARLY ENDOSCOPIC OR cesarean. Immediately following surgery, she developed SURGICAL INTERVENTION right hypochondria pain with data of peritoneal irritation, interpreted as hemorrhage. In the blood test followed, the REQUIRED? HELLP syndrome is confirmed, appreciating hemolysis, 1 2 3 4 R. Lahiri , A. Olaussen , A. Frampton , M. Smith , elevated liver enzyme levels, a low platelet count. CT scan 4 2 2 C. Pilgrim , L. Niggemeyer , K. Martin , showed a sub capsular right liver hematoma and hepatic 5 2 J. Koukounaras and M. Fitzgerald lacerations. 1 2 The Trauma Unit, The Alfred Hospital, National Trauma Exploratory laparotomy is performed. Hemoperitoneum 3 Research Institute, HPB Surgery, Imperial College and the rupture of hepatic hematoma were confirmed 4 5 London, United Kingdom, HPB Surgery, and Depart- during operation. Packing and Hemostasis with electro- ment of Interventional Radiology, The Alfred Hospital, cautery was done and no signs of further bleeding were Australia observed during the surgery even later.

HPB 2018, 20 (S2), S333eS504 S482 Electronic Posters (EP01A-EP01E) - Liver

Conclusion: Subcapsular liver hematoma is a rare but Introduction: Liver transplantation (LT) is currently the potentially life-threatening complication of preeclampsia best treatment for end-stage liver diseases. Less than 10% and HELLP syndrome. It may present with nonspecific of LT indications are due to unusual etiologies. We aim to signs and symptoms, none of which are diagnostic. If assess the clinical results of LT unusual indications at our rupture is suspected, ultrasound examination may show institution. intra- or extra-hepatic bleeding, but hepatic complications Methods: A retrospective cohort study including all LT are best characterized by MRI or CT. performed between March 1994 and December 2016. Treatment depends on the clinical presentation from a Biodemographic variables, the indication of transplant, conservative management to emergent laparotomy. Other retransplantation requirement, early mortality and overall treatment modalities like endovascular embolization and and graft survival were recorded. even liver transplantation can be used successfully. Results: Two hundred and ninety-five LT were performed, on 261 patients; 34 (11.5%) were due to unusual in- dications. Twenty-seven (79.4%) were performed on adults EP01E-025 and 7 (20.6%) on pediatric patients. The indications of THE UTILITY OF CA 19-9 IN THE adult patients are shown in Table 1. MANAGEMENT OF PYOGENIC LIVER

ABSCESS Table [Liver transplant indications in adult patients] V. Shanmugam, S. Kapoor, H. Singh and S. Balakrishnan Indication Number KMCH, India Porto/Hepatopulmonary Syndrome 11 Introduction: CA 19-9, a well-known tumor marker in Polycystic disease 9 gastro-intestinal malignancies, is also elevated in benign conditions like acute cholangitis, chronic liver disease etc. NET liver metastases 3 Its elevation in liver abscess is rarely reported. Niemann - Pick disease 2 Methods and results: A 71-year-old male, a known dia- Rendu-Osler-Weber Syndrome 1 betic and coronary artery disease, presented with breath- GIST liver metastases 1 lessness for 3 days. He had leukocytosis and bilobar cannon-ball lesions on chest radiograph. HRCT chest Total 27 revealed bilateral patchy lung consolidation and a 8x6cms liver abscess in right lobe(Figure 1). His CA 19-9 was 747 while AFP and CEA were normal. His clinical diagnosis Pediatric LT indications were: Hepatoblastoma in 3 pa- was intrahepatic cholangiocarcinoma with secondarily tients, OTC deficiency in 2 and once case each of Alagille infected necrosis. He rapidly developed multi-organ failure Syndrome and Niemann Pick-Disease. Median age at and managed with mechanical ventilation, inotropes, he- transplant in the pediatric patients was 17 months (6-192); modialysis and antibiotics. Percutaneous drainage in 2nd mean age in adults was 52 30.3 years. Of the 9 patients week revealed thick pus. CA 19-9 increased to 922 and with the polycystic disease, 4 patients had an early hepatic 1198 in 2nd and 3rd weeks. Multiple percutaneous drains artery thrombosis (HAT); 2 required retransplantation. The achieved adequate drainage by end of 3rd week. CA 19-9 overall mortality of the entire group was 9.3% (3 patients). fell thereafter to 667, 130 and 108 at 4, 6 and 10 weeks No statistically significant differences in overall and graft respectively. Trucut biopsy of the lesion and colonoscopy survival were observed (p=0.36) between patients with did not reveal any malignancy. He gradually recovered and common indications of LT versus unusual indications. was discharged after 10 weeks stay. At 2 months follow-up, Conclusions: LT should be offered in a diverse variety of the patient is fine with CA 19-9 of 24, with a residual 2 x 2 diseases with caution in polycystic disease. No overall and cms liver cavity and complete resolution of lung lesions on no graft survival difference was found between frequent imaging. and unusual indications. Conclusion: CA 19-9 elevation in liver abscess is probably common and does not mean a co-existing malignancy. It can be biochemical marker of abscess resolution and can be used in the follow-up. EP01E-027 BILE DUCT MANIPULATION INCREASES RISK OF SURGICAL SITE EP01E-026 INFECTIONS AFTER OPEN UNUSUAL INDICATIONS OF LIVER HEPATECTOMY IN ASIANS WITHOUT TRANSPLANTATION HEPATOLITHIASIS A. Troncoso Trujillo1, S. Pacheco Santibañez1, Q. -D. Hu, B. -F. Huang, R. -S. Que, X. -L. Bai and A. Cancino Marambio2, P. Dellepiane Merello2, T. -B. Liang C. Benitez Gajardo3, R. Wolff Rojas1, J. C. Pattillo Silva4, Department of Hepatobiliary and Pancreatic Surgery, The E. Briceño Valenzuela1, J. F. Guerra Castro1 and Second Affiliated Hospital, Zhejiang University School of J. Martinez Castillo1 Medicine, China 1Department of Surgery, 2Liver Transplant Program, 3Department of Gastroenterology, Pontificia Universidad Introduction: Open hepatectomy has many confound- Católica de Chile, School of Medicine, and 4Department of ing risk factors. Asian populations have higher risk of Pediatric Surgery, Pontificia Universidad Católica de hepatolithiasis and related infection which might cause Chile, Chile notable confounding bias. There is currently limited

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S483 evidence of risk factors of surgical site infections (SSI) Conclusion: We found no correlation between preopera- after hepatectomy in East Asian populations without tive ICG test and GSA-S results. GSA-S may not be useful hepatolithiasis. for predicting PHLF after Hx with EBDR for perihilar Method: We identified 351 consecutive patients with no cholangiocarcinoma. evidence of hepatolithiasis who underwent open hepatec- tomy between January 2012 and August 2014 in a Chinese medical center. Logistic regression was applied to identify EP01E-030 independent risk factors of postoperative SSI after open HEPATIC ANGIOCRINE HGF hepatectomy. Results: Postoperative SSI occurred in 14 patients (3.99 SIGNALING PLAYS A VITAL ROLE IN %). Univariate logistic regression showed that Child-Pugh THE EARLY STAGE OF LIVER class B/C, operation time 200 min, hepaticojejunostomy, REGENERATION AFTER PHX IN MICE blood transfusion, and ICU admission might increase the X. -J. Zhang1, B. Wang1, V. Olsavszky2, risk of postoperative SSI after open hepatectomy. Further K. Schledzewski2, C. Géraud2, N. Hüser1, G. O. Ceyhan1, fi multivariate regression identi ed two independent risk H. Friess1, G. von Figura3 and D. Hartmann1 factors: hepaticojejunostomy (OR 10.61, 95% CI, 3.309 - 1Department of Surgery, Klinikum rechts der Isar, Tech- < 34.02, P 0.001) and blood transfusion (OR 4.993, 95% nical University of Munich, 2Department of Dermatology, CI, 1.465 - 17.01, P = 0.010). Venereology and Allergology, Medical Faculty Mannheim, Conclusions: Bile duct manipulation and blood transfusion Heidelberg University, and 3Department of Internal fi signi cantly increase the risk of postoperative SSI after Medicine II, Klinikum rechts der Isar, Technical Univer- open hepatectomy in an East Asian population without sity of Munich, Germany hepatolithiasis. Introduction: Hepatocyte growth factor (HGF) is a com- plete hepatic mitogen and is considered an initiator of liver regeneration. Liver regeneration following partical hepa- EP01E-029 tectomy (PHx) is a complex process where liver sinusoidal A STUDY ON CORRELATION BETWEEN endothelial cells (LSEC) play an important role. LSEC are ICG REGRESSION TEST AND regarded one of the most important liver cell types that 99MTC-GSA SCINTIGRAPHY IN LIVER produce HGF, but the exact contributions of LSEC to liver fi FUNCTION EVALUATION BEFORE regeneration remain to be de ned. Methods: To investigate the effects of hepatic angiocrine fl fl HEPATECTOMY FOR PERIHILAR HGF signaling on liver regeneration, Stab2-Cretg/wt;HGF / CHOLANGIOCARCINOMA (HGF-LSECKO) mice, where HGF is specifically knocked A. Inoue, T. Noji, Y. Nakanishi, T. Asano, T. Nakamura, out in LSEC, were used. 70% PHx was performed on these T. Tsuchikawa, K. Okamura, T. Shichinohe and S. Hirano mice and the kinetics of liver-to-body weight ratio, hepa- Department of Gastroenterological SurgeryⅡ;, Graduate tocyte proliferation, HGF/c-MET signaling pathways and School of Medicine, Hokkaido University, Japan cell-cycle-associated genes were analyzed at different time Introduction: Post-hepatectomy (Hx) liver failure (PHLF) points after PHx. is a serious problem after Hx with extrahepatic bile duct Results: We found that HGF-LSECKO mice showed a fi resection (EBDR). To avoid PHLF, assessing preoperative signi cantly reduced liver-to-body weight ratio compared liver function is important, for which indocyanine green to the control group at 72 hours after PHx. HGF-LSECKO regression (ICG) test or 99mTc-galactosyl human serum mice had a higer mortality after PHx and the proliferation of fi albumin scintigraphy (GSA-S) has been used in Japan. We hepatocytes was signi cantly impaired at 48 hours after aimed to evaluate GSA-S as an alternative to ICG test to PHx in HGF-LSECKO mice. predict PHLF following Hx with EBDR for perihilar Conclusions: Hepatic angiocrine HGF signaling plays a cholangiocarcinoma. vital role in the early stage of liver regeneration after PHx in Patients and methods: From January 2006 to December mice. Hepatic angiocrine HGF signaling is not only 2015, 139 patients who underwent both ICG test and GSA- essential for liver regeneration after injury, but also for the S underwent Hx with EBDR in our department. We growth of the liver and even the whole organism. retrospectively examined correlations between these tests. We also calculated GSA-S cutoff values for predicting EP01E-031 PHLF. To define PHLF, we used Mullen’s criterion of total PROTEOMIC CHARACTERIZATION OF bilirubin >7 mg/dL during postoperative days 1-7. BIOLOGICAL FEATURES IN THE Results: No correlation was found between GSA-S pa- SMALL FOR SIZE FUTURE RAT LIVER rameters (heart activity at 15 min divided by heart activity REMNANT at 3 min (HH15) and liver activity at 15 min divided by 1 1 1 heart plus liver activity at 15 min (LHL15)) and the plasma M. Meier , K. Jarlhelt Andersen , A. Riegels Knudsen , M. Ludvigsen2, B. Honoré2 and F. Viborg Mortensen1 disappearance rate of ICG (r = 0.267 and 0.240, respec- 1 tively) or the ICG retention rate at 15 min (r = 0.224 and Department of Surgical Gastroenterology, Section for fi Upper Gastrointestinal and Hepato-Pancreatico-Biliary 0.210, respectively). Strati ed analyses were performed 2 according to sex, age, preoperative cholangitis, preopera- Surgery, Aarhus University Hospital, and Department tive biliary drainage, and preoperative serum albumin level, of Biomedicine, Aarhus University, Denmark but these factors had no effect. Both HH15 and LHL15 Small for size liver syndrome (SFSLS) may occur after showed low AUC levels (0.592 and 0.557, respectively) to extended partial hepatectomy (PH); characterized by predict PHLF. insufficient function of the future liver remnant (FLR);

HPB 2018, 20 (S2), S333eS504 S484 Electronic Posters (EP01A-EP01E) - Liver biochemically demonstrated by low proconvertin-pro- EP01E-033 thrombin-ratio (PP) and high bilirubin (BR). The aim of this ongoing study is to characterize differences in protein RADICAL GASTRECTOMY WITH expression between different size of FLRs and to identify ENBLOC LIVER RESECTION FOR proteins specific for the regenerative process of minimal GASTRIC CANCER: A CASE SERIES size FLR (MSFLR). J. S. Bhanu and R. S. Ayloor 104 male Wistar rats subjected to 30%, 70%, or 90% PH Department of Surgical Oncology, Cancer Institute (WIA), (MSFLR in rats); SHAM or no operation. Blood and liver India tissue harvested at post-operative day (POD)1, 3, and 5 Introduction: For curative resection of locally advanced (n=8 per group). Main parameters assessed: Proteomic T4 gastric cancers, radical gastrectomy with D2 dissection expression by 2D-PAGE and liquid-chromatography mass- with en bloc multiorgan resection should be performed. The spectrometry, liver regeneration rate (RR) by change in aim of the study was to analyze the short term surgical and liver weight, and serum PP and BR. pathological outcomes of patients who underwent radical 149 protein-spots were significantly different expressed gastrectomy with D2 dissection with en bloc liver resection. between groups (FDR< 0.05, fold-change>2). By hierar- Methods: Three patients underwent curative resection for chical cluster analysis 3 separate clusters formed: PH(90) gastric cancer along with enbloc liver resection. All three POD1, POD3, POD5. Identification of the protein spots patients received three cycles neoadjuvant chemotherapy revealed 57 proteins, all specific for PH(90)-groups (up-/ (EOX) and then were reassessed for surgery. down-regulated compared to the other groups). RR Results: Of the three patients, two were females. Imaging increased significantly with size of PH. Significantly, PP done prior to surgery did not suggest liver infiltration. The was critically reduced in PH(90) at POD1 and BR elevated; details of the surgeries performed in these three patients: 1. both normalized at POD5. Extended total gastrectomy + D2 dissection, 2. Total gas- Most pronounced changes in proteomic expression after trectomy + D2 dissection and 3. Subtotal gastrectomy + D2 PH were found in the PH(90)-group; initially mimicking dissection along with en bloc liver resection. There was no SFSLS by low PP and high BR at POD1, later recuperating incidence of postoperative morbidity. Histological liver liver function and growth. 57 proteins specific for PH(90)- parenchymal infiltration was noted in only one patient. In groups were identified pending further ongoing analyses. the second patient, perihepatic connective tissue in the site Identification of biological factors of liver regeneration in of adhesion showed tumor infiltration while in the third MSFLR is important in attempt to improve outcome after patient liver was free(ypT4a disease). The first patient had extended PH and potential SFSLS. node negative disease, whereas the remaining two patients had node positive disease. All three patients had high grade EP01E-032 adenocarcinoma. All three patients are disease free, with SURGICAL MANAGEMENT OF NON longest follow up of 12 months. CIRRHOTIC PORTAL HYPERTENSION: Conclusion: En bloc liver resection can be safely A SINGLE SURGEON EXPERIENCE performed along with curative gastrectomy. Neoadjuvant chemotherapy does not increase the risk of morbidity. R. Singh Bhandari Department of Surgery, T U Teaching Hospital, Nepal Introduction: Among the non- cirrhotic causes of portal EP01E-034 hypertension, EHPVO followed by Non Cirrhotic Portal A CASE OF ECHINOCOCCAL CYST Fibrosis (NCPF)make the major bulk of the portal hyper- COMPLICATED BY CYSTO-GASTRIC tensive diseases managed surgically in our part of the FISTULA world. The surgical options offered when indicated has H. Roh, H. J. Kim and C. K. Cho excellent outcome. Department of Surgery, Chonnam National University Methods: Prospectively maintained medical records of the Medical School, Republic of Korea patients managed surgically by a single surgeon between Oct 2012- Dec 2017 were reviewed. Demographics, pre- Background: Hydatid disease known as Echinococcosis is sentations, indications and type of surgery performed, a zoonosis that is prevalent in Mediterreanean contries, the perioperative outcome and follow up were studied. Middle East, Far East, South America, Austrailia, and east Results: Total 35 cases were operated during the Afreca. However, echinococcosis is rarely reported in mentioned period. The male: female ratio was 20:15 while South Korea. We report a rare case of hepatic hydatid cyst fi age of presentation ranged between 4years - 37years.All manifested with cysto-gastric stula and pelvic cavity cyst. patients had at least one episode of major bleed with Case presentation: A 49-year-old Uzbekistan male patient hypersplenism. Types of procedures performed included presented with a fever and right upper quadrant pain for fi Splenectomy Devascularisation - 18 and shunts- 17 seven days. An abdominal CT scan showed a calci ed mass (Proximal spleno-renal-14, spleno-adrenal- 2, Mesocaval- in the left hepatic lobe communicating to the gastric lumen. fi 1). There was no perioperative mortality and grade 3 or Two calci ed masses were also observed in the pelvis. more complications. Total 4 (11%) patients developed Endoscopy revealed a huge gastric ulcer with pus recurrence during follow up period of 2- 60 months and coming out from the base. Culture from endoscopic ultra- fi were managed endoscopically. sonography-guided ne needle aspiration of the abscess Conclusion: Proximal spleno-renal shunts followed by was positive for Streptococcus constellatus and Prevotella splenectomy devascularisation are two main surgical op- heparinolytica. The patient was treated with parenteral tions offered for our patients with non cirrhotic portal hy- antibiotics. Enzyme-linked immunosorbent assay (ELISA) pertension with excellent outcome. for echinococcus was positive. Albendazole was started

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S485 and a left lateral sectionectomy with gastric wedge resec- Introduction: Hepatic portal venous gas (HPVG) is rela- tion was performed. Deoxyribonucleic acid (DNA) tively rare radiological sign and considered to be lethal in sequencing from the tissue revealed Echinococcus gran- the past, suggesting extensive necrotic bowel. However, ulosus. Twenty days following the operation, the patient recent reports have shown that there are HPVG patients was discharge without any complications. who are candidates for conservative treatment. We inves- Conclusions: Hepatic hydatid cyst can progress with tigated the correlation of SOFA score in HPVG patients. complications such as bacterial superinfection, rupture, or Method: Twenty-five HPVG patients were diagnosed by formation of cavity. So it should be treated by surgical abdominal computed tomography (CT) between April 2014 primarily or percutaneous aspiration without spillage for and December 2017. Clinical findings were assessed preventing anaphylaxis. Although South Korea is not an including management and mortality. Also, SOFA score endemic area, echinococcosis must always be included in was calculated upon HPVG diagnosis to determine its the differential diagnosis of hepatic space occupying le- feasibility for predicting survival. sions in travelers and immigrants from the endemic area. Results: The average age was 76.7 years old. Patients without GI symptoms were observed without any compli- cation. Frequent underlying pathologies were cardiovas- EP01E-035 cular disease and diabetes mellitus. Eight patients had ENHANCED RECOVERY AFTER recent gastrointestinal surgical intervention before HPVG diagnosis. Serum lactate was within normal limit in 14 out SURGERY (ERAS) PROGRAM IN of 23 patients measured (61%). Average base excess was ELDERLY PATIENTS UNDERGOING -5.5 mmol/L. Among nine critically ill patients, seven had LAPAROSCOPIC HEPATECTOMY abnormal serum lactate level (average 7.0 mmol/L) and L. Xiao, Wenbin Jiang, QiJiang Mao, Hanning Ying and base excess of -11.2 mmol/L. Their SOFA score averaged XiuJun Cai 5.8, whereas other non-critical patients were 3.1 Sir Run Run Shaw Hospital of Zhejiang University, China (p=0.0579). SOFA score of patients with performance status of 0,1,2 and 3,4 were 2.1 and 4.1, respectively Objective: To explore the effect and safety of Enhanced (p=0.0510). HPVG distribution and extra-portal vein gas Recovery After Surgery (ERAS) program in elderly pa- did not correlate with the clinical condition. tients undergoing laparoscopic hepatectomy. Conclusion: Initial SOFA score upon HPVG diagnosis Methods: A retrospective study included 28 elderly pa- tend to be relatively low, which may associate with mild tients (65) in ERAS group and 44 patients in the tradi- ischemic change in the bowel. However, many underlying tional care group received laparoscopic liver resection in clinical factors make complicated outcome that multilateral Sir Run Run Shaw Hospital from June 2014 to August bed-side evaluation is mandatory. 2016 was performed. Operation time, blood loss, length of hospital stay(LOS), complications, hospitalization expense were compared between the two study group respectively. Results: Compared with control group, there were no EP01E-037 significant differences the in blood loss(187.8209 ml in SERUM PROCALCITONIN ERAS group vs 232.0217.5 ml in control group, CONCENTRATION WITHIN 2 DAYS P=0.400) and operation time (170.686.3 min vs POSTOPERATIVELY ACCURATELY 182.6 74.3 min ,P=0.533).The median postoperative PREDICTS OUTCOME AFTER LIVER hospital stay was 6.43.0d in the ERAS group, which was significantly shorter than that in the control group RESECTION (9.74.9d, P=0.001).The hospitalization cost was CNY Y. Aoki1, N. Taniai1, M. Yoshioka1, Y. Kawano2, 48275.9613804.9 in the ERAS group and CNY T. Shimizu1, T. Kanda1, R. Kondo1, Y. Kaneya1, 56314.1420968.49 in the control group (P=0.001).Like- H. Furuki1 and E. Uchida1 wise, the postoperative complication was decreased in 1Department of Gastrointestinal and Hepato-Biliary- ERAS group (28.57%) vs control group (56.82% , Pancreatic Surgery, Nippon Medical School, and P=0.019). 2Department of Surgery, Nippon Medical School Chiba Conclusions: ERAS protocol is feasible and safe for Hokusoh Hospital, Japan elderly patients undergoing laparoscopic hepatectomy. Introduction: Relatively high mortality and morbidity Elderly patients in ERAS group have shorter postoperative rates are reported after liver resection (LR). However, the LOS, less hospital costs and faster postoperative recovery. early predictors of complications after LR are not clear. Serum procalcitonin (PCT) is reportedly useful for pre- diction of postoperative complications in various types of EP01E-036 surgery. The purpose of this study was to clarify the use- SOFA (SEQUENTIAL ORGAN FAILURE fulness of PCT for the early detection of postoperative ASSESSMENT) SCORE MAY ASSOCIATE complications after elective LR. Methods: This observational study included 72 consecu- WITH SURVIVAL OF HEPATIC PORTAL tive patients who underwent elective LR from December VENOUS GAS PATIENTS 2015 to March 2017. Patients were categorized into two H. Baba1, Y. Nakayama2, T. Takei3, A. Watanabe1, groups: those with and without postoperative complica- H. Ono1 and M. Sugita1 tions. The values of postoperative inflammatory markers 1Surgery, 2Emergency Medicine, and 3Intesive Care Unit, [white blood cell (WBC) count, C-reactive protein (CRP), Yokohama City Red Cross Hospital, Japan and PCT] were compared between the two groups.

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Results: CRP and PCT were significantly higher in patients Aim: To assess whether Gd-EOB-DTPA enhanced-MRI with than without complications; however, the WBC count study is useful to determine liver function in comparison to showed no difference within 5 days postoperatively. The Child Pugh (CP), Model for End-stage Liver Disease PCT level peaked within 2 days postoperatively in 61 pa- (MELD) and biochemical test. tients (85%). The maximum PCT level within 2 days Materials and methods: We retrospectively reviewed all postoperatively (PCT1-2) was significantly higher in pa- Gd-EOB-DTPA enhanced-MRI studies performed, be- tients with than without complications (0.52 vs. 0.19 ng/ml, tween May 2011 and September 2017, to characterize focal p < 0.001). A cut-off PCT1-2 level of 0.35 ng/ml achieved liver lesion. Patients were divided in study and control 80% sensitivity and 83% specificity. PCT1-2 was superior group according to the presence/absence of liver cirrhosis. to CRP level within 2 days postoperatively (CRP1-2) for Signal intensity was calculated as the rate of liver-to- correct diagnosis of complications after LR (p = 0.006). In muscle ratio on contrast-enhanced T1-GE sequences in the patients without complications, there was no difference portal (SI-POR) and hepatobiliary phase (SI-HEP) and than in PCT1-2, even if the surgical procedure was different (p = normalized for liver volume (SI-POR/LV and SI-HEP/LV). 0.935). Results: A total of 303 Gd-EOB-DTPA enhanced-MRI Conclusions: PCT1-2 is an early prediction maker after LR studies, performed in 221 consecutive patients, were and can be similarly used regardless of surgical procedure included. Cirrhosis was present in 191 (63.0%) MRI studies. of LR. SI-HEP was significantly lower in cirrhotic than in non- cirrhotic patients( 0.550.29 vs 0.660.40,p=0.004), while no difference was found in SI-POR. EP01E-038 SI-HEP progressively decreased from CP-A group to < CLINICAL APPLICATION OF 3D CP-C group (0.59 0.28 to 0.25 0.19, p 0.0001) and from MELD10 to MELD 19-24(0.580.30 to 0.54 RECONSTRUCTION TECHNIQUE ON 0.49, p=0.773). SI-HEP had a good performance in LAPAROSCOPIC HEPATECTOMY distinguishing CP-A from CP-B/C patients (AUC=0.75; L. Xiao 95%CI=0.66-0.83). Sir Run Run Shaw Hospital of Zhejiang University, China Among biochemical parameters a moderate correlation Objective: To evaluate the clinical value of three-dimen- was found between SI-HEP and total bilirubin (R=-0.324), sional reconstruction technique in precise hepatectomy for GOT (R=-0318) and albumin (R= 0.320). primary liver cancer. Comparable results were observed when SI-HEP was Methods: This article analyses 94 cases of laparoscopic normalized for liver volume. right half and partial hepatectomy from January 2014 to Conclusion: SI-HEP of Gd-EOB-DTPA enhanced-MRI August 2016.And 10 patients with primary liver cancer in studies can be effectively used to evaluate liver function. In Sir Run Run Shaw Hospital from January 2014 to today. clinical practice MRI could be performed both to correctly Volume of total liver volume, tumor volume, predicted characterize liver lesions and to assess the severity of liver resection volume and the remnant liver volume were disease especially in the perspective of surgical treatment. measured by the liver ３D reconstruction system(- HexaUnion3D), the data of volume was compared with that were calculated based on the 2-dimensional imaging and EP01E-040 actual operation. All of the 3D models of liver were SURGICAL TREATMENT OF reconstructed successfully. RUPTURED LIVER TUMOURS e A Conclusion: The 3D reconstruction of liver benefits a lot to WESTERN CASE SERIES preoperative assessment, and have important significance E. Santos1, H. Alexandrino1,2, L. Ferreira3, R. Martins1, in precise hepatectomy. M. Serôdio1, J. G. Tralhão1,2, F. Castro e Sousa2 and J. Soares Leite1,2 1Department of Surgery, Coimbra University Hospital, EP01E-039 2Faculty of Medicine, University of Coimbra, and 3Depart- ASSESSING LIVER FUNCTION: ment of Surgery, St. Vincents University Hospital, Ireland DIAGNOSTIC EFFICACY OF Introduction: Spontaneous rupture of liver tumours is potentially life-threatening. Hepatocellular Carcinoma PARENCHYMAL ENHANCEMENT AND (HCC) and Hepatocellular Adenoma (HCA) are the most LIVER VOLUME RATIO DURING frequent pathological diagnosis. Choice of therapy depends HEPATOBILIARY PHASE, OF on: clinical status, severity of pre-existing liver disease and GADOLINIUM-ETHOXYBENZYL- tumour burden. Treatment options include immediate or DIETHYLENETRIAMINEPENTAACETIC delayed surgery (resection or perihepatic packing), with or ACID (GD-EOB DTPA) ENHANCED without Transarterial Embolization (TAE). Methods: We analysed thirteen consecutive patients (ten MAGNETIC RESONANCE IMAGING male; mean age 60,8 years) who underwent surgery for (MRI) STUDIES hepatic tumour rupture in our surgical department (January S. Famularo1, A. Pecorelli2, E. B. Orsini2, 1st 1988 to January 1st 2018). Inclusion criteria: sponta- C. Talei Franzesi2, L. Gianotti1, A. Giani1 and neous rupture and evidence of intra-peritoneal bleeding. D. Ippolito2 Clinical presentation: abdominal pain in ten; hemorrhagic 1Surgery, Ospedale San Gerardo, and 2Radiology, Ospe- shock in nine cases. Mean tumour size: 7.35cm (4-17). dale San Gerardo, Università Milano-Bicocca, Italy Eight patients had HCC, three HCA and two metastases.

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Twelve patients underwent hepatectomy (minor in eleven; jaundice (21,7%). Underlying comorbidities like diabetes major in one); one peri-hepatic packing only. Five patients mellitus, alcoholism, or inmunocompromised (recipient of needed immediate surgery, four urgent and four delayed. a liver transplant) were presented in 36,6%, 19,8% and Six patients underwent TAE. 9,7% respectively. The most common abscess location was Postoperative morbidity according to Dindo-Clavien. the right hepatic lobe (73,9%), followed by the left one Statistical analysis with SPSS v23.0 (significance with p< (18,5%), being both side located in 7,6%. CT and 0.05). abdominal US were used in all 208 patients. The average Results: Median length of stay was 10 days (4-68). Major maximum diameter of an abscess was 5,93,3 cm. K. morbidity in three patients (23%); mortality in two cases pneumoniae was identified in the 20% of the patients in the (15%). Number of transfused units associated with increased aspiration culture. risk of complications (p< 0.05). Five-year overall survival Portal vein thrombosis was identified in 9,8% of the was 50%; 45% in HCC patients; 100% in HCA (p< 0.05). patients. Percutaneous drainage (PD) was performed in 131 patients (63%). 15 patients needed surgical intervention because of the underlying cause; in 10 of them a chole- cystectomy and surgical drainage was performed, in 3 a laparoscopic drainage, and in one patient a left hepatectomy was required. Conclusions: The mainstay treatment of PLA was PD. K. pneumoniae is an emerging cause of PLA in our region.

EP01E-043 ICG APPLICATIONS IN HEPATOBILIARY SYSTEM: OF FLUORESCENCE, FRONTIERS AND FALSE POSITIVES K. Panganiban1, C. Teh2, L. Boni1,2, J. J. Domino1,2, Figure 1 Kaplen–Meyer curves of overall survival in the study popula- M. Siozon1,2, V. Porciuncula1,2, J. Adora1,2, tion (N = 13 patients) undergoing surgery for ruptured liver tumours 5- M. Melendres1,2, A. D. Rana1,2 and R. V. Naranjo1,2 year survival in patients with hepatocellular carcinoma was 45%. 1Division of Minimally Invasive & Robotic Surgery, ’ Conclusion: Rupture of liver tumours is a severe compli- Institute of Surgery, St. Luke s Medical Center, and 2 cation. Hepatic resection, with or without preoperative TAE, Hepatopancreaticobiliary Surgery, Institute of Surgery, ’ should be considered gold standard for management in pa- St. Luke s Medical Center, Philippines tients with adequate preoperative hepatic reserve. Evidence Fluorescence-guided surgery (FGS) is revolutionizing of continued bleeding should define the treatment strategy. current standards of practice, w indispensable possibilities. Its use in hepatobiliary system has long been existent, but clinical applications have just been recently accepted & EP01E-042 broadly utilized. This paper aims to strengthen data on FGS PYOGENIC LIVER ABSCESS: A using Indocyanine Green (ICG) in hepatobiliary system - decreasing morbidities & providing real-time intraoperative RETROSPECTIVE STUDY OF 208 CASES assessment. Second, of frontiers, in laparoscopic chole- IN A SINGLE SURGERY DEPARTMENT cystectomy, liver resection of tumors & liver trauma - the O. A. Nutu, I. Justo Alonso, M. García-Conde Delgado, preoperative & intra-operative techniques involved. Also, A. A. Marcacuzco Quinto, L. Alonso Murillo, to present an index case of ICG use for a liver abscess, P. Del Pozo Elso, J. Calvo Pulido, A. Manrique Municio, which to the primary author’s knowledge, none has been I. Lechuga Alonso and C. Jiménez Romero reported yet. Third, false positive lesions were also Hepatobiliopancreatic Unit and Abdominal Organs reported. Transplantation, 12 de Octubre University Hospital, Spain 38 cholecystectomies, 4 liver resections & 1 exploration Introduction: Pyogenic liver abscesses (PLA), a special secondary to trauma were performed under laparoscopic suppurative infection of the hepatic parenchyma, accounted FGS. Equipment: KARL STORZ ICG system. ICG was for 48 percent of visceral abscesses. Among risk factors administered at different dosages & timing, depending on diabetes mellitus, underlying hepatobiliary or pancreatic the planned surgery. disease were identified. Hepatobiliary structures, pathologies & false positive fi Methods: We performed a retrospective study during the lesions identi ed. For liver resection, ICG demarcation of period between January 2003 and January 2016. De- transection corresponded w/ that of the intraoperative ul- mographic data, underlying disease, clinical presentation trasound. No adverse reactions observed. Operative time, fi and treatment were analyzed. not signi cantly affected. Results: 208 patients with (PLA) were identified. The Dosage & timing of ICG administration and integrity of fi mean age was 62,117,6 years, 125 patients were male hepatobiliary system are signi cant in the outcomes of fl fi (male to female ratio 1,5:1). The most common presenting uorescence-guided surgery. Non-speci c nature of ICG- sintomatology were fever (88%), followed by abdominal plasma protein binding & hepatic excretion of ICG leads to ’ pain (70,7%), nausea (59,8%), anorexia (56,5%) and observance of false-positive lesions. It s one of the few

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fluorescence imaging techniques for cancer that has present study was to define incidence and identify factors reached clinical application. With continuous studies, dy- associated with readmission after a hepatic resection. namic innovations & finding solutions for its limitations, Methods: 45-day readmission after discharge and factors FGS might become a standard of practice in the future for associated with a higher risk of readmission were examined hepatobiliary surgery. among patients undergoing a hepatic resection at Charles Nicolle University Hospital in Rouen between 2008 and 2014. EP01E-044 Results: Among the 430 patients, the median age was 59 A NEW MODIFIED TECHNIQUE IN years. Indications for surgery included liver metastasis (n=151 ; 35.1%), hepatocellular carcinoma (n=146 ; HERNIA REPAIR IN PATIENTS WITH 33.9%), and benign disease DECOMPENSATED CIRRHOSIS AND (n=97; 22.5%). Surgical resection consisted of less than a COMPLICATED HERNIA: SINGLE hemi-hepatectomy in the majority of patients (n = 327, CENTER EXPERIENCE 74%). The median index hospitalization length-of-stay (LOS) was 6 days. Overall and major complication rates T. Yassein were 40% and 10% respectively. Mortality rate was 3.5%. Surgery, Menoufia University, National Liver Institute, Overall 45-day readmission was 14.5% (n = 60), with a Egypt mean time of 20 days. On multivariable analysis, the Patients with decompensated cirrhosis have a high inci- strongest independent predictors of readmission were age dence of abdominal wall hernias To evaluate the outcome (OR = 0,952 IC à 95% (0.930-0.975) p< 0.0001), sero- of a new technique in the repair of complicated hernias in positivity for hepatitis C virus (OR = 6.948 IC à 95% decompensated cirrhotic patients. Thirty decompensated (2.196 - 21.981) p=0.001), and ascites (OR = 6.056 IC à cirrhotic patients underwent herniorraphy for complicated 95%(1.404 - 26.126) p=0.016). hernia. Patients were in G I (New technique:15): and II Conclusion: Readmission occurs in approximately one out (non-anatomical repair, 15). Patients were followed for one of every seven patients after a hepatic resection. With year. Comparable between G I and II regarding age regard to our results the only way to optimize the post (48.27 9.51vs. 44.33 9.98, P=0.279), sex [12 males operative outcomes and limit readmission is a better se- (80%) vs. 12males (80%), P=1], grade of ascites [moderate: lection of surgical indication. 3 (20%) vs. 11 (73.3%) and marked: 12 (80%) vs. 4 (26.6%), P=0.003]. Wound dehiscence and leakage (ascitic fluid) were significantly lower in group I [0% vs. 5 (33.3%), P=< 0.005 and 0% vs. 8 (53.3%), P=0.003, respectively]. EP01E-046 In concern to morbidity there is significant difference be- HUMAN UMBILICAL CORD tween GI and II (negative in GI 11(73.3%) vs. 5(33.3%) in MONONUCLEAR CELLS COULD GII (P=0.028). The grade of ascites was reduced in GI vs. II AMELIORATE SCHISTOSOMAL [marked: 0% vs. 7 (46.7%), P=0.003]. Postoperative HEPATIC FIBROSIS. AN hematemesis was lower in GI {negative in 15(100%) in G I EXPERIMENTAL STUDY vs. 7(46.7%) in GII and P=0.003)}, and hospital stay was 1 2 1 shorter in GI vs. II (6.54.0 vs. 12.83.0, P< 0.0001). D. Abou Rayia , S. Elkowrany , H. Hussein , 2 1 2 3 Hernia recurrence was lower in GI at 6 and 12 months [no K. Elnouby , D. Ashour , A. Ezzat , E. Arafa and 4 recurrence in GI 13 (86.67%) vs. G II 5 (35.7%), P=0.014. M. Amer 1 2 3 and no recurrence in GI, 11 (73.33%) vs. G II 4 (28.57%), Medical Parasitoloy, Medical Parasitoloy, Clinical 4 P=0.011 respectively]. Pathology, and Gastrointestinal Surgery, Mansoura The new technique of hernia repair was associated with a University, Egypt significant reduction in wound leakage, dehiscence, hos- Hepatic fibrosis is considered a worldwide public pital stay, morbidity and recurrence. health problem. Liver transplantation is the treatment of choice. Rejection, post-operative complications and un- availability of donors are major obstacles. Recent treat- EP01E-045 ment modalities include cell therapy but more researches COULD WE REALLY LIMIT are still needed. Human umbilical cord blood is a rich source for mononuclear cells which recently have shown READMISSION RATE AFTER PLANED promising anti-fibrotic results. The present study aimed to LIVER RESECTION? ABOUT A FRENCH evaluate the potential effect of human umbilical cord MONOCENTRIC COHORT OF 430 blood mononuclear cells infusion on an experimental PATIENTS model of hepatic fibrosis caused by Schistosoma mansoni. Assessment of liver fibrosis was done by haematoxylin, J. Cahais1, T. Codjia1, E. Roussel1, M. Scotte2, eosin and Masson’s trichrome staining. Homing to injured J. J. Tuech1 and L. Schwarz1 liver was assessed by staining of human specificnuclear 1Digestive Surgery, Rouen University Hospital, and antigen. Liver functions, collagen and hepatic stellate 2Rouen University Hospital, France cells staining were done. Our results revealed marked Introduction: Readmission after discharge from the hos- improvement of liver fibrosis raising the possibility for pital is an undesirable outcome and can occur in 10 to 18% the mononuclear cells clinical use in patients with hepatic of cases after liver resection surgery. The purpose of the fibrosis.

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EP01E-047 PRIMARY PERITONEAL HEPATOID CARCINOMA e A CASE REPORT E. Akaishi1, F. Costa1, M. Arakaki1, I. Galindo1, E. Silva1, H. Lima1, N. Mizumoto1 and E. Utiyama2 1Hospital Sírio Libanês, and 2Hospital das Clinicas of University of Sao Paulo School of Medicine, Brazil Introduction: Hepatoid carcinoma (HC) is a rare and aggressive tumor, defined as a primary extrahepatic tumor with morphology similar to hepatocellular carcinoma (HCC). The diagnosis is usually difficult only by the clin- ical basis and histological examination, but the association with immunohistochemistry may facilitate the diagnosis. Methods: We present an unusual case of primary perito- Figure [PDV.jpg] neal hepatoid carcinoma (PPHC). He is 61 years-old patient Post-operative course was uneventful and the patient was with multiple mesenteric and peritoneal tumor nodules. He discharged in POD 5. Serum ammonia and liver test were received neoadjuvant treatment with 9 cycles of GEMOX normal at 1-month follow-up. After 2 months, echocardi- and sorafenib with partial respose and 90% reduction in ography confirmed the absence of pulmonary hypertension alpha-fetoprotein level (AFP) followed by optimal cytore- on exertion. At 6-months follow up, abdominal complaints ductive surgery (CRS) and intraperitoneal chemotherapy recurred. (HIPEC) with cisplatin. During the 5 month follow-up, The diagnosis and management of PDV in adult pa- there was an increasing in AFP and the investigation tient remains controversial. In our experience surgical showed small peritoneal nodules on the CT Scan. He management is safe and effective in larger PVD after resumed 5 cycles of same regimen with tumor stabilization multidisciplinary hemodynamic evaluation. Mini-inva- followed by second CRS and HIPEC with mitomycin C. He sive approach is feasible in case of extra-parenchymal has been followed up, with a 14-month and until now, there PDV. is no evidence of recurrence disease. Conclusion: CRS and HIPEC showed be feasible and safe in the treatment of PPHC. EP01E-049 MANAGEMENT OF SYMPTOMATIC EP01E-048 SIMPLE HEPATIC CYSTS AND LAPAROSCOPIC LIGATION OF A POLYCYSTIC DISEASE IN 25 PATIENTS PATENT DUCTUS VENOSUS (ARANTII A. J. López Marcano, J. M. Ramia Ángel, DUCTUS) IN AN ADULT PATIENT A. Manuel Vázquez, T. Carrascosa Miron, B. González Sierra, V. Arteaga Peralta, M. Valente1, S. Cecchini1, V. Serra2, A. Placci2, R. De la Plaza Llamas, A. Medina Velasco, M. T. Mita1, G. Dalmonte1, V. Violi1 and F. Marchesi1 C. García Amador and R. Latorre Fragua 1Dipartimento di Scienze Chirurgiche, and 2Cardiologia, General and Digestive Surgery, Hospital Universitario de Parma University Hospital, Italy Guadalajara, Spain The ductus venosus is an embryological portosystemic Simple liver cysts are produced by congenital alterations shunt that connects umbilical vein and inferior vena cava. of the bile ducts development, present in up to 5% of the During fetal life, oxygenated blood bypasses liver circula- population, can be unique (SC) (Gigot I) or multiple tory system through this duct which closes after birth with diffusely distributed in the hepatic parenchyma (PCD) postpartum hemodynamic changes. Persistent patency can Gigot II/III. Rarely causing symptoms, not requiring be a congenital or acquired condition. treatment. There is no consensus for best approach to We present a case of a 34 year-old male who came symptomatic cysts. complaining abdominal pain and exertional dyspnea. Objective: Share the experience of HPB Units managing Abdominal CT-scan and MRI documented the presence SC and PCD. of a portosystemic shunt from a patent ductus venosus Material and methods: Retrospective descriptive study. (PDV), associated with stenosis of the celiac tripod. Trans- Period: 1/7/10 - 1/7/2017, All symptomatic LC or PCD esophageal contrast ultrasound excluded intracardiac shunt. patients were analysed. The portal phase during arteriography revealed a high-flow Results: 25 patients, 19 women - 6 men, mean age portacaval shunt consistent with a large Arantius’ duct. 67,3y15,7y (37-87y, median 73y), 14 QC and 11 PCD. An hemodynamic percutaneous approach was excluded Most frequent symptom: abdominal pain. Mean size of the by multidisciplinary assessment due to the large size of the major cyst 13.48cm10.8 (3-60cm, median 12.2cm). 6 duct (23 mm), hence a laparoscopic surgical approach was patients treated with laparoscopic approach (mean stay 2.3 performed. Intraoperative hemodynamic variations of pul- days): fenestration(5), left lateral segmentectomy(1). Lap- monary and hepatic blood flow were ruled out by clamping arotomy approach(19) (7 infection/rupture) (average stay test of the duct through invasive monitoring, thus the PDV 7.7 days): fenestration(11), left lateral segmentectomy(1), was divided with a linear vascular stapler.

HPB 2018, 20 (S2), S333eS504 S490 Electronic Posters (EP01A-EP01E) - Liver fenestration and segmentectomy(2). 4 patients treated for EP01E-051 puncture and sclerosis (average stay 5.7 days), 1 patient managed conservatively. Morbidity: 2 patients operated via POINT-OF-CARE HEMOGLOBIN laparotomy, Clavien I (2) and Clavien II (2). Only one TESTING AND LIVER SURGERY punctured patient with pain in the puncture site. Follow-up: J. Rekman1, A. Workneh1, P. Rao2, F. Balaa1, K. Bertens1, complete resolutions on surgically treated patients, sclero- J. Abou Khalil1, G. Martel1 and The Ottawa Hospital HPB therapy: 2 partial remissions and 2 complete resolutions. Surgery Group Conclusions: In symptomatic patients, percutaneous scle- 1General Surgery, and 2Anesthesia, University of Ottawa, rosis has a minimal morbidity and mortality, but high Canada relapse. Fenestration has low relapse and minimal Introduction: Point-of-care testing (POCT) is used to morbidity. Surgical treatment usually by laparoscopy is the rapidly assess intra-operative haemoglobin (Hb) levels. best approach, offering shorter stay and fewer complica- Standard accepted differences between POCT Hb and gold- tions, although safer in urgent circumstances, on non- standard lab testing are 10 g/L. This study looked at the urgent patients it increases average stay and morbidity. accuracy of POCT Hb values in reflecting serum values and informing transfusion decisions in liver resections. Methods: Using a database of liver resection patients at EP01E-050 The Ottawa Hospital (2010-2017), intra-op POCT Hb THE ASSESSMENT OF FUNCTIONAL values within 2 hours of operative end-time were gathered REMNANT LIVER RATE FOR THE and compared to closest-in-time (within 8 hours) post- operative serum values. Blood transfusion, trigger Hb value HEPATECTOMY BASED ON THE used to determine transfusion, and IV fluid volume were FUSION IMAGE OF 3DCT AND 99MTC- collected. GSA SPECT Results: 205 patients had POCT (HemoCueÒ 12.7%, M. Sakaguchi, N. Kuriyama, Y. Iizawa, Y. Murata, iStatÒ 78.5%, both 8.8%). Average age was 62y Y. Azumi, M. Kishiwada, S. Mizuno, M. Usui, (49.3,74.7), 88.3% had malignant disease, 68.3% had H. Sakurai and S. Isaji major liver resections, and mean blood loss was 1012cc Department of Hepatobiliary Pancreatic and Transplant (255;1769cc). Median time-interval between POCT Hb and Surgery, Mie University School of Medicine, Japan next serum Hb value was 110 minutes (80,171). The dif- Introduction: Preoperative assessment of future remnant ference between POCT and serum Hb values of 91 patients < liver (FRL) function is critical for major hepatectomy to (44.2%) fell outside of the accepted difference (r: 0.63, p avoid postoperative liver failure (PLF).Indocyanine green 0.00001). 43 patients had 1+ transfusions based on POCT clearance of the FRL (Krem), which is calculated as the with mean trigger Hb values of 87.4g/L (62.9;112). Of ratio of FRL volume to total liver volume by CT, is reliable those, 24 (55.8%) had Hb trigger values outside of the index for estimating PLF and its threshold is 0.05. How- acceptable lab testing difference. ever, Krem assumes homogenous uptake throughout the Conclusions: Allowing for a short time discrepancy, this liver.For damaged livers with functional heterogeneity, study indicates poor correlation between intra-op POCT fusion images combining 99mTc-GSA SPECT and 3D-CT and serum Hb values during liver resection. Doubt is are helpful to estimate the functional reserve of the FRL. therefore introduced into whether POCT should be used as Our aim was to determine the utility of functional Krem (F- a sole measure determining need for transfusion. Krem) by comparing volumetric Krem (V-Krem). Methods: Between July 2015 to December 2017, 45 patients received preoperative dynamic CT and 99mTc- EP01E-052 GSA SPECT and underwent major hepatectomy. We MANAGEMENT OF CYSTOBILIARY constructed fusion image of 3D-CT and 99mTc-GSA COMMUNICATION IN HEPATIC SPECT. V-Krem by CT volumetry and F-Krem by fusion HYDATIDOSIS image were compared in each patient to estimate which is 1 2 more reliable. C. A. Maravadi Jayaraman , A. Anbalagan , 3 2 Results: In 88.9% of the patients, F-Krem was bigger than G. R. Senthilkumaran , S. Rajendran and 2 V-Krem (Figure). The ratio of F-Krem/V-Krem (F/V) was O. L. Naganath Babu 1 1.1160.12 (meanSD). In the patients with portal vein Institute of Surgical Gastroenterology, Madras Medical 2 occlusion (PVO) or large tumor (LT) of 500ml or more, F/ College, Institute of Surgical Gastroenterology, and 3 V ratio was significantly bigger than that of the other pa- Rajiv Gandhi Government General Hospital and Madras tients: 1.1810.082 (n=8, PVO)vs.1.0970.118 (n=37, Medical College, India non-PVO), 1.3060.174 (n=4,LT)vs.1.110.097 (n=41, Aim: Communication to the bile duct is the most common non-LT), (p=0.01, respectively). There were significantly complication of hepatic echinococcosis.As non surgical correlation between F-Krem and postoperative-parameters treatment options have no primary role in the management (T-Bil and platelets counts in POD1,3,7). In 5 patients with of hepatic hydatidosis with cysto biliary communication, V-Krem less than 0.05,a patient had F-Krem more than optimization of the surgical approach is imperative. 0.05, resulting in good post-operative course. Materials and methods: Medical records of 22 patients Conclusion: In almost patients who need major hepatec- who underwent surgical management of Hydatid cyst of tomy, F-Krem is bigger than V-Krem, because liver func- liver with cystobiliarycommunication analysed retro- tion of the diseased side is impaired compared with residual spectively.Study Period - between January 2013 and side. F-Krem is a more reliable index than V-Krem. October 2016.All patients were followed up for a period of

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S491 atleast 2 months to 36 months. Readmission and re- Conclusion: 99mTc-mebrofenin hepatobiliary scintig- currences were evaluated raphy may be a helpful tool to improve the estimation and Results: Cystobiliary communication could be identified accuracy of PHLF prediction, but the impact still remains pre operatively in 9 out of the 22 patients whereas in the rest unclear. Therefore further investigations are necessary. it was made intraoperatively.Cyst evacuation with omen- toplasty and partial pericystectomy were considered as conservative surgeries whereas total cystopericystectomy EP01E-054 and right or left hemi hepatectomies were considered as LIVER TRAUMA e SURGICAL radical procedures. 2 patients who were offered conserva- tive surgical treatment underwent post op ERCP.CBD INTERVENTION STILL NECESSARY? A exploration and T tube placement was necessitated in 7 SINGLE CENTRE OBSERVATIONAL patients. STUDY Conclusion: Treatment options are multiple. While con- N. Venkateshwara Mahadevan, A. Amudhan, fi servative approaches carried a small but signi cantly high S. Rajendran and O. L. Naganath Babu incidence of recurrence, radical surgery has its own dis- Institute of Surgical Gastroenterology, Rajiv Gandhi advantages in terms of prolonged operating time, higher Government General Hospital and Madras Medical Col- blood loss and in its need for a HPB surgeon. The need for lege, India CBD exploration and T tube drainage was comparable in Aim: This study aims to analyse the outcomes of liver both approaches. Larger studies are needed to formulate a trauma in relation to severity of injury and mode of protocol. management. Material and methods: Liver trauma patients between August 2016 to November 2017 were prospectively EP01E-053 analyzed. All trauma victims sustaining blunt trauma to the HEPATOBILIARY SCINTIGRAPHY TO liver with or without associated injuries were included. EVALUATE LIVER FUNCTION AND Isolated injury to visceral structures without liver trauma SHORT-TERM OUTCOME FOR were excluded. Patients underwent serial monitoring of vitals, haema- PATIENTS UNDERGOING MAJOR tocrit, liver function. Severity of liver trauma was done LIVER RESECTION through CECT based AAST grading system. K. Joechle1,2, A. Jud2, M. Menzel2, H. P. Neeff2, J. Ruf3, Results: Of 46 patients, 3 patients were hemodynami- F. Schiller3, P. T. Meyer3, J. Neubauer4, cally unstable and 43 were hemodynamically stable. S. Fichtner-Feigl2 and S. A. Lang2 Majority of patients had Grade 2 and 3 liver injury 1Surgical Oncology, MD Anderson Cancer Center, United (71.6%). Patients were grouped into 3 categories - non States, 2General and Visceral Surgery, 3Nuclear Medicine, operative management, failed non operative management and 4Radiology, University Medical Center Freiburg, and immediate surgery. Non operative management was Germany initiated in 41 patients and 5 were taken for laparotomy. Introduction: While post hepatectomy liver failure Four patients out of 41 patients underwent delayed lap- (PHLF) was shown to be accurately predicted by liver arotomy. Among the failed NOM group, 2 patients had volumetry based on computed tomography (CT), the role of Grade 5 injury, one patient had Grade 4 injury with sepsis 99mTc-mebrofenin hepatobiliary scintigraphy is not well and one patient had Grade 3 injury with associated assessed. splenic injury. Methods: Patients who underwent hepatectomy of 4 Conclusion: Irrespective of the grade of liver injury, non Couinaud’s segments at the University Medical Center operative management is advocated in hemodynamically Freiburg in 2017 were analyzed. 99mTc-mebrofenin stable patients. The cornerstone of successful non operative hepatobiliary scintigraphy and liver volumetry based on management of patient is continuous surveillance. In CT of the future liver remnant (FLR) were performed operative management, perihepatic packing is the most preoperatively. A FLR < 20% for healthy livers and < common salvage procedure done. 30% for previously injured livers was determined insuffi- cient to maintain an adequate liver function. The impact of estimated liver function vs CT volumetry on short-term EP01E-055 outcome was analyzed. PHLF was defined acording A CHALLENGING DIAGNOSTIC FOR > “ ” to PeakBil 7 mg/dl, the 50:50 criteria and ISGLS GIST LIVER: A REPORT OF ONE CASE fi classi cation. IN CIPTO MANGUNKUSUMO HOSPITAL Results: The study included 20 patients. One patient un- derwent ALLPS procedure due to an insufficient FLR and R. A. Syaiful, Y. Mazni, T. J. M. Lalisang, A. Satria and liver function. However, critical liver function (< 2.7 I. Situmorang %/min/m2) was observed in 15 patients (75%). 5 patients Departement of Surgery, Universitas Indonesia, Indonesia (25%) developed ISGLS-defined PHLF (2 patients grade Introduction: Gastrointestinal stromal tumors (GISTs) A, 3 patients grade B), including 4 patients (20%) with account less than 1% of gastrointestinal (GI) tract tumors, PeakBil >7 mg/dl. Of these, 3 patients showed critical however they are the most common mesenchymal preoperative liver function but only one had an insufficient neoplasm. GIST on the liver was a rarity. We present one FLR. Postoperative complications according to Dindo- case of a patient with a huge mass on the liver, suspected as Clavien IIIb occurred in 3 patients (15%), 30-day mor- a primary liver tumors but on further investigation was tality was 0%. diagnosed as GIST liver.

HPB 2018, 20 (S2), S333eS504 S492 Electronic Posters (EP01A-EP01E) - Liver

Methods: A descriptive of one case. Subject was diagnosed as liver tumor and was discussed multidisciplinary meeting in our hospital. Results: A 56-year-old woman presented with buldging in right upper quadrant of the abdomen. Abdominal ultra- sound showed liver mass. We suspected as primary liver tumor, although she has no history of hepatitis nor alco- holism. She underwent multiphase CT Scan abdomen which resulted as cyctic-appearing lesions, hemorrhagic lesion, enhance on arterial phase, with central necrosis. Based on this we diagnosed as GIST liver and performed core liver biopsy. Histopathology confirmed it as GIST. Conclusions: Multiphase CT Scan can accurately diagnose GISTs on liver, however definite diagnosis must be done by histopathologic examination. Figure [RPM image]

EP01E-056 EP01E-057 RESECTION PROCESS MAP: NOVEL OPERATIVE MANAGEMENT OF NON- SOFTWARE TO VISUALIZE PARASITIC LIVER CYSTS e A SINGLE INTRAOPERATIVE LIVER CENTRE EXPERIENCE DEFORMATION K. Mohan1, S. Devakumar2, R. Shanmugasundaram2 and 2 1 1 2 1 O. L. Naganath Babu Y. Uchida , K. Taura , M. Nakao and S. Uemoto 1 2 1Division of Hepatobiliary Pancreatic Surgery and Institute of Surgical Gastroenterology, and Rajiv Gandhi Transplantation, Department of Surgery, Kyoto Univer- Government General Hospital and Madras Medical Col- sity, Graduate School of Medicine, and 2Graduate School lege, India of Informatics, Kyoto University, Japan Introduction: Non-parasitic liver cysts include Simple Introduction: Detailed preoperative planning is essential cysts, Multiple cysts in the setting of Polycystic disease and for safe and appropriate hepatectomy because there are a lot Cystic neoplasms. They are usually found as an incidental fi of variations in intrahepatic anatomy. nding on imaging. Not more than 10-15% cause symp- Improvement of imaging software has greatly contrib- toms. Surgical management offers symptomatic relief with uted for preoperative liver evaluation. However, it has not minimal morbidity. yet accomplished to visualize intraoperative liver defor- Methods: Retrospective analysis was made of patients with mation preoperatively. Deviation of vessels and tumors by non-parasitic liver cysts who were managed surgically in liver deformation may cause surgeons to misunderstand the Institute of Surgical Gastroenterology, Madras Medical intraoperative anatomy, therefore, it is important to acquire College over a period of 3 years. Patient demographics, preoperative imaging which can visualize dynamic intra- symptoms, cyst characteristics, operative procedure, operative liver deformation. We have developed novel morbidity, mortality, length of hospital stay and histo- simulation software: “Resection Process Map” which can pathological diagnosis were analysed. dynamically visualize intraoperative deformation of liver Results: Between 2014 and 2017, 14 patients underwent according to planned hepatectomy. The aim of this study is surgery for symptomatic non-parasitic liver cysts. Majority to evaluate the feasibility of this novel software. were female. Mean age was 49 years. Abdominal discom- Methods: We prospectively applied Resection Process fort was the predominant symptom. One patient had Map to 24 patients who had undergone hepatectomy at recurrent cyst. Preoperative diagnosis was simple cyst, Kyoto University Hospital from October 2016 to January multiple cysts and biliary cystadenoma in 8,4 and 2 patients 2018. Questionnaires from attending surgeons were respectively. The mean cyst diameter was 12.56 cm. evaluated. Laparoscopic fenestration, open fenestration/partial exci- Results: Questionnaires were obtained from 41 attending sion and open resection were performed in 9,3 and 2 pa- surgeons. Sixty-one-percent of participants replied that tients respectively. The recurrent cyst was diagnosed as Resection Process Map had achieved good similarity. choledochal cyst on histopathological analysis. Mean Seventy-nine percent of participants replied that Resection length of hospital stay was 6.71 days. Morbidity developed Process Map had been useful for operations. Eighty-seven in two patients in the form of bile leak which was managed percent of participants affirmed educational effect of conservatively. There was no mortality. Resection Process Map. Conclusion: Laparoscopic fenestration is an effective Conclusions: Resection Process Map has good feasibility treatment for symptomatic non-parasitic, non-neoplastic to visualize dynamic intraoperative liver deformation and liver cysts. Open fenestration should be considered for fi potentially contributes to safe hepatectomy and surgical recurrent cysts and those with dif cult laparoscopic access. education. Resection is preferred for neoplastic liver cysts.

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EP01E-058 Hepaticojejunostomy with Jejunoduodenostomy as access loop to the first part of duodenum (4 cases). Cholecystec- MANAGEMENT OF PYOGENIC LIVER tomy was done in all patients without prior ABSCESSES IN SINGLE HOSPITAL cholecystectomy. OVER 5 YEAR PERIOD Conclusion: Hepatolithiasis is rare in South India. Surgical L. Lukjanova, A. Ozolins, J. Vilmanis, R. Stucka, management depends on liver parenchymal status, chol- M. Tirane, P. Prieditis and J. Gardovskis angitis, diameter of CBD, biliary stricture and distribution Surgery, PSKUS, Latvia of stones. The access to the biliary system was made either by choledocoduodenostomy or access loop to the first part Introduction: Pyogenic liver abscesses are uncommon but of duodenum. still challenging diagnosis, which demands multidisci- plinary approach. They develop following intraabdominal infection with subsequent spread to liver via portal circu- EP01E-060 lation or via direct spread from biliary tract infection. Also CLINICO-RADIOLOGICAL hematogenous spread is possible. Modern management of INDICATIONS FOR DRAINAGE OF pyogenic liver abscess prefer antibacterial and minimally ISOLATED AMEBIC LIVER ABSCESS invasive procedures over surgical treatment.The aim of this USING A RULE OF 5’S: RESULTS OF A study is to review our experience in pyogenic liver abscess 10 YEAR RETROSPECTIVE REVIEW management, compare it with literature data and to develop local guidelines. A. Adeyeye1, M. Bojuwoye2, O. Oyinloye3, Method: in 5 year period 41 patient presented in a single K. Okonkwo2 and S. Udoh4 1 2 3 4 teaching hospital with pyogenic liver abscess. Clinical Surgery, Internal Medicine, Radiology, and University presentation, demographic, diagnostic, treatment and of Ilorin Teaching Hospital, Nigeria aethiological details were reviewed. Introduction: Liver abscesses from amebiasis are primar- Results: Mean age was 63 years. Male to female ratio- ily managed using medical therapy. Although guidelines 51%: 49%. Common clinical features: abdominal pain exist for drainage of hepatic abscess, these indications are 41%, weakness and fatigue 36%, fever 36%. All patients usually individualized. A simplified approach to determine received antibacterial therapy and percutaneous drainage as the need for surgical intervention may be desirable. first treatment in 88% of cases. Antibacterial therapy alone Methods: A 10 year retrospective study was carried out at was sufficient in 5 cases where abscesses were under 5 cm the University of Ilorin Teaching Hospital, Nigeria between in diameter. In one case open surgical approach was needed October 2007 and September 2017. A structured pro forma due to failure of percutaneous drainage. One patient died was used to study patients with suspected amebic liver right after percutaneous drainage due to multiorgan failure. abscess. Patient demographics, clinical and laboratory Median abscess diameter was 6,8 cm, localized in right features as well as radiological findings were noted. The liver lobe in 73%. In 61% solitary abscess was found. Most types of treatment and outcomes of management were also common causative microorganisms were Escherichia coli determined. The SPSS v20 software was used. Appropriate and Klebsiella pneumoniae. statistical analysis including chi square, Fischer’s exact, Conclusions: Modern management of liver abscesses Independent T test and Mann U Whitney test were utilized. include treatment in tertiary medical center, antibacterial A p- value of < 0.05 was considered significant. therapy and percutaneous drainage. Surgical approach is Results: A total of 89 patients were treated for amebic liver still an option in selected cases, when percutaneous abscess during this period. Thirteen (13) patients required drainage fails. drainage. Variables associated with drainage included the following: Symptom duration >5 weeks, Abscess cavity >5cm, estimated fluid volume >500mls on imaging, ab- EP01E-059 scess cavity wall thickness >5mm, liver segment involved MANAGEMENT OF HEPATOLITHIASIS < segment 5(i.e. segments 1-4 or the left hemi-liver) and IN A TERTIARY CARE CENTRE IN parenteral antibiotic therapy lasting more than 5 days. Open SOUTH-INDIA drainage via a mini-laparotomy was the preferred method of intervention for technical reasons. P. Gopal, L. Joseph, R. Shanmugasundaram and Conclusion: A simplified rule of 5’s may be used to O. L. Naganath Babu determine the need for drainage of liver abscesses. These Madras Medical College, India findings need to be validated by appropriately powered Aim: This study is to analyse the clinicopathologic fea- prospective studies. tures, diagnosis and treatment for hepatolithiasis in a ter- tiary centre. Methods: This is a retrospective study of prospectively maintained database between June 2012 to October 2017. EP01E-061 The demography, clinical presentation, surgical manage- FABIB: A PROPOSED NEW SEVERITY ment were analyzed. GRADING SYSTEM FOR LIVER Results: The age range was between 24 to 70 years. The SURGERY-SPECIFIC COMPLICATIONS study includes 20 patients (M - 4, F - 16). Hepatectomy was J. Li1, M. Moustafa1, E. Freiwald2, L. Motazedi1, done in 12 patients. Left lateral segmentectomy (8), left L. Fischer1 and B. Nashan1 hepatectomy(1), Segmental resections done in 3 patients. 1Department of Hepatobiliary Surgery and Trans- All these patient had access to the bile duct through plantation, and 2Department of Medical Biometry and Choledochoduodenostomy in 16 patients and

HPB 2018, 20 (S2), S333eS504 S494 Electronic Posters (EP01A-EP01E) - Liver

Epidemiology, University Medical Center Hamburg- Results: Ten patients (15%) did not undergo planned sur- Eppendorf, Germany gery after receiving TIPS procedure. Preoperative TIPS Introduction: Additional to the definitions of Liver sur- placement was associated with less postoperative ascites gery-specific postoperative complications introduced by (HR=0.33, 95 per cent i.c. 0.14 to 0.78) but this did not ISGLS, the authors added two other parameters to compose translate into better postoperative outcomes. Patients with a novel complication severity grading system with the hepatic venous pressure gradient (HVPG) 13 mmHg and acronym “FABIB” which includes liver Failure, Ascites, MELDNa 15 seemed to benefit from preoperative TIPS Bile leakage, Infection, Bleeding” (Table 1). The study was placement in terms of severe postoperative complications aimed to evaluate the reproducibility and the applicability (HR=0.21, 0.05 to 1.02 and HR=0.16, 0.03 to 1.05, of FABIB grading system in the clinical practice. respectively). TIPS patients in colorectal surgery and Method: Postoperative complications in 501 consecutive HVPG >13 mmHg subgroups required more intraoperative liver resections (LR) at authors’ center from July 2012 to red blood cells transfusions (HR=15.03, 1.71 to 132.17 and December 2016 have been assessed according to Clavien- HR=4.10 1.16 to 14.47, respectively). Dindo and to FABIB grading systems. The outcome has Conclusions: Although TIPS placement before elective been analyzed by using a generalized linear mixed model to surgery decreased postoperative ascites, this study failed to predict the length of hospital stay (LOS) and analyze demonstrate a benefit in terms of intra and postoperative variate risk factors. outcome. Results suggest nevertheless a decrease in severe Results: There were 177 major LR and 324 minor LR, postoperative complications in patients with mild hepat- including 36 laparoscopic LR and 34 ALPPS. A FABIB opathy (HVPG 13 mmHg and MELDNa 15) but further score from 0 to 11 have been documented in this cohort. evaluation is necessary. FABIB was found to have much higher predictive value over Clavien-Dindo classification for LOS (Figure 1, p< 0.05). Patients with biliary digestive anastomosis as well as EP01E-064 undergoing ALPPS procedure, had a significantly higher N TERMINAL-DDR1, A SERUM < fi FABIB scores (p 0.05). After ltering independent risk PROGNOSTIC MARKER FOR LIVER factors, minor LR has a mean FABIB score below 1, while extended right hepatectomy has a FABIB score over 3. FIBROSIS Conclusion: FABIB is a reproducible liver surgery specific Z. Zhang1, Y. Zhang2, Z. Zeng1, P. Fan1, W. Zhang1 and grading system and correlates more accurately to length of X. Chen1 hospital stay and complexity of surgical procedure 1Tongji Hospital, Tongji Medical College, and 2Hepatic compared to Clavien-Dindo. FABIB grading system pro- Surgery Center, Tongji Hospital, Tongji Medical College, vides solid parameters for quality control in form of Huazhong University of Science and Technology, China complication after liver surgery. Introduction: Discoidin domain receptor 1 (DDR1) is a receptor tyrosine kinase that binds and transmits sig- nals from various collagens in epithelial cells, which EP01E-063 including liver cells. However, how DDR1-dependent TRANSJUGULAR INTRAHEPATIC signaling is regulated has not been understood. It was PORTOSYSTEMIC SHUNT AS A BRIDGE report that collagen binding induces ectodomain shed- ding of DDR1. As we know, organ fibrosis is highly TO ELECTIVE ABDOMINAL SURGERY dependent on collagens aggregation in target organ. But, IN CIRRHOTIC PATIENTS: FRIEND OR no one reported the relationship between DDR1 shedding FOE? and liver fibrosis. N. Tabchouri1, L. Barbier2, B. Menahem3, Methods: Here, we valuated the N-Terminal DDR1 in cell J. -M. Perarnau1, F. Muscari4, J. Dumortier5, A. Alves3, culture suspension, which treated by collagen I. We also J. Lubrano3, C. Bureau4 and E. Salamé2 contributed DDR1 shedding in (Bible- Duct Ligation) BDL fi 1Digestive Surgery, Tours University Hospital, France, mouse model, CCL4 induced liver brosis mouse model, fi 2Tours University Hospital, France, 3Caen University HBV related liver brosis mouse model, and checked the Hospital, France, 4Toulouse University Hospital, France, serum N-terminal DDR1 by Elisa Assay. Furthermore, and 5Lyon University, France clinical blood specimens from patients with different stage of liver fibrosis were measured by DDR1-N terminal anti- Background: While abdominal surgery is associated with body using Elisa Assay. higher morbidity and mortality in cirrhotic patients, preop- Results: We found that shedding is not a result of DDR1 erative TIPS has been suggested as a means to reduce portal signaling, but it results from collagen binding to the ecto- hypertension and postoperative complications. This study domain of DDR1. More collagen added in culture cell, aims to compare cirrhotic patients with preoperative trans- more N-terminal DDR1 could be detected in suspension. jugular intrahepatic portosystemic shunt (TIPS) placement The worse fibrosis of liver in all three mouse models, the and cirrhotic patients without TIPS, in terms of morbidity more DDR1 shedding was diagnosed. Furthermore, the and mortality after elective extra hepatic abdominal surgery. worse fibrosis of patients, the more N- teminal DDR1 was Study design: Patients were retrospectively included from checked out in their serum. 2005 to 2016 in four tertiary referral hospitals. Patients who Conclusion: In this report, we identified DDR1 shedding underwent preoperative TIPS (n=66) were compared to could secret N-teminal DDR1 in serum, which is induced control patients without TIPS (n=68). Postoperative by collagen binding. N- teminal DDR1 was supposed to be outcome was analyzed using inverse probability of treat- a diagnostic hall marker of liver fibrosis. ment weighting.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S495 fi ’ EP01E-065 Results: The vacuum mattress perfectly ts to the patient s body in the supine position and open legs. By means of a DOES TRANJUGULAR INTRAHEPATIC valve, the air inside the mattress is suctioned, producing a PORTOSYSTEMIC SHUNT IN vacuum and the patient can be immobilized quickly and REFRACTORY ASCITES AND securely. It’s shown how, even the most extreme tilting of VARICEAL RE-BLEEDING GUARANTEE the surgery table, does not change the defined position of SAME SUCCESSFUL RESULTS? the patient allowing better visualization during right hepatic lobe mobilization and retrohepatic cava vein and right he- C. C. Zingaretti1, L. Bortolasi1, G. Puppini2, P. Violi1, 1 2 1 1 patic vein dissection. A. Carraro , G. Puntel , U. Montin and U. Tedeschi Conclusions: The vacuum mattress is useful for the fixa- 1General Surgery and Liver Transplantation, AOUI 2 tion of the patient to the table during laparoscopic liver Verona, and Radiology, AOUI Verona, Italy surgery, allowing extreme positions and minimizing the Introduction: Tranjugular intrahepatic portosystemic risk of landslides and injuries. shunt (TIPS) has became increasingly relevant in control- ling recurrent variceal bleeding and intractable ascites in EP01E-067 patients with portal hypertension due to advanced liver PRECONDITIONING BY SEVOFLURANE cirrhosis. Complications and success rate seem to be related to the pre-procedure conditions of the patients. The endo- METABOLITE HEXAFLUORO-2- points of this study are to value outcome of patients with PROPANOL DECREASES LIVER variceal bleeding and ascites. ISCHEMIA REPERFUSION INJURY: Methods: Between 2013 and 2017, 41 patients with mean PRELIMINARY RESULTS age 58.6 10.9 years, underwent TIPS. Indications were J. A. Rocha-Filho1, E. R. R. Figueira2, A. V. Moscoso3, variceal bleeding in 20 patients, ascites in 19 patients, both in C. Lanchotte4, B. Beck-Schimmer5, M. Urner6, 1 and post-LT (liver transplantation) in 1 patient; in 3 pa- D. M. Ferreira3, M. J. C. Carmona1 and tients the procedures were subsequent to LT and in other 10 L. A. C. D. Albuquerque4 patients were carried out as bridge to LT. Clinical status was 1Surgery/ Division of Anesthesiology, 2Gastroenterology/ assessed according to the model of end-stage liver disease Division of Digestive Surgery, 3Gastroenterology, (MELD), pre and post-TIPS gradient pressure were 4Gastroenterology, Division of Liver and Digestive Organ measured, as well as ammonemia level. Outcome was valued Transplantation, Hospital das Clinicas of University of assessing recurrence of bleeding or ascites and survival. Sao Paulo School of Medicine, Brazil, 5Anesthesiology, Results: Pre and post-TIPS comparison showed a statisti- University Hospital Zurich, Switzerland, and 6Interde- fi cally signi cant reduction in portal pressure gradient (18.4 partmental Division of Critical Care Medicine, Toronto vs 10.5 mmHg) with an increase in ammonemia level (49.4 General Hospital. University of Toronto, Canada vs 59.5 mmol/L) without clinical syptoms; however no Liver ischemia-reperfusion (IR) injury is still a signifi- differences were observed in MELD (13.8 vs 14.3). cant cause of complications after liver resection and Bleeding and ascites recurred in 4 out of 21 patients and in transplantation. Sevoflurane has been demonstrated to 14 out of 20 patients, respectively. Encephalopathy was decrease IR injury. present in 11 patients. Overall actuarial survival was 82%, Objective: To investigate if preconditioning with the 74% and 47% at 6, 12 and 24 months, respectively. sevoflurane metabolite hexafluoro-2-propanol (HFIP) de- Conclusion: TIPS seems to reduce more efficacy the risk of creases liver normothermic IR injury. bleeding than ascites without modifying liver function. Methods: Rats anaesthetised with ketamine+xylazine were EP01E-066 submitted to 30min of partial warm liver ischemia alone (Control group; n=8), or preconditioned with HFIP 67mg/ USE OF A VACUUM MATTRESS FOR kg through intravenous infusion, 10 min prior to ischemia PATIENT PLACEMENT IN (HFIP group; n=8). Immediately after reperfusion non- LAPAROSCOPIC LIVER SURGERY ischemic right and caudate lobes were resected, allowing J. Camps, E. Herrero, M. García Domingo, evaluation global IR liver injury. Blood samples were ac- L. Martinez de la Maza, J. Tur, M. Galofré and E. Cugat quired at 4h after reperfusion. fi Hospital Universitari Mutua Terrassa, Universitat de Results: HFIP group showed signi cantly decreased levels Barcelona, Spain of AST (2,336 809UI/L) and ALT (2,251 768UI/L) compared to Control group (4,8593,053UI/L and 4,484 Introduction: One of the limitations of laparoscopic liver 2,678UI/L, respectively). Ionized calcium and potassium surgery is obtaining an adequate patient positioning on the levels were significantly increased in HFIP (5.256 operating table to achieve a good operative field. The usual 0.7mg/dL and 6.8130.645mEq/L, respectively) compared fixings methods can cause slips and lesions to the patient. to Control group (4.7730.256 and 6.0860.422, respec- The aim of this poster is to present the use of a vacuum tively). Base excess, bicarbonate, lactate, chloride and mattress to provide a correct subjection of the patient glucose levels in HFIP group were not significantly in the operating table, which allows extreme positional different from Control. changes to be made with comfort and safety, thus Conclusions: In experimental warm liver IR injury, sevo- obtaining the adequate internal vision for liver mobili- flurane metabolite HFIP maybe related to the non-anaes- zation and transection. thetic effects of sevoflurane in promoting liver protec- Material and method: Demonstration of the use of a tion. This is suggested by the marked decrease in liver styrofoam microballs vacuum mattress (Vacuform 2.0, transaminases in the model of IR liver injury. Ionic B. u. W. Schmidt GmbH, Garbsen, Germany) for the pa- imbalance of serum potassium and calcium maybe related tient positioning during a laparoscopic right hepatectomy.

HPB 2018, 20 (S2), S333eS504 S496 Electronic Posters (EP01A-EP01E) - Liver to increased intracellular release with possible changes in associated with a mutation on the ABCB4 gene, resulting in cellular membrane potential. It is possible that HFIP co- lower levels of phospholipid content of bile and increased administration with sevoflurane anaesthesia can increase cholesterol saturation. It has a female predominance man- liver protection effects in clinical situations such us liver ifests before the age of 40 as a recurrent cholelithiasis after transplantation. Care must be taken to the patient potassium cholecystectomy. levels monitoring. Material and methods: We report a case of a 31-years-old woman, who underwent cholecystectomy six years ago, for EP01E-068 pancreatitis lithiasis, with multiple posterior episodes of IMPACT OF ENDOTHELIAL CELLS ON cholangitis. Endoscopic retrograde cholangiopancreatog- THE ENGINEERED LIVER raphy revealed obstruction of the lower third of main biliary duct, and magnetic resonance cholangiopancreatography RECELLULARIZED WITH PRIMARY showed a dilation of intrahepatic biliary tree, particularly in RAT HEPATOCYTES segments 6 and 7, suggesting intrahepatic lithiasis. LPAC H. Kojima, T. Ishii, K. Fukumitsu, Y. Oshima, was suspected and a genetic analysis was performed. H. Kawamoto, T. Minami, Y. Miyauchi, R. Yamaoka, Partial hepatectomy with resection of main biliary duct T. Kawai and S. Uemoto was performed with Roux-en-Y hepaticojejunostomy Department of Surgery, Graduate School of Medicine, reconstruction. Kyoto University, Japan Results and discussion: Gross examination revealed Introduction: Tissue decellularization produces a three- dilated intrahepatic biliary ducts with yellow friable stones. dimensional scaffold that can be potentially used to fabri- Microscopic evaluation showed non-cirrotic parenchyma, cate functional liver grafts following recellularization. intraductal lithiasis and ulceration of the epithelium, lym- However, no clinically relevant recellularized liver graft phocytic infiltrate and parietal fibrosis of the biliary duct. has yet been achieved due to inappropriate cell distribution Smaller ducts presented with concentric fibrosis, periportal and clotting during blood perfusion. Endothelial cells can ductular reaction and periportal copper deposits were found facilitate blood circulation and prevent thrombus forma- in large and ectatic portal tracts. Intrahepatic lithiasis asso- tion. Therefore, we evaluated the impact of endothelial cells ciated with LPAC was diagnosed, with genetic identifica- on the recellularized liver intending to produce practical tion of punctual mutation on ABCB4 gene. liver graft under blood perfusion. LPAC is a rare entity and should be suspected in young Methods: The Lewis male rat livers were used for gener- females with recurrent symptoms and complications asso- ating the whole-organ decellularized scaffolds. Liver si- ciated with cholelithiasis. nusoidal endothelial cells (LSECs) or human umbilical vein endothelial cells (HUVECs) were seeded into the liver EP01E-070 scaffold recellularized with primary rat hepatocytes. We NONOPERATIVE MANAGEMENT OF evaluated the liver function and thrombogenicity in the HEPATIC TRAUMA: THE EXCEPTION recellularized liver grafts. OR THE RULE? Results: We achieved appropriate cell distribution of parenchymal cells via Biliary Duct-seeding (BD-seeding) F. Sánchez-Bueno, A. Romera, R. Garcia-Perez, P. Gil, and endothelial cells via Portal Vein-seeding (PV-seeding). F. Alconchel and P. Parrilla ’ ’ Although both LSECs and HUVECs supported hepatocyte Hospital Clinico Universitario Virgen de la Arrixaca , viability owing to their antithrombogenicity, HUVECs Spain suppressed more thrombus formation than LSECs in the Introduction: According to the US National Trauma Data recellularized liver grafts. Whereas, LSECs were better at Bank, the liver is the most frequently injured abdominal maintaining hepatocyte function than HUVECs during organ that is most affected by penetrating chest and perfusion culture. abdominal traumas, and is the second most affected organ in Conclusions: The impact of endothelial cells on thrombus blunt traumas (78%) after the spleen (92.7%). At the present formation and hepatic function might depend on their cell time, non-surgical treatment (NST) is the elective treatment types. Although it is suggested that endothelialization could and only 15% of the hepatic trauma requires surgery. The improve the hemocompatibility and hepatocyte viability in aim is to present our experience in the diagnosis and ther- recellularized liver scaffolds, further studies are required to apeutic management of liver trauma, in a series of 189 pa- investigate the most adequate endothelial cell source for tients, recorded over a 17-year period (2001-2017). proper hepatic function of recellularized liver grafts under Methods: In order to predict the need for emergency blood perfusion. surgery in hepatic trauma, we use two parameters: the Injury Severity Score (severity >25 points) and arterial EP01E-069 hypotension at admission. Hepatic injury is graded (I through VI) depending upon the extent and depth of liver LOW PHOSPHOLIPID-ASSOCIATED fi e hematoma and/or laceration as identi ed on abdominal CHOLELITHIASIS AN UNCOMMON CT, or at the time of surgery. In our series 179 cases were CASE OF INTRAHEPATIC LITHIASIS closed while 10 were open. Mean age was 29.6 years and R. Almeida1, R. Caetano Oliveira1, R. Martins2, 75,1 % was male. In our series, 20,1% of the 189 cases M. R. Silva1, M. A. Cipriano1 and J. Guilherme Tralhão3 underwent surgical treatment while the remaining 79,9% 1Pathology Department, 2Surgery Department, and 3Sur- received NST. gery Department, Portugal Results: Our series, overall mortality was 3.1% (6/189 Objetives: Low phospholipid-associated cholelithiasis cases). Mortality for the NST patients was 0, 6 % while for (LPAC) is a rare syndrome, first described in 2001, the surgical treatment group was 13.1%.

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S497

Conclusions: Mortality has decreased with the introduction (CT-scans) over time and liver biopsies, we assessed the of non-operative management strategies and damage con- relationship between survival and liver steatosis as well as trol techniques. Mortality for low-grade (grades I, II, III) preoperative changes in muscle fat content and body injuries is rare, but for high-grade injuries ranges from 10 to composition in patients with colorectal liver metastases. 30%t (grades IV, V, VI). Methods: Patients with two preoperative CT-scans were selected from a cohort of 289 patients with colorectal liver EP01E-071 metastases undergoing partial hepatectomy. Scans were BILIOVASCULAR COMPLICATIONS OF analysed using a single CT-slice at the L3 level to assess MAJOR LIVER TRAUMA adipose tissue and skeletal muscle mass. Muscle fat content was assessed by calculating average Hounsfield units of Y. Sakaray, V. Gupta and T. D. Yadav muscle tissue (radiation attenuation). Liver biopsies were General Surgery, Post Graduate Institute of Medical Ed- histologically scored for steatosis using the SAF-score. ucation and Research, India Results: 137 patients had two available preoperative CT- Introduction: Biliovsascular complications are expected in scans with a mean interval of 3.2 months. In multivariate high grade liver injury. Present study is planned to evaluate cox-regression analysis, reduction in muscle radiation incidence, management, outcome of biliovascular compli- attenuation, reflecting fat accumulation, was associated cations arising as result of major hepatic trauma. with shorter disease-free survival (HR 1.98, 95%-CI:1.20- Methods: 56 patients with grade III or more liver injury 3.28;p< 0.01) and shorter overall survival (HR 1.79, 95%- were studied prospectively from July 2013-Dec 2014 at CI:1.12-2.86;p=0.01). Liver steatosis was also associated PGIMER; Chd. Patients surviving over 24 hours were with shorter overall survival (HR 1.77, 95%-CI:1.07- included. Biliary and vascular complications were evalu- 2.90;p=0.03). In contrast, high baseline total adipose tissue ated with CT/HIDA and CT angio respectively. In- mass was related to increased disease-free survival (HR terventions required to manage complications were 0.60, 95%-CI:0.45-0.80;p< 0.01) and overall survival (HR analyzed and patients were followed up to 6 weeks. 0.75, 95%-CI:0.58-0.98;p=0.03). Changes in skeletal Results: Grade3 (n=29), grade4 (n=17) and grade 5(n=10). muscle mass were not associated with survival. 17(30.35%) patients developed biliovascular complica- Conclusion: Ectopic fat in muscle and liver may be an tions. Biliary complications (n=5), intraabdominal collec- important marker of tumour progression since it was tions (n = 1), ascites (n = 2) ,biliary peritonitis (n=1), biliary associated with shorter disease-free survival and overall leak from intraabdominal drains left after laparotomy survival. (n=1). ERCP with biliary stenting (n=2), surgical inter- vention for biliary perotinitis(n=1). ERCP failed in (n=1), EP01E-073 later operated for biliary stricture. Arterial complications INDOCYANINE GREEN (n=8), venous complications (n=9) were seen in 14 patients. FLUORESCENCE GUIDED SURGERY IN AE alone (n=5), operated for rebleed after AE (n=1), sur- gery for hemodynamic instability, later with AE (n=2). PRIMARY AND METASTATIC LIVER Venous injuries were managed conservatively. Operative TUMORS: PRELIMINARY RESULTS intervention, grade, size of hematoma, delayed CECT and FROM A SINGLE-CENTER blood transfusion requirement were statistically significant EXPERIENCE in detecting biliovascular complications.7 (12.5%) deaths, G. Patania1, G. Impellizzeri1, S. Garritano1, M. Messina2, 2 hepatic-related mortalities occured due to uncontrolled E. Sinagra3, G. Martorana1, M. Iacopinelli1, bleed. N. Borsellino4 and M. Spampinato1 Conclusion: High grade liver injury will have high inci- 1Division of Oncology Surgery, 2Oncology Unit, 3Endo- dence of developing biliovascular complications which scopic Unit, and 4Oncology, Ospedale Buccheri-La Ferla, needs multimodality treatment strategies. CECT in patients Italy with clinical evidence of biliary complications and vascular fl complications is effective screening tool. ERCP and Introduction: Indocyanine green uorescence-guided angioembolisation role in management of high grade liver surgery (ICG-FGS) has emerged as a potential new imag- injuries is safe and effective. ing modality for improving the detection of hepatic focal lesions in both, primary and metastatic liver tumors. We want demonstrate the technique and details for a complete EP01E-072 and safe liver resection through using ICG-FGS surgery ECTOPIC FAT IN SKELETAL MUSCLE and to assess its potential applications. AND LIVER IS ASSOCIATED WITH Methods: From December 2017 to 15 January 2018, 5 SHORTER SURVIVAL IN PATIENTS patients (1 primary, 4 metastatic tumors) underwent surgery WITH COLORECTAL LIVER with ICG-FGS. ICG (0.4 mg/kg) was injected intrave- nously 24 h before surgery. We perform hepatic IOUS, as METASTASES usually, at every patient. Fluorescence was investigated D. van Dijk1, M. Aberle1, J. Zhao1, K. Kemter1, prior to resection to detect liver lesions, during hepatic V. Baracos2, C. Dejong1, S. Rensen1 and S. Olde Damink1 transection to guide surgery (with particular attention to 1Maastricht University, The Netherlands, and 2University assess surgical margins) and for pathological esamination. of Alberta, Canada Results: All operations were successful and had a mean Introduction: Whereas high adipose tissue mass is associ- duration time of 224’(range 120-480). ICG- Fluorescence ated with longer survival in patients with cancer (cachexia), Imaging (ICG-FI) detected all already known lesions (n= 7) ectopic fat in muscle and liver appears to be related to poor and identified 1 additional small tumor (1 metastasis, survival. Using multiple computed tomography scans diagnostic improvement 12,5%). All metastatic nodules

HPB 2018, 20 (S2), S333eS504 S498 Electronic Posters (EP01A-EP01E) - Liver were hypofluorescent with a hyperfluorescent rim, whereas nature of the liver anatomy, so 3D printing is a promising hepatocellular carcinoma was hyperfluorescent. In all new tool for surgical planning. cases, in vivo and ex vivo fluorescence revealed cleared Mehtods: Complex hepatic tumors (bilobar disease, infil- liver margins, and postoperative pathological examination tration of suprahepatic veins or two-stage resection or greatly benefited of liver fluorescence to assess radicality. intrahepatic vascular reconstruction). A CT and / or MRI Conclusions: ICG-FGS was shown to be an effective and was performed preoperatively to document the tumor dis- safe instrument to help intraoperative staging and to assess tribution, estimate the remaining volume of the future liver radicality in the surgical treatment of primary and meta- and identify tumor-vessel relationships. In all patients, a 3D static liver tumors. digital image reconstruction and a 3D printing model were performed. EP01E-074 Results: A 3D digital image reconstruction and a 3D COMPARISON OF CT AND printing model were performed in a total of 10 patients. In 6 HEPATOBILIARY SCINTIGRAPHY IN of them an ALPPS was performed (3 due to hepatic metastasis of colorectal ca, 1 hepatocellular carcinoma, 1 VOLUMETRY OF FUTURE LIVER intrahepatic cholangiocarcinoma and 1 Klastkin tumor), in REMNANT AFTER PORTAL VEIN 1 patient an extended right hepatectomy with Roux-en-Y EMBOLIZATION AND RALPPS hepaticojejunostomy for Klatskin tumor, in 1 patient a right M. Efanov1, R. Alikhanov1, P. Kim1, L. Bondar2, hepatectomy for intrahepatic cholangiocarcioma, in 1 pa- O. Melekhina3, Y. Kulezneva3, I. Kazakov1, tient an exploratory laparotomy for assessment of response A. Vankovich1, S. Iskhagi1 and V. Tsvirkun4 to neoadjuvant treatment of colorectal cancer metastasis, 1HPB Surgery, 2Radioisotope Laboratory, 3Department of and in 1 patient a renal venal graft in right suprahepatic Interventional Radiology, and 4Moscow Clinical Scientific metastasis of colorectal cancer. Center n.a. A.S. Loginov, Russian Federation Conclusions: Surgeons reported greater confidence with the use of the 3D model for the identification of the intra- Background: The study was aimed to compare accuracy of hepatic and extrahepatic structure, segmentation and spe- CT and hepatobiliary scintigraphy (HBS) in volumetric cific tumor extension. At the same time, they highlighted its estimation of future liver remnant (FLR) before and after applicability in the teaching of students and residents as portal vein embolization (PVE) and Radiofrequency well as its usefulness in the information of the patient. Assisted Liver Partition with Portal vein embolization in Staged liver resection (RALPPS). Methods: During three years (January, 2015-December, 2017) 46 patients with different malignancies of liver and EP01E-076 bile ducts included in the study: PVE (29) and RALLPS INVESTIGATION OF IMMUNOLOGICAL (17) were performed when major liver resection was indi- ROLE OF LIVER SINUSOIDAL cated in patients with small FLR. ENDOTHELIAL CELLS IN ANTI-HCV Results: After PVE alone the mean rate of FLR hypertro- phy estimated by HBS was significantly larger than the IMMUNE RESPONSE USING MOUSE mean rate estimated by CT-volumetry: 71(20-171)% and MODEL 31(10-97)%, respectively (p=0,001). After RALPPS the T. Onoe1,2, K. Taguchi1,2, S. Hashimoto2, Y. Tanaka2 and mean rate of FLR hypertrophy estimated by HBS was also H. Ohdan2 significantly larger than the mean rate estimated by CT- 1National Hospital Organization Kure Medical Center, volumetry: 86(25-264)% and 45 (0-113)%, respectively and 2Department of Gastroenterological and Transplant (p=0,027). There was no significant differences in the rate Surgery, Applied Life Sciences, Institute of Biomedical and of FLR hypertrophy between PVE and RALPPS, estimated Health Sciences, Hiroshima University, Japan by CT (p=0,099) and HBS (p=0,471). Introduction: We have previously shown that liver sinu- Conclusion: HBS is more effective and more precise soidal endothelial cells (LSECs) suppress anti-donor method of FLR volumetry in comparison with CT-volu- response in liver transplantation and the immunosuppres- metry as HBS considers volumetry of functioning liver sive property of LSECs is impaired in portal hypertension, parenchyma. In terms of FLR hypertrophy RALPPS did not resulting in an accelerated anti-donor reaction. In this study, show evident advantage over PVE, nevertheless, there was we investigated tolerogenecity of LSECs for anti-HCV a tendency to more effectiveness of RALPPS. immunological response using mouse model. Method: In this study, we injected HCV-specific antigen EP01E-075 (NS protein) to Balb/c mice via portal vein, isolated LSECs APPLICABILITY OF 3D PRINTING IN by collagenase digestion and cytometric cell sorting and THE PLANNING OF COMPLEX LIVER evaluated phenotype of LSECs and endocytosis of NS SURGERY (LIV3DPRINT) protein. Further, we investigated suppressive property of LSECs for HCV-specific T cell response by suppression B. Gomez Perez, V. Lopez-Lopez, R. Robles, D. Garcia, assay and cytotoxic assay in vitro. A. Lopez-Conesa, R. Brusadin, F. Alconchel, Results: Phenotypic analysis revealed that LSECs express A. Navarro and P. Parrilla MHC class II and co-stimulation molecules along with PD- Hospital Clinico Universitario ’Virgen de la Arrixaca’, L1 and endocytosed injected NS protein. The suppression Spain assay revealed LSECs significantly attenuated anti-HCV Introduction: Three-dimensional (3D) printing has gained specific T cell proliferation and cytotoxicity and attenuated popularity in medicine in the last decade. Hepatic re- IFN-g secretion by T cells. Tetramer assay showed sup- sections are challenging operations due to the complex pression of specific T cell clone. Furthermore, suppression

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S499 of HCV specific proliferation and cytotoxicity was abro- splenic vein obstruction, causing gastrointestinal bleeding. gated by PD-L1 blockade. Pancreatic disorders like carcinoma and pancreatitis have Conclusion: The results suggest that LSECs suppress anti- been related to it; however, retroperitoneal fibrosis has HCV T cell response by antigen presentation and PD-L1/ rarely been reported as its cause. PD-1 axis in HCV infected livers and might contribute to Case presentation: A[PI1] 77-year-old man with a back- immune evasion of HCV. However, it also imply that ground of retroperitoneal fibrosis and obstruction of the left LSECs suppress excessive immune reaction and avoid liver ureter, currently on[PI2] treatment with mycophenolate. He damage. Therefore, together with previous results, collapse was remitted to our clinic due to recurrent episodes of upper of LSECs’ suppressive function might be one of underlying gastrointestinal bleeding with a haemoglobin of 6.8 gr/dL, mechanism of post-operative liver failure after major sur- requiring transfusions of red cell units. A gastroscopy gery of the HCV infected liver. showed diffuse fundal gastric varices but no oesophageal varices; a Computerized Tomography (CT) scan showed EP01E-077 splenomegaly and a retroperitoneal mass obstructing the splenic vein with diffuse varices around the gastrosplenic ARTERIO-BILIARY FISTULA and gastrohepatic ligament. With the diagnosis of left-sided FOLLOWING BLUNT LIVER TRAUMA portal hypertension due to retroperitoneal fibrosis, the pa- V. M. Leow1,2 and M. K. Subramaniam2 tient was submitted to an oesophagus-preserving modified 1Oncology, AMDI, USM, and 2HPB Unit, Department of Sugiura procedure. Intraoperative examination showed Surgery, Hospital Sultanah Bahiyah, Malaysia diffuse varices around the splenic hilum, gastric fundus and Blunt liver trauma is one of the commonest injuries lesser sac. A splenectomy with a disconnection of gastric resulting from road traffic accidents. Hemodynamic insta- vessels on the lesser curvature was performed, preserving bility as a result of bleeding either in acute or chronic the pylorus branches of the Latarjet nerves. Post-operative complications still mandate surgical treatment. Herein, we [PI3] was uneventful and the patient was discharged four present a patient who has history of blunt liver trauma days after surgery. After three months of follow-up he has presented with upper gastrointestinal hemorrhage despite not presented any further episode of bleeding and his interventional radiological treatment. haemoglobin has remained stable. A 17-year-old adolescent male was injured in a road Conclusions: Retroperitoneal fibrosis is an extremely rare traffic accident. CT scan revealed deep laceration at left cause of left-sided portal hypertension. An oesophagus- lateral section extending into segment IV of the liver with preserving modified Sugiura procedure is an excellent surrounding haematoma around the liver and minor splenic alternative to treat the hypertension and prevent further injury. He was treated conservatively. After one month, he episodes of bleeding. was readmitted for abdominal pain and anemia. An urgent CT showed bleeding pseudoaneurysm of the left hepatic artery. Emergency angiography and coil embolization was EP01E-079 performed. Unfortunately, the coil migrated proximally THE MISSING LINK: THE INTEGRATION from the targeted site. However, he remained stable. Two OF ADVANCED PRACTICE PROVIDERS weeks later he had hematemesis at home. An emergency upper endoscopy demonstrated hemobilia. Emergency IN HEPATOBILIARY SURGICAL laparotomy findings revealed left lateral section was ONCOLOGY RESEARCH necrotic and fused to the spleen. Blood clots were seen in J. D. Velasco1, M. E. Arvide2, S. H. Wei1 and the biliary tract. Left lateral sectioncectomy, splenectomy J. N. Vauthey1 and removal of embolization coil were performed. Post 1The University of Texas MD Anderson Cancer Center, operatively, the patient recovered and was discharged well. United States, and 2Surgical Oncology, The University of The main principal in managing blunt liver injury is Texas MD Anderson Cancer Center, United States haemodynamic stability. Role of non-surgical management Introduction: Recent changes in the surgery workforce entails angioembolisation, image-guided drainage and have created a need for highly skilled and trained APPs to endoscopic retrograde cholangiopancreatography. Failure care for a complex patient population. In addition to various in nonsurgical management can potentially fatal and needs clinical roles, APPs are increasingly being utilized in non- to be recognized early and treated promptly. clinical roles, including research. Hepatobiliary surgery is a Complications following blunt hepatic trauma are un- specialized discipline where APPs can contribute in a va- common, but once occurred dedicated multidisciplinary team riety of ways to enhance research outcomes, quality and approach is essential to ensure comprehensive treatment. performance improvement, as well as improved patient education. Engaging in research roles beyond clinical care allows for increased collaboration and partnership between EP01E-078 physicians and other APPs, improvement of clinical com- LEFT-SIDED PORTAL HYPERTENSION petencies, and consequentially lead to more opportunities DUE TO RETROPERITONEAL in professional development, such as publishing and/or oral presentations. FIBROSIS: A RARE CASE REPORT Methods: We describe four specific clinical research roles M. Di Martino and E. Martín-Pérez that APPs are engaged in as part of a multi-step process in a Department of Surgery, University Hospital La Princesa, complex hepatobiliary practice at MD Anderson Cancer Spain Center. Introduction: Left-sided portal hypertension is a very 1. Screening patients for clinical or translational research uncommon condition that mainly occurs as a result of trials

HPB 2018, 20 (S2), S333eS504 S500 Electronic Posters (EP01A-EP01E) - Liver

2. Patient education and informed consent process University of Vienna, 3Clinical Department of Pathology, 3. Evaluation of clinical data and collection of labs/tissue Medical University of Vienna, General Hospital Vienna, specimens 4Department of Surgery, Rudolfstiftung Hospital Vienna, 4. Implementing quality and performance improvement and 5Department of Surgery, Medical University of projects Vienna, Austria Results/conclusion: The roles of APPs in hepatobiliary Background: Experimental data on osteopontin (OPN) research continue to evolve and expand. It represents an in regard to liver regeneration (LR) is not conclusive. Of opportunity for APPs to not only advance academically and note, there is no human data on OPN after liver resection professionally but also to enhance the visibility and con- available. Thus, we aimed to investigate the role of OPN tributions of the APP on the hepatobiliary surgical in patients undergoing hepatic resection. Further, we oncology interprofessional team. This integration allows to aimed to explore a potential association to YAP1 improve the quality and efficiency of research outcomes in dependent sonic hedgehog (SHH) signalling, as this was a possibly more cost-effective manner. Future studies are shown to be a relevant inducer of OPN expression in fatty needed to validate the impact of the APP contributions to liver disease. hepatobiliary surgical oncology research. Methods: 48 patients were included in this study. OPN levels in plasma were assessed at different time points. EP01E-080 Further, biopsies of the liver were collected at baseline and during regeneration. Gene expression was assessed using SURGICAL TREATMENT OF RT-PCR and presence of OPN was assessed immunohis- CYSTOBILIARY COMMUNICATIONS IN tochemically. Postoperatively, patients were followed up HEPATIC HYDATIDOSIS for liver dysfunction (LD). , fi N. Lekic1, D. Basaric1 2, V. Djordjevic1, S. Matic1, Results: OPN showed a signi cant increase already 2 hours S. Ostojic1, A. Ninic1 and M. Milicevic1 after induction of liver regeneration (p=0.017). Further, SHH 1Clinic for Digestive Surgery-First Surgical Clinic, Clin- and YAP1 correlated significantly with OPN expression ical Center of Serbia, and 2Medical faculty, University of during regeneration (r=0.628,p=0.005;r=0.558,p=0.016; Belgrade, Serbia respectively). Indeed, high induction of SHH was associated to higher fold changes of YAP1 (p=0.035) and OPN The cystobiliary communications (CBC) are communi- (p=0.044) mRNA. Intriguingly, also levels of OPN protein cations of hydatid cyst and biliary tree and present a serious determined by immunohistochemistry showed a rapid in- complication in 60% of patients with liver hydatidosis. The crease after 2 hours of liver regeneration (p=0.028). How- frequency of concealed CBC accounts for 5-17% while the ever, patients with LD showed higher levels of OPN on direct CBC occur in 10-37% cases. POD1 (p=0.039,AUC=0.704), and a suitable cut-off was Study includes 1381 patients surgically treated for liver found to identify patients with postoperative LD (10.5% hydatidosis from 01.01.1966. until 31.12.2017. The existence vs52.4%,p=0.005). of CBC was confirmed in 279 patients (20.20%). Echoso- Conclusion: Taken together, OPN seems to be an early nography and computed tomography were useful in the dif- protagonist in liver regeneration. However, in case of ferentiation of abscesses and hydatid cysts with or without overshooting OPN expression, potentially as a cause of CBK. The analysis included: symptomatology, number, size YAP1 dependent SHH signalling, patients seem to be prone and segmental involvement in relation to the existence of to develop postoperative LD. CBK, the type of surgery on the cyst and bile duct, post- operative complications, reoperations and mortality. Pain, dyspeptic symptoms and palpable mass in abdomen were the most common symptoms. Cysts of 5-10 EP01E-082 cm localized in IV, VI and VII segment was verified in 53% EXTRAHEPATIC HYDATIDOSIS e of cases, often peripheral (62%) affecting one or two seg- UNUSUAL LOCALIZATION WITH ments. A single CBC was recorded in 92% cases. The SURGICAL SIGNIFICANCE operation of choice on the biliary tree was suture with or 1,2 1,2 1 1,2 without with T-drainage (93.5%), and partial peri- D. Basaric , N. Lekic , V. Djordjevic , S. Ostojic , 1,2 1 2 cystectomy on cyst (92.11%). Postoperative complications S. Matic , A. Ninic and M. Milicevic 1 were reported in 70 (25.09%) patients. Fifteen patients were Clinic for Digestive Surgery-First Surgical Clinic, Clin- 2 reoperated with a mortality of 2.18%. ical Center of Serbia, and Medical Faculty, University of Adequate diagnosis and appropriate surgical treatment of Belgrade, Serbia patients with CBK significantly reduce the patients’ Liver represents the most frequent localization of intra- morbidity and preserve their working ability. abdominal echinococcosis. Primary extrahepatic echino- coccosis is rare (lungs 25%, kidneys 3%, spleen 2.2%, ovary 0.2-2.25%, peritoneum and pelvic organs 1.6%, EP01E-081 pancreas 1.1%, small and large intestine, gallbladder and adrenal gland in 0.6%). OSTEOPONTIN SEEMS TO BE AN Study included 78 patients surgicaly treated from EARLY REGULATOR OF LIVER 01.01.1966 to 31.12.2017, 46 males and 31 females, with REGENERATION IN HUMANS average of 42.31 years old. Symptomology, number, size D. Pereyra1, M. Finsterbusch2, J. Stift3, A. Assinger2, and cyst relationship with surrounding structures, methods C. Brostjan1, T. Grünberger4 and P. Starlinger5 of surgical treatment and postoperative morbidity and 1Department of Surgery, Medical University of Vienna, mortality analyzed. The collected data analyzed by the General Hospital Vienna, 2Institute of Physiology, Medical statistical program SPSS (v.13.0).

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Hydatid cysts were located in: spleen 26, retro- experienced PHLF. FLR volumes between the two groups peritoneum 17, lungs 14, adrenal gland 7, omentum 5, did not show any statistical significance. meso of large and small bowell 3, ovary 2, and in 1 case on Conclusions: The HIBA-i seems a promising tool able to kidney, peritoneum, pancreas and gallbladder each. Golden estimate residual liver function. Prospective clinical trial standard for spleen hydatidosis was splenectomy, adrenal- are warranted to define more precise cut-offs of FLR-F ectomy for supraadrenal gland, ovaryectomy for ovarian when SPECT/CT is associated. hydatidosis and distal splenopankreatectomy for hydatid cyst of the tail of pancreas. Partial and total cystoper- icystectomy wrer applied in retroperitoneal, lung and EP01E-084 omental hydatidosis. Postoperative complications were LAPAROSCOPIC MANAGEMENT OF observed in 13 (16.67%) cases, and 3 patients were reop- erated (3.85%). No mortality was observed. LIVER ABSCESS CAUSED BY INGESTED Although rarely represented, primary extrahepatic echi- ANIMAL BONE e A CASE REPORT nococcosis is extremely important because if inadequately I. Siddiqui diagnosed and treated leads to a significant reduction in the Hepatopancreatobiliary Surgery, St.Vincent’s Medical working capacity of patients suffering from this benign Center, United States disease. Background: Liver abscesses in the Western hemisphere are caused usually as result of infections in the biliary tract, other GI sources or source elsewhere in the body with EP01E-083 bacterial spread. An unusual source would be an ingested HEPATOBILIARY SCINTIGRAPHY foreign body perforation with an infected source in the COMBINED WITH SPECT/CT IN porta-hepatis. PREDICTING LIVER FAILURE BEFORE Case: 56 y old otherwise healthy Haitian male presented with abdominal pain and fevers. He had epigastric tender- MAJOR HEPATECTOMY: ness with no peritonitis. Leucocytosis, transaminitis and PRELIMINARY RESULTS OF THE HIBA- mildly elevated alkaline phosphatase.CT imaging demon- INDEX AT A SINGLE CENTER strated a 5 cm complex liver abscess in segment 4B and 4A M. Serenari1, C. Pettinato2, L. Zanoni3, C. Bonatti1, with gall bladder wall thickening and hyperdense foreign S. Brocchi4, A. Cucchetti1, M. Ravaioli1, S. Fanti3, body in the region of the porta-hepatis anterior and abutting A. D. Pinna1 and M. Cescon1 the common hepatic artery. 5 cm long piece of animal bone fi 1General Surgery and Liver Transplantation Unit, was identi ed and removed from the porta-hepatis anterior Department of Medical and Surgical Sciences, 2Medical to the hepatic artery residing in a well formed sinus tract Physics Unit, Radiology Unit, 3Department of Nuclear extending to the infundibulum of the gall bladder from the Medicine, and 4Radiology Unit, Department of Diagnostic gastric antrum. The tract was also removed. This was and Preventive Medicine, S.Orsola Malpighi Hospital, accomplished laparoscopically under navigational guid- Italy ance of laparoscopic ultrasound. A laparoscopic cholecys- tectomy was performed with an intra-operative Introduction: Hepatobiliary scintigraphy (HBS) is able to cholangiogram, which was normal. Laparoscopic marsup- estimate future liver remnant function (FLR-F) and may be lization of the loculated liver abscess was performed and useful to predict post-hepatectomy liver failure (PHLF) drains were placed. No obvious enteric fistulous opening before major hepatectomy. Existing cut-off values for was appreciated. PHLF (FLR-F < 2.69%/min/m2) were previously set using Conclusion: We present a rare case of liver abscess due to only planar acquisitions but not combined with single an ingested foreign body and demonstrated important photon emission computed tomography (SPECT/CT). A principles of liver abscess management. Advanced lapa- new index, the so-called Hospital Italiano De Buenos Aires roscopic techniques along with training in laparoscopic index (HIBA-i), has been recently used to measure sectorial ultrasound are needed to perform this in a minimally liver function in two-stage hepatectomy setting. invasive fashion. Method: All consecutive patients submitted to major hepatectomy between November 2016 and November 2017 at Sant’Orsola-Malpighi Hospital (Bologna, Italy), were analyzed. Patients were resected according to their preop- EP01E-085 erative volumetry. Data regarding preoperative HBS were COLLATERAL ARTERIAL FLOW OF retrospectively reviewed. FLR-F and HIBA-i were calcu- LIVER e A CASE REPORT fi lated as previously described. PHLF was de ned according S. H. S. Reddy, D. Jain and N. R. Dash to the International Study Group of Liver Surgery criteria. GI Surgery and Liver Transplantation, AIIMS Delhi, India Results: Twenty-seven patients were submitted to major Introduction: hepatectomy (13 right hepatectomies, 8 left hepatectomies, Hepatic artery (HA) contributes to 35% of fl 5 right trisectionectomies, 1 left trisectionectomy). PHLF liver blood ow and 50% of oxygen supply. The impact of ’ (grade A/B/C) was observed in 9 out of 27 patients its ligation on liver function isn t well established. Some studies have shown collateral arterial supply to the liver and (33.3%). The HIBA-i differed significantly (p=0.002) be- tween patients with (14.37%, IQR 8.64-16.14) and without portal venous compensation. Here, we present our experi- PHLF (24.31%, IQR 15.74-39.53). Eight of 16 patients ence of proper HA ligation in a case of large pancreas with a preoperative FLR-F < 2.69 %/min/m2 did not tumor.

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Case description: A 24-year-old male with pain abdomen incidence of this condition and possible secondary com- was found to have a large pancreas head neuroendocrine plications of malnutrition. tumour with no vascular involvement on evaluation with imaging. A pancreatoduodenectomy was planned. During dissection the large tumour with necrosis and vascular EP01E-087 stroma got ruptured and bled which necessitated acceler- HEPATOFLUO: A PROSPECTIVE ated resection. Due to the presence of collaterals and lack of space in the hepatoduodenal ligament, the tissues were MONOCENTRIC STUDY ASSESSING taken down in bunches that included the proper HA. THE BENEFITS OF INDOCYANINE Arterial reconstruction was not possible because the distal GREEN (ICG) FLUORESCENCE FOR end could not be identified. Post-operatively there was mild HEPATIC SURGERY hyperbilirubinemia (maximum 5.2mg/dL) and trans- A. Dupré1, E. Blanc2, M. Rivoire2, D. Pérol2, aminitis (maximum AST and ALT of 3222 and 1802 U/L S. Guillermet3 and P. Peyrat2 respectively) that subsided by itself in early post-operative 1Surgical Oncology, Centre Léon Bérard, 2Centre Léon period. Follow-up CT at one month showed a small infarct Bérard, and 3Fluoptics, France in segment 8 of the liver and faint opacification of intra- hepatic arterial channels. Both of these had improved Background and objectives: Fluorescence imaging using further by 3 months, possibly from collaterals in bare area indocyanine green (ICG) is undergoing extensive devel- of liver. opment. This study aimed to assess the merits of ICG in Conclusions: Collateral arterial supply to the liver can regard to hepatic surgery. compensate for HA blood supply in some instances if the Methods: Patients with liver lesions that required a resec- ligamentous attachments to the liver are not divided. tion were eligible. They received an injection of ICG the day before the surgery. Step1 allowed assessment of use of the medical device under surgical conditions. Steps 2 and 3 assessed the capacity of the MD to detect known tumorous EP01E-086 lesions and to spot a predefined area of the liver following USE OF SUBJECTIVE GLOBAL injection of ICG into the portal vein (ICGp). ASSESSMENT METHOD IN PATIENTS Results: The 1st step allowed for validation of the MD use WITH TUMORS OF PANCREAS, LIVER with three patients. Between 04-2013 and 04-2015, 45 pts AND BILIARY were included (40 eligible) in steps 2 and 3. All of the fl 1 2 tumorous lesions (95/119) exhibited uorescence. Four M. G. Serna Thomé , G. D. Leal González , new metastasis were detected in 3 pts, and two missing H. M. Álvarez del Castillo2, H. N. López Basave1 and 1 metastases in 1 pt. False positive were 22%. The maximal A. E. Padilla Rosciano fl 1 2 depth for detection by uorescence was 13 mm. Injection of National Cancer Institute Mexico, and UANL, Mexico ICGp allowed the corresponding anatomical area to be Background: The prevalence of malnutrition is frequent in identified in 16/20 patients. oncology patients. The consequences of malnutrition Conclusion: This study confirmed that intraoperative include an increased risk of complications. decreased fluorescence is a helpful and relevant tool for the liver response and tolerance to oncological treatment, and surgeon. (NCT 01738217) decreased survival. ASPEN establishes a screening method to identify characteristics related to nutrition problems which aims to perform an appropriate nutritional assess- EP01E-089 ment to identify patients at risk of malnutrition. Materials and methods: Prospective, descriptive study OUR EXPERIENCE WITH BLUNT was carried out in 172 patients in department of digestive HEPATIC TRAUMA tract tumors at National Cancer Institute of Mexico were S. R. V. Gunturi, V. Thumma, J. R. Bathalapalli, evaluated. To collect the data, the subjective Global N. Kunduru and B. Nagari Assessment generated by the patient was used. Surgical Gastroenterology, Nizams Institute of Medical Results: There were 40% men and 60% female, the Sciences, India average age was 60 . The incidence of tumors reported Introduction: The incidence of blunt abdominal trauma is 50% pancreatic cancer, 36% liver cancer, 22% bile ducts. increasing.Initial Non operative management is the stan- > 55% of patients had a weight loss 10% in 6 months. dard of care in stable patients with isolated hepatic trauma 40% presented anorexia. Xerostomia and early satiety we want to present our experience. were the highest incidence with 57% and 48% respec- Method and results: We retrospectively analysed our data tively. In the VGS-GP 84% presented some degree of of last 7 years and these are our observations. Most of the malnutrition, the type of cancer with highest incidence of patients with blunt hepatic trauma responds to conserva- malnutrition was pancreatic cancer with 86%, followed tive management if they are stable and if there is no other by liver cancer with 81%. intra abdominal injury which requires surgical interven- Conclusion: Malnutrition is common in patients with tion. In grade III and above patients there is an increased gastrointestinal tumors. Prevalence of malnutrition was risk of biliary collections requiring percutaneous drain- high, this could be related to the symptomatology and age,In few of them there is a need for sphincterotomy and reduction of the habitual consumption of the food. The stenting. subjective global assessment generated (VGS-GP) to Conclusions: In Blunt hepatic trauma ,most of the patients identify patients At risk of malnutrition, this tool allows a improve with conservative management.but high grade timely nutritional intervention that can reduce the high injuries needs close monitoring for associated extra

HPB 2018, 20 (S2), S333eS504 Electronic Posters (EP01A-EP01E) - Liver S503 abdominal and evolving intra abdominal injuries. In high EP01E-091 grade injuries symptomatic biliary collections can be drained with percutaneous drainage but needs to be POOR RESULTS WITH LAPAROSCOPIC differentiated from mesenteric injuries with repeat imaging FENESTRATION FOR “SIMPLE” LIVER and appropriate intervention. CYSTS J. Mathew1, H. Ramesh2 and M. Subramaniaiyer1 EP01E-090 1VPS Lakeshore Hospital, and 2Surgical Gastroenterology MINIMIZING ANAPHYLAXIS WITH & Liver Transplantation, Lakeshore Hospital & Research CHEMOTHERAPY IN HEPATIC Center, India HYDATIDOSIS Background: Laparoscopic Poor results with laparoscopic “ ” S. Bhanou, M. V. Newton, S. Govindaraj, C. Prakash and fenestration for simple liver cysts fenestration has been “ ” P. B considered optimum treatment for simple liver cysts. St. John’s Medical College Hospital, India Aim of the study: a retrospective analysis of the out- comes after laparoscopic fenestration for liver cysts. Introduction: Incidence of intraoperative Hydatid Patients and methods: Out of 66 patients (age group 21- anaphylaxis is 0.2-3.3% Reporting of such rare cases is 80 years, 38 men, 28 women), 14 patients underwent crucial for future reference fenestration at another center (group 1) and the remaining Case history: 52 years old lady presented with hepatic 52 at our center (group 2). hydatidosis. Computed Tomography showed 2 cystic le- Results: all 14 patients in group 1 were reoperated: hydatid sions; 6.1x6.5x8.3 cm in segment 6, 7 in proximity to cyst with biliary communication (n=2), squamous cell Inferior Venacava and right hepatic vein; multiseptated carcinoma with cystic degeneration (1), biliary cystadeno- 5.1x5.5x8.1 cm lesion in segment 4 adjoining the middle mas (3), and residual infected biliary cyst in 4. In group 2, hepatic vein. No rupture seen. Preoperatively she was 22 patients were operated - cyst wall biopsy of cystade- prescribed Albendazole 400mg twice-daily for 3months. noma (4), 8 patients had recurrent symptoms and imaging She was given Hydrocortisone before surgery. 10% povi- suggestive of cystadenoma (operative biopsy missed the done iodine mops to prevent intraperitoneal spillage and pathology), 2 patients had biliary leak, and 8 others had hypertonic saline used to flush the cyst. One hour after persistent cyst with infection and symptoms treated by anesthesia when the Segment IV cyst close to middle he- excision with CUSA. Four patients had postoperative patic vein was punctured she had anaphylactic shock, percutaneous aspiration, and 4 others underwent ERCP and resuscitated, started on inotropic support. Marsupialization stenting for biliary leak successfully. 10 patients had re- of both the cysts with omentoplasty and intracystic drains sidual cysts though asymptomatic. Finally 56 out of 66 done. She recovered well and was discharged with patients were free of both symptoms and cyst Albendazole for 1 month. Conclusions: “Simple liver cysts” are not often simple. Discussion: Incidence of intraoperative Hydatid They may be a complicated cyst or tumour in around half anaphylaxis is 0.2-3.3% Growing cyst produces complex the cases. Laparoscopic fenestration has only limited suc- echinococcal antigens, increased cellular immune cess rate. Careful preoperative assessment of liver cysts is response, Th2 balanced with Th1; elevated immuno- required to avoid unnecessary unexpected findings at globulin levels. In dead cysts Th2 responses drop surgery. rapidly. Albendazole 10mg/kg for 3 months causes good cyst wall degeneration, less viability of protoscoleces and cyst, less echinococcal antigen production. After the surgery we found that she had stopped albendazole in the EP01E-092 preoperative period, which she did not reveal pre-oper- ALUMINIUM PHOSPHIDE INDUCED atively fearing delay in surgery. Inadequate albendazole, LIVER INJURY e THE “DILI” DILEMMA close proximity of cysts to vascular structures would P. R. Sreenath1, N. M. Shawnas Bahnou2, have predisposed to develop anaphylactic shock during H. Devarbhavi3 and D. Ganga4 cyst handling. 1General Surgery, St. John’s Medical College, Bangalore, Conclusion: Albendazole can reduce anaphylaxis, 2General Surgery, 3Gastroenterology, St. John’s Medical morbidity and mortality. College Hospital, and 4Department of Gastroenterology, St John’s Medical College, India Introduction: Phosphide containing rodenticide poisoning is a recognized cause of acute liver failure. Its treatment has a myriad of obstacles and treatment modalities range from medical (N-acetyl cysteine) to surgical (liver trans- plantation). We report 5 cases of Drug induced Liver Injury (DILI) following ingestion of Phosphide containing rodenticide for suicidal purpose and their outcomes. Methods: Retrospective analysis of 5 cases of phosphide containing rodenticide poisoning admitted to St. John’s Medical College Hospital during the period of 2015-2017. Results: All 5 patients were females with a median Figure [pic 1] age of 25 years (range 24-31). No one had past history

HPB 2018, 20 (S2), S333eS504 S504 Electronic Posters (EP01A-EP01E) - Liver of alcohol consumption, chronic liver disease or other (60%) succumbed to their illness in ICU. Average length co-morbidities. All 5 patients were nursed in Intensive care of stay was 11.2 days(5-21). unit. During the course of stay, all patients had deranged Conclusions: Acute liver failure due to DILI often affects liver function test and coagulation profile. Complications young individuals and has a high risk of morbidity and noted during the period were acute kidney injury (80%, mortality. As there is no effective antidote for phosphide n=4) of which three required hemodialysis, worsening poisoning, Liver transplantation at the earliest often re- metabolic acidosis (60%, n=3) and adult respiratory mains the only life saving therapy. Regularly used crite- distress syndrome (40%, n=2) requiring mechanical rias for transplantation doesnot address phosphide ventilation. Two patients (40%) recovered with conserva- poisoning and hence a scoring model for the same is tive management (N-acetyl cysteine) and three patients warranted.

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