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ABSTRACTS

Abstracts of Papers Submitted to the IASGO World Congress, HBP SurG Meeting, November 15-17, 2017, Lyon, France

ORAL PRESENTATIONS (O)

O-001 O-004

SURGICAL ANATOMY IN PANCREATIC HEAD RESECTION SURGERY FOR ADVANCED PDAC A. Horiguchi, M. Ito. Y. Asano, S. Arakawa, M. Shimura, T. Ochi, Thilo Hackert C. Hayashi, H. Yasuoka, T. Kawai, Department of Gastroenterological Surgery, Fujita Health O-005 University School of Medicine. Nagoya, 454-8509, Japan In recent years there has an increase in the indications for CONVERSION SURGERY FOR INITIALLY UNRESECTABLE LOCALLY pancreatic resection of benign or low-grade malignant lesions, ADVANCED PANCREATIC FOLLOWING especially in young patients with long life expectancy. We present MULTIDISCIPLINARY TREATMENT about vascular anatomy of the pancreas when performing Tsutomu Fujii, S. Yamada, H. Takami, I. Yoshioka, K. Shibuya, pancreatic head resection. When DPPHR (duodenum preserving H. Baba, T. Okumura, Y. Kodera pancreatic head resection) applies to patients with benign or low- University of Toyama, Toyama, 930-0194, Japan grade , it is important to remove completely the pancreatic head to avoid tumor remnant and pancreatic fistula, In the treatment of , the most innovative recent because the majority of the patients with these tumors have the change is the introduction of FOLFIRINOX and nab-paclitaxel as an normal pancreatic exocrine , and variation of the branch duct of effective protocol. By multidisciplinary treatment using them, there the head of the pancreas. On the other hand, if complete resection of are increasing cases in which resection is possible in pancreatic the head of the pancreas is performed, there is danger of ischemia cancer which was un-resectable at the time of initial diagnosis. In and perforation of the bile duct or duodenum. During resection of the Japan, this is called “Conversion Surgery”, implying strategy-conver- head of the pancreas, therefore, it is absolutely essential to maintain sion. There is no clear evidence on the validity and usefulness of the blood supply to the bile duct and the duodenum in order to this option; however, good prognosis has been reported little by prevent early postoperative complication. DPPHR is technically little. I will review previous reports of conversion surgery for initially difficult and time-consuming due to reconcile these antinomic unresectable locally advanced pancreatic cancer following multi- techniques, namely, complete resection in the pancreatic head and disciplinary treatment and state the experience and results of our preservation of both the bile duct and the pancreaticoduodenal institution. vessels. The posterior superior duodenal artery crosses the distal bile duct anteriorly and descend along the right border of the bile O-006 duct and crosses again posteriorly at the level of the papilla. The posterior superior pancreaticoduodenal vein has to be preserved to EFFECTIVENESS OF MULTIMODALITY TREATMENT FOR PANCRE- avoid the congestion of the duodenum. For patients, it would ATIC CANCER be beneficial for their QOL if PD could be avoided. Oncologic radi- cality and organ preserving operation is important. DPPHR is just M. Sho, M. Nagai, T. Akahori, S. Nishiwada, K. Nakagawa, enough operation. K. Nakamura, N. Ikeda, T. Tanaka, H. Nishiofuku, T. Tamamoto, M. Hasegawa, K. Kichikawa. Nara Medical University, Nara, 634-8522, Japan O-002 Objectives: The aim of this study was to retrospectively evaluate the impact of neoadjuvant chemoradiotherapy (NACRT) on peri- TECHNICAL CHALLENGES IN PANCREATIC SURGERY operative and long-term clinical outcome in pancreatic cancer (PC). Doris Henne-Bruns Methods: One hundred sixty patients who preoperatively received full-dose gemcitabine (1000 mg/m2) with concurrent radiation of 54 Gy between 2006 and 2016 were analyzed. One hundred thirty O-003 patients who underwent upfront surgery were served as control. Results: Among the 160 patients treated with NACRT, 153 patients WHEN TO PERFORM A PANCREATICODUODENECTOMY IN (96%) completed the protocol treatment. The reasons of failure to THE ABSENCE OF A POSITIVE HISTOLOGY FOR PANCREATIC complete NACRT were drug-induced pneumonia, acute mucosal CANCER injury, severe cholangitis and poor performance status (PS). Furthermore 21 (13%) couldn’t undergo pancreatic resection after Helmut Freiss NACRT because of distant metastasis in 9 patients, tumor progres- sion in 7 and poor PS in 5. The rate of pancreatic fistula was lower and hospital stay was shorter in the NACRT group compared to the

Surgery, Gastroenterology and , 22 (3), 2017 139 ABSTRACTS

control group (P=0.033, P=0.002). Furthermore, the rate of lymph O-008 node metastasis, R0 resection and pathological stage were favorable in the NACRT group (P <0.0001, P=0.006, P<0.0001). The MANAGEMENT OF POSTOPERATIVE COMPLICATIONS AFTER completion rate of adjuvant chemotherapy was also higher in the PANCREATODUODENECTOMY NACRT group (P=0.015). Importantly, patients treated with NACRT Zerbi Alessandro had a better prognosis than those without (median survival time: 60.2 vs. 28.5M, P=0.008). In addition, according to tumor O-013 resectability status, patients were classified as R (resectable), BR-P (borderline resectable with venous involvement) and BR-A (border- IMPACT OF SLEEVE GASTRECTOMY AND GASTRIC BYPASS ON line resectable with arterial involvement) groups. As a result, OBESITY COMORBIDITIES IN COMPARISON TO CONSERVATIVE patients treated with NACRT had a better prognosis than those THERAPY AFTER 5 YEARS. without in the R and BR-P groups (58.6 vs. 34.2M, P=0.013, 62.4 vs. 18.8M, P=0.015), while NACRT had no significant impact on N.A. Gad El Hak, Stefan Post, M.A. El Refai. prognosis in the BR-A group. Conclusions: Neoadjuvant chemoradiotherapy may have a variety Objectives: Obesity represents nowadays a global. Obesity is not of favorable impact in pancreatic cancer treatment. Furthermore, only a burden per se, but is also tightly connected to large number NACRT may improve the prognosis especially in resectable and of diseases e.g. diabetes mellitus type 2, hypertension, and borderline resectable pancreatic cancer with venous involvement. dyslipidemia. This clinical study was planned to examine the impact of bariatric surgery procedures (LRYGB and LSG) on obesity related comorbidities in comparison to conventional medical O-007 therapy of morbidly obese patients after 5 years. Methods: Patients were recruited from the outpatient clinic for NEOADJUVANT TREATMENT AND AGGRESSIVE SURGICAL obesity care. 30 operated patients were matched and compared to RESECTION FOR BR AND UR PANCREATIC CANCER. IS R0 30 patients in the conventional group who received medical RESECTION THE KEY FOR BETTER PROGNOSIS? therapy of obesity. Measured outcomes were weight loss, changes in retinal Arteriovenous ratio (AVR), diabetes, dyslipidemia, quality H. Yoshitomi, K. Furukawa, T. Takayashiki, S.Kuboki, S. Takano, of life D. Suzuki, N. Sakai, S. Kagawa, H. Nojima, T. Mishima, Results: %EWL and % TWL were 59.7% and 29.4% after bariatric M. Miyazaki, M. Ohtsuka. surgery versus 3.3 % and 0.5% respectively among medical patients Department of General Surgery, Chiba University, Graduate (P<0.001). Bariatric surgery resulted in improvement of patients’ School of Medicine, Chiba, 260-8670, Japan. lipid profile. Total plasma cholesterol dropped by –37.2 mg/dl after Backgrounds: The optimal treatment for borderline resectable surgery versus only -4.2 mg/dl in conventional therapy group pancreatic cancer (BR) is still controversial. (P<0.001).Triglycerides and LDL dropped postoperatively by -48.8 Aim: To estimate the roles of neoadjuvant treatment and surgical mg/dl and -37.9 mg/dl respectively. Baseline fasting blood sugar resection for pancreatic head BR with arterial involvement (BR-A) decreased significantly from 106.1 mg/dl to 92.1 mg/dl after by retrospective analysis of patients who underwent surgical resec- surgery. After mean of 5 years, 66.2% of our operated patients with tion and pursuit the optimal treatment. DM at baseline examination were in remission at follow up versus Methods: Medical records of 105 patients with BR located in 25% in control group. Our results show that bariatric surgery pancreatic head who underwent surgical resection between 2002- resulted in an amelioration of endothelial function. AVR increased 2014 in Chiba University Hospital were analysed retrospectively. significantly in interventional patients (+0.03, P= 0.05).In control BR-PV and -A were defined according to 7th JPS classification. group, AVR deteriorated and decreased with time by (-0.03) Results: Patients characteristics; M/F: 68/37, Median age: 65 y.o. (35- reflecting metabolic aggravation of endothelial dysfunction. 82), BR-A/-PV: 44/61, Operation methods PD/TP: 102/3. Thirty Conclusion: Bariatric surgery is more effective than conventional patients were treated with neoadjuvant therapy (NAT) (GEM+S-1 medical therapy of obesity in terms of sustained weight loss, (n=21), GEM (n=2), GEM or S-1+radiation (n=5), radiation (n=2)). The improved dyslipidemia and remission of diabetes mellitus. median duration between initiation of NAT and surgery was 2.6m .Beneficial metabolic impact of bariatric surgery on obesity related (range: 1.0-36.1m). Patients treated with NAT survived significantly comorbidities can be witnessed on long term follow up after 5 longer in BR-A (MST: NAT+/- (n=22/22): 51.5/15.2m p=0.0002), but not years. in BR-PV (MST: NAT +/- (n=8/53): 20.5/22.9m). There were no statisti- cal differences in OS between patients with R0 and R1 resection in both BR-A and BR-PV. In contrast, R2 resection resulted in poor prog- O-014 nosis in both groups (MST of R0/1/2; BR-A (n=21/14/9): 28.2/22.7/6.7m, BR-PV (n=41/16/4): 26.8/22.9/4.6m). In BR-A patients, SLEEVE GASTRECTOMY FOR MORBID OBESITY IN there was no statistical difference in local recurrence rate between R0 A WESTERN AFRICAN COUNTRY. FIRST STEPS IN SENEGAL and R1 resection. Multivariate analysis of BR-A patients showed NAT O. Kâ, M.L. Guèye, A.O. Touré. (+ vs. - p=0.0003) was an independent prognostic factor for OS along General Surgery Department. Faculty of Medicine. Cheikh Anta with R (R0, 1 vs. R2 p=0.0003), operation time (≦494 vs. >494min Diop University. Dakar, Senegal p=0.005), post-operative CA19-9 level (≦ vs. >37 U/ml p=0.02) and nodal involvement (N0 vs. N1 p=0.045). Objectives: In Senegal, the practice of obesity surgery is very Conclusion: The combination of NAT and surgical resection recent. The objective of this study is to report the results of our first improves survival of patients with BR-A pancreatic head cancer. The experience of bariatric surgery in Senegal. prophylactic extended resection should not be performed for those Methods: We did at the Clinique de la Madeleine in Dakar, patients. during one year, a prospective study in 21 patients under-going

140 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

surgery for obesity. The study included patients who had sleeve O-016 gastrectomy by laparoscopy. A total of 19 patients were included. We evaluated at one year, weight loss, diabetes control, high blood ENDOSCOPIC VACUUM-ASSISTED CLOSURE SYSTEM pressure, dyslipidemia and patient satisfaction. FOR THE TREATMENT OF UPPER GASTRO-INTESTINAL Results: They were 2 men and 17 women (sex ratio: 0.1). The mean ANASTOMOTIC LEAKAGES: REPORT OF TWO CASES. age was 35.5 years (range: 27 years-52 years). Body mass index, H. Belkhodja1, O. Glehen2, G. Phelip1, P. Rousset3, E. Cotte2, BMI, was 43.27 kg / m2 (range: 40.2 kg / m2 - 50.6 kg / m2). Four D. Cabelguenne4, M. Chauvenet1, P Dominici1, P. Rocca1, patients were treated for arterial hypertension), 19 for knees G. Passot2, S. Nancey1, G. Boschetti1 arthrosis, 8 for low back pain and 2 for primary infertility. Four (4) 1Department of Gastroenterology, Lyon-Sud hospital, Hospices patients had type II diabetes and were treated with oral anti- Civils de Lyon, Université Lyon1, Lyon, France diabetics. Hypercholesterolemia was found in 5 patients, hyper- 2Department of Digestive Surgery, Lyon-Sud hospital, Hospices triglyceridemia in 3 patients and metabolic syndrome in 4 patients. Civils de Lyon, Université Lyon1, Lyon, France Abdominal ultrasound had eliminated biliary lithiasis in all patients 3Department of Radiology, Lyon-Sud hospital, Hospices Civils and had recovered hepatic steatosis in all patients. In peroperative de Lyon, Université Lyon1, Lyon, France time, one patient presented barotrauma to intubation with a left 4Department of Pharmacy, Lyon-Sud hospital, Hospices Civils pneumothorax requiring exsufflation and postponement of the de Lyon, Université Lyon1, Lyon, France procedure. One patient presented an early stenosis of the gastric sleeve. The mean weight loss was 48.5 kg (39 kg-65 kg), type Background: Treatment of digestive anastomotic leakages remains II diabetes and high blood pressure were controlled in 4 patients by challenging and there are no specific recommendations of care. the diet alone; Dyslipidemia was corrected in 8 patients. 18 Recently, endoscopic vacuum-assisted closure system (E-VAC) was patients were satisfied. Morbidity was 2/19 and mortality was zero. developed and used to treat intestinal leakage not responding to Conclusions: The preliminary results of our study are encouraging standard treatment. This technique provides wound drainage, and motivate us to develop bariatric surgery in Senegal. promotes tissue granulation and closure of the fistula. Data come from cases reports or small series suggesting that (E-VAC) is a safe and effective procedure. O-015 Methods: We report here two cases of upper gastro-intestinal anastomotic leakages treated by E-VAC. The endoscopic procedures CHRONIC GASTRIC LEAKS AFTER SLEEVE GASTRECTOMY: were performed under general anesthesia with intubation. After an RISK FACTORS OF RADICAL SURGICAL TREATMENT endoscopic assessment of the leak and the cavity, the size of the polyurethane sponge was adjusted. The sponge was introduced into N. Wallach1,2, A. Pasquer1,2, E. Pelascini1, G. Poncet1,2, the cavity through the luminal defect with a gastroscope. A negative E. Disse2,3, M. Robert1,2 pressure was applied constantly to the sponge and the E-VAC was 1Department of Digestive Surgery, Specialized and Integrated changed every week. Center for Obesity Management, Hospices Civils de Lyon Results: We treated with E-VAC, leakage of one esophago-jejunal Hôpital Edouard Herriot, 5, place d’Arsonval, 69437 Lyon, France and one gastroduodenal anastomosis. Both were complicated by 2Université Claude Bernard Lyon 1, Lyon, France liquid collections. Sponges were changed two and three times 3Department of Endocrinology, Diabetes and Nutrition, respectively and time interval between each change of sponge was Specialized and Integrated Center for Obesity Management, between 5 and 7 days. No complications were observed during the Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, 165, treatment with E-VAC. This procedure closed both leaks after three chemin du Grand Revoyet, 69495 Pierre Bénite, France weeks of treatment. No reopening of the fistulas was observed Introduction: 2% of the sleeve gastrectomy (SG) lead to gastric leak after more than 6 months of follow-up. (GL). Surgical treatment (total gastrectomy) is the treatment of Conclusion: E-VAC should be considered as an effective and safe chronic GL. The aim of this study is to determine the risk factors treatment of upper gastro-intestinal anastomotic leakages. This (RF) of chronic GL. procedure requires a multidisciplinary approach and has to be Material and methods: This retrospective monocentric study compared to standard care in larger and controlled studies. compares the patients of our service specialized in bariatric surgery, who had a GL after SG. We realized 264 SG between O-017 december 2008 and december 2016, and 4 patients had a GL. 18 patients with a GL went from other hospitals, 22 patients were POSITIVE FUNGAL CULTURE IN PATIENTS OF PEPTIC ULCER included in the study. We compared the datas of 10 patients who PERFORATION – A SIGNIFICANT RISK FACTOR FOR ADVERSE had a gastrectomy and 12 patients who have not been operated. OUTCOME. Results: The RF of chronic GL are a gastro-cutaneous fistula, an intra-peritoneal abscess and a large fistule (more than 1 cm) Mahim Koshariya, Surbhi Garg, Abhishek Shitole, Sheikh (respectively 16 % vs 80%, p = 0.003, 25% vs 70%, p = 0.035, 25% Behram, Prashant Kharat, A.Rai, M.C. Songra. vs 70%, p = 0.035). A previous gastric surgery (16% vs 60%, p = Gandhi Medical College and Hamidia Hospital, Bhopal, 0.074), aged patients (average of 39.6 years vs 48 years p = 0.073), 462001, India. high BMI (45.5 vs 50.7kg/m², p = 0.213) and denutrition (prealbumine Background: Although the incidence of peptic ulcer disease has rate 0.21 vs 0.16g/L, p = 0.076) seems to be RF of total gastrectomy. reduced, the peptic ulcer perforation rates remain constant. Till Conclusion: The RF of chronic GL are gastro-cutaneous fistula, recently the emphasis has been given on identification of microbial intra-peritoneal abscess and large fistula. Others studies are flora associated with peritonitis caused by perforated peptic ulcer. required to have better knowledges about the RF of chronic GL and The aim of this study was to determine the incidence and the necessity to execute a gastrectomy for GL after SG. significance of intraoperative peritoneal fluid culture of fungus in Key words: Gastric leak, sleeve gastrectomy, chronic patients with perforated peptic ulcers.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 141 ABSTRACTS

Materials and method: In this study, we included 53 patients of mutagenesis were compared between standard recipe kimchi perforated gastroduodenal ulcers (confirmed intreaoperatively) (sKimchi) and special recipe cpKimchi in in vitro H. pylori-infected admitted in our hospital. Patients were evaluated pre-operatively; cell model. The erythematous and nodular changes, mucosal ulcera- intra-operative peritoneal fluid specimen was sent for culture & tive and erosive lesions in the stomach were noted at 24th weeks, but sensitivity; post-operative records of various parameters were cpKimchi administration significantly ameliorated. After 36th studied; patients morbidity & mortality were evaluated with weeks, scattered nodular masses, some ulcers, and thin nodular reference to their culture outcome. gastric mucosa were noted in H. pylori-infected mice, whereas Results: Out of the total 53 patients studied, 35 patients (66%) had these gross lesions were significantly attenuated in cpKimchi group. gastric ulcer perforation and 18 patients (34%) had pyloroduodenal On molecular analysis, significant expressions of COX-2 and IL-6, ulcer perforation. Fungal cultures of peritoneal fluid were positive in activated NF-κB and STAT3, increased apoptosis, and marked 24 out of 53 patients (45.2%), Candida being the most common oxidative stresses were noted in H. pylori-infected group relevant isolated species in 22 patients (91.6%) followed by Apergillus. Fungal to tumorigenesis, but these were all significantly attenuated in cultures were found positive more commonly in patients above 50 cpKimchi group. cpKimchi extracts imparted significant selective years of age and in females. Age, preoperative organ failure, delay in induction of apoptosis only in cancer cells, led to inhibition of operation, high Mannheim Peritonitis Index (MPI) and Acute H. pylori-induced proliferation, while no cytotoxicity through Physiology And Chronic Health Evaluation (APACHE) II scores, significant HO-1 induction in non-transformed gastric cells. In smoking, alcohol abuse, steroid use, H2 blockers and preoperative conclusion, daily dietary intake of cpKimchi can be an effective way antibiotic therapy were risk factors for a positive fungal culture. either to rejuvenate H. pylori-atrophic gastritis or to prevent Increased morbidity was observed in fungal peritonitis patients in tumorigenesis supported with the concerted actions of anti- comparison to non-fungal peritonitis cases. 18.18% mortality was oxidative, anti-inflammatory, and anti-mutagenic mechanisms. observed in Candida peritonitis group and 3.44% mortality in non- Candida peritonitis group. O-019 Conclusion: Fungal positivity was a significant risk factor for adverse outcome in patients with a PPU. Patients having associated risk factors LAPAROSCOPIC SURGERY FOR GASTRIC CANCER-HOW TO AVOID and a MPI score >24 and APACHE II score of >12 with positive intra- UNDERSIRED EVENTS? operative peritoneal fluid fungal culture can be considered for early antifungal treatment. Belev N., Atanasov B., Penkov R., Popov S., Krastev P., Petleshkov I., Dgarov G. UMPHAT - Eurohospital, Plovdiv-4000, Bulgaria. O-018 Objectives: Gastric cancer is second most common cause of death NUTRITIONAL AND DIETARY INTERVENTION TO LESSEN GASTRIC among all . Several meta-analyses have show better CANCER RISK short-term results after laparoscopic gastrectomy compere to open procedure, with similar oncological outcomes. In this study Ki Baik Hahm, Ji Young Oh, Jong Min Park, Young Min Han, patients with resectable gastric cancer was included. Sung Pyo Hong Metods: Patients with histologically proven, surgically resectable Digestive Disease Center, CHA University Bundang Medical gastric cancer (T1-4a,N1-3b, M0) and European Oncology Study Center, Seongnam, CHA Bio Complex, Cancer Prevention Group performance status 0,1,2 are eligible to participate in this Research Center, and CJ Food, Suwon, Korea study. Primary endpoint is operative time and morbidity rate. From Inflammatory mediators alter the local environment of tumors, 01.03.2014-30.12.2016 52 patients underwent laparoscopic gastric known as the tumor microenvironment. Mechanistically, chronic resection for gastric cancer. We performed 21 total D2 gastrectomy inflammation induces DNA damage, but understanding this hazard with intracorporal esophagojejunal anastomosis and 31 subtotal may help in the search for new chemopreventive agents for gastric gastrectomy with gastrojejonoanastomosis. We performed 64 cancer which attenuate Helicobacter pylori-associated inflamma- open gastrectomy (36 total and 32 subtotal gastrectomy) for this tion. In the clinic, gastric cancer still remains a major cause of period. cancer-associated mortality in spite of advances in screening and Results: The mean duration of the laparoscopic procedure was 210 non-invasive treatment, chemoprevention with anti-inflammatory min. versus 150 min in open group. There was 1 conversion due agents to mitigate H. pylori-associated mutagenic inflammation is to mesenterial as a reason for short jejunal lооp. Mean thought to be a realistic approach to reduce gastric cancer. In this hospital stay was 5,6 days in laparoscopic group and 9,4 days in open lecture, I will provide insights to explain the mechanistic connec- group. Fore postoperative complication (7,6%) after laparoscopic tion between inflammation and gastric cancer, as well as describe procedure (internal pancreatic fistula, leakage of oesophagojejunal a feasible cancer prevention strategy based on anti-inflammatory anastomosis, ileus, wound infection) was reported. Six postoperative treatments. Especially, I will introduce kimchi intake as nutritional complication (9,3%) after open surgery (duodenal stump leakage, and dietary intervention to prevent gastric cancer. To prove whether external pancreatic fistula with bleeding, leakage from oesophago- dietary intervention can prevent Helicobacter pylori-induced atrophic jejunal anastomosis) was founded. All of patients with postoperative gastritis and gastric cancer, we developed cancer preventive kimchi complication were in advanced stage gastric cancer disease (T3- (cpKimchi) through special recipe and administered to chronic H. 4aN1-3bM0). pylori-initiated, high salt diet-promoted, gastric tumorigenesis Conclution: The implementation of laparoscopy to clinical practice mice model. H. pylori-infected C57BL/6 mice were administered in patients with gastric cancer can result in improved postoperative with cpKimchi mixed in drinking water up to 36 weeks. Gross and care quality, shortening of hospital stay, and quicker return to nor- pathological gastric lesions were evaluated after 24 and 36 weeks, mal activity. We did not found significant differences in morbidity respectively and explored underlying molecular changes to explain rate between laparoscopic and open operated patients. efficacies. Cancer preventive actions of anti-inflammation and anti-

142 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-020 tumors near the EGJ while minimizing the extent, invasiveness and morbidity of the procedure. In this video, we describe a technique for SKIN PERFORATOR (LICAP) FLAP PEDICLED BY INTERCOSTAL MUSCLE laparoscopic intragastric resection of a submucosal tumor located FOR REPAIR OF A TRACHEOBRONCHOESOPHAGEAL FISTULA close to the EGJ in a 64-year-old male in BMA General hospital Bangkok, Thailand. This video demonstrates the technique for Bertheuil N., Rayar M., Gaignard E., Watier E., Meunier B. operative field setup, port placement, and step of the operation.

Background/aim: A tracheobronchial fistula (TBF) is a rare compli- cation when surgery is performed to treat esophageal ; O-022 no consensus treatment strategy has emerged over past years. Materials and methods: Here, we describe a surgical interposition INTRAGASTRIC SINGLE-INCISION LAPAROSCOPIC SURGERY FOR strategy, using a new flap, to repair a TBF arising when esophageal GASTRIC : A STEPWISE APPROACH squamous cell carcinoma was treated via neoadjuvant chemo- JB. Cazauran, F. Mercier, A. Pasquer, P. Dominici, E. Cotte, radiation. This intervention is ideal after minimally invasive D. Vaudoyer, O. Glehen, G.Passot. esophagectomy by thoracoscopy but is also feasible after thoracoto- Lyon Sud Hospital, Dept of Surgical oncology, Hospices Civils my. We performed a skin perforator propeller (lateral intercostal de Lyon, Université Lyon 1, 69310 Pierre-Bénite, France. artery perforator) flap pedicled by the intercostal muscle 1. Here, we describe the surgical technique and our result on our four patients. Background: Laparoscopic wedge resection without lymph node Result: We performed this flap in four patients in emergency for dissection is commonly used as the standard treatment for small this life threatening complication. Two patients were saved and gastric subepithelial lesions suspect of gastrointestinal stromal were alive by this technique. In the post-operative, 1 patient was tumor (GIST). Esophagogastric Junction (EGJ) represents a difficult re-operated on 11 months later to treat a residual tracheal fistula. location for surgical resection. We report a successful single- Two patients were died, one of mesenteric ischemia and one of incision laparoscopic and endoscopic cooperative surgery (LECS) massive digestive hemorrhage but without complication on the for a suspected GIST of the EGJ. treated fistula. The last patient was alive without complication. Patient: A 51-year-old man with bleeding and dysphagia symptoms Conclusion: This treatment allows survival in the acute phase; if was diagnosed with tumor near the EGJ. Preoperative CT scan and there is a residual fistula or recurrence, resection and anastomosis endoscopic ultrasonography showed a 35mm hypo echoic sub can be performed when the patient is stabilized. We believe that mucosal tumor at the smaller curvature of the EGJ, suspect of GIST. this perforator flap using the lateral intercostal perforator pedicled The lesion was only visible in retrograde vision, which made the with an intercostal muscle flap is safe and simple. The very long endoscopic resection not feasible. pedicle can reach deeper sites and opens new doors when there Technique: The patient was placed in the supine position, and both are complications during esophageal surgery. In conclusion, this arms in abduction (French position). First laparoscopy allowed an strategy is a valuable option and may be the optimal first-line treat- abdominal cavity exploration, the release of the vessels at risk of ment, especially in the context of neoadjuvant radiation therapy. bleeding after stapling. After a short gastrotomy in the antrum and We are convinced that this flap affords new options for intratho- skin fixation, the single-incision device was placed in the gastric racic reconstruction. cavity. The suspected GIST was definitively identified and the Reference: 1 - Bertheuil N, Cusumano C, Meal C, Harnoy Y, Watier stapler was placed under laparoscopic vision and gastoscopic retro- E, Meunier B.Skin Perforator Flap Pedicled by Intercostal Muscle for vision control, insuring the absence of EGJ stenosis. The resection Repair of a Tracheobronchoesophageal Fistula. Ann Thorac Surg. was performed, using 2 ranges of staples while removing the tumor 2017 Jun;103(6):e571-e573. and the muscular layer. Conclusion: LECS provide a better control for stapling and prevent for post-operative EGJ stenosis. Transgastric single-incision allows O-021 single gastrotomy, ergonomic laparoscopy, while protecting the gastric wall from peroperative tearing. LAPAROSCOPIC INTRAGASTRIC RESECTION OF SUBMUCOSAL TUMORS NEAR THE EGJ N. Boonyagard, T. Sawangsangwattana, P. Aimsupanimitr, O-023 P. Thaweepworadech, I. Viratanapanu, D. Charoenthong, S. Chartchaiyarerk, S. Ussavarojpong, C. Suwitchakul SMALL LIVER MET: RADIOFREQUENCY VERSUS RESECTION: A BMA General Hospital, Bangkok Thailand 10100. COMPARATIVE STUDY There are many types of submucosal tumors of the stomach. The Demartines Nicolas most common submucosal tumor of the stomach is Gastrointestinal stromal tumor (GIST). Because of the low risk of lymphatic spread, O-024 surgery remains the main curative treatment. Laparoscopic wedge resection is used as the standard treatment for small submucosal tumors of the stomach including GIST. By the way, resection of tumors REPEAT LAPAROSCOPIC LIVER RESECTION FOR TUMOUR RECUR- located near the esophagogastric junction (EGJ) remains challenging RENCE Extensive resection can compromise function, cause significant Belli Giulio morbidity, and technically difficult laparoscopically. Laparoscopic intra-gastric resection allows for resection of small submucosal

Surgery, Gastroenterology and Oncology, 22 (3), 2017 143 ABSTRACTS

O-025 Results: ALPPS was completed after a median time of 12 days. At ALPPS-2, baseline FLR/TLV and FLR/BW showed significant negative "ASSOCIATING LIVER PARTITION WITH PORTAL VEIN correlation with volume gain (p=0.002 and p=0.02 respectively). A LIGATION FOR STAGED HEPATECTOMY" (ALPPS) DOES significant positive correlation was found between final indexed NOT PROMOTE COLORECTAL TUMOR GROWTH portal vein flow (iPVF) and volume gain (p=0.002). In patients with portal vein pressure (PVP) <20 mmHg and portal gradients (HVPG) P. Kambakamba, M. Linecker, C. Reiner, T.D.L. Nguyen Kim, <15 mmHg a significantly higher volume gain was recorded: 76.7% P. Limani, I. Romic, J. Figueras, H. Petrowsky, P.A. Clavien, vs. 30.6% (p=0.04). Similarly, the median increase of the MEBROFLR M. Lesurtel. uptake was significantly higher: 26.7% vs. -0.13% (p=0.02). A 1 Croix-Rousse University Hospital, Hospices Civils de Lyon, decreased MEBROFLR uptake before ALPPS-2 was observed in 2 Surgery, Lyon. patients, the first despite a 50% FLR volume gain. Perioperative mor- 2 University Hospital Zurich, Surgery, Zurich, Switzerland. tality was seen in 2 (9.5%) patients, both displaying low regeneration 3 Community Hospital Muri, Surgery, Muri, Switzerland. rates and a PVP>20 mmHg and HVPG>15 mmHg following ALPPS-1. Objectives: The effect of ALPPS on tumor proliferation, remains a Conclusions: The volume increase in ALPPS procedure is partially concern. This study investigated the impact of ALPPS on growth of correlated to the MEBRO uptake, being higher in patients exhibiting colorectal metastases in mice and human. a moderate hemodynamic stress. Patients with HVPG <15 mmHg or Methods: The effect of ALPPS and 90% portal vein ligation (PVL) on PVP <20 mmHg showed a higher increase of functional growth and a colorectal liver and lung metastases was investigated in mice. In higher volume gain. vivo tumor progression was assessed by magnetic resonance imaging (MRI), histology and survival experiments. The effects of ALPPS, PVL and control sera on colorectal cancer cells (MC38 and O-027 CT26) were tested in vitro. Additionally, the international ALPPS registry enabled to identify patients with remaining tumor in the EXTENDED LIVER VENOUS DEPRIVATION BEFORE MAJOR HEPA- future liver remnant (FLR) after ALPPS stage 1. TECTOMY. A SAFE ALTERNATIVE TO ALPPS? Results: Two and three weeks after ALPPS stage 1, PVL or sham F. Quénet, O. Sgarbura, MH. Pissas, P. Rouanet, F. Vauchot, surgery, liver MRI showed similar intrahepatic tumor numbers S. Carrere, E. Deshayes, B. Guiu. ((p=0.14/0.82), sizes (p=0.45/0.98) and growth kinetics (p=0.58/0.68). Institute of Cancer Montpellier, 34298, France Tumor growth was not different between ALPPS and PVL groups after CHU St Eloi Montpellier, 34000, France completion of stage 2. Survival after tumor cell injection was similar after sham surgery and completion of ALPPS and PVL (36 days (IQR Objective: Extended liver venous deprivation (eLVD) was previously 32-40) vs. 42 days (IQR 36-48) vs. 39 days (IQR 35-42), p=0.237). defined by our group as the combination of right portal vein Pulmonary metastases progression and in vitro cell proliferation were embolisation and right and middle hepatic vein embolisation in the comparable among groups. Observations in humans failed to identify premises of major hepatic surgery in order to achieve a future liver accelerated tumor growth in the FLR within the regenerative phase remnant (FRL) functional increase. The aim of the present study is to after ALPPS stage 1. investigate the surgical outcome of these patients. Conclusion: The accelerated regeneration process associated to Methods: All consecutive patients treated in our center between ALPPS does not enhance the growth of residual colorectal liver October 2015 and May 2017 that were referred to eLVD were metastases. included in the present study. eLVD was only proposed to non- cirrhotic patients with a FRL volume <25% of the total liver or a small FRL function assessed by 99mTc-mebrofenin hepatobiliary scintigra- O-026 phy (HBS) . Morbidity and mortality were recorded alongside with disease related variables. REGENERATION OF THE FLR, 99MTC-MEBROFENIN Results: Nine patients out of 10 included underwent post eLVD HEPATOBILIARY SCINTIGRAPHY AND HEMODYNAMIC major hepatectomy for colorectal liver metastases (n=7), breast STRESS IN ALPPS: A PROSPECTIVE STUDY. cancer liver metastases (n=1) and intrahepatic (n=1). The sex ratio of operated patients was M:F=5:4. The average Tomassini F., D’Asseler Y., Lecluyse C., Colman M., Ariotti R., age was 57.33 years. FRL function increased by 81.86% (range Lambert B., Sainz-Barriga M., Hoorens A., Van Dorpe J., Geboes 19.65-225%) and the maximum FRL function was at day 7. The FRL K., Troisi R.I. volume increased by +44.44% at 21 days. Six extended right Dept. of General, Hepatobiliary and Liver Transplantation hepatectomies were performed out of which five were extended to Surgery. Ghent University Hospital, 9000 Ghent, Belgium. segment IV and one was extended to both segments I and IV. The Objective: To prospectively assess hemodynamic changes and rest of the surgical operations were standard right hepatectomies. their relationships with regeneration and function in Associating Mean hospital time was 15 days. Two Clavien Dindo grade IIIA Liver Partition and Portal vein ligation for Staged hepatectomy complications were observed. The rest of the cases did not present (ALPPS). any major complication. One patient had a PT<70 at postoperative Summary Background Data: Regeneration of future liver remnant day 5 but no post-hepatectomy liver failure was reported. No (FLR) and function are two processes that not always coincide. patient died in the 90 days following surgery. Methods: Twenty-one patients underwent ALPPS between June Conclusion: Post eLVD major hepatectomy is feasible and safe. If 2013 and November 2016. Total liver volume (TLV) were evaluated. those early results are confirmed by larger studies, eLVD could FLR function was assessed by 99mTc-Mebrofenin (MEBRO) scintig- constitute a safe and effective alternative to ALPPS. raphy. Liver hemodynamics were assessed by transit time flow and pressure measurements.

144 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-028 bilobar CRLM treated with chemotherapy and surgery. Methods: 597 consecutive patients undergoing first liver resection ALPPS POSSIBILITIES IN THE TREATMENT OF THE FOCAL HEPATIC (LR) for CLM between 2002 and 2015 were considered. Patients carrier of multiple (≥4) CLM with intrahepatic major vascular contact were included. Voskanyan S.E., Artemiev A.I., Naydenov E.V., Zabezhinsky D.A., Results: 210 patients were analyzed. OSH was performed in 195 Shabalin M.V., Rudakov V.S., Shcherbin V.V., Zhurbin A.S. (93%), 28 patients received new devised surgical intervention State Research Center Burnazyan FMBC of the FMBA of Russia, (SERPS, transversal hepatectomy, mini-mesohepatectomies, liver Moscow, Russia. tunnels). Thirty-one patients received vascular reconstruction. Aim: Immediate results of the Associated Liver Partition and Portal Fifteen patients underwent two stage hepatectomy (TSH). 14 Vein Ligation for Staged Hepatectomy (ALLPS) at the focal liver patients of the OSH group underwent major hepatectomy lesions at the Small Liver Remnant after liver resection have been associated to limited resection. The median number of resected studied. CRLMs was 8 (4-48) and 77 (37%) patients had >10 nodules. Twenty- Materials and methods: 22 ALPPS have been performed in our seven patients were R0, 36 R1 vascular only, 75 R1vascular + clinic from December 2011 to June 2017. Multiple metastases of R1parenchimal, 64 parenchymal only. Mortality and morbidity rates colorectal cancer (9 patients), (3 were 1,4% and 37%. Five-year survival was 28% (median overall patients), advanced alveolar disease of the liver (6 patients), survival 30 months). At univariate analysis extrahepatic disease, cholangiocellular carcinoma (1 patients), (1 patient), radiological response, vascular reconstruction, RAS mutation and metastatic neuroendocrine cancer of the liver (1 patient) and re hepatectomy were all independent factor affecting survival. At metastases of the adrenocortical cancer in the liver (1 patient) with multivariate analysis only RAS mutation HR 2.230285 CI 1.019159- Small Liver Remnant (<25%) after liver resection according data of 4.880663 p= 0.045, re-hepatectomy HR .2643287 CI 0.0924081 - the CT-volumetry have been indications for surgery. 0.756099 p= 0.013 and early recurrence HR 4.822064 CI 2.26014- Results: At the first stage of the surgery duration of the surgery was 10.28799 p=0.000 were independently associated with survival. 240 (210-290) minutes; the average blood loss was 1000 (800- Conclusions: OSH for CRLMs is safe and effective. TSH must be 1500) ml. At the second stage of the surgery duration of the reserved for a selected number of patients. Parenchymal spare surgery was 90 (70-100) minutes; the average blood loss was 300 resections must be attempted whenever possible to allow re (200-400) ml. Morbidity was 40.9%. 6 patients (27.3%) had the bile resection. leakage from the liver stump with biloma formation (drainage of the bilomas through ultrasound). One patient (4.5%) had intra- O-030 abdominal bleeding with hematoma formation (drainage of the hematoma through ultrasound). One patient (4.5%) had acute LIVER PROCUREMENT ON SWINE: A PILOT STUDY ON A renal failure developed (completely interrupted after the second SIMULATION-BASED PROGRAM FOR ADVANCED SURGICAL stage of the surgery). Postoperative liver failure (ISGLS, 2011) was TRAINING not amoung all patients. Hospital mortality was 4.5% (1 patient with massive pulmonary embolism). Postoperative hospital-stay B. Darnis, Jy. Mabrut, Jb. Cazauran, C. Vogt, C. Ducerf, K. Mohkam. was 22 (18-29) days. Digestive surgery and liver transplantation unit. Croix-Rousse Conclusion: ALPPS at extensive liver damage by the primary and University Hospital. 103, Grande rue de la Croix-Rousse 69317 secondary focal lesions and at the small liver remnant after liver Lyon Cedex 4. resection allows achieve the desired growth of the liver remnant Objectives: Liver procurement (LP) from deceased donor is a and perform the resection of the affected liver. challenging procedure often performed by junior surgeons. The current modalities for teaching LP to surgical trainees (STs) rely on O-029 theoretical lectures and patient-based apprenticeship. Porcine LP may represent an alternative for teaching LP without putting patients at MULTIPLE BILOBAR COLORECTAL LIVER METASTASES WITH MAIN risk, but its effectiveness is ill-defined. Herein, we assessed the VASCULAR CONTACT: SURVIVAL ANALYSIS AND PROGNOSTIC feasibility and utility of a porcine simulation model of LP. FACTORS Methods: A pilot course for STs combining theoretical lectures and a hands-on simulation of LP on swine was organized. An anony- M. Cimino, L. Vigano’, F. Procopio, M. Donadon, D. Del Fabbro mous survey was conducted before and after the course to assess and G. Torzilli. STs’ background knowledge and feedback. Department of Surgery Divison of Hepatobiliary & General Results: Among the 30 attending STs, 21 (70%) had previously Surgery - Director: Guido Torzilli MD, PhD, FACS performed at least one step of LP on patient as first operator, but Humanitas Research Hospital & Humanitas University 27 (90%) expressed lack of confidence for performing the proce- Objectives: Multiple colorectal liver metastases (CRLM) is one of dure on patient without senior assistance. All porcine LPs were the most challenging disease for a hepatobiliary team. Complete conducted successfully, except for one animal that died from clearance of the disease is often not possible due to the small hemorrhage during cannulation. Twenty-six (87%) STs considered volume of the future remnant liver. Several strategies have been that the proposed training program should be mandatory before proposed to overcome this problem (es. Staged procedures, intra- performing LP on patients. operative radiofrequency ablation). We proposed the complete Conclusions: The porcine simulation model of LP is feasible and removal of all lesions in a single stage (one stage hepatectomy, greatly valued by STs, allowing them to learn a complex procedure OSH) thank to the extensive use of intraoperative ultrasonography. without putting patients at risk. The aim of the study is to analyze the outcome of patients with

Surgery, Gastroenterology and Oncology, 22 (3), 2017 145 ABSTRACTS

O-031 at the surgeon’s discretion. Intraoperative and in-hospital course were compared between the 2 groups to validate the feasibility of POSTOPERATIVE LIVER DYSFUNCTION AFTER RIGHT LOBE MSS. An analysis of the hemodynamic and metabolic efficiency of HEPATECTOMY IN LDLTX spontaneous shunts using staged lactate measurements was realized M.M. Shobari, A. Shehta, T. Salah, A. Sultan, A. Nabih, O. Fathy, to validate the observation. M. Sadany, A. Yassin, M. Morshedy, O. Sheha, M. Abdel-Razik, Results: MSS and PCS showed a comparable hemodynamic and and M. Abdelwahab. metabolic efficiency with no significant difference in terms of portal Gastroenterology Surgical Center, Jehan Street, Mansoura, pressure variation and gut lactate production. Moreover there was no Egypt 35516 significant difference in terms of short-term outcomes. Conclusion: The anatomy of spontaneous portosystemic collaterals Objectives: Evaluation of the incidence of postoperative liver should be analyzed before transplantation as they can guide the dysfunction after right lobe donation and searching for risk factors: need for portal decompression. T When a portal decompression is Methods: In the period between may 2004 and may 2016,440 needed, classical portacaval anastomosis may be realized but cases of living donor liver transplantation were done in Mansoura passive mesenterico-saphenous shunt could be particularly helpful gastroenterology surgical center in Egypt, 434 right lobe. Age 27 in cases of portal thrombosis and/or pedicle collaterals to avoid a (18-47). Males 310 females 124.bmi 26.3.almost all are related difficult dissection. In this setting, it seems feasible and sure and donors. Residual liver volume 38.4 (28.9-52.7). GRWAR 1,1 (0.53- exerts comparable short-term outcome to classical portacaval 2.46). double HA was found in 3% trifurcated portal in 4.1% and shunt. double portal in 0.5%.dominant MHV in 9%.makuchi in 24%.seg V in 36%segment VIII in 42%.parenchymal transaction was kellyclasia in 6%,harmonic in 74%spray diathermy in 10.8%.operative time O-033 410 min. parenchymal transaction time 77min,blood loss average LIVER 500cc: Results: Hospital stay 10 days.biliary complications 9.4%,internal Treska V., Ferda J., Daum O., Liska V., Skalicky T., Bruha J. haemorrhage 2.3%.serum bilirubin day 0 1.7mg, day3 2.2,day 6 1.1.inr day 0 1.3, day 3 1.5 and day 6 1.3.postoperative liver dys- Objectives: Liver are rare conditions representing function in 11.5%.grade A 10.8%,B O.5%andC 0.2%. PREDICTIVE approximately 5% of all cystic lesions of the liver. The aim of this study FACTORS of liver dysfunction were residual liver volume less than was to establish an optimal diagnostic and therapeutic approach and 35%and blood transfusion. Age, Sex, BMI. Operative time laboura- to emphasize a danger of their malignant transformation. tory, steatosis are not significant. Methods: In a retrospective study, 15 female patients primarily Conclusions: Postoperative liver dysfunction occurred in 11.5% diagnosed as having cystadenoma of the liver were evaluated of cases and residual liver volume less than 35% and blood transfusion between 2000 - 2016. In 6 patients, serum CA 19-9 and CEA levels are the only significant risk factor in univariant and multivariant were determined pre-operatively. Enucleation of the cystadenoma analysis. So, residual liver volume of 35% at least should be insisted. was performed in 7 (46.7 %) and liver resection in 6 (40 %) patients. Due to the localization, complete enucleation or radical liver O-032 resection could not be performed in two patients (13.3 %). Results: Tumor marker levels were normal. In 3 patients, grade III- PROXIMAL OR DISTAL PORTOSYSTEMIC SHUNTS DURING a complications (Clavien – Dindo) were recorded after surgery. No LIVER TRANSPLANTATION HAVE SIMILAR HEMODYNAMIC patient died within 30 days of surgery. The average length of hos- AND METABOLIC EFFICIENCY pitalization was 26 (5–52) days. Malignant transformation occurred in 2 patients with incomplete removal of the cystadenoma. In both F. Faitot, P. Addeo, C. Besch, E. Felli, C. Oncioiu, P. Bachellier. cases, CA 19-9 serum levels were elevated during the follow-up CHRU de Strasbourg, Hepatobiliary, Pancreatic and General period. In the first patient, a R1 resection reoperation was surgery Department, 67000 Strasbourg, France. performed with subsequent oncological treatment. The patient Introduction: Cirrhotic patients undergoing liver transplantation died 28 months after primary surgery. The second patient failed to often develop spontaneous portosystemic collaterals that may undergo the recommended liver transplantation. The remaining render surgical decompression unnecessary. On the other hand, patients are all well, with no signs of recurrence. spontaneous pedicle collaterals and/or portal thrombosis make the Conclusions: The only possible treatment of cystadenomas pedicle dissection difficult. In this latter situation, an alternative to involves their radical surgical removal. Any other incomplete the classical portacaval anastomosis may be proposed to decrease surgical treatment is insufficient and associated with a high risk of blood loss. The goal of this study was to compare the hemodynamic malignant transformation. In patients where for technical reasons and metabolic efficiency of spontaneous and surgical proximal R0 resection or complete enucleation cannot be performed, liver versus distal shunts. transplantation should be considered. Material and method: Patients transplanted between January 2014 and January 2016 who underwent a portal decompression during O-034 the anhepatic phase were included. Patients were compared according to 2 types of surgical decompression techniques: classical TAILORED APPROACH FOR VERY LOW RECTAL CANCER portacaval shunt (PCS) (n=44) and passive mesenterico-saphenous shunt (MSS) (n=77). MSS consisted of a passive shunt between Panis Yves inferior mesenteric vein and saphenous vein. The type of shunt was

146 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-035 experience in the field of Gastro-Intestinal Tract Ultrasound & Diagnostic as well Therapeutic Interventional Sonography. He is the NEW TECHNIQUE FOR SUTURED LAPAROSCOPIC ILEOCOLIC Pioneer of Gastro-Intestinal Tract Sonography, especially Gastro- ANASTOMOSIS ENTEROTOMY CLOSURE Duodenal Sonography. He has delivered many Guest Lectures in Indian as well International Conferences in nearly 27 countries as an C.C. Pereira, C.M. Insua, S. Costa, I. Romero, J.C. Pereira. Invited Guest Faculty, since March 2000. He is a Consultant Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal Radiologist & the Specialist in Conventional as well Unconventional Introduction/Objective: Intracorporeal anastomosis after right Gastro-Intestinal Tract Ultrasound & Diagnostic as well Therapeutic laparoscopic hemicolectomy is associated with lower complica- Interventional Sonologist in Pune, India. tions and shorter length of stay. However, the closure of the enterotomy made for the stapling device requires advanced laparo- O-037 scopic skills and is time consuming. We report a new technique of sutured enterotomy closure COLORECTAL CANCER IN PATIENTS YOUNGER THAN 50 YEARS: Methods: We use a slowly absorbing surgical suture cut to roughly A RETROSPECTIVE MULTICENTER STUDY ON BEHALF Y-SICO 25 cm. On the free end, we create a loop by first placing a double – PRELIMINARY RESULTS. knot and then looping the thread 4 times. We begin the suture on the posterior edge of the defect, and after the first stich is passed the Patrizia Marsanic, Andrea Muratore, Alfredo Mellano, Donatella needle is passed through the loop made previously making a self- Marino, Annamaria Squicciarino, Marco Veltri, Dario Parini, locking knot. We make a full thickness running suture and on the Maximilian Scheiterle, Sara Pollesel, Laura Lorenzon, Genoveffa other end of the defect we tie a Cushieri knot, we continue back Balducci, Roberta Tutino, Giuseppe Salamone, Rega Daniela, Delrio using the same thread to make a running seromuscular suture. Paolo, Matteo Frasson, Carmen Muniesa Gallardo, Gaetano Gallo, Finally, we tie a knot using the needle edge and the free edge left in Mario Trompetto, Raffaele De Luca. the beginning of the suture. Edoardo Agnelli Hospital, 10064 Pinerolo,Italy. Results: Using the standard technique of double layer suture the Background: In the last ten years, the incidence and mortality surgeon must tie four knots. This technique requires the surgeon to rates of colorectal cancer (CRC) have been decreasing in adults over tie only one standard knot intracorporeally and to throw one 50 years and increasing in adults under 50 years. CRC in patients Cushieri knot. under 50 yrs can be distinguished in hereditary and sporadic forms. Conclusion: By using self-locking knots and a single suture this Regardless of age at diagnosis, the vast majority of patients with technique has the potential to decrease the complexity and time CRC have sporadic disease and are “average risk” patients without spent on enterotomy closure in intracorporeal ileocolic anastomosis. a family or personal history of colorectal , inflammatory bowel disease, polyposis syndromes, or other risk factors. Objectives: A growing number of studies, which examine the rising O-036 incidence of CRC among patients under 50 years age, have been published, but they are small cohort studies with some bias like the “TRANSABDOMINAL SONOGRAPHY OF THE SMALL & LARGE inclusion of hereditary forms. Aim of the present study is to analyze INTESTINES” the data of a large cohort of <50 years and ≥50 years old CRC patients to understand if young patients (<50 years old), when Vikas Leelavati Balasaheb Jadhav, D.Y. Patil. matched for stage, have different prognosis and prognostic factors University, Pune, Maharashtra, India. compared with old ones (≥50 years old) and if young patients need TransAbdominal Sonography of the Small & Large Intestines can a different approach in terms of follow up or perioperative reveal following diseases. Bacterial & Viral Entero-Colitis. An Ulcer, chemotherapy. whether it is superficial, deep with risk of impending perforation, Methods: Multicenter international retrospective study comparing Perforated, Sealed perforation, Chronic Ulcer & Post-Healing fibrosis patients <50 years with patients >50 years stratified by TNM classi- & stricture. Polyps & Diverticulum. Benign intra¬mural tumours. fication. We have enrolled patients <50 years with sporadic cancers Intramural haematoma. Intestinal Ascariasis. Foreign Body. radically operated in 9 centers in the last 10 years. We have used as Necrotizing Entero-Colitis. Tuberculosis. Intussusception. control group patients >50 years from the same centers Inflammatory Bowel Disease, Ulcerative Colitis, Cronhs Disease. Results: Nowadays we have enrolled 2925 patients with colorectal Complications of an Inflammatory Bowel Disease – Perforation, cancer operated in the last 10 years. 338 (11%) are young patients: Stricture. Neoplastic lesion is usually a segment involvement, & 233 with colon cancer and 105 with rectal cancer. Mean follow up shows irregularly thickened, hypoechoic & aperistaltic wall with loss is 42 months. In the present series, we didn’t notice an increasing of normal layering pattern. It is usually a solitary stricture & has incidence of colorectal cancer in young patients between period eccentric irregular luminal narrowing. It shows loss of normal Gut 2006-2010 and 2011-2016 (49,8% vs 50,2%, p=0.009). We have Signature. Enlargement of the involved segment seen. Shouldering noticed a higer rate of T4 in patient <50 years than in ones>50 years effect at the ends of stricture is most common feature. Primary (27% vs 12.4% p=0.000). Furthermore we have noticed a higer rate arising from wall itself & secondary are invasion from adjacent malig- of lympho node metastases (N+ 59.4% vs 39.5 %, p 0.03) and nancy or distant metastasis. All these cases are compared & proved distant metastases (M+20.2% vs 17.7%, p0.000). However, the with gold standards like surgery & endoscopy. Some extra efforts recurrence free survival and the overall survival were significantly taken during all routine or emergent ultrasonography examinations better in group under 50 years. (respectively 25.94 months old vs can be an effective non-invasive method to diagnose primarily 41.22 months young, p 0.03 and 14,76 months old vs 21.98 months hitherto unsuspected benign & malignant Gastro-Intestinal Tract young, p 0.01). Mortality rate was 20,2% in young patients and lesions, so should be the investigation of choice. 13,8% in old patients, p 0.000. We have studied the correlation Biography: Dr. Vikas Leelavati BalaSaheb Jadhav has completed between stage and age stratifying the patients in 5 groups for age. PostGraduation in Radiology in 1994. He has a 23 Years of We observed higher rates of T3-T4 (88.9% vs 75,8% p 0.09), N+

Surgery, Gastroenterology and Oncology, 22 (3), 2017 147 ABSTRACTS

(61% vs 51% p 0.05), M+(28% vs 20.6% p 0.47), and undifferenziat- etiological link between schistosoma japonicum and colorectal ed tumors (38.9% vs 27.3%, p 0.18) in patient between 20-40 years cancer. However, the available data regarding the role of schistosoma than between 41-50 years. However, the recurrence free survival mansoni in colorectal carcinogenesis are conflicting and most often do was similar among the groups whereas the overall survival was sig- not show causality. We report on a patient with sigmoid colonic nificantly better in group between 41-50 years. (33.9 months vs cancer associated with schistosomiasis mansoni, and we provide a 50.8 vs 42.9, p 0.03). review of the literature with regard to this relationship. Conclusion: In our serie young patients with sporadic colorectal Schistosomiasis is a fairly prevalent communicable disease in cancer seem to have more advanced disease, expecially patients tropics and subtropics caused by a trematode of the genus schisto- with age between 20 and 40 years. soma. It affects more than 200 million people worldwide, with over 700 million living under conditions favouring transmission. [1] Human schistosomiasis is generally caused by three major species: O-038 Schistosoma mansoni (S. mansoni) endemic in Africa, the Middle NEOADJUVANT THERAPY AND SURGERY IN RECTAL East, and South America, Schistosoma japonicum (S. japonicum) . ANALYSIS OF PATIENTS WITH common in Southeast Asia, and Schistosoma haematobium (S. COMPLETE PATHOLOGICAL RESPONSE haematobium) prevails in Africa and the Middle East. [1] In endemic areas, schistosomal infestation has been implicated in the H.D. Elsiddig, O.EL.Salim, A.H.Widatalla, S.Z.Ibrahim, aetiology of several human malignancies including bladder, liver, S.H.Suliman. and colorectal cancer. [2] However, while sufficient evidence Soba University Hospital, Departments of General and supports a causal relationship between S. hematobium infection Gastrointestinal Surgery, University of Khartoum, Khartoum, and bladder cancer, the association between schistosomal infesta- postal code: 8081 Sudan. tion and colorectal cancer has apparently low status within the Objectives: Neoadjuvant chemoradiotherapy and total mesorectal canons of medicine and reports from the publishing world. [3] excision are considered the standard treatment for locally Furthermore, most of the published data refer to S. japonicum advanced rectal cancer. Various studies have reported a complete species, whilst the evidence linking S. mansoni to colorectal cancer pathological response rate of 15%–27% following neoadjuvant occurrence is meagre. We herein present three cases of sigmoid chemoradiotherapy which has translated into improved survival. colonic adenocarcinoma associated with deposited schistosoma Our objective is to determine the incidence and outcome of mansoni eggs, and we discuss the probable etiological role of complete pathological response in our African setting with younger chronic schistosomal infestation in colorectal cancer. We also patients and aggressive tumour biology. describe the a new endoscopic finding. Methods: Between 2011 and 2016, one hundred and ten patients of locally advanced rectal cancer underwent surgical resection at O-040 Soba university hospital following preoperative chemotherapy and short course radiotherapy. 33 patients (30%) underwent APR and INTRAMURAL SPREAD AND LYMPH NODE METASTASES 77 patients underwent anterior and low anterior resections. DETECTED IN THE MESORECTUM DISTAL TO CARCINOMA Results: Eleven patients (10%) showed complete pathological OF THE RECTUM BY THE CLEARING METHOD response. The median age of presentation was 49 years and 63.6% were males. The median interval between completion of preopera- J. Hida, H. Ushijima, Y. Yoshioka, K. Daito, J. Kawamura, tive chemoradiotherapy and surgery was 72 days (range 42-120 K. Ueda, T. Tokoro, I. Matsumoto, T. Yasuda, K. Okuno. days). Four patients (36.4%) underwent abdominoperinreal resec- Department of Surgery, Kindai University School of Medicine, tion and 7 patients (63.6%) had anterior and low anterior resection. Osaka, 589-8511 Japan The median nodes dissected at surgery were 8 (range 1–16). After a Objectives: Total mesorectal excision (TME) effectively reduces median follow-up of 39.3 months (range 10–70 months), the 3-year the local recurrence rate of carcinoma of the rectum. This study overall survival (OS) was 90.9% and the 3-year disease-free survival was undertaken to clarify the rationale for TME. (DFS) was 100%. The locoregional and systemic recurrence rates Methods: We retrospectively reviewed the records of 198 patients were 0%. who underwent resection of a carcinoma of the rectum. The pres- Conclusion: In the African scenario, despite younger age, aggres- ence of nodal metastases in the mesorectum distal to the primary sive disease and late presentation, outcome in complete respon- tumor was examined by the clearing method. ders is good and is in concordance with world literature. Efforts Results: Twenty-one patients (10.6%) were positive with distal need to be made to increase complete response rates in order to intramural spread. Patients with a higher pT number showed a get the maximum benefits in terms of survival and local control. higher positive rate. The distal spread was 2cm at maximum. The maximum distal spread in of the rectosigmoid and O-039 carcinomas of the upper rectum was 2cm, and in carcinoma of the lower rectum the distal spread was 1cm. The metastatic rate in the COLORECTAL CARCINOMA ASSOCIATED WITH distal mesorectum was 20.2%. The metastatic rates according to SCHISTOSOMIASIS: A POSSIBLE CAUSAL RELATIONSHIP the extent and site of the tumor were as follows: pT1, 0%; pT2, 0%; pT3, 21.9%; pT4, 50%; rectosigmoid, 10%; upper rectum, 26.3%; Omer El- Faroug Hafiz Salim1,2§, Hytham K Suliman2*, and lower rectum, 19.2%. The longest distal spread from the pri- Salwa Osman Mekki3*, Suleiman Hussein Suleiman1,2, mary tumor to the metastatic node was 2 cm in carcinoma of the Hilmi Doud, Shakir Zein Ibrahim1,2* rectosigmoid, 4 cm in carcinoma of the upper rectum, and 3 cm in Soba University Hospital. Sudan carcinoma of the lower rectum. The association between schistosomiasis and colorectal malignancy Conclusions: Distal mural resection of at least 3cm is required for has long been suggested in the literature, but it is not uniformly patients with carcinoma of the rectosigmoid and carcinoma of the accepted. In the Far East, considerable evidence supports an upper rectum, a 2cm distal mural resection is required for patients

148 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

with carcinoma of the lower rectum, and a 1cm distal mural resec- Objectives: Familial adenomatous polyposis (FAP) is an autosomal tion is required for patients with T1 and T2 tumors. In addition, dominant disorder caused by a germline mutation in the - TME is required for patients with T3 and T4 tumors in the lower tous polyposis coli (APC) gene. These patients have innumerable rectum, and excision of all mesorectal tissue down to at least 5 cm adenomatous polyps in their colorectum and develop colorectal below the tumor is required for patients with T3 and T4 tumors in cancer (CRC) unless polyps are adequately removed. The aim of the upper rectum. this study is to reveal clinicopathological features of FAP patients with surgical treatments. O-041 Methods: Clinicopathological factors of fifty-seven patients (male: 32, female: 25), who underwent surgical treatment for FAP in SURGICAL MANAGEMENT OF RECTUM TUMORS IN Tohoku University Hospital between 1984 and 2017, were retro- CONSIDERATION OF MODIFIED NEOADJUVANT THERAPY spectively analyzed. Results: The median age at surgical treatment was 31 years old Attila Paszt, Márton Vas, Szabolcs Ábrahám, Zsolt Simonka, (12-64). Total proctocolectomy with ilealpouch-anal anastomosis Anikó Maráz, György Lázár. (IAA), Subtotal colectomy with ileo-rectal anastomosis (IRA), total University of Szeged, Faculty of Medicine, Department of Surgery. proctocolectomy with permanent ileostomy, and low anterior Introduction: Nowadays the therapeutic treatment for advanced, resection were performed in 44, 10, 2, and 1 patients, respectively. T3-T4 staged rectum cancer and rectum adjacent to the Nineteen patients (33.3%) had CRC at initial surgical treatments, anal sphincter is neoadjuvant radio-chemotherapy and subsequent and all CRC occurred in patients age twenty and older (6 patients, surgical intervention. 11%). Pathological stage of those 19 patients with CRC was Stage 0: Method: Neoadjuvant oncological treatment for rectum cancer con- 3, Stage I: 4, Stage II: 5, Stage III: 7, respectively. Patients with CRC sisted of a standard-dose (50.4 Gy) radiotherapy and the intravenous were significantly older than patients without CRC (38.2 vs 30.1, p administration of leucovorin and 5-fluorouracil. In the course of the = 0.019). Four patients died from distant metastases. Although new protocol, patients receive the same dosage of radiotherapy with total proctocolectomy with IAA is considered to be standard proce- the oral administration of capecitabine. We analyzed retrospectively dure, subtotal colectomy with IRA was also performed in several the effect of these two oncological protocols to the surgical out- patients, such as older patients and advanced CRC patients. Out of comes in case of T3-T4 rectum tumors between 29th of September 10 patients with IRA, 2 patients required additional surgeries for an 2012 and 20th of May 2016 (n=94). We assessed the clinical data of occurrence of rectal cancer or an increased number of polyps. 87 patients since 7 case proved to be technically inoperable. The Conclusions: The standard procedure for FAP is total proctocolec- effectiveness of oncological therapy is best characterized by the tomy with IAA. Careful surveillance of the rectal remnant is Tumor Regression Grade (TGR1 means total regression, whilst TGR5 needed in patients who had subtotal colectomy with IRA. indicates progression). We evaluated the type of operations, the sur- gical technique of the operation, the number of removed regional O-043 lymph nodes and the proximity of resection margins. Results: Comparing the two groups we found that in case of per os LOW RECTAL CANCER – EVALUATION OF SURVIVAL neoadjuvant chemotherapy (Group 1, n=44) we could achieve IN ANTERIOR RECTAL RESECTION VERSUS ABDOMINO-PERINEAL complete regression in 13 cases (29.5%), while in case of intra- AMPUTATION venous administration (Group 2, n=43) complete regression M.L. Matos, L. Carvalho, A.M. Correia, I. Bessa, J. Costa, A.C. occurred in 4 cases (9.3%) only. Comparing the surgical techniques Soares, M.R. Sousa, J. Costa Pereira, G. Gonçalves, M. Nora. we found, that the sparing of the anal sphincter was significantly Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da higher with modified treatment as opposed to the old neoadjuvant Feira, 4520-211, Portugal. therapy. Furthermore, in case of laparoscopic resection after the modified neoadjuvant therapy the number of removed lymph Objectives: In low rectal cancer the long term results of abdomino- nodes increased from 7,7 to 10,7 pcs/pts. In the safety resection perineal amputation (APA) usualy are worst than the low anterior margins (distal, circumferential) weren’t significant different rectal resection (LAR). The goal of this study was to compare the between the groups. impact of two surgical techniques for low rectal cancer on overall- Conclusions: As a result of the modification of oncological survival and disease-free survival. protocol in case of advanced rectum cancer, the number of cases Methods: We analysed a retrospective cohort of patients submit- with complete tumor regression is significantly increased. The ted to low rectal cancer surgery - both LAR and APA - with curative results strongly suggest that the modified neoadjuvant treatment intent from January 2012 to December 2014. Exclusion criteria following laparoscopic surgery has several advantages over the were: non-curative resection, stage IV disease, Hartmann’s proce- previous methods in the surgical solution for advanced (T3-T4) dure and benign . We used the log rank test for compar- rectum cancers. ison of the Kaplan-Meier curves. P values < 0.05 were considered statistically significant. O-042 Results: We identified 32 patients – 34.4% of which were submitted to APA (n=11) and 65.6% underwent LAR (n=21). Neoadjuvant radio- SURGICAL TREATMENTS FOR PATIENTS WITH FAMILIAL therapy was given to 46.9% of the patients (n=15). Half of the ADENOMATOUS POLYPOSIS (FAP); A SINGLE-INSTITUTE patients were between 50 and 70 years old and 43.8% of the patients EXPERIENCE were older than 70 years old. Stage I/II was found in 46.9% of the S. Ohnuma, H. Karasawa, K. Watanabe, H. Suzuki, .H Imoto, patients (n=15) and stage III in the remaining 53.1% (n=17). We did T. Aoki, K. Kudoh, N. Tanaka, M. Nagao, H. Musha, F. Motoi, not identify a statistical significance between both surgical T. Kamei, T. Naitoh, M. Unno. techniques on overall survival and disease-free survival. However, Department of Surgery, Tohoku University Hospital, Sendai, in patients submitted to LAR there was a tendency for shorter 980-8574 Japan. overall survival (p= 0.06).

Surgery, Gastroenterology and Oncology, 22 (3), 2017 149 ABSTRACTS

Conclusion: The results of this study do not favour one of the tech- O-048 niques over the other, so in selected cases a sphincter preserving technique can be offered to patients. BILIARY DUCT-TO-DUCT RECONSTRUCTION WITH OR WITHOUT A TUNNELED RETROPERITONEAL T-TUBE IN ORTHOTOPIC LIVER TRANSPLANTATION O-044 K. Mohkam, B. Darnis, A. Rode, F. Lebossé, S. Mezoughi, LDLT IN PATIENT WITH HCV 540 CASES SINGLE CENTER H. Demian, A. Bonnet, C.Ducerf, M. Lesurtel, J-Y. Mabrut. EXPERIENCE Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, Abdel-Wahab Mohamed 69317 Cedex 04, France. Objectives: The interest of T-tube for biliary reconstruction during O-045 OLT remains controversial because of frequent T-tube inherent biliary complications (BC). The use of a tunneled retroperitoneal NEW TECHNOLOGIES FOR DIFFICULT LIVING DONOR LIVER T-tube (TRT) may decrease such complications. The aim of this study TRANSPLANTATION was to assess the impact of TRT on biliary outcome following OLT. Methods: We retrospectively compared the biliary outcome of OLT Voskanyan Sergey with duct-to-duct biliary reconstruction with or without a TRT performed from 2005 to 2015. A propensity score-matching was O-046 performed to adjust for potential confounders. Results: Of the 571 OLT performed over the study period, 457 had LIVER TRANSPLANTATION FOR HCC: OPTIMAL SELECTION a duct-to-duct biliary reconstruction, including 358 with a TRT and CRITERIA 99 without splintage. Of these, 97 recipients in each group were matched. Patient median follow-up was 36 (IQR: 14-70) months. The Takada Yasutsugu rate of bile leak was similar in both groups (7.2% in the non-TRT group, 4.1% in the TRT group, p=0.55). There were 4 TRT inherent BC in the O-047 TRT group: 2 cholangitis managed conservatively, and 2 leakages occurring at TRT removal, which required invasive treatment. Patients IMPACT OF SARCOPENIA IN HEPATO-BILIARY-PANCREATIC in the TRT group had a lower rate of overall BC (10.3% versus 25.8%, AND TRANSPLANT SURGERY p=0.009), severe (Clavien grade ≥3) BC (9.3% versus 21.6%, p=0.02), anastomotic biliary stricture (7.2% versus 19.6%, p=0.02), and a better T. Kaido, Y. Hamaguchi, S. Okumura, A. Kobayashi, H. Shirai, BC-free survival (HR=0.38 [95% CI: 0.18-0.79], p=0.01). There was no S. Uemoto. difference in patient and graft survival between the 2 groups. Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Conclusions: The use of TRT during OLT reduces the incidence of Department of Surgery, Graduate School of Medicine, Kyoto overall BC and anastomotic biliary strictures, without influencing University, Kyoto, 606-8507, Japan. the risk of leakage. Duct-to-duct biliary anastomosis with TRT may Objectives: We investigated the impact of sarcopenia on outcomes represent a new standard for biliary reconstruction after OLT. in hepato-biliary-pancreatic (HBP) and liver transplantatation (LT). Methods: Patients who underwent living donor LT (LDLT, n=250), liver resection for hepatocellular carcinoma (HCC, n=465) or intra- O-049 hepatic cholangiocarcinoma (ICC, n=109), and resection for pancreatic cancer (n=301) were enrolled. The impact of preoperative COST OF METABOLIC ADAPTATION IN LIVER skeletal muscle mass [standard muscle mass (SMM), psoas muscle TRANSPLANTATION: GUIDING DONOR-RECIPIENT mass index (PMI) or skeletal muscle mass index (SMI)], muscle MATCHING THROUGH REAL-TIME METABOLOMICS quality [intramuscular adipose tissue content (IMAC) or muscle F. Faitot, S. Battini, C. Besch, E. Ruhland, M. Onea, P. Addeo, attenuation (MA)], and visceral adiposity [visceral to subcutaneous ML. Woehl-Jaeglé, B. Ellero, P. Bachellier, IJ. Namer adipose tissue area ratio (VSR)] on outcomes was examined. CHRU de Strasbourg, Hepatobiliary, Pancreatic and General Results: • LDLT: The overall survival (OS) rate in patients with low surgery Department, 67000 Strasbourg, France. SMM was significantly lower than those with normal SMM. Perioperative nutritional therapy significantly increased OS in The purpose of this study was to evaluate the potential value of patients with low SMM. The OS rate was significantly lower in high-resolution magic-angle-spinning nuclear magnetic resonance patients with low PMI or SMI, high IMAC (muscle steatosis) and (HR-MAS-NMR) metabolomic analysis of native liver and back- high VSR (visceral adiposity) than each respective normal group. table biopsies for the prediction of early allograft dysfunction and Based on these results, we have revised our inclusion criteria for donor-recipient matching. Indeed there is an emerging need to LDLT since January 2013. After revision of the criteria, the OS rate assess the metabolic state of liver allograft especially in the novel has dramatically improved. • HCC: Preoperative low SMI, high setting of machine perfusion preservation. HR-MAS-NMR could be IMAC and high VSR were independent risk factors for death after a useful tool in this setting as it can extemporaneously provide hepatectomy. • ICC: Multivariate analysis revealed that low SMI untargeted metabolic profile. In order to validate this method, the and low MA were independent predictors of survival. • Pancreatic metabolic profiles obtained by HR-MAS-NMR of back-table cancer: Multivariate analysis showed that high VSR was an biopsies were compared according to the presence of early independent risk factor for mortality and recurrence together with allograft dysfunction. The identification and quantification of low SMI and low MA. differentially expressed metabolites showed that intragraft lactate Conclusions: Pretransplant sarcopenia was closely involved with level >8 mmol/g and phosphocholine content >0.646 mmol/g were outcomes after HBP surgery and LDLT. significantly associated with graft dysfunction with an excellent

150 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

accuracy (AUROClactates=0.906; IC95% 0.813-0.999) and known modalities of management of hepatocellular carcinoma (HCC). Limitations and complications exist for both of them. This AUROCphosphocholine=0.816 (IC95% 0.679-0.954)). A graft metabolic score was designed to predict early graft function. Metabolic pro- study aims to evaluate both methods in the management of HCC in files from native livers from sarcopenic patients, who experience cirrhotic patients. higher morbidity, showed opposite content in lactate and Methods: Retrospective analysis of the files and electronic data of glycerophosphocholine. In sarcopenic patients, the risk of EAD was Child A or B cirrhotic patients who underwent liver resection (LR) significantly higher when transplanting a graft exerting high risk or living donor liver transplantation (LDLT). Those within tumours graft metabolic score. This study underlines the cost of metabolic proven to be within UCSF criteria were identified. The early post- adaptation identifying lactate and choline-derived metabolites as operative, recurrence and survival data were compared. predictors of poor graft function in both native livers and liver Results: 120 patients were included in this study. 84 (60%) patients grafts. Moreover HR-MAS-NMR seems a valid technique to evaluate were treated by liver resection (LR group) and 36 (40%) underwent the quality of a graft and the consequences of cold ischemia on LDLT (LT group). In LR group, 60 (71.4%) patients underwent non- the graft and could thus be used to assess the efficiency of graft anatomical resections. Anatomical resections were done in 24 resuscitation on machine perfusion in future studies. (28.6%) patients. All LT group underwent right lobe-LDLT not including the middle hepatic vein. There was no operative mortality in both groups. Blood loss and blood transfusion were significantly O-050 more in the LT group. p= <0.001. Patients with early complications in LR group were 33 (61.1%) versus 21 (58.3%) in LT group with no OUTCOMES OF ABO COMPATIBLE AND DSA POSITIVE significant statistical difference, (p = 0.829). Tumor recurrence was LIVING DONOR LIVER TRANSPLANTATION. observed in 43/76 (56.6%) cases in the LR group and 3/31 (9.7%) cases in the LT group, p= <0.001. Disease-free survival was signifi- T. Mizota, M. Shinoda, H. Obara, M. Kitago, T. Hibi, Y. Abe, cantly better in LT group with mean of 127.7±7.3 months compared H. Yagi, K. Matsubara, T. Wakabayashi, O. Itano, Y. Kitagawa to 43.2±3.5 in LR group, p= <0.0001. Survival was better in LT group Surgery, Keio University School of Medicine with mean survival of 91.4±10.4 months compared to 48.3±3.4 160-0016 35 Shinanomachi Shinjuku-ku Tokyo Japan. months in LR group but not statistically significant, p= 0.085. Background: We analyzed the outcomes of ABO compatible and Conclusion: LR and LDLT are viable options for HCC in early cirrhotic DSA positive living donor liver transplantation (LDLT) focusing on patients. Recurrence is significantly less with LDLT but this has not preformed or de novo donor specific anti-HLA antibody (DSA). been yet translated into better survival. Improvement of early out- Patients and Methods: I) Twenty-five recipients whose anti-HLA come of LDLT can lead to better overall survival and make the choice antibody test (screening test, PRA) was examined were divided into more clear. 4 groups depending on the result of (PRA and ABO incompatibility (ABOI))＝(-, -), (+, -), (-, +), (+, +), and 6-month survival was assessed in each group. In the group of (+, -), anti-HLA antibody test O-052 (single antigen test, Luminex) was performed and preformed DSA positive recipients were identified. II) In the 257 LDLTs, recipients LIVER TRANSPLANTATION AND WHIPPLE SURGERY who developed antibody mediated rejection (AMR) were COMBINED WITH CHEMO-RADIOTHERAPY FOR retrospectively identified and the outcomes were assessed. TREATMENT OF HILAR CHOLANGIOCARCINOMA IN Results: I) Six-month survivals were 62, 81, 100, 100％ in (-, -), (+, THE CONTEXT OF PRIMARY SCLEROSING CHOLANGITIS -), (-, +), and (+, +), respectively. Out of the 9 patients in (+, -), 4 Saman Nikeghbalian, Alaa eldin Ahmed, Alireza Shamsaeefar, recipients were strongly positive for preformed DSA (>10,000MFI). S.A.M. Hossaini All 4 recipients postoperatively received immunosuppression Organ transplant center, Namazi hospital, including portal infusion therapy and their postoperative courses Shiraz University of Medical Sciences, Shiraz, Iran were uneventful. None of them developed AMR. II) Four recipients were identified to have developed AMR postoperatively. Their pre Objectives: Hilar cholangiocarcinoma (CC) is a fatal malignant tumor and postoperative examinations suggested that de novo DSA that is often diagnosed in advanced stages leading to very short-term appeared. Three died of AMR and 1 survived after re-transplantation. survival despite surgical intervention. Here in, we described our Three did not receive portal infusion therapy because of individual experience of liver transplantation and Whipple surgery combined reasons. with chemo-radiotherapy in patients with primary sclerosing Conclusion: Outcomes of recipients who had preformed DSA was cholangitis (PSC) diagnosed with hilar CC. satisfactory but those of recipients who developed do novo DSA Methods and Materials: A descriptive analysis of patients who was poor. Our immunosuppression protocol including portal underwent liver transplantation at Shiraz organ transplant center, infusion therapy may be associated with the outcomes. Iran, was performed in March 2016.. Data and outcomes of patients with PSC patients and hilar CC that underwent with liver O-051 transplantation and Whipple surgery combined with peri-operative chemo-radiotherapy were extracted and reviewed. LIVER RESECTION VERSUS LIVING DONOR LIVER Results: Among more than 2500 liver transplant patients at Shiraz TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA Transplant Center, 4 patients (2 males and 2 females) with PSC IN CIRRHOTIC PATIENTS underwent liver transplantation with Whipple surgery and peri- operative chemo- radiation. Patients received mycophenolate A.M. Sultan, H.E. Elgendy, O. Fathy, A.K. Abu El Ghet. mofetil, prednisolone and sirolimus as immunosuppressive Gastrointestinal surgical center, Mansoura University, regimens. One of our patients survived 36 months after surgery but Mansoura, Egypt. P.O: 35516. died due to tumor recurrence, metastasis and other complications of Objectives: Liver resection and liver transplantation are well transplantation. The other three patients survived 21, 9 and 17

Surgery, Gastroenterology and Oncology, 22 (3), 2017 151 ABSTRACTS

months after transplantation without tumor recurrence. There were those classified as SMA(+). Type B patients survived significantly one episode of portal vein thrombosis treating with anti-coagulation longer than did types C and D patients. The compliance with post- and acute rejection treating with methylprednisolone pulse. operative chemotherapy of patients with BR group was inferior to Conclusion: Liver transplantation and Whipple surgery combined patients with R group. The optimal treatment strategy may differ with peri-operative chemo-radiotherapy can be considered as a among various subgroups within the BR category. modality of treatment in patients with hilar cholangiocarcinoma in the context of PSC. O-055

O-053 CUSTOMIZED PREOPERATIVE MANAGEMENT OF PATIENTS WITH BILE DUCT TUMORS. LIVER TRANSPLANTATION USING LIVER GRAFT FROM HEPATITIS B CORE ANTIBODY-POSITIVE DONORS FOR HEPATITIS B SURFACE Van Gulik Thomas ANTIGEN NEGATIVE RECIPIENTS: Chutima Soparat, Methee Sutherasan, Wipusit Taesombat, Boonchoo O-056 Sirichindakul, Supanit Nivatwongs, Bunthoon Nonthasoot. Department of Surgery, King Chulalongkorn Memorial SURGERY FOR CHRONIC PANCREATITIS Hospital, Chulalongkorn University, Bangkok, 10330, Thailand. Conlon Kevin Objectives: Using liver from donors who are positive for hepatitis B core antibody (anti-HBc) to hepatitis B surface antigen (HBsAg) positive recipient is routinely practiced. But using this kind of donor O-057 for HBsAg negative is still controversial. To overcome the problem IMPORTANCE OF REAL ERAS COMPARED TO ERAS-LIKE IN LIVER of organ shortage and to save life of recipient who are on waiting SURGERY FOR OUTCOME list for liver transplantation, it is necessary in our center to use this strategy. This retrospective study present our experience in using Demartines Nicolas liver graft from anti-HBc positive but HBsAg-negative donor for HBsAg negative recipient. O-058 Methods: Between January 2007 and May 2017, 181 liver transplan- tations procedures were performed at our center. We evaluated THE PLACE OF THE PELVIC EXENTERATION IN using HBcAb-positive liver graft in HBsAg-negative recipient. All our THE TREATMENT OF EXTENDED PELVIC CANCERS patient receives nucleos(t)ide analogue (Lamivudine 100mg/day) for prophylaxis against de novo HBV infection K. Zarkov, Chr Petkov, A. Assenov, M. Mouchurova, P. Velinov, Results: The prevalence of anti-HBc positive liver donors is 43.65% H. Yousef, S. Bekir, L. Penev; A. Vlahova. (79/181). There are 53 HBsAgnegative recipients whom received First Surgical Department, Fifth General Hospital, Sofia, anti-HBc positive liver. Twenty-nine of these (54.7%) were antiHBs Bulgaria. positive. With a median follow up of 42 months (range 1-112 Background: Pelvic cancers are extended primary or relapse rectal, month), only one of 53 (1.8%) patients who receiving a graft from genital and urological malignancies. Pelvic exenterations (PE) are anti-HBc positive donors developed de novo hepatitis B. the operations, performed to remove these tumors. What is the Conclusions: From our small transplant series, we found that liver place of PE in the complex treatment of extended pelvic cancers? grafts from anti-HBc positive donors can be safely used and HBsAg The place of radio-chemotherapy? Lecture defines the multi- negative recipients should receive nucleos(t)ide analogue for disciplinary team for PE – does it need surgeon, urologist and gyne- prophylaxis against de novo HBV infection. cologist to remove a pelvic cancer. Lecture assesses postoperative complications, mortality; survival. O-054 Patients: The lecture is based on 289 PE patients for 1992-2011 - total 88, posterior 116, anterior 85 - advanced primary or relapse SURGICAL AND ONCLOGICAL PROBLEMS OF BORDERLINE rectal (54), genital (223) and urological (12) carcinomas. Radical RESECTABLE PANCREATIC CANCER PE–197; palliative-92. Primary–107; secondary PE-124 relapse and Akimasa Nakao 58 persisting tumors. Results: Duration 3-5 hours. Mortality – intraoperative – 0%; post- Department of Surgery, Nagoya Central Hospital Nagoya, operative – 6%. Complications: early and late Gastrointestinal–18%; 453-0801, Japan. urinary – 48%; pelvic floor – 44%. Survival - radical PE: 5-years – We have been performing aggressive surgery combined with vascu- 22%. Palliative PE– up to 18-30 months. Palliations –6-9 months. lar resection for pancreatic cancer. The patients who had undergone Postoperative treatment, analysed in –primary PE - RT – 17; RT&CT resection of pancreatic cancer in our institution were reviewed and – 15; CT – 23; no – 10; secondary – RT – 14; RT&CT – 13; CT – 46; no the survival differences among the resectable (R), borderline – 26. resectable (BR), unresectable (UR) group and subgroups of BR dis- Discussion: Most PE were secondary. For persisting tumors pre- ease were analyzed. BR were further classified into 3subgroups: por- exenterative radio-chemotherapy was like preoperative; persisting tal invasion (PV (+)), common hepatic artery invasion (CHA (+)) and after operation means that PE was already indicated at the time superior mesenteric artery invasion (SMA (+)). PV (+) was subdivided of the primary surgery. Most common complications - urinary, into types B, C, and D according to the degree of portal invasion. especially infections. Palliative PE patients have significantly higher Patients in the R group had significantly better survival than those morbidity and lower survival than radical. in the PV(+) group, who in turn survived significantly longer than Conclusions: Since PE is the only more radical method for treatment

152 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

of the extended pelvic tumor, it takes the main place in the complex Methods: We conducted a retrospective analysis of 556 colorectal therapy. Complex treatment is important for improvement of post- patients who underwent conventional or laparoscopic colorectal operative results and especially survival after PE. We prefer to surgery for CRC. Data was categorized into 3 groups: patients perform PE before RT or very close after RT because complications operated by laparotomy, the C-CRS cohort (n = 317, from January increase after RT. We aim at simple reconstructive procedures 1993 to December 2002); the first hundred patients operated by that result in significantly shortened operative time and less compli- laparoscopy, the EL -CRS cohort (n = 101, from January 2008 to cations. December 2012); and those operated by laparoscopy with more advanced experience, the AL -CRS cohort (n = 138, from January O-059 2013 to December 2016). Results: The patients in the C-CRS cohort had a significantly higher TOTALLY LAPAROSCOPIC RIGHT HEMICOLECTOMY FOR COLON rate of overall complications (P < 0.001), more wound related CANCER: A COMPARATIVE STUDY complications (P<0.0001), respiratory infections (P < 0.001), and higher length of hospital stay (P < 0.001). A higher operative time and D. Apa, D. Spoletini , F. Castaldi, M. Grieco and M. Carlini. proportion of harvested lymph nodes occurred in the C-CRS and S. Eugenio Hospital ASL Roma 2- Rome-Italy. EL-CRS cohorts, when compared to the AL -CRS cohort (P < 0.001). Objectives: The totally laparoscopic right hemicolectomy has We found no statistically significant differences in conversion rate, gained popularity in recent years while requiring greater expertise intraoperative adverse events, anastomotic related complications or of laparoscopic technique. Aim of this study was to evaluate short mortality. and medium term results of the methodology and comparing it Conclusions: Laparoscopic colorectal surgery presents as a feasible with extracorporeal anastomosis. and safe technique for CRC patients, with better short term out- Methods: A retrospective chart review of consecutive patients who comes than the conventional approach. Additionally, we can state underwent laparoscopic right hemicolectomy, from January 2014 to that best postoperative outcomes come with higher experience. December 2016, was performed. Multivariate regression analysis Therefore, a solid and well-defined learning and training model in was used to compare postoperative outcomes. laparoscopy should be adopted towards proficiency. Results: Between January 2004 and December 2016 at our Institution, 215 right hemicolectomy were performed for right colon O-061 cancer. In the last three years a total of 93 consecutive patients were identified. The extracorporeal group (EA) included 47 patients and SAFETY OF LAPAROSCOPIC SURGERY IN COLORECTAL the intracorporeal group (IA) 46 patients. There were no statistically CANCER PATIENTS WITH SEVERE SYSTEMIC COMPLICATIONS. significant differences in demographics and disease-related charac- teristics between the two groups. Conversion to open surgery was H. Hachiya, Y. Iwasaki, K. Takagi, H. Nagata, M. Ishizuka, T. Aoki, not required. Mean operative time was longer in the extracorporeal K. Kubota. group (94+/-22 min vs 80+/- 25 min p<0.05). Major morbidity was Second Department of Surgery, Dokkyo Medical University, recorded only in EA: 2 cases (4.3%) of wound infection, 2(4.3%) Tochigi, 321-0293, Japan. anastomotic leakage that required re-intervention (Clavien-Dindo III Objectives: In colorectal cancer surgery, the indication for laparo- 4.3 % vs 0% p= 0.015). Mean time of return of bowel function (3.1 scopic surgery in patients with severe systemic complications has +/0.7 vs 4.1 +/-08 days p <0.0001) and mean length of hospital stay not been established. We investigated the safety of laparoscopic (4.2 +/- 1.2 vs 6.3 +/-1.9 days p<0.0001) were significantly shorter surgery in colorectal cancer patients with severe systemic compli- in IA. Similarly, minilaparotomy was smaller in IA (3.8 +- 0.9 vs 6.2+- cations. 0.9 cm p <0.00001). There was no significant difference in the Methods: The subjects were colorectal cancer patients who under- median number of lymph nodes harvested while length of opera- went surgical treatment in our hospital from January 2006 to May tive stump was superior in IA (29.54+-11.09 vs 25.03+-4.32). 2017. Patients were classified into 3 groups according to the Conclusions: The rationale of totally laparoscopic right hemicolectomy severity of systemic condition based on the American Society of is based on technical factors, such as unnecessary mobilization of the Anesthesiologists (ASA) physical status: 31 patients in class 3 who transverse colon and the absence of manipulation and traction of the underwent laparoscopic surgery (LAP 3 group), 377 patients in class small bowel. Shorter hospital stay and optimal cosmetics results have 2 or lower who underwent laparoscopic surgery (LAP 1/2 group), contributed to the spread of this surgical option. and 97 patients in class 3 who underwent open surgery (O 3 group). We compared the clinical data among 3 groups. O-060 Results: In the LAP 1/2 group and the LAP 3 group, there was no significant difference in operation time (225min vs 205min, COLORECTAL SURGICAL MANAGEMENT: LOOKING BACK, p=0.099) and intraoperative bleeding amount (16ml vs 14ml, LEAPING FORWARD p=0.500). Postoperative complications were observed in 156 patients (41%) in the LAP 1/2 group and 14 patients (45%) in the D. Parente, I. Gil, I. Sales, N. Rama, P. Alves, S. Ferraz, B. Lopes, LAP 3 group, which also showed no significant difference. Also, V. Faria. between the LAP 3 group and the O 3 group, there was no signifi- Cirurgia 1, Centro Hospitalar Leiria, 2410-197, Leiria, cant difference in operative time (205min vs 192min, p=0.483), but Portugal intraoperative bleeding amount (14ml vs 238ml, p=0.500) was Objectives: The aim of this study was to compare the outcomes for larger in the O 3 group. Postoperative complications were observed colorectal cancer (CRC) patients who underwent conventional (C- in 14 patients (45%) in the LAP 3 group and 57 patients (58％) in CRS) or laparoscopic colorectal surgery (L-CRS). In the laparoscopic the O 3 group, which showed no significant difference (p=0.185). group we compared two distinct periods: the early and the Conclusions: Laparoscopic surgery can be performed safely in advanced experience. colorectal cancer patients with severe systemic complications. In

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addition, laparoscopic surgery had advantages including less Results: Patients consisted of 6 women and 3 men with a mean age bleeding and shorter hospital stay compared with open surgery in of 60.3years. Mean operative time was 128min.The blood loss was patients with the same degree of severe complications. minimal and average length of hospital stay was 5.1 days. In follow up three patients had some degree of constipation and could be managed with laxatives. There was no mortality or any significant O-062 perioperative complications. In short follow up results, there is no recurrence. LAPAROSCOPIC TOTAL EXCISION OF THE RIGHT MESOCOLON Conclusion: Abdominal approach is preferred modality of treat- ment for rectal prolapse. In abdominal procedure, mesh rectopexy J. Costa, M.L. Matos, A.M. Correia, L. Carvalho, I. Bessa, has fewer complications and mortality compared to suture fixation, A.C. Soares, M.R. Sousa, J. Costa Pereira, G. Gonçalves, M. Nora. resection rectopexy and other intervention. Laparoscopic posterior Centro Hospitalar de Entre o Douro e Vouga, mesh rectopexy is a safe and effective procedure for full rectal Santa Maria da Feira, 4520-211, Portugal. prolapse and possibly be considered as first choice procedure in Introduction: The concept of total excision of the mesocolon feasible candidates. encompasses the intact removal of the mesocolon by its embry- References: 1) Eung Jin Shin: Surgical Treatment of Rectal Prolapse: ological plane and central vascular ligation. Its impact on patient J Korean Soc Coloproctology. 2011 Feb; 27(1): 5–12. 2) Jean-Luc survival and morbidity and mortality is not yet established. Faucheron et al:Anterior rectopexy for full-thickness rectal pro- Objective: Demonstration of the technique of total excision of the lapse: Technical and functional results: World J Gastroenterol. 2015 right mesocolon by laparoscopy. Apr 28; 21(16): 5049–5055. 3) Manash Ranjan Sahoo et al: A single Methods: Video demonstrating the technique of total excision of centre comparative study of laparoscopic mesh rectopexy versus mesocolon in patients with right colon neoplasia. suture rectopexy:J Minim Access Surg. 2014 Jan-Mar; 10(1): 18–22. Technique: Identification and ligation of ileocolic vessels at their 4) Deepraj S. Bhandarkar: Laparoscopic rectopexy for complete origin, with exposure of the superior mesentery vein. Following the rectal prolapse: mesh, no mesh or a ventral mesh? J Minim Access mobilization of the right colon, separating the mesocolon from the Surg. 2014 Jan-Mar; 10(1): 1–3. retroperitoneum allowing visualization of the retroperitoneal organs: duodenum, pancreas and Gerota's fascia. Subsequently the O-064 section of the distal ileum and the transverse colon with endostapler is made. Finally, intracorporal ileocolic anastomosis is performed. NOVEL APPROACHES TO REDUCE SURGICAL DIFFICULTY Conclusion: This approach allows a complete resection of the right IN LAPAROSCOPIC PANCREATICODUODENECTOMY. mesocolon throught embriologic planes, allowing an excelent recovery in postoperative period. Nagakawa Yuichi

O-063 O-065

RECTAL PROLAPSE: IS LAPAROSCOPIC POSTERIOR MESH PROS AND CONS OF LAPAROSCOPIC DISTAL PANCREATECTOMY RECTOPEXY THE PROCEDURE OF CHOICE? FOR PANCREATIC DUCTAL ADENOCARCINOMA. Vinay Kumar Shaw Nagakawa Yuichi

Introduction: Rectal prolapse present a dilemma in management as O-066 there is no single treatment which can be set as gold standard .Surgery is the only option for cure and variety of options exist. The WHAT CAN WE DO TO OBTAIN LONG-TERM SURVIVORS common goal of any type of surgery is to control the prolapse, OF PANCREATIC CANCER? restore continence and prevent constipation or impaired evacuation H. Shimamura. [1]. Therapeutic procedures are broadly divided between Department of Surgery, Sendai Medical Center, Sendai, abdominal and perineal procedures and an abdominal procedure 983-8520, Japan. are usually considered for younger and fitter patients. With refine- ments in surgical and anaesthesist technique and also great strides Objectives: To obtain long-term survivors of pancreatic cancer in minimal invasive surgery present literature is more in favour of (pancreatic ductal adenocarcinoma; PDAC) is not easy. Although such abdominal procedures even in elderly group. [2,3,4]The aim of tough situation, the number of survivors from PDAC is increasing, our study was to analyse the efficacy and safety of laparoscopy even at the city hospital level. Here we review our long-term survivors posterior mesh rectopexy in all age group and review with existing and discuss what we can do now. literature to plan an algorithm in management. Methods: Patients with PDAC, who underwent surgical resection in Material and methods: Retrospective data of 9 patients operated for our institute between January 2000 and August 2012, and have full rectal prolapse in the period from April 2014 to Jan 2017 was survived more than 5 years, were extracted. Characteristics of taken. All underwent laparoscopic posterior mesh rectopexy in our these patients, including contents of medical treatments and hospital. The surgical procedure comprised of complete mobilisation histopathological characteristics, were retrospectively reviewed. of rectum and sigmoid and a 6X6’ polypropylene mesh was fixed to Patients with invasive carcinoma derived from intraductal papillary- the presacral fascia with absorbable tacks. The mesh was customised mucinous neoplasm were excluded. so as to wrap 4/5 of the rectum and fixed with 3-0 absorbable suture. Results: Sixteen out of 115 patients (13.9%, Male/Female: 9/7, Operative time, blood loss, length of hospital stay, mortality, average age 67.0) were eligible. Median survival was 108 months morbidity and recurrence rate were evaluated. Review of literature (62-132). Most patients resulted in Stage IIA or B (UICC), 3 of which was done to further analyse the efficacy of the procedure. had lymph node metastasis. We had only one Stage IA patient.

154 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Histopathological examination revealed that no tumor tissue was O-069 diagnosed as poorly differentiated ductal adenocarcinoma (all belonged to G1 or G2). Portal vain resection was performed in 3 out THE CRITERIA OF EARLY DRAIN REMOVAL REDUCED of 12 patients who underwent pancreaticoduodenectomy (PD). PANCREATIC FISTULA AFTER PANCRATODUODENECTOMY One patient underwent total pancreatectomy. Radical (R0) H. Kosaka, S. Satoi, H. Yanagimoto, T. Yamamoto, S. Hirooka, resection was achieved in all cases. Gemcitabine and/or S-1 were S. Yamaki, M. Kotsuka, Y. Ryota, T. Michiura, K. Inoue, Y. Matsui, administered to the patients as adjuvant chemotherapy. Four M. Kon. patients died of recurrent malignancy (liver, lung or brain mets), Kansai Medical University, Department of Surgery whereas 7 cases survived without recurrent diseases. Hirakata city, 573-1010 Japan Discussion: Cases who underwent neo-adjuvant chemotherapy (NAC) were not included in this study. NAC study is now under clinical Objectives: Since 2012, we introduced own criteria of early drain studies, which may yield more long-term survivors. In addition, removal after pancreatectomy. In this study, we retrospectively precision therapy should be considered in the near future. verified a usefulness of our recent criteria concerning to postopera- Conclusion: What we can do to obtain long-term survivors of PDAC tive complications after pancreatoduodenectomy by comparing with at the city hospital level are achieving R0 resection and adequate former criteria. chemotherapy. Methods: The perioperative data of consecutive 522 patients who underwent pancreatoduodenectomy during recent 10 years were O-067 compared between 255 patients with recent criteria and 267 patients with former criteria. A detail of our recent criteria is both PANCREATECTOMIES WITH ARTERIAL RESECTION FOR MALIGNANCY: drainaged fluid amylase value (DFA) under 5000 U/L on postopera- WHICH RESULTS AND WHO ARE BEST CANDIDATES?” tive day (POD) 1 and DFA under 3000 U/L on POD3. If criteria was satisfied, drain was removed on POD3. On the other hand, our Bachellier Philippe former criteria was DFA under 375 U/L on POD3. Results: There were no significant differences in primary disease, O-068 patient’s backgrounds and fistula risk score between two groups. After introducing recent criteria, intra-abdominal abscess develop- EARLY REMOVAL OF INTRAPERITONEAL DRAINAGE ment was statistically decreased (12.2 vs 24.3%). Clinically relevant AFTER PANCREATODUODENECTOMY IN SELECTED PATIENTS: postoperative pancreatic fistula (CR-POPF) was also statistically A RANDOMIZED CLINICAL TRIAL decreased (12.6 vs 19.1%), while biochemical leak was increased (31.0 vs 19.5%). A median duration of postoperative hospital stays J. Dembinski, C. Mariette, J.J. Tuech, F. Mauvais, G. Piessen, was statistically shortened (12 vs 14 days). To detect an independ- D. Fuks, L. Schwarz, S. Truant, C. Cosse, F.R. Pruvot, ent predictive factor of CR-POPF, patient’s factor, operative factors J.M. Regimbeau. and drain removal criteria were analysed by logistic regression Department of Digestive Surgery analysis. As a result, both recent criteria and soft pancreatic texture CHU Amiens and University of Picardie were revealed as predictive factors (Odds: 0.45 and 6.6, P<0.01). Avenue René Laennec – Salouel – 80054 Amiens, cedex France Conclusions: These results indicated that implementation of the Objectives: To determine whether the timing of removal of recent criteria could realize appropriate patient selection for early abdominal drainage (AD) after pancreatoduodenectomy (PD) drain removal on POD3, resulting in a decreased incidence of influences the 30-day surgical site infection (30-day SSI) rate. CR-POPF. Methods: A multicenter randomized, intention-to-treat trial with two parallel arms (superiority of early vs. standard AD removal on SSI) was performed between 2011 and 2015 in patients with no O-070 pancreatic fistula (PF) on POD3 after PD (NCT01368094). The primary endpoint was the 30-day SSI rate. The secondary endpoints VISCERAL OBESITY AND OPEN DRAINAGE ARE INDEPENDENT RISK were specific post-PD complications (grade BC PF), postoperative FACTORS OF PANCREATIC FISTULA AFTER DISTAL PANCREATECTOMY. morbidity, reoperation rate, 30-day mortality, postoperative Charles Vanbrugghe1, Maxime Ronot2, François Cauchy1, infectious complications and length of stay. Christian Hobeika1, Safi Dokmak1, Béatrice Aussilhou1, Results: One hundred and forty-one patients were randomized: 71 Emilia Ragot1, Olivier Soubrane1, Alain Sauvanet1 in the early arm, 70 in the standard arm (70.2% of pancreatic adeno- 1Department of Hepato-Pancreato-Biliary Surgery, carcinomas; 91.5% of pancreatojejunostomies; 66.0% of bilateral 2Department of Radiology drainages; feasibility: 39.9%). Early removal of drains was not Hospital Beaujon, AP-HP, University Paris VII, Clichy, France associated with a significant decrease of 30-day SSI (14.1% vs. 24.3%, p = 0.12). A lower rate of deep SSI was observed in the early arm Objective: To identify predictive risk factors of clinically relevant (2.8% vs. 17.1%, p = 0.03), leading to a shorter length of stay (17.8 ± pancreatic fistula (CR-PF) following open and laparoscopic distal 6.8 vs. 21.0 ± 6.1, p = 0.01). Grade BC PF rate (5.6%), severe morbidity pancreatectomy (DP). (17.7%), reoperation rate (7.8%), 30-day mortality (1.4%) and wound- Background data: Predictive risk factors of CR-PF after DP have not SSI rate (7.8%) were similar between arms. After multivariate been consensually identified. analysis, the timing of AD removal was not associated with an Methods: Analysis of a prospectively maintained database of increase of 30-day SSI (OR = 0.74 (95%CI 0.35 – 1.13, p = 0.38)). elective DP. Preoperative and intraoperative clinical data were Conclusion: In selected patients with no PF on POD3, early collected. Radiologic analysis on preoperative CT-scan included removal of abdominal drainage does not seem to increase or measure of Visceral Fat Area (VFA), Total Fat Area (TFA), decrease surgical site infection’s occurrence. Subcutaneous Fat Area (SFA), pancreas density, retro renal fat thickness and Total Muscle Area (TMA: parietal+paraspinal+psoas).

Surgery, Gastroenterology and Oncology, 22 (3), 2017 155 ABSTRACTS

Sarcopenia was defined according to Prado et al. (Lancet Oncol O-072 2008) with a Surface Muscle Index <38,9cm2/m2 in female and 52,4cm2/m2 in male. Occurrence of a CR-PF as defined by ISGPF ROLE OF SOMATOSTATIN IN PANCREATICODUDENECTOMY: A (grade B or C) was the main end point. All variables associated with PROSPECTIVE CONTROLLED RANDOMIZED TRIAL. a p value <0.1 in univariate analysis were included in a logistic Ayman El Nakeeb, Ahmed Nabeh, Mahmoud A Abd El Wahab, regression model for multivariate analysis. Ahmed Shehta, Mohamed El Refea, Ahmed Abdelrafee, Ahmed Results: From 2012 to June 2016, 208 patients have been included. Moneer. CR-PF occurred in 31(15%). In univariate analysis, risk factors of CR-PF were: BMI >25kg/m2 (p=0.023), a dilated main pancreatic Background: Somatostatin have well-recognized inhibitory effects duct (>3mm; p=0.035), laparotomy (p=0.008), ligation of the main on pancreatic exocrine secretion. But its efficacy to prevent post- pancreatic duct (p=0.027), venous resection (p=0.02), blood loss operative pancreatic fistula (POPF) after pancreaticodudenectomy >150ml (p=0.007) and a passive drainage using a multichannel (PD) still controversial. This study was conducted to evaluate the drain (p<0.001) while a suction drainage decreased this risk effect of postoperative use of octreotide on the postoperative out- (p<0,001). A VFA >92cm2 (p=0.052), a TFA >245cm2 (p=0.080) and comes, POPF, after PD. a soft pancreas (p=0.072) trend to increase the risk of CR-PF. In Patients and methods: This is a prospective randomized controlled sub-group analysis, obese sarcopenic patients had a higher risk to trial for post-operative use of somatostatin in patients after PD develop a CR-PF (p=0.009). In multivariate analysis, a VFA >92cm2 during the period from June 2015 till December 2016. Patients (OR: 3.057 [1.06-8.8]; p=0.038) and a multichannel passive enrolled in the study were randomized to 2 groups. Group I include drainage (OR: 7.120 [1.7-29.3], p=0.007) were two independent patients who did not receive postoperative somatostatin. Group II predictive factors of CR-PF. Sarcopenia did not increased this risk include patients who did not receive postoperative somatostatin. The (p=0.128). primary outcome of the study is the rate of development of POPF. Conclusions: Both visceral obesity and passive drainage increase Results: 104 patients included in the study and divided into two the risk of CR-PF. Sarcopenia did not influence this risk except in randomized groups. No significant difference in median output obese patients. between both groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients O-071 (21.2%) in group I, and in 10 patients (19.2%) in group II, and this was statistically non-significant (p = 0.807). Also, there was no sig- LAPAROSCOPIC VERSUS DISTAL PANCREATECOMY: A nificant differences between both groups regarding the incidence SINGLE-INSTITUTION COMPARATIVE 10-YEAR EXPERIENCE. of biliary leakage (p = 0.083), delayed gastric emptying (p = 0.472), and early postoperative mortality (p = 0.727). Francisco S Moura, Nigel B Jamieson. Conclusion: Somatostatin did not reduce postoperative morbidities, Glasgow Royal Infirmary, Glasgow, Scotland. reoperation and mortality rate. Also, it did not affect the incidence of Background: Distal pancreatectomy is the standard curative post-operative pancreatic fistula and its clinically relevant variant. treatment for symptomatic benign, pre-malignant and malignant Based on these results, the routine use of octreotide after PD is not diseases of the pancreatic body and tail. This study was designed to recommended. compare clinical outcomes for laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) performed over a 10- year period at a single specialist tertiary referral centre. O-073 Methods: This retrospective study included 127 patients that underwent distal pancreatectomy between 2006 and 2017. The A NEW SIMPLE AND SAFE PANCREATICOJEJUNAL patient data was divided into two groups based on surgical ANASTOMOSIS. THREE GRADE B PANCREATIC LEAKS AFTER 100 approach: LDP (n=50; 39.4%) and ODP (n=77; 60.6%). Data was CONSECUTIVE PEOCEDURES collected on pre-operative patient characteristics, intra-operative Egorov V.I., Petrov R.V. details, post-operative outcomes and pathological results. All Bakhrushins Brothers Moscow City Hospital, Moscow Clinical statistical analyses were carried out on SPSS software for Windows. Scientific Centre, Sklifosovsky Emergency Institute, Russia, Results: Intra-operative blood loss (500mls vs 1620mls), rate of 107076. splenectomy (28% vs 74%), new post-operative diabetes (10% vs 28.6%) and length of hospital stay (7 days vs 8 days) were significantly Background: Postoperative pancreatic fistula (POPF) is the main less in LDP compared to ODP. There were no significant differences in cause of fatal complications after pancreatoduo-denectomy. There is operative time, major complications, post-operative pancreatic still no universally accepted technique for pancreaticojejunal anasto- fistula and haemorrhage, day of drain removal, 30 day re-admission mosis (PJA), especially in patients with soft and fragile pancreas. rate, further procedures, perineural and venous invasion. 26% were Method: Pull-through M- with locking U-sutures and internal STent converted from LDP to ODP. There was no 30-day patient mortality one-layer invaginated end-to-end PJA (MUST) has become a main in either procedure. anastomotic technique in our department Postoperative morbidity Key statement: LDP is as safe a surgical approach as is ODP. Still, and 90- days mortality were registered in 100 consecutive patients LDP has the advantages of shorter hospital stays, less intra- who underwent PJA with MUST technique between November operative blood loss, lower splenectomy rates and reduced rate of 2014 to September 2016. post-operative diabetes. Results: Retrospectively assessed rate of clinically relevant POPF Key words: Distal pancreatectomy; Laparoscopic distal pancreate- was significantly lower for MUST (3% Grade B and no Grade C) as ctomy; Open distal pancreatectomy well as rate of fistula-related mortality in MUST group compared to modified Cattell –Warren method (6%-Grade B and 4% Grade C POPF) which we used during the last 9 years. The length of post- operative hospital stay was significantly shorter in MUST group.

156 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Conclusion: A retrospective analysis confirmed the efficacy of O-077 MUST technique for any pancreatic parenchyma type and any duct size. To finally prove this method as a standard for PJA it must be HILAR CHOLANGIOCARCINOMA: A NEW NATIONAL STRATEGY the subject of prospective randomized trials. Launois Bernard

O-074 O-078

JAPANESE PRACTICE GUIDELINES FOR HEPATOCELLULAR THE ROLE OF TELOMERE DYSFUNCTION DURING LIVER CARCINOMA 2017 CIRRHOSIS DEVELOPMENT AND HEPATOCARCINOGENESIS Kokudo Norihiro Hartmann Daniel

O-075 O-079 RE-EVALUATION OF CLINICAL IMPORTANCE OF INTRADUCTAL PAPILLARY NEOPLSM OF THE BILE DUCT PROGNOSTIC IMPACT OF INTRAHEPATIC CHOLANGIOCARCINOMA: A MULTI-INSTITUTIONAL STUDY BY HIROSHIMA SURGICAL STUDY K. Kubota GROUP OF CLINICAL ONCOLOGY (HISCO). Second Department of Surgery, Dokkyo Medical University, Tochigi, 321-0293 Japan. A. Oshita1,2, M. Ohira2, T. Kobayashi2, M. Hashimoto3, T. Abe4, H. Tazawa5, K. Oishi6, T. Kohashi7, T. Irei8, H. Ohdan2 Objectives: Intraductal papillary neoplasm of the bile duct (IPNB) is 1 Department of Gastroenterological Surgery, Hiroshima characterized by dilated intrahepatic bile ducts filled with a non- Prefectural Hospital, Hiroshima, 7348530, Japan invasive papillary or villous biliary neoplasm covering delicate 2Department of Gastroenterological and Transplant Surgery, fibrovascular stalks. About one third of IPNB secrete mucin in the Applied Life Sciences, Institute of Biomedical and Health duct lumen. However, there are several problems. First, neoplasms Sciences, Hiroshima University, Hiroshima, 7348551, Japan diagnosed as IPNB are different according to institutes. Second, 3Department of Surgery, Chuden Hospital, Hiroshima, 7308562, Japan tumor location and the incidence of associated invasive malignancy 4Department of Surgery, JA Onomichi General Hospital, are different according to reports. This discrepancy may be, at least Onomichi, 7228508, Japan in part, due to different diagnostic criteria. 5Department of Surgery, Chugoku Rosai Hospital, Kure, Methods: The clinicopathological characteristics of 21 IPNBs were 7370193, Japan re-evaluated. 6Department of Surgery, National Hospital Organization Results: The median age was 66 years. The symptoms included Higashihiroshima Medical Center, Higashihiroshima, 7390041, Japan abdominal pain, jaundice and cholangitis. 11 IPNBs were located in 7Department of Surgery, Hiroshima City Asa Citizens Hospital, the intrahepatic bile duct, 10 were in the extrahepatic bile duct. Hiroshima, 7310293, Japan There were significant differences between intrahepatic and extra- 8Department of Surgery, National Hospital Organization Kure hepatic IPNBs in CA19-9 levels (10 vs 257 (IU/dl)) and presence of Medical Center, Kure, 7370023, Japan gross mucin (82% vs 20%). Intrahepatic IPNB showed low- or inter- mediate-, or high-grade neoplasia, while extrahepatic IPNB showed Objectives: While surgical resection is the main treatment for intra- IPNB with an associated invasive carcinoma. 5-year relapse free hepatic cholangiocarcinoma (ICC), the indication of lymph node survival rates were 82% and 16%, respectively. Univariate and dissection (LND) has been still controversial. The aim of this study multivariate analyses showed that tumor location and tumor grade is to identify the prognostic factor and the impact on the LND in were significant factors for 5-year relapse free survival. patients with ICC with the database from the multi-institutional Conclusions: Location of the tumor was one of the independent study. risk factors for postoperative relapse-free survival. Methods: This retrospective study included 97 patients who Proposal: This study demonstrated that there are two types of underwent hepatectomy for ICC in Hiroshima Surgical study group IPNB. • Type 1 IPNB (classical IPNB) is histologically similar to IPMN of Clinical Oncology (HiSCO) from 2005 to 2015. The prognostic of the pancreas, typically develops in the intrahepatic bile ducts factors for cancer-specific survival were analyzed using the Kaplan- and contains macroscopic mucin. • Type 2 IPNB (so-called papillary Meier method and Cox proportional hazards regression models. carcinoma or cholangiocarcinoma), has a more complex histologi- Results: Five-year overall survival (OS) and disease free survival cal architecture with irregular papillary branching or with foci of (DFS) were 48.2% and 40.4%, respectively. While CA19-9 elevation solid-tubular components, typically involves the extrahepatic bile (hazard ratio [HR] 2.74 (p = 0.004)) and hepatic venous invasion ducts and is mostly associated with invasive cancers. We should re- ([HR] 2.56 (p = 0.023)) were identified as prognostic factors for OS, evaluate IPNBs by classifying them into two types. hepatitis B viral infection ([HR] 2.66 (p = 0.046)), portal invasion ([HR] 2.27 (p = 0.018)) and intrahepatic metastases ([HR] 2.31 (p = O-076 0.043)) were identified as those for DFS. The strategy of LND depended on operators and hospitals’ policies. Lymph node metas- GENOMIC PROFILING OF CHOLANGIOCARCINOMA tases (LNMs) were found in 10 of 25 cases undergoing LND and 9 of 72 cases not undergoing LND. Portal invasion ([HR] 4.41 (p = Borad Mitesh 0.015)), intrahepatic metastases ([HR] 5.44 (p = 0.014)) and the hilar location of the tumor ([HR] 4.64 (p = 0.012)) were identified as predictive factors for LNM. Moreover, the patients with recurrence

Surgery, Gastroenterology and Oncology, 22 (3), 2017 157 ABSTRACTS

were analyzed. CA19-9 elevation at recurrence (hazard ratio [HR] O-081 17.61 (p = 0.005)), the surgical treatment for recurrence (hazard ratio [HR] 13.90 (p = 0.007)) and biliary invasion ([HR] 4.36 (p = SELECTION OF HEPATIC RESECTION RATHER THAN 0.018)) were identified as prognostic factors after recurrent ICC. TRANSPLANTATION FOR CIRRHOTIC PATIENTS WITH Conclusions: Multidisciplinary therapy should be applied for the HEPATOCELLULAR CARCINOMA. patient with a high level of CA19-9 and/or vascular invasion. LND Yanaga Katsuhiko might be necessary in patients with portal invasion, intrahepatic metastases and/or the tumor located in the hilar region. Recurrent sites should be resected if possible when the patient would have O-082 recurrence. SURGICAL RESECTION FOR HCC WITH MACROSCOPIC VASCULAR INVASION O-080 K. Hasegawa, T. Kokudo, S. Yamashita, M. Ohmichi, Y. Nishioka, ASSESSMENT OF PREOPERATIVE LIVER FUNCTION IN PATIENTS Y. Kawaguchi, H. Okinaga, J. Togashi, J. Kaneko, N. Akamatsu, WITH HEPATOCELLULAR CARCINOMA – THE ALICE GRADE J. Arita, Y. Sakamoto, N. Kokudo. Hepato-Biliary-Pancreatic Surgery Division, Department of T. Kokudo, C.Shirata, Y.Miyazaki, K.Amikura, T.Yamaguchi, Surgery, Graduate School of Medicine, University of Tokyo, J.Arita, J.Kaneko, N.Akamatsu,Y.Sakamoto, A.Takahashi, Tokyo 113-8655, Japan. H.Sakamoto , N.Kokudo, K.Hasegawa Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ Objectives: The presence of macroscopic vascular invasion in and Transplantation Division, Department of Surgery, Graduate patients with hepatocellular carcinoma (HCC) is regarded as School of Medicine, The University of Tokyo, Tokyo, Japan. indicating an advanced stage, and surgical resection is not recom- Division of Gastroenterological Surgery, Saitama Cancer mended in the Western guidelines. Center, Saitama, Japan. Methods: Between October 1994 and December 2011, we performed surgical resection in 84 cases with portal vein tumor Objective: Most patients with hepatocellular carcinoma (HCC) thrombus (PVTT), 34 cases with hepatic vein tumor thrombus have underlying liver disease, therefore, precise preoperative (HVTT), and 19 cases with bile duct tumor thrombus (BDTT). The evaluation of the patient’s liver function is essential for surgical surgical outcomes were analyzed. decision making. The aim of the study is to develop a preoperative Results: The median survival time (MST) of patients with PVTT was liver function evaluation system that is useful for predicting the 2.19 years for PVTT limited to the second order branch and 2.37 postoperative outcomes after liver resection. years for PVTT invading the first order branch. The MST of patients Methods: We developed a grading system incorporating only two with HVTT was 3.95 years for HVTT limited to the major hepatic variables, namely, the serum albumin level and the indocyanine veins and 1.39 years for inferior vena cava invasion. Since the only green retention rate at 15 minutes (ICG R15), to assess the pre- recommended treatment option for advanced stage is palliative operative liver function, based on the overall survival of 1868 Sorafenib treatment with an expected median survival of 0.89 patients with HCC who underwent liver resection. We then analyzed years, the survival benefit of surgical resection certainly exists in the predictive power for the postoperative short-term outcome after advanced stage. liver resection in 1488 Child-Pugh A patients with HCC, in 343 Conclusions: Surgical resection for advanced HCC even with macro- patients with colorectal liver metastasis, and in 166 patients with bil- scopic vascular invasion can be identified in some selected cases. iary tract cancer. Results: The Albumin-Indocyanine Green Evaluation (ALICE) grading system was developed in a randomly assigned training cohort: linear O-083 predictor = 0.663 × log10ICG R15 (%) - 0.0718 × albumin (g/L) (cut-off VASCULAR LIVER DISEASES AND LIVER TRANSPLANTATION value: -2.20 and -1.39). This new grading system showed a predictive power for the overall survival similar to the Child-Pugh grading Lerut Jan system in the validation cohort. Determination of the ALICE grade in Child-Pugh A patients allowed further stratification of the post- O-084 operative prognosis. Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure and CUSTOMIZED PATIENT CARE FOR GASTRIC CANCER mortality (ascites: grade 1, 2.1%; grade 2, 6.5%; grade 3, 16.0%; Ming-Tsan Lin mortality: grade 1, 0%; grade 2, 1.3%; grade 3, 5.3%) than the Department of Surgery, National Taiwan University Hospital, previously reported model based on the presence/absence of portal Taipei, Taiwan. hypertension. Determination of the ALICE grade also allowed prediction of the risk of postoperative liver failure in patients with Despite of the decreasing incidence, gastric cancer remains one of the colorectal liver metastasis and biliary tract cancer. common neoplasms and results in the 3rd leading cause of Conclusions: This new grading system is a simple method cancer-related death worldwide. Surgical resection is the most for prediction of the postoperative long-term and short-term effective and potentially curative treatment for gastric cancer. In addi- outcomes. tion to the discipline of the radical eradication of gastric malignancy, our team devoted for years in developing the innovative surgical devices and techniques of minimal invasive surgery to minimize the operative stress and to reduce the post-operative complications. Moreover, it has been realized that only a multidisciplinary team provides the best treatment strategy for the cancer patients. New modalities, including chemotherapy, radiation therapy, immuno-

158 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

therapy with target agents, and hormone therapy, have been and quality control study were recently opened and the 3 year documented to be proper adjuvant treatments along with the relapse-free survival will be analyzed in next year. KLASS-03 study is surgery, or even considered as alternatives for patients without a phase II study to evaluate the safety of laparoscopic total gastrec- feasible operation. In our institute, an integrated expertise team tomy (LTG) in patients with early stage gastric cancer. Regarding provides detail discussions and full-fledged plans during pre-operative the trials related with function-preserving surgery, SENORITA is a assessments and postoperative adjuvant treatment and follow-up. In multicenter phase III trial to validate the clinical role of laparoscopy more depth, we emphasize the importance of nutritional support sentinel node biopsy. KLSS-04 and KLASS-5 are multicenter phase III and early rehabilitation program to accelerate the postoperative trials to compare laparoscopic pylorus-preserving gastrectomy recovery. The para-medical supports not only stand for periopera- with LDG or laparoscopic proximal gastrectomy with double tract tive recovery, but also long-term postoperative care. The newly reconstruction with LTG in patients with middle third or upper developed telecare system is organized with multidisciplinary third located early gastric cancers. These trials focus on not only teams for different types of cancers in our institute. To fit different reducing postgastrectomy syndrome but also improving nutritional postoperative requirements, a personalized plan of treatment will outcomes and quality of life after surgery. Recently, two KLASS trial be established on the agreement of expertise. In fact, nutrition series are preparing for the launch within this year. KLASS-06 trial is specialists are in companion with surgeons for adjusting treatment a multicenter study to compare laparoscopic spleen-preserving plans in out-patient-clinic. In addition, a new National Taiwan total gastrectomy with open total spleen-preserving gastrectomy University Cancer Center, a new Radiation Science, and a proton for upper third advanced gastric cancer. KLASS-07 trial is a multi- therapy center are under construction, which would facilitate the center study to compare laparoscopy-assisted distal gastrectomy most modern service for cancer treatment. Certainly, the early with totally laparoscopic distal gastrectomy. detection of cancer may ensure an early and most successful treatment of the disease. In our society, several public health O-087 programs regarding cancer screening have been conducted in recent 20 years. The programs mainly cover most prevalent CURRENT STATUS OF ROBOTIC SURGERY IN GASTRIC CANCER cancers, including those from gastrointestinal tract, breast, oral, and cervical origins. Our hospital provides a friendly way for those Kakiashvili Eli in need to access the health program. In addition, a separated health management center in National Taiwan University Hospital O-088 helps provide the high quality protocol though early cancer screenings to accomplish cancer treatments. Taking together, the TREATMENT OF GASTRIC CANCER IN A LOW VOLUME CENTER best treatment strategy for gastric cancer should be personalized. Along with the improvement of disease prognosis, a more delicate Valsangiacomo Pablo plan including early diagnosis, sharpened surgical skill, and effective adjuvant therapy should be arranged to accomplish the modern medicine for gastric cancer patients. O-089 BILLROTH II WITH BRAUN RECONSTRUCTION IN THE ERA O-085 OF TOTALLY LAPAROSCOPIC DISTAL GASTRECTOMY

OPTIMAL SURGICAL APPROACH FOR ADENOCARCINOMA Sang-Uk Han. OF THE ESOPHAGOGASTRIC JUNCTION Department of Surgery, School of Medicine, Ajou University, Suwon, 16499 South Korea Yamashita Hiroharu Objectives: Theoretically, Braun anastomosis can divert a substan- tial amount of bile from the remnant stomach to the efferent loop, O-086 thereby it may reduce the afferent loop syndrome compared with Billroth II without Braun anastomosis. This simple and easy method CURRENT CLINICAL TRIALS OF LAPAROSCOPIC may be used as a good alternative to Roux-en-Y reconstruction for GASTRECTOMY FOR GASTRIC CANCER PATIENTS IN KOREA patients undergoing totally laparoscopic distal gastrectomy (TLDG). Sang-Uk Han (SU, Han). However, it is unclear whether Billroth II Braun anastomosis results in superior perioperative outcomes when compared with Roux-en- Department of Surgery, School of Medicine, Ajou University, Y reconstruction, or vice versa, after TLDG. (Methods) From Jan Suwon, 16499 South Korea. 2013 to Dec 2015, 56 patients who underwent TLDG for gastric In the era of minimally invasive surgery, there are presently several cancer at Ajou University Hospital, followed by Billroth II Braun or trials underway in Korea, especially related to laparoscopic surgery Roux-en-Y reconstruction, were retrospectively analyzed. Surgical for gastric cancer. These trials can be classified in two major outcomes, including length of operation, quantity of blood loss, categories; the trials related with the feasibility and oncologic safety and postoperative complications, were compared in the two of laparoscopic gastrectomy and the trials related with function- groups. preserving gastrectomy. Regarding the trials related with the Results: Mean length of operation was significantly longer in the feasibility and oncologic safety, KLASS-01 study is a first large-scale Roux-en-Y group than the Billroth II Braun group (157.3 min vs. multicenter randomized controlled trial to compare laparoscopic 134.6 min, p < 0.010), but length of hospital stay, blood loss, and distal gastrectomy (LDG) and open distal gastrectomy (ODG) in complication rate did not differ between the two groups. Ileus clinical stage I gastric cancer. Its long-term outcomes are expected occurred in three patients (10.0%) in the Roux-en-Y group. to be published soon. KLASS-02 study is a phase III study to evaluate Endoscopic findings 6 months after surgery showed bile reflux in the efficacy of LDG with D2 lymph node dissection for advanced seven (28%) patients in the Billroth II Braun group and five (17.2%) gastric cancer. The short-term outcomes of postoperative morbidity in the Roux-en-Y group (p = 0.343), but no significant differences in

Surgery, Gastroenterology and Oncology, 22 (3), 2017 159 ABSTRACTS

rate of gastric residue or degree of gastritis in the remnant the patient and becoming one of the most common procedures in stomach in the two groups. Regarding gastrointestinal symptoms abdominal surgery, the subsequent exploration of the common during postoperative 6 months, Roux-en-Y groups showed various bile duct in case of choledocholithiasis has not met an equal symptoms such as gas bloating, diarrhea, and dyspepsia, however dissemination in the surgical community dominated by there was no significant difference in occurrence rate between two laparoscopy, maybe because of the high technicity required. In groups (11.5% in the Billroth II Braun group vs. 30.0% in the Roux- contrast, gastro-enterologists are becoming more aggressive in the en-Y group, p=0.114). endoscopic procedures but they do not have an answer to all Conclusions: These findings indicate that Billroth II Braun anasto- situations such as the growing population with a gastric bypass. On mosis may be a good alternative to Roux-en-Y reconstruction in the hand of some clinical cases and video’s, the importance of the treating bile reflux. surgical bile duct exploration is illustrated.

O-090 O-093

TREATMENT OF DIFFICULT BILE DUCT STONES: ENDOSCOPY & THE EVOLUTION OF LAPAROSCOPIC LIVER SURGERY: FROM SURGERY INNOVATION, TROUGH IMPLEMENTATION, TO MASTERY Akaraviputh Thawatchai Perioperative and Oncological Outcomes of 2238 Patients from Four European Specialized Centers. O-091 Objective: To evaluate a large cohort undergoing laparoscopic liver resection (LLR) from 2000 to 2015, focusing on the technical SHORT TERM OUTCOMES OF BILLLIARY ENTERIC approaches, perioperative and oncological outcomes, and ANASTOMOSIS FOR DIFFERENT INDICATIONS IN evolution of practice over time. A TEACHING TERTIARY HOSPITAL OVER TWO YEARS. Methods: The demographics and indications, intraoperative, peri- operative and oncological outcomes of 2238 patients were evaluated. H.S. Haile, R.Dawit. The trends in practice and outcomes over time were assessed. Addis Ababa university college of health science Results: LLR has increased from 5% to 43%. Pure laparoscopy was Addis Ababa, Ethiopia, p.o.box 9086 used in 98.3% of cases. Wedge resections were the most common Objective: There are different types billiary enteric anastomosis operation; they were predominant at the beginning of LLR and done with literatures preferring one over the other for different then decreased and reached a steady percentage at approximately reasons. This study is conducted to compare and see the outcomes 53%. Major hepatectomies were initially uncommon and then of the commonly done billiary enteric bypass surgeries namely increased and reached a stable percentage at approximately 16%. choledochoduodenostomy, choledocojejunostomy, hepatico- Overall, 410 patients underwent resection in the posterosuperior jejunostomy, and cholecystojejunosstomy segments; these were more frequent with time, and the highest Methods: All patients admitted and operated in the duration of percentage was in 2015 (26%). The blood loss, operative time and January 1 2013 up to December 31 2014 are included and chart conversion rate significantly improved with time. The 5-year review done retrospectively to fill out a preformed questionnaire overall survival rates were 73% and 54% for hepatocellular and the data analyzed using 10.1 SPSS data processor. carcinoma (HCC) and colorectal liver metastases (CRLM), Results: 39 patients were operated in the duration Out of these respectively. The 5-year recurrence-free survival rates were 50% 28(71.8%) were females and 11(28.2) were males. 18(46,2%) were and 37% for HCC and CRLM, respectively. in the age group 50 – 70 years and 14 patients age between 30 – Conclusions: Since laparoscopy was introduced, a long implemen- 50 years. Over all 12 (30.7%) patient had postoperative complica- tation process was necessary to allow for standardization and tion 8 (20.5%) wound infections, three (7.7%) billiary leaks and one improvement in surgical care, mastery of the technique and the sepsis of pulmonary origin. All 19 cases 0f choledochoduodenos- ability to obtain good perioperative results with safe oncological tomies, had no billiary leak but 3 (15.8%) had wound infection. 7 outcomes. cases of choledochojejunostomies complicated with 2 (28.5%) wound infection. Seven cholecystojejunostomies done and there were two (28.8%) cases of wound infection and two cases (28.8%) O-094 of temporary billiary leak. Six patients had hepaticojejunostomy. of which one patient (16.7% ) had wound infection, one patient MY FIRST TWENTY ROBOTIC RIGHT HEPATECTOMY: OUR INITIAL (16.7% )had transient billiary leak EXPERIENCE Conclusion: Though the number of patients are small to induce M.V. Marino, G. Shabat, G. Gulotta. deduction according to this study there is no statistically significant P.Giaccone Hospital, Palermo, 90127, Italy. different in the immediate outcome of patients operated with all four types of billiay enteric anastomosis. Objective: Firstly described in 2002, the robotic liver surgery didn’t gain a wide acceptance due to its high cost and the lack of a O-092 standardized training program. Still considered a "development in progress" technique, we decided to evaluate the potential REDISCOVERINGTHE SURGICAL BILE DUCT EXPLORATION advantages of the robotic over laparoscopic approach for a complex liver procedure also in hands of a young surgeon during his initial L.F. Abreu de Carvalho, A. Vanlander, F. Berrevoet, R.I. Troisi. experience. Department of general, HPB surgery and liver transplantation Methods: We analyzed the postoperative outcomes of 20 patients Ghent University Hospital, 9000 Ghent, Belgium. undergoing to robotic right hepatectomy since March 2015 to The treatment of gallstone disease has evolved since the upcoming September 2016. of laparoscopic cholecystectomy. While improving the recovery of Results: The overall mean operative time was 430 min (range

160 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

290,550) and the estimated blood loss was 325 ml (range 120,720), (the number of myofibroblasts and content of extracellular matric no blood transfusion was required. Only 2 patients (10%) under- components). went to conversion to open surgery both for oncologic reason; the Conclusion: PlGF/Nrp1 inhibition showed potent antitumor effects. overall morbidity was 3/20 (15%) and all complications occurred Treatment effects on tumor stroma indicated normalization of (two biliary fistula and one transient liver failure) were classified tumor vessels and microenvironment, which holds promise for like minor according to Clavien-Dindo score. The histological combinations with other therapies (cytotoxics, immunotherapy) in characteristics showed a mean surgical margin of 25 mm and we this intractable disease. achieved a R0 resection rate of 95% (19/20). The reoperation and 90-days mortality rate were both null. The 1-year overall and disease free-survival rate were 92.3% and 84.6% respectively. O-096 Conclusions: Nevertheless some concerns regarding the cost- effectiveness and the absence of liver-specific robotic tools, the PRELIMINARY REPORT OF PERCUTANEOUS CHOLECYSTOSTOMY robotic right hepatectomy is a safe and feasible technique, AS DIAGNOSIS AND TREATMENT OF BILIARY TRACT TRAUMA providing interesting short-term outcomes and oncological results J.B. Cazauran, A. Muller, B. Hengy, P.J. Valette, L. Gruner, also in the initial phase of learning curve. O. Monneuse General and emergency surgery department, Edouard Herriot O-095 hospital, Hospices Civils de Lyon, 69003 Lyon, France ABERRANT ACTIVATION OF PLACENTAL GROWTH Objective: Biliary leak following severe blunt liver injuries (BLI) is a FACTOR/NEUROPILIN 1 PATHWAY IN INTRAHEPATIC complex problem becoming more frequent with improvements of CHOLANGIOCARCINOMA: THERAPEUTIC POTENTIAL non-operative management (NOM). Standard treatment requires main bile duct drainage usually performed by endoscopic sphinc- 1 1 1 1 S. Aoki , S. Kitahara , T. Hato , E. Birnbaum-Mamessier , terotomy and stent placement. We report our experience with 1 1 1 1 D. Schanne , K. Shigeta , A. Khachatryan , R. R. Ramjiawan , cholecystostomy as a first minimally invasive diagnostic and 1 1 1 1 2 K. A. Koch , S. Kozin , A. Matsui , R. K. Jain , S. Dima , therapeutic approach. 3 3 4 2 3 N. Bardeesy , L. Goyal , G. M. Boland , I. Popescu , A. X. Zhu , Methods: We performed a retrospective analysis of consecutive 1 D. G. Duda . patients with post-traumatic biliary leak between 2006 and 2015. 1 Edwin L. Steele Laboratories for Tumor Biology, Department of In the first period (2006-2010), biliary fistula was managed using Radiation Oncology, Massachusetts General Hospital, Harvard perihepatic drainage and endoscopic, percutaneous or surgical Medical School, Boston, USA main bile-duct drainage. After 2010, cholecystostomy as an initial 2 Centre of Digestive Diseases and Liver Transplantation, minimally invasive approach was performed. Fundeni Clinical Institute, Bucharest, Romania Results: Of 341 patients with BLI, 21 had a post-traumatic biliary leak. 3 Department of Medicine, Massachusetts General Hospital, Ten patients received standard treatment and eight patients under- Harvard Medical School, Boston, USA went cholecystostomy. The cholecystostomy (75%) and the standard 4 Department of Surgery, Massachusetts General Hospital, treatment (80%) groups presented similar success rates as first biliary Harvard Medical School, Boston, USA drainage procedure (p=0.80). Cholecystostomy presented no severe Objectives: To determine the role of placental growth factor complication and resulted when successful in a bile flow rate (PlGF)/Neuropilin 1 (Nrp1) pathway in progression of intrahepatic inversion between the perihepatic drains and the gallbladder drain cholangiocarcinoma (ICC). within a median [IQR] 4 days [1-7]. The median time for bile leak Methods: We evaluated the expression of PlGF/Nrp1 in resected resolution was 26 days in the cholecystostomy group and 39 days in human ICC specimens, ICC patient-derived xenografts and genetically the standard-treatment group (p=0.09). No significant difference was engineered mouse models. We also examined the downstream found considering median duration of hospital stay (54 and 74 days signaling in ICC, hepatic stellate cells (HSCs) and cancer-associated respectively, p=0.37) or resuscitation stay (17.5 and 19.5 days, myofibroblasts (CAFs) upon PlGF stimulation or inhibition and p=0.59). evaluated their interaction in in vitro co-culture systems. Finally, we Conclusion: Cholecystostomy in NOM of biliary fistula after BLI is tested in vivo the effect of PlGF inhibition in orthotopic (intra-hepatic) an effective, simple, and safe first-line procedure in the diagnostic mouse models. and therapeutic approach of post-traumatic biliary tract injuries. Results: PlGF and Nrp1 were expressed in 87.8% and 100% of the resected specimens, respectively, and Nrp1 was expressed also in O-097 endothelial cells and CAFs. HSCs secreted more PlGF than ICC cells and PlGF expression was stimulated under hypoxic condition. PlGF PATHOLOGIC GRADE AND MULTIPHASE CONTRAST-ENHANCED or Nrp1 knockdown in ICC cells significantly inhibited proliferation COMPUTED TOMOGRAPHY ATTENUATION LEVEL IN PANCREATIC though down-regulated Akt pathway. In CAFs, PlGF inhibition down-regulated Akt signals and decreased the expression of profibrotic/ activation markers (αSMA/collagen I). PlGF stimulation J.K. Ryu, J. Kang, S.H, Lee, Y-T. Kim. or co-culture with CAFs led to significantly larger tumor spheroids Department of Internal Medicine and Liver Research Institute, and increased invasion. In vivo, PlGF knockdown (sh-PlGF) signifi- Seoul National University College of Medicine, Seoul, 03080, cantly inhibited orthotopic tumor growth and improved prognosis Korea compared with control. In tumor specimens, PlGF inhibition Objectives: We aimed to investigate whether computed tomography decreased the number of proliferating (Ki67+) cancer cells. In (CT) enhancement pattern is associated with the pathologic tumor tumor microenvironment, it inhibited angiogenesis (number of grade and can predict that of pancreatic neuroendocrine tumor CD31+ vessels) and increased pericyte coverage (CD31+/aSMA+), (PNET). indicative of vascular normalization, and also reduced desmoplasia Methods: Ninety PNET patients who underwent multi-phase

Surgery, Gastroenterology and Oncology, 22 (3), 2017 161 ABSTRACTS

enhanced CT before pathologic diagnosis between 2011 and 2015 recurrence are G grade, regional LN mets, and positive margin. were retrospectively reviewed. CT enhancement values at each Conclusions: G grade, regional LN mets, and positive margin are phase were measured and its relation with pathologic grade was the independent predictors of earlier recurrence. Small PNET or assessed. G1 PNET has non-negligible proportion of regional LN mets. We Results: Ninety pancreatic NETs included sixty-two G1 (68.9%), recommend all PNET including small PNET should be resected and twenty-one G2 (23.3%), seven G3 (7.8%). The enhancement values regional LN dissection should be performed. of the early arterial phase were significantly different among three groups (G1 vs. G2; p=0.043, G1 vs. G3; p=0.001, G2 vs. G3; O-101 p=0.027). In the late arterial phase, there was a difference between grade 1/2 and 3 but no significant difference between grade 1 and NEUROENDOCRINE LIVER METASTASES – CURRENT SURGICAL grade 2 (G1 vs. G2; p=0.804, G1 vs. G3; p=0.016, G2 vs. G3; p=0. PERSPECTIVES 0.022). The enhancement value of the portal phase did not differ significantly among the three groups. Diagnostic ability of the early Cerwenka Herwig arterial enhancement value for the differentiation of the grade 1 (cutoff value 109.5HU; sensitivity 73.3%; specificity 62.5%) O-102 was comparable to that of the tumor size (cut-off value 20.5mm; sensitivity 68.9%; specificity 66.7%) VASCULARITY AND TUMOR SIZE ARE SIGNIFICANT PREDICTORS Conclusions: CT enhancement value at early arterial phase and its FOR RECURRENCE AFTER RESECTION OF PANCREATIC changing pattern can be a useful predictor for the differentiation of NEUROENDOCRINE TUMOR pathologic grade of pancreatic neuroendocrine tumors. Y. Yamamoto, Y. Okamura, T. Sugiura, T. Ito, R. Ashida, K. Ohgi, M. Yamada, N. Watanabe, K. Uesaka. O-098 Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka 4118777 Japan. SMALL NON-FUNCTIONING PANCEATIC NEURODENDOCRINE TUMORS (PNET): OBSERVATION OR RESECTION ? Objectives: It is difficult to identify the high risk patients of recurrence after pancreatectomy for pancreatic neuroendocrine Sauvanet Alain tumor (PNET) only using grading classification, especially in the G2 category which includes both benign and low- and high-grade O-099 malignant tumors. Methods: Forty-one patients with PNET who underwent pancrea- ANALYSIS OF LONG-TERM OUTCOME AND RISK FACTORS OF tectomy were enrolled. We defined the CT-ratio as the CT value of RECURRENCE IN PATIENTS WITH RESECTABLE PANCREATIC the tumor divided by that of non-tumorous pancreatic parenchyma NEUROENDOCRINE TUMORS using the late arterial phase dynamic CT. The optimal cut-off values for the CT-ratio and tumor size were determined using p-values C.Y. Yang, T.C. Kuo, J.M. Wu, Y.W. Tien. that were calculated using the log-rank test. Division of General Surgery, Department of Surgery, Results: The optimal cut-off values of the CT-ratio and tumor size National Taiwan University Hospital; Department of Surgery, for dividing patients according to the greatest difference in the College of Medicine, National Taiwan University, Taipei, Taiwan. disease-free survival (DFS) were 0.85 (p<0.001) and 3.0 cm Objectives: The incidence of pancreatic neuroendocrine tumors (p<0.001). The CT-ratio (p=0.007) and tumor size (p=0.003) were (PNET) is increasing in past 30 years. However, the experience individually associated with the Ki-67 proliferative index in analysis of each hospital, esp. in Asia country, is rare. Several studies from by Spearman’s correlation coefficient. Cox proportional hazard western countries suggested small PNET (<= 2cm) could be followed analysis identified that CT-ratio <0.85 (n=10, p=0.006) and tumor up with no need of resection. The optimal management about this size >3.0 cm (n=13, p=0.023) to be independent prognostic factors issue is still controversial. This study analyzed the parameters to associated with the DFS. All patients in the CT-ratio >0.85 and predict recurrence of PNET and re-appraised whether the policy of tumor size <3.0 cm group (n=23, including 7 patients with G2) did “non-operative management for small PNET” is optimal. not develop recurrence after surgery. On the other hand, the Methods: The clinicopathologic profile, surgical findings, and post- 5-year DFS in the CT-ratio <0.85 and tumor size >3.0 cm group (n=5, operative follow-up were retrospectively collected for patients with including 3 patients with G2) was zero. resectable PNET from 1995 to 2012. The end of follow-up was Oct. Conclusions: PNETs with a CT-ratio <0.85 and tumor size 2017. We statistically analyzed recurrence pattern and identified >3.0 cm should be considered to have high risk of recurrence after the independent predictors. pancreatectomy. Results: There were totally 126 PNET patients with mean age 52.7 years old. Only 19.8% of patients have functional PNET symptoms. The median size of tumor was 2.55 cm. Most of tumors (73%) O-103 located at neck, body or tail. The no. of each grading is G1 86, G2 37, and G3 3. The no. of AJCC staging is IA:52 IB:19 IIA:20 IIB:14 III:1 UPFRONT RESECTION OF PANCREATIC NEUROENDOCRINE IV: 20. We found 8.8% of small PNET (< =2cm) was G2 lesion, and TUMORS: ANALYSIS OF PROGNOSTIC FACTROS OF SURVIVAL 5.3% of small PNET has LN mets. G1 PNET has 8.1% with regional Pietro Addeo, Antonio d’Alessandro, Gerlinde Averous, Leonardo LN mets. The median recurrence free survival has not reached. Centonze, François Faitot, Philippe Bachellier. 17.14% of patients has recurrence. The presence of symptoms, HepatoPancreatoBiliary Surgery and Liver Transplantation, duration, age, and operative methods do not correlate with earlier University of Strasbourg, Strasbourg, France. recurrence. By Kaplan-Meier estimates, AJCC(7th) staging predicted recurrence well. The independent predictors of Background: Pancreatic neuroendocrine tumors (pNET) remain

162 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

rare, with few large series evaluating prognostic factors of survival Conclusions: Pancreatic stiffness can be quantified using intra- after resection. The present study aimed to evaluate short and operative elastography. Elastography can be used to diagnose long-term outcomes after resection of pNET in a large cohort. stiffness of pancreas and may be thus be useful in predicting the Methods: This study retrospectively evaluated 131 consecutive occurrence of POPF. In the future, if the change of the operative pancreatic resections performed for PNET between January 1995 method and drainage method could select by this intraoperative and December 2016. The 2010 World Health Organization grading evaluation, it was thought to prevent POPF. system was used for classifying all specimens. Univariate and multivariate Cox analysis were performed to assess survival O-105 prognostic factors. Results: Median age was 56 (range, 18-80, years) and there were NEOADJUVANT CHEMOTHERAPY FOR PATIENTS WITH 106 non-functioning tumors (81.5%) and 11 tumors in the context of RESECTABLE PANCREATIC CANCER an inherited syndrome. There were 32 pancreaticoduodenectomies, 51 splenopancreatectomies, 27 distal pancreatectomies, 5 total Unno Michiaki pancreatectomy and 16 various parenchymal-sparing resections. Forty-three patients (32.8%) had synchronous metastatic disease. O-106 Forty-five patients required extended resections including: synchro- nous liver resection (27), portal vein resection (10) or resection of UPDATES ON MANAGEMENT OF LOCALLY ADVANCED adjacent invaded organs (11). Overall mortality and morbidity were PANCREATIC CANCER 0.7% and 38%. The 1-,3-,5, and 10-year overall survival rates were E. Usova 96%,87%,76% and 56%, respectively. In presence of synchronous A.V. Vishnevsky Institute of Surgery, Moscow, 117997, Russia. liver metastases, the 1-,3-,5-, and 10-year overall survival rates were 92%,78%,61% and 34%, respectively. In multivariate analysis, tumor The definition of locally advanced pancreatic cancer and its grade (P=<0.0001) and synchronous metastatic disease (P=0.006) resectability have been changed during the last decades. However were identified as independent poor prognostic factors. many issues remain to be unclear. The aim is to highlight the Conclusions: Tumor grade and presence of synchronous metasta- current state of resectability for locally advanced pancreatic cancer. tic disease were identified as prognostic factors of overall survival The literature data as well as our institution experience were in resected pNET. Even in presence of synchronous liver metas- analysed in order to evaluate the main challenges and advances of tases, long term survival can be achieved. venous and arterial resection for locally advanced pancreatic cancer. Recent consensus review of the guidelines for treatment of pancreatic cancer showed agreement on work-up methods despite O-104 the lack of evidence. However there exists a disagreement with insufficient evidence on the point of definition of borderline THE EVALIATION OF SOFT PANCREOUS DURING OPERATION resectable pancreatic cancer and portal vein resection. We USING ELASTOGRAPHY proposed the own combination of computed tomography with angiography for detection of vascular involvement. The results of Masahiro Ito, Y. Asano, A. Horiguchi. treatment of patients underwent vascular resection in our Fujita Health University, Nagoya City, 470-1192, Japan. study are reported to be beneficial comparing to those of standard Introduction: Postoperative pancreatic fistula(POPF) is still regarded resection given more advanced adjuvant therapy of former ones. as a most serious and important complication. It has been reported a Literature data and our experience demonstrated the role of rate of occurrence of the POPF is due to the stiffness of the pancreas. radiological work-up and need for advanced chemotherapeutic However, pancreatic stiffness is judged subjectively by surgeons, approach. Minimally invasive approach for extended pancreatectomy without objective criteria. with vascular resection remains an extremely rare procedure and so Aims: In the present study, pancreatic stiffness was quantified far is not justified as beneficial. using intraoperative ultrasound elastography, and its relevance to was investigated. O-107 Materials and Methods: 62 patients underwent elastography during PD at our department from June 2012 to December 2016. CENTRAL PANCREATECTOMY - THE DAGRADI-SERIO-IACONO Methods: Measured Velocity of shear wave(Vs value, m/s) by OPERATION: PAST, PRESENT AND FUTURE. Acoustic Radiation Force Impulse (ARFI). Velocity of shear wave of the 10 locations of pancreatic stump. The average value of the 8 Iacono Calogero points expect for the upper and lower measured value. The defini- tion of POPF used that proposed by the ISGPF. In this study, we classified No-POPF Group(no fistula, and Group A) and POPF Group O-108 (Group B and C). and also the examination of the stiffness of the pancreas take effect pathologically. RECENT ADVANCE OF PALLIATIVE CHEMOTHERAPY Results: The final diagnosis were pancreatic carcinoma (n=31), intra- OF ADVANVCED PANCREATIC CANCER ductal mucinous neoplasm (n=15), bile duct carcinoma (n=8), Ji-.Kon Ryu papilla ampulla carcinoma (n=3), pancreatic neuroendocrine tumor Department of Internal Medicine and Liver Research Institute (n=1), serous adenoma (n=1), chronic pancreatitis (n=1), Seoul National University College of Medicine, Seoul, 03080 duodenum carcinoma (n=1), Ewing (n=1). Multivariate Korea. analysis showed that pancreatic carcinoma or not and Vs(1.885m/s<) value are associated with pancreatic fistula. It was proved Pancreatic adenocarcinoma (PC) is one of the fatalist malignancies. A pathologically. large proportion of patients are diagnosed with unresectable stage at

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the time of presentation. Gemcitabine is a standard chemotherapeu- Conclusion: Regular curses of IA-therapy (CAI, OCE, CAI+OCE) tic agent since 1997, but survival benefit is not satisfactory. Recent cause tumor control in 2/3 of pts with locally advanced pancreatic clinical study proved that several new combination chemotherapy head adenocarcinoma. Improvement of survival in these patients regimens (FOLFIRINOX, gemcitabine with nab-paclitaxel (Gnp)) are can be expected. Following studies including individualization of superior to gemcitabine single chemotherapy, and extended overall IA-methods of treatment are necessary. survival. The current standard therapy for metastatic PC patients with good performance status is either FOLFIRINOX or Gnp. O-110 However, no head-to-head clinical trials comparing these two new regimens have been published and inter-study comparisons are RADIOLOGIC PREDICTIVE FEATURES OF HEPATIC METASTASIS IN limited. FOLFIRINOX significantly increased grade 3 neutropenia PATIENTS WITH PANCREATIC ADENOCARCINOMA compared with gemcitabine (45.7% vs 21%), as well as febrile neutropenia (5.4 vs 1.2%), thrombocytopenia, diarrhea, and KJ Lee, SY Kim, HJ Kim, JH Kim, SS Lee, MG Lee. neuropathy. Gemcitabine is an appropriate treatment option for Department of Radiology and Research Institute of Radiology, patients who choose to receive less-toxic therapy, and those who Asan Medical Center, University of Ulsan College of Medicine, have either poor PS or comorbidity profiles. In NAPOLI-1 phase III Seoul 05505, Korea. randomized trial, the effects of nanoliposomal irinotecan were Objectives: To evaluate the imaging predictive findings of hepatic examined in patients with metastatic PC who previously received metastasis in patients with pancreatic adenocarcinoma. gemcitabine-based therapy. Median progression free survival (PFS) Methods: This retrospective study included 590 patients with was 3.1 months vs. 1.5 months, which was statistically significantly pathologically confirmed pancreatic adenocarcinoma between greater for patients who received nanoliposomal irinotecan with January 2012 and December 2013 who underwent initial multi- 5-FU/leucovorin compared with patients who did not receive phase CT and pertinent follow-up images. We evaluated the irinotecan (P<.001). Irinotecan liposomal injection, combined with relationship between hepatic metastasis within six months of initial 5-FU/leucovorin, was approved by the US FDA as second-line treat- work-up studies and the radiologic findings of intrahepatic arterio- ment following gemcitabine-based therapy. Retrospective study portal (AP) shunt, invasion of portal/superior mesenteric/splenic showed that GnP can extend PFS survival with an acceptable toxicity veins (PV/SMV/SV), thrombus in PV/SMV/SV, and bile ductal as second-line treatment following FOLFIRINOX. Recently, more dilatation shown on initial dynamic CT scan. attention has been paid to immunotherapy to abolish immune Results: The invasion of PV/SMV/SV and thrombus in PV/SMV/SV bypass mechanisms. However, current evidence strongly suggests shown on initial dynamic CT were significantly associated with the critical limiting challenges ahead for evolvement of immunotherapy manifestation of hepatic metastasis within six months (relative risk in PC treatment, due to the poorly immunogenic nature of PC. 2.74; 95% CI 2.07-3.62; p < 0.0001, relative risk 2.15; 95% CI 1.57- 2.93; p < 0.0001, respectively). The presence of intrahepatic AP O-109 shunt or bile ductal dilatation on initial CT had no significant relationship with the manifestation of hepatic metastasis within six INTRA-ARTERIAL (IA) CHEMOTHERAPY OF LOCALLY ADVANCED months (p =0.9165 and p =0.1055, respectively) PANCREATIC CANCER Conclusions: The invasion of PV/SMV/SV and thrombus in PV/SMV/SV on initial CT scans were the predictive findings of P.G. Tarazov, A.A. Polikarpov, A.V. Pavlovskij, A.V. Kozlov. hepatic metastasis in patients with pancreatic adenocarcinoma. Russian Scientific Center of Radiology and Surgical Technologies, St.Petersburg, 197758, Russia. O-111 Aim: To study the results of IA-chemotherapy in unresectable, locally advanced pancreatic cancer. TAILORED PANCREATIC RECONSTRUCTION AFTER Materials and methods: Between 2002 and 2016, IA-chemotherapy PANCREATICODUODENECTOMY: A SINGLE CENTER was performed in 220 pts (109 men, 111 women, mean age 60 EXPERIENCE OF 892 CASES years) with morphologically proven pancreatic adenocarcinoma of TNM stages T3-4 N0-1M0 located in the pancreatic head (76%), body Waleed Askar, Ayman El Nakeeb (20%) or tail (4%). Obstructive jaundice (68% of patients) was Background: Pancreatic reconstruction following pancreatico- treated by surgery or PTBD before IA-chemotherapy. Celiac artery duodenectomy (PD) is still debatable even for pancreatic surgeons. infusion (340 CAI, 1 to 6, mean 2) of gemcitabine 1000 mg/m2 Ideally, pancreatic reconstruction after PD should reduce the risk of (since 2012 plus oxaliplatin 75 mg/m2) every 4 wks was performed POPF and its severity if developed with preservation of both exocrine in 168 pts. Oily chemoembolization (109 OCE, 1 to 7, mean 2; and endocrine pancreatic functions. It must be tailored to control the gemcitabine 600-1000 mg/m2 with 3-5 ml Lipiodol in the feeding morbidity linked to the type of reconstruction. This study was arteries; every 4 wks) was made in 52 pts. Combined treatment planned to show the best type of pancreatic reconstruction (OCE + CAI, gemcitabine 500+500 mg/m2) was used in 44 pts (143 according to the characters of pancreatic stump. procedures, 1 to 6, mean 3.2). Only pts who received > 3 courses of Patients and method: We studied all patients who underwent PD IA-therapy were considered and stratified according sex, gender, in Gastroenterology Surgical Center from January 1993 to tumor stage, and dose of chemotherapy. December 2015. Patients were categorized into three groups Results: 60 pts (20+20+20) were stratified, all had pancreatic head depending on the presence of risk factors of postoperative compli- adenocarcinoma. The first treatment course of CAI resulted in cations. Low risk group (absent risk factor, G1), moderate risk group partial response in 6 (30%), stable disease in 7 (35%), and tumor (presence of one risk factor, G11) and high risk group (presence of progression in 7 pts (35%). The rates of PR, SD, and PD were 40%, two or more risk factors, G111). 25%, and 35% after OCE and 30%, 40%, 30% after OCE+CAI. All 60 Results: 892 patients underwent PD for resection of periampullary pts died; the mean survival was 15.0+4.8, 14.1+3.9, and 17.9+3.3 tumor. BMI > 25, liver cirrhosis, soft panaceas, pancreatic duct mo, respectively (P>0.05). <3mm, and pancreatic duct location from posterior edge < 3mm

164 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

are risk variables for development of postoperative complications. Nagoya University Graduate School of Medicine, Nagoya 466- Postoperative pancreatic fistula (POPF) developed in 128 (14.3%) 8550. Japan. patients. Delayed gastric emptying occurred in 164 (18.4%) Objectives: The indication for surgery in hepatic metastases seems patients, biliary leakage developed in 65 (7.2%) and pancreatitis to depend on which type of cancer they originate from. Unlike the presented in 20 (2.2%) patients. POPF in G1,G11 and G111 were 26 case with colorectal cancer, gastric cancer hepatic metastases have (8.3%), 65 (15.7%), and 37 (22.7%) patients respectively. rarely been considered as oncologically resectable. Methods: In Postoperative morbidities and mortality were significantly lower order to prepare for a clinical question on hepatic metastasis in the with pancreaticogastrostomy (PG) in G111 while pancreatico- Japanese Guidelines for the Treatment of Gastric Cancer Ver. 4, jejunostomy (PJ) decreases incidence of postoperative steatorrhae literature research was conducted using the PubMed. Consequently, in all groups. solitary metastasis was found to be the prognostic factor in several Conclusion: Selection of proper pancreatic reconstruction according case series, and the indication for surgical treatment was found not to the risk of patients may reduce POPF and postoperative complica- to be deniable for a limited population of patients with this disease tions and mortality. PG is superior to PJ as regards short term out- (Kodera et al. Gastric Cancer 2014;17:206-12, presented also at the comes in high risk group but PJ provides better pancreatic function in IASGO in Bucharest,). Further literature search was conducted as a all groups. So, PJ is superior in low and moderate risk groups. follow up. O-112 Results: After the initial literature search, a largest single-institution study was reported from Yonsei University, Korea, and the largest CURRENT STATUS OF LAPAROSCOPIC LIVER RESECTION multi-institution series from Kinoshita et al., Japan. In several latest series including these two reports, 5-year survival rates in carefully Han Ho Seong selected case series exceeded 30%, justifying surgical intervention even in this challenging disease. Although the number of metastatic nodules is one of important criteria for proceeding to surgery, the O-113 methodology to evaluate the number had been varied due to the chronological progress in the diagnostic imaging modalities. The CURRENT AND FUTURE PERSPECTIVES IN PRIMARY LIVER most recent report featured a case-series selected based on the TUMORS contrast-mediated MRI, in which 28 patients with ≤3 metastatic nodules benefited with a 5-year survival rate of 32% (Tatsubayashi et Polak Wojciech al. Gastric Cancer 2017; 20: 387-393). Conclusions: Gastric cancer hepatic metastases in carefully selected O-114 patients based on the number of metastatic nodules could be indicated for hepatectomy with long-term outcomes that cannot be "THE X-Y CLASSIFICATION : AN EASY WAY TO DEFINE denied. Prospective clinical trials to further explore the treatment RESECTABILITY OF PERIHILAR CHOLANGIOCARCINOMA» strategy for this disease is warranted. Boudjema Karim O-119

O-115 THE MULTICENTER COMPREHENSIVE METHODOLOGICAL AND TECHNICAL ANALYSIS OF 832 PRESSURIZED INTRAPERITONEAL SKULTPTURING THE LIVER FOR MORE AND SAFER AEROSOL CHEMOTHERAPY (PIPAC) INTERVENTIONS PERFORMED HEPATECTOMIES IN 349 PATIENTS FOR PERITONEAL CARCINOMATOSIS Torzilli Guido TREATMENT. AN INTERNATIONAL SURVEY STUDY M. Nowacki, M Alyami, L. Villeneuve , M. Hubner, W. Willaert, W O-116 Ceelen, M. Reymond, D. Pezet, C. Arvieux, V. Khomyakov, L. Lay, S. Gianni, W. Zegarski, N. Bakrin, O. Glehen PERSONALIZED MEDICINE FOR HEPATO-BILIARY-PANCREATIC The Department of Surgical Oncology, CHU Lyon Sud, MALIGNANCIES Hospices civils de Lyon, University of Lyon, 69495, Pierre Bénite, France. Dobrila-Dintinjana Renata Introduction: The Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new drug delivery method offered for selected patients O-117 suffering from peritoneal carcinomatosis (PC). There are still a lack number of publications analyzing in details the multicenter PIPAC COMMON PRACTICE AND CONTROVERSIES programs. That is why we distributed a survey among 15 PIPAC IN THE THE SURGICAL TREATMENT OF PANCREAS CANCER centers actively reporting their clinical findings in scientific literature. Dervenis Christos Methods: The established and fully prepared by author’s survey has been sent electronically to the all most relevant and active PIPAC centers on the world. The survey was proposed on a voluntary basis. O-118 The questionnaire was reviewed beforehand by 2 surgeons (MN, MULRISIDCIPLINARY THERAPY FOR HEPATIC METASTASES FROM MA), and consisted of a 34 questions. The survey was conducted GASTRIC CARCINOMA over a period of 3 months starting from March 2017. Results: From the total number of 15 prepared and distributed Y. Kodera, S. Takeda, N. Iwata, T. Fujii, and A. Nakao. questionnaires we have received answer from 12 centers (80%) but

Surgery, Gastroenterology and Oncology, 22 (3), 2017 165 ABSTRACTS

only 9 responds were proved to be fully and accurately completed DESCRIBE POST-OPERATIVE OUTCOME AFTER CRS AND HIPEC and finally accepted to study (60%) in order to preserve the full M. Alyami, B.J. Kim, V. Képénékian, D.Vaudoyer, L. Villeneuve , scientific and meritorious purity. Respondents represented centers N.Bakrin, F.N. Gilly, E. Cotte, O.Glehen, G. Passot. from six countries: Argentina, Belgium, France, Germany, Russia The Department of Surgical Oncology, CHU Lyon Sud, and Switzerland. In this study we have obtained data related to the Hospices civils de Lyon, University of Lyon, 69495, Pierre practical and technical aspects of PIPAC procedures performed in Bénite, France. each center. Conclusion: This data can confirm that the execution of the PIPAC Background: The postoperative morbidity and mortality after procedure, while preserving all general conditions to be safe for CRS-HIPEC has been widely evaluated. However, there is a major patients. We are also confident that the high standardization of discrepancy between rates reported due to different metrics used. the procedure will allow it to be properly verified in the future in Objective: To evaluate the legitimacy of 90-day morbidity and different clinical trials and multicenter evaluation projects. mortality based on the (NCI-CTCAE) v4.0 classification as criteria of quality for CRS-HIPEC. Methods: A prospective database of all patients undergoing O-120 CRS-HIPEC for peritoneal carcinomatosis between 2004 and 2015 CYTOREDUCTIVE SURGERY AND HYPERTHERMIC INTRAPERITONEAL was queried for 90-day morbidity and mortality, and survival. CHEMOTHERAPY FOR PERITONEAL CARCINOMATOSIS Results: Among 881 patients, the 90-day major complication rate IN THE ELDERLY – A CASE-CONTROLLED, MULTICENTER STUDY based on NCI-CTCAE classification and Clavien-Dindo’s classifica- tion were 51% (n=447 patients) and 25% (n=222 patients), respec- M. Alyami, P. Lundberg, V. Kepenekian, D. Goéré, J.M. Bereder, tively. Among patients who presented with a 90-day complication S. Msika, G. Lorimier, F. Quenet, G. Ferron. E. Thibaudeau, based on the NCI-CTCAE classification, 50% (n=225 patients) K. Abboud, R. Lo Dico, D. Delroeux, C. Brigand, MD, C Arvieux, presented a medical complication not reported by Clavien-Dindo’s F. Marchal, J.J. Tuech, J.M. Guilloit, F. Guyon, P. Peyrat, D. Pezet, classification. After surgery, 24 patients (2.7%) died of postopera- P. Ortega-Deballon, F. Zinzindohoue, C. de Chaisemartin, R. tive complications, for only 10 (42%) of them the death occurred Kianmanesh, O. Glehen, G. Passot. within 30-day after surgery. The Department of Surgcal Oncology, CHU Lyon Sud, Hospices Conclusion: Among commonly reported morbidity’s classification, civils de Lyon, University of Lyon, 69495, Pierre Bénite, France. 90-day morbidity based on NCI-CTCAE classification represents a Objective: To identify factors associated with morbidity and legitimate metric of CRS-HIPEC quality. Postoperative morbidity mortality in patients over 70 years who underwent cytoreductive after CRS-HIPEC should be reported using 90-day NCI-CTCAE. surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). O-122 Background: Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only PIPAC PROCEDURE FOR NON-RESECTABLE PERITONEAL current potential curative therapy, but the risks inherent to this CARCINOMATOSIS (WITH VIDEO) patient population have called its benefits into question. J-B. Cazauran, M. Alyami, A. Lasseur, I. Gybels, O. Glehen, Methods: We retrospectively analyzed a prospectively maintained, N. Bakrin. multi-center database from 1989 to 2015. All patients who under- Department of Surgical Oncology, Lyon Sud Hospital, Hospices went CRS and HIPEC for PC were selected and patients older than 70 Civils de Lyon, 69310 Pierre-Bénite, France were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Background: Peritoneal carcinomatosis (PC) is a common evolution Major morbidity and mortality were analyzed. of abdominal cancers and is associated with poor prognosis in the Results: Out of 2328 patients, 188 patients over 70 were matched absence of aggressive multimodal therapy (1). Pressurized with 704 younger patients. Patients over 70 demonstrated a higher intraperitoneal aerosol chemotherapy (PIPAC) is a safe and innova- American Society of Anesthesiologist score (> ASA III 10.8% vs. 6.6%, tive approach, which enhances the effect of chemotherapy (2) p=0.008). There was no difference in overall 90-day morbidity (≥70: without reported renal/hepatic toxicity (3,4). It requires mastery of 45.7% vs. <70: 44.5%; p=0.171), however patients over 70 had technical aspects to reduce postoperative morbidity, increase significantly more cardiovascular complications (13.8% vs 9.2%, effectiveness, and prevent caregiver chemotherapy exposure. We p=0.044). Differences between the older and younger cohorts failed therefore report herein the surgical protocol after two years of to reach significance for 90-day mortality (5.4% and 2.7%, respectively; implementation in our university center specialized in PC manage- p=0.052), and failure-to-rescue (11.6% and 6.1%, respectively; ment, accompanied by a short video, to share our experience. p=0.078). In multivariate analysis, PCI>7 (95%IC: 1.051-5.798, Methods: The procedure was performed under general anesthesia p=0.038) and HIPEC duration (95%IC: 1.106-6.235, p=0.028) were and capnoperitoneum (12mmHg, 37°C) using two balloon trocars independent factors associated with morbidity. placed on the midline, in accordance with the open laparoscopic Conclusion: CRS and HIPEC appear feasible for selected patients over technique. Explorative laparoscopy allowed Sugarbaker peritoneal 70, albeit with a higher risk of medical complications associated with cancer index to be determined. Parietal biopsies were taken and increased mortality. ascites was removed for peritoneal cytology. The nebulizer was inserted and connected to a high-pressure injector. A pressurized aerosol containing chemotherapy agents was then administered; O-121 cisplatin (7.5mg/m2 in 150ml 0.9%NaCl) immediately followed by 2 NINETY-DAY POSTOPERATIVE MORBIDITY AND MORTALITY doxorubicin (1.5mg/m in 50ml 0.9%NaCl), or oxaliplatin alone 2 USING THE NATIONAL CANCER INSTITUTE’S COMMON (92mg/m in 150ml 0.9%NaCl), based on PC origin and chemo- TERMINOLOGY CRITERIA FOR ADVERSE EVENTS BETTER therapy history. Aerosol was kept in a steady-state for 30 min

166 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

then exhausted through a closed filter system and trocars were A newly established surgical oncology service in Pakistan has retracted. Each step is illustrated in the video. started management of peritoneal surface malignancies (PSM) Conclusion: This video protocol provides a better understanding of almost a year ago. Looking back at the process of development, the the PIPAC procedure and the safety measures essential for this problems and challenges faced were identified. The challenges of method of chemotherapy administration. It should help all teams dealing with management of PSM were multifaceted. These include wishing to implement a PIPAC therapy program. lack of awareness of physicians and patients, lack of organized multidisciplinary teams for PSM management, appropriate peri- O-123 operative management including anaesthesia, theatre staff and intensivists, and availability of equipment for delivery of HIPEC. PREDICTIVE UTILITY OF PREOPERATIVE PROGNOSTIC NUTRITIONAL These challenges are looked at from the standpoint of resource- INDEX IN PATIENTS WITH EARLY-STAGE GASTRIC CANCER limited settings. We describe how each of these challenges were dealt by our team. Possible solutions in view of our experience in 1 1 1 1 1 M. Urabe H., Yamashita A., Tanabe K., Yagi S., Aikou S., setting up a peritoneal surface oncology service in a developing 1 2 1 Nomura T., Watanabe Y., Seto country are put forward. This will serve as a guide to centres 1 Department of Gastrointestinal Surgery and interested in developing programs especially in resource limited 2 Department of Surgical Oncology, Graduate School of settings. Medicine, the University of Tokyo, Tokyo, Japan 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan O-125 Objectives: Postoperative relapse are rare events in patients with early-stage gastric cancer, and causes of deaths among such a population are thus mainly comprised of other diseases. However, CORRELATION BETWEEN THE IMMUNOHISTOCHEMICAL tools to prognosticate mortality from non-primary diseases are EXPRESSION OF C-MET, IGF-1R Y VEGFR-2 AND THE limited before surgery. Prognostic nutritional index (PNI) has been RECURRENCE OF GASTRIC ADENOCARCINOMA. frequently proposed as a predictive indicator in various solid tumours A.M. Frunza1, P. Jimenez2, A. Carmona3, I. Gonzalez-Pinto1 including gastric cancer. We retrospectively assessed the relationship 1General Surgery Department. between preoperative PNI and long-term outcome in early gastric University Central Hospital of Asturias (Spain). cancer, especially focusing on mortality from other diseases. 2Medical Oncology Department. Methods: Preoperative PNI were retrospectively examined in 903 University Central Hospital of Asturias (Spain). consecutive patients who underwent curative surgical resection for 3Medical Oncology and Hematology Department. T1 (mucosal/submucosal) gastric adenocarcinoma from 1999 to Morales Meseguer Hospital of Murcia (Spain). 2014. Patients with synchronous malignancies, liver cirrhosis, collagen diseases, or inflammatory diseases were excluded. The Introduction: Gastric adenocarcinoma has a poor prognosis, survival time was evaluated with log-rank test and Cox regression with a 5-year survival of 30%. This has led to the research of analysis. complementary treatments including molecular targeted. Results: Of 903 enrolled patients, 9 died of recurrence, whereas 29 Objectives: To determine the expression of c-MET, IGF-1R and died of other malignancies and 47 died of non-tumorous diseases VEGFR-2 markers in gastric adenocarcinoma cells in the gastrectomy (e.g. pneumonia) during the follow-up period (median 69.8 specimen biopsy and to correlate clinical, anatomopathological and months). Preoperative PNI, as a continuous variable, was signifi- immunohistochemical data with tumor recurrence. cantly correlated with overall survival (OS) and disease-specific sur- Method: This retrospective study was performed on 245 patients vival (DSS) in univariate Cox regression analysis (both P < 0.001). In who underwent gastrectomy for adenocarcinoma between 2000 multivariate analysis adjusted with clinicopathological factors (age, and 2012. The immunohistochemical analysis was made using the gender, location, histology, submucosal invasion, nodal metastasis, tissue microarray technique. A Cox uni and multivariate propor- and lymphatic/venous involvement), preoperative PNI still showed tional hazards model was constructed to evaluate the effect of T independent correlation with OS (HR per 10-unit increase 0.65, and N stage, histological grade, Lauren histological type and the 3 95% CI 0.52-0.81; P < 0.001) but not with DSS (P = 0.43). biomarkers in the relation to recurrence. Preoperative PNI (mean ± SD) was 47.1 ± 4.7 in 9 patients dying of Results: The expression of the tumor markers was 27.3% for c-MET, recurrence, 48.8 ± 6.0 in 29 patients dying of other malignancies, 19.2% for IGF-1R and 1.6% for VEGFR-2. The absence of c-MET 45.9 ± 6.7 in 47 patients dying of other non-tumorous diseases, and expression was associated with an increased nodal involvement, 49.8 ± 6.0 in censored population (n = 818), indicating significant higher histological grade and diffuse Lauren type. The absence of differences among them (P < 0.001, ANOVA). IGF-1R expression was correlated with greater nodal involvement Conclusions: Preoperative PNI is of value to prognosticate long- and diffuse type. The median time to recurrence was 24 months term outcome in early-stage gastric cancer, especially mortality (95% IC, 15-36) with 46% recurrences. In the univariate analysis, from other diseases. stage T3/4, diffuse type and differentiation grade 2/3 were associated with an increased risk of recurrence. In multivariate analysis only T and N stages had prognostic value. O-124 Conclusions: None of the 3 biomarkers studied influenced directly CHALLENGES OF SETTING UP DEDICATED PERITONEAL SURFACE the recurrence of the gastric adenocarcinoma, having only T and N MALIGNANCY CENTRE IN RESOURCE LIMITED SETTINGS parameters prognostic value. Raza Sayyed1, Samiullah Khan Niazi2 1Surgical Oncologist, Patel Hospital, Karachi Pakistan 2Assitant Professor, Liver Transplant and epatopancreatobiliary Unit, Dow University of Health Sciences, Karachi Pakistan

Surgery, Gastroenterology and Oncology, 22 (3), 2017 167 ABSTRACTS

O-126 amounted 32% and was significantly superior to palliatively treated patients (5y-OSR: 1%). Within the curatively treated cohort, patient MULTICENTRIC INITIAL EXPERIENCE WITH THE USE OF THE that received surgical resection demonstrated the best outcome (5y- PRESSURIZED INTRAPERITONEAL AEROSOL CHEMOTHERAPY OSR: 46%) compared to patients that were treated by RT, CT or RCT (PIPAC) IN THE MANAGEMENT OF UNRESECTABLE PERITONEAL (5y-OSR: 20%). Perioperative mortality was 5% and perioperative CARCINOMATOSIS. morbidity 63%. Analyzing clinical and pathological factors revealed M. Alyami, J. Gagniere, O. Sgarbura, D. Cabelguenne, age, tumor localization, histological subtype, grading, tumor stage L. Villeneuve, D. Pezet, F. Quenet, O. Glehen, N. Bakrin, G. Passot and surgical procedure as important prognostic factors for survival. The Department of Surgical Oncology, CHU Lyon Sud, Surgical resection in combination with multimodal treatment Hospices civils de Lyon, University of Lyon, 69495, Pierre concepts achieves the longest survival rates compared to non- Bénite, France. surgical therapies and provided the highest chance for cure. However, it should be considered that surgical resection is often Background: PIPAC is a recent approach for intraperitoneal pursed in patients with less advanced tumor stages and without chemotherapy with promising results for patients with PC. We severe comorbidity. Nevertheless, future attempts will aim to aimed to evaluate the postoperative outcome of pressurized increase the number of patients suitable for surgical therapy. To intraperitoneal aerosol chemotherapy (PIPAC) in patients with accomplish this, optimization of neoadjuvant therapeutic concepts non-resectable peritoneal carcinomatosis (PC) during our initial to effectively achieve down-staging of the tumor will be required. experience of the technique. Moreover, perioperative morbidity and mortality needs to be Methods: All patients who underwent PIPAC for non-resectable PC diminished by novel minimal invasive surgical techniques and peri- in three centers experienced in the management of peritoneal operative minimization of potential risk factors such as pulmonary carcinomatosis (PC), were analyzed regarding postoperative out- function and nutritional status. comes. Results: From December 2015 to December 2016, 73 patients O-128 underwent 164 PIPAC. PC was from colorectal, gastric, ovarian, malignant , or other ITALIEN EXPERIENCE OF SURGICAL TREATMENTS origins in 20, 26, 13, 8, 1 and 5 patients, respectively. At the time of FOR CHOLANGIOCARCINOMA the first PIPAC, the median PCI was 19 (1-39), and 57 patients Guglielmi Alfredo presented with symptomatic PC (pain: 33; ascites: 35; transit disorder: 11). Forty-five (62%), 31 (42%), 8 (11%), 6 (8%), 1 (1%) patients underwent a second, third, fourth, fifth, and sixth PIPAC, O-129 respectively. Major complications occurred for 16 PIPAC (9.7%). For 64 (88%) patients, systemic chemotherapy was associated with NOVEL TARGETS FOR BILE DUCT CANCER PIPAC and could be administered after PIPAC with a median delay of Song Si Young 14 days (2-28). Among 57 patients with preoperative symptoms related to PC, 31 (63.5%) patients presented with complete disappearance of symptoms. PCI improved in 64.5% of patients. O-130 Conclusions: Implementing a PIPAC program in association with systemic chemotherapy is feasible and is associated with a risk of THE ROLE OF THE PATHOLOGIST IN THE MANAGEMENT OF postoperative morbidity, even in teams highly experienced in PC CHRONIC HEPATITIS OR IMPORTANT CASE STUDIES IN GI AND management. International consensus is mandatory to determine LIVER: MY EXPERIENCE a standardized PIPAC protocol. Duduyemi Babatunde

O-127 O-131 SURVIVAL OF 456 ESOPHAGEL CANCER PATIENTS ISOLATED HEPATIC PERFUSION CHEMOTHERAPY AFTER SURGICAL AND NON-SURGICAL TREATMENT FOR UNRESECTABLE MALIGNANT HEPATIC TUMORS. J. Lemke, G. Cammerer, J. Teufel, M. Kornmann, D. Henne-Bruns PRELIMINARY RESULTS Clinic of General and Visceral Surgery, University of Ulm, Emilio Vicente Albert-Einstein-Allee 23, 89081 Ulm, Germany. Esophageal cancer (EC) remains a major challenge in oncology due to In patients with hepatic metastases from solid-organ malignancies, significant mortality and morbidity. Depending on the tumor stage surgical resection may be a potentially curative option, but it is not and histological subtype, different therapeutic strategies including possible in most cases. Chemosaturation with percutaneous hepatic surgical resection, chemotherapy (CT), radiotherapy (RT), radio- perfusion was developed for the management of unresectable chemotherapy (RCT) or multimodal concepts, are pursued in EC. metastases to the liver. In Europe, chemosaturation with percuta- Here, we analyzed the survival in an unbiased cohort of 456 patients neous hepatic perfusion was commercially launched in 2012, and a diagnosed with EC between 1996 and 2011 in our clinic, focusing on second-generation, high-efficiency filter was approved for use in different therapeutic concepts as well as clinical and histopathologi- conjunction with a proprietary hepatic delivery system that same cal factors. Majority of patients was diagnosed with squamous cell year. Chemosaturation with percutaneous hepatic perfusion is a carcinomas (336 patients, 74%). Of all 456 patients 238 patients minimally invasive, repeatable, regional therapy in which a high (52%) received curative treatment. Of these curatively treated dose of melphalan is directly infused into the liver via the hepatic patients, 97 patients (41%) were treated by surgical resection. 5-year artery using a percutaneous approach.3,9,10 The liver is isolated overall survival rate (5y-OSR) of curatively treated patients from the systemic circulation by a double-balloon catheter

168 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

inserted through the femoral vein. Chemotherapy-infused blood is S. Conci1, L.Viganò2, G. Ercolani3, A. Ruzzenente1, A. Fontana2, then diverted through the arterial catheter via an extracorporeal F. Bertuzzo1, A. Dore1, C. Lacono1, D. A. Pinna3, G. Torzilli2, pump circulation and is then filtered and returned to the patient A. Guglielmi1. via venovenous bypass and the jugular vein. Study patients in 1Department of Surgery; Division of General and Hepatobiliary different trials had a variety of primary tumor types, including Surgery; G.B. Rossi University Hospital; University of Verona; ocular melanoma, cutaneous melanoma, cholangiocarcinoma, Verona; Italy. , and colorectal, breast, and gastric cancers. In these 2Department of Surgery, Division of Hepatobiliary and General studies, rates of overall hepatic response ranged from 50% to 75%. Surgery, Humanitas Clinical and Research Center, Humanitas Hepatic responses were seen in those with cholangiocarcinoma, University, Rozzano, Italy. colorectal cancer, ocular melanoma, cutaneous melanoma, and 3Department of General and Emergency Surgery and Organ leiomyosarcoma. Complete responses were observed in patients Transplantation, S. Orsola-Malpighi Hospital, University of with cholangiocarcinoma and ocular melanoma. The experience Bologna, Bologna, Italy. is very limited. Until now, no more than 200 cases have been Background and aims: The aims of the study were to compare the published. The aim of this lecture is to present the technical aspects clinicopathological features and survival after surgery of patients and our experience with this approach. with intrahepatic cholangiocarcinoma (ICC) according to the pattern of presentation O-132 Methods: A retrospective analysis of a multi-institutional series of 282 patients with ICC was carried out. Patients were further classified NOVEL TECHNIQUE OF RIGHT HEPATIC ARTERY RECONSTRUCTION according to the pattern in single tumor (type I), single tumor with FOR THE TREATMENT OF HILAR CHOLANGIOCARCINOMA WITH satellites in the same liver segment (type II) or multifocal scattered ARTERIAL INVASION BY TRANSPOSITION OF COMMON HEPATIC tumors (type III) ARTERY. Results: 173 (61.3%) patients were type I, 61 (21.6%) type II and 48 (17%) type III. Curative liver surgery was performed in 259 (91.8%) Alikhanov R., Fedorov E., Efanov M., Kim P., Starostina N., patients with a significant difference according to the pattern: Voronov D. 94.8%, 96.7% and 75% in type I, II and III, respectively (p<0.001). Moscow Clinical Scientific Center. The 5-years overall survival for the entire cohort was 38.2% and Department of hepatopancreatobiliary surgery. 48.9%, 26.4% and 7.3%, in type I, II and III, respectively (p<0.001). Backround: In hilar cholangiocarcinoma(CC) Bismuth type IIIB, the On multivariate analysis factors related with survival were pattern expansion of the tumor can lead to involvement of the RHA and/or type II and type III (OR 3.499, p<0.001, and OR 4.394, p<0.001, the portal vein (PV) or its branches. Arterial reconstruction may be respectively), Ca 19-9 >55 U/mL (OR 2.105, p=0.021), LN metas- difficult in case of tumor invasion to hepatic artery propria(HAP). tases (OR 2.254, p=0.007), R1 resection (OR 1.929, p=0.023) and Authors describe a novel technique that allowed an oncological size >5cm (OR 1.900, p=0.046), respectively resection in patient with hilar CC Bismuth type IIIB and contralateral Conclusion: ICC could have three distinct pattern of presentation arterial invasion using transposition of common hepatic artery(CHA). with different prognosis that should be considered in the therapeu- A 48-year-old man presented with jaundice. The pre-operative tic decision. In type III patient’s surgery should be reserved only for computed tomography scan and magnetic resonance imaging con- selected cases and after a multidisciplinary discussion firmed hilar CC type IIIB with contralateral vascular invasion. During the surgical procedure, reconstruction of the RHA was performed: after transection of the CHA at the origin from celiac trunk and O-134 transposition of it to the distal portion of RHA, anastomosis was done between CHA and RHA just before anterior and posterior ROLE OF LYMPH-NODE DISSECTION IN SMALL (≤ 3CM) branches of RHA was divided. Arterial clamping time was 15 min. INTRAHEPATIC CHOLANGIOCARCINOMA Patient underwent a left hepatectomy with caudate lobe resection. S. Conci1, L.Viganò2, G. Ercolani3, A. Ruzzenente1, A. Fontana2, The tumor was resected en-bloc with the liver parenchyma, the T. Campagnaro1, A. Dore1, C. Lacono1, D. A. Pinna3, G. Torzilli2, involved PV and the extrahepatic bile duct. PV reconstruction was A. Guglielmi1. accomplished by end-to-end anastomosis. The portal clamping 1Department of Surgery; Division of General and Hepatobiliary time was 15 min. Doppler ultrasonography confirmed a patent HA Surgery; G.B. Rossi University Hospital; University of Verona; and PV with an adequate blood flow. Patient made a full recovery Verona; Italy. and was discharged 10 days after surgery. Pathological examination 2Department of Surgery, Division of Hepatobiliary and General confirmed hilar CC with disease-free vascular and surgical margins. Surgery, Humanitas Clinical and Research Center, Humanitas At 7s month patient remain disease free. The novel technique that University, Rozzano, Italy. include of using CHA transposition for RHA reconstruction was 3Department of General and Emergency Surgery and Organ clinically and technically feasible allowing an oncological resection Transplantation, S. Orsola-Malpighi Hospital, University of to be performed in patient with tumor invasion of RHA and Bologna, Bologna, Italy. extention to HAP. Background and aims: The role of lymph-node dissection (LD) in patients with small intrahepatic cholangiocarcinoma (ICC) is still O-133 under debate. The aims of the study were to compare the lymph- node (LN) status and its correlation with survival in patients with PROGNOSTIC IMPACT OF DISTRIBUTION OF HEPATIC NODULES ICC after surgery according the tumor size (SINGLE, SATELLITES OR MULTIFOCAL) AFTER RESECTION FOR Methods: A retrospective analysis of a multi-institutional series of INTRAHEPATIC CHOLANGIOCARCINOMA 259 patients submitted to curative surgery was carried out.

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Patients were further classified according to the tumor size in Results: Five patients were operated using above technique. 3 small-ICC (≤ 3cm) and large-ICC (> 3cm) patient underwent right trisegmentectomy, one left hepatectomy Results: Fifty-three patients had small-ICC and 206 had large-ICC. with caudate lobectomy and one left trisegmentectomy with LD was performed in 194 (74.9%) patients, with a significant caudate lobectomy. One patient required 5 units of transfusion due difference between small-ICC and large-ICC, 62% and 78%, respec- to severe cholestatic liver, other wise mean transfusion requirement tively (p=0.016). LN metastases were identified in 38% of the entire was 2 units of PCV. One patient died due to sudden cardiac arrest at cohort, in 30% and 39% of small-ICC and large-ICC, respectively 4th post -operative day after he was shifted out of ICU, One patient (p=0.216). No differences in the number of LN retrieved, number of developed small for size syndrome after right trisegmentectomy, LN metastases and LN ratio were identified between small and which was settled down with conservative management. One large-ICC who underwent LD. The 5-years overall survival (OS) was patient had frozen portal due to multiple metal stenting which could 52% for small-ICC and 34% for large-ICC (p=0.019). Regarding also be operated easily. small-ICC, the 5-years OS according to the LN status was 85% in the Conclusion: Anterior approach and parenchymal first technique N0 and 36% in the N+ (p=0.035). using modified glissonian approach is feasible and applied every - Conclusion: Despite the lower rate of LD in small-ICC group, one where and learning curve for the same is less. third of the patients had LN metastases with important prognostic implications. LD should be performed, also in small-ICC, for a O-136 correct staging and for the allocation to adjuvant therapy OUR STRATEGY IN HEPATOPANCREATODUODENECTOMY FOR O-135 CHOLANGIOCARCINOMA TO REDUCE INVASIVENESS OF THE PROCEDURE LIVER RESECTION IN HILAR CHOLANGIOCARCINOMA USING PARENCHYMAL FIRST APPROACH WITH MODIFIED GLISSONIAN S. Hirano, T. Noji, K. Tanaka, Y. Nakanishi, T. Asano, APPROACH- TECHNICALLY EASIER TECHNIQUE EVEN IN FROZEN Y. Kurashima, Y. Ebihara, S. Murakami, T. Nakamura, PORTA HEPATIS. CASE SERIES OF 5 PATIENTS. T. Tsuchikawa, K. Okamura, T. Shichinohe. Department of Gastroenterological Surgery II, Division of Bhavin B. Vasavada, Hardik Patel. Surgery, Hokkaido University Faculty of Medicine, Sapporo, Department of Hepato-pancreatico-biliary and Liver Transplant 060-8638, Japan. Surgery, Shalby Hospitals, Ahmedabad, Gujarat, India-380054 Objectives: Hepatopancreatoduodenectomy (HPD) is technically Background: Liver resection for hilar cholangiocarcinoma is techni- demanding and is usually associated with high mortality and cally demanding surgery. We describe our technique of anterior morbidity rates. Therefore, it has been yearned to decreasing the approach of parenchyma first approach for resection of hilar operative invasiveness by improving the results of the procedure. cholangiocarcinoma which can be easily applied to even difficult For this occasion, we have begun to utilize brand new devise (water porta hepatis with repeated metal stenting. jet dissector) in hepatic transection so as to reduce the operative Our technique: After opening abdomen, we routinely look for time, blood loss, and vascular occlusion time. Additionally, the metastasis, if no metastasis is seen. After portal hepatis is looped, pancreas was transected in the final stage of the resection, and we start parenchyma transection first. reconstructed using modified Blumgart technique. We herein Right trisegmentectomy: After looping portal hepatis for pringle present operative procedures in which the new strategies were maneuver if needed, we start Liver transection just right to umbilical employed. fissure, and reach to left hepatic duct and left portal vein intra- Methods (Case presentation): An early 60’s gentleman were hepatically and loop them. After that left hepatic duct is cut and presented with jaundice and diagnosed as having extrahepatic bile margin is sent for frozen section. Then we dissect left hepatic duct duct cancer spreading towards hilar and intrahepatic ducts. and right hepatic duct and common hepatic duact and tumor mass Preoperative biliary decompression was successfully performed from underlying portal vein if possible and then cut bile duct just with biliary drainage. Estimated hepatic reserve after portal above pancreas and sent for frozen section. If separating from portal embolization was sufficient for right hemihepatectomy. Then, right vein is not possible left portal vein is cut and then main postal vein is HPD was scheduled. The surgical procedure was performed dissected and then portal vein reconstruction is carried out. Mass in order as follows: (1) Mobilization of the pancreas and the with right-sided glissonian pedicals are cut, ligated and over sutured duodenum with jejunal and gastric division, (2) Dissection of hepa- with prolene4-0 enmass. In the end hepaticojejunostomy is done in toduodenal ligament, (4) Mobilization of the right hemiliver and left hepatic duct. caudate lobe, (5) Wedge resection of the left portal vein at bifurca- Left trisegmentectomy with caudate lobectomy: After looping the tion after transection of ventral and caudal part of the liver, (5) porta hepatis, liver transection line is marked by marking right Transection of the liver along to the middle hepatic vein followed hepatic vein ultrasonographic guided or some times we mark along by division of the right hepatic vein, (6) Division of the left hepatic the line between Rouviere sulcus and right hepatic vein and then duct, (7) Transection of the pancreas and retrieve of the specimen, we isolate and loop right posterior pedical intrahepatically and (7) Reconstruction in the modified Child’s fashion. loops, rest of the bile duct is looped enmass with the cancer and Results: Hepatic transection was completed without any vessels ligated and cut. Margins are sent for frozen section. If portal vein occlusion to the remnant liver. The operative time was 13 hours involved then main and left portal vein is looped and portal vein and 39 minutes and blood loss was 1600 ml. Postoperative reconstruction is done. maximum serum bilirubin value was 1.8 mg/ dL. Right and left hepatectomy: Transection plane is marked via marking Conclusions: Right HPD could be performed with the strategies the middlehepatic vein ultrasonographically or line from plane including new hepatic transection procedure which might between hepatic vein confluences. Pedical looping technique is same contribute to reducing the invasiveness of the procedure. as above.

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O-137 metastatic as well. Multiogan resection in the case of invasion of cancer to the adjacent organs or structures, two-stage hepatectomy, NEAR-INFRARED FLUORESCENT CHOLANGIOGRAPHY AS A NEW associated liver partition and portal vein ligation (ALPPS) or repeated TOOL FOR A SAFER DISSECTION DURING ELECTIVE LAPAROSCOPIC hepatectomies for liver metastases, lung resection for lung metas- CHOLECYSTECTOMY. tases, cytoreductive surgery + HIPEC in peritoneal dissemination - are A. Pesce, S. Latteri, TR. Portale, B. Di Stefano, D. Russello, the surgical solutions proposed for these patients. S. Puleo, G. La Greca. Material and methods: There were 72 total pelvic exenterations, Department of Medical and Surgical Sciences and Advanced 210 liver resection including repeated hepatectomies for locally Technologies “G.F. Ingrassia”, University of Catania, Via S. advanced and metastatic colorectal cancer provided in last 15 Sofia 84, 95123 Catania, Italy. years, 12 HIPEC procedures with or without peritonectomy in last 2 years for peritoneal dissemination at single institution provided. Objectives: The primary aim was to evaluate, in this preliminary Totally there were more than 1800 patients with colorectal cancer experience, the efficacy of near-infrared fluorescent cholangio- from 2001 to 2016 operated on at Surgical Department, Thomayer graphy (FC) in real-time visualization of the biliary tree during Hospital Prague, Czech Republic. elective laparoscopic cholecystectomy. The second aim was to Results: With multidisciplinary approach we have in advanced analyze the possible factors influencing the visualization rates of stages of colorectal cancer the 5 - year survival in TNM stage III 69% the biliary system by FC. (group of total pelvic exenteration 5-year survival 49%), in TNM IV Methods: Fifty consecutive elective laparoscopic cholecystectomies stage 38%. In colorectal liver metastases the 5-year survival is 40%, were performed with fluorescent cholangiography. FC was performed including repeated and multiple-staged resections. at three time point during laparoscopic cholecystectomy: (1) following Conclusion: All patients having gastroinstestinal malignancy should exposure of Calot’s triangle, prior to any dissection; (2) after be assessed by a multidisciplinary team in a cancer centre. The partial dissection of Calot’s triangle; (3) after complete dissection of benefits of multidisciplinary disease management include reducing Calot’s triangle, according to the “Critical View of Safety”(CVS) recurrent disease, optimizing timing of surgery and organ preserva- technique. tion, prolonging survival for the patient and enhancing the surgical Results: Fluorescent cholangiography was successfully performed in possibilities and response to targeted therapies as well. all 50 patients undergoing elective laparoscopic cholecystectomy. Supported by grants: GACR P304/17-16857S, AZV15-27939A. The mean age was 55.4 years-old (range 24-80 ys) with 13 males and 37 females. The mean body mass index (BMI) was 26.8 (range 17.7- 44.0). The cystic duct (CD) was successfully identified by FC in 43 of O-140 50 patients (86%) and in 45 of 50 patients (90%) before and after Calot’s dissection respectively (p>0.05). The common hepatic duct SIGNIFICANCE OF MULTIDISCIPLINARY APPROACH FOR (CHD) and the common bile duct (CBD) were successfully identified ADVANCED COLORECTAL LIVER METASTASES: A SINGLE in 12 of 50 patients (24%) and in 33 of 50 patients (66%) before INSTITUTIONAL EXPERIENCE Calot’s dissection respectively (p=0.007) and in 26 of 50 patients J. Shindoh, Y. Kiya, T. Sugawara, Y. Kobayashi, M. Hashimoto. (52%) and in 47 of 50 patients (94%) after complete Calot’s dissec- Department of Gastroenterological Surgery, Toranomon tion respectively (p=0.001). No statistically significant differences Hospital,Tokyo, 105-8470 Japan. were observed between frequencies of CD, CHD and CBD visualiza- tion by BMI (25 as cut-off value), by age (median value 57.5 years as Objectives: Multidisciplinary team (MDT) approach has reportedly cut-off) and by a history of cholecystitis, except for the CBD visualiza- been a keyword for the treatment of Stage IV cancers in the era of tion rate that was increased in patients without previous cholecysti- modern chemotherapy. However, actual impact of MDT approach tis (p=0.017). No major and/or minor bile duct injuries were on the treatment outcomes of colorectal liver metastases has not reported. yet been discussed so well. The objective of this study was to Conclusions: ICG fluorescent cholangiography could be considered clarify the significance of MDT approach in clinical decision making a valid and useful tool for a safer dissection during elective laparo- process for advanced colorectal liver metastases. scopic cholecystectomies. Methods: Based on the retrospective review of a prospectively collected clinical database in a single high-volume hepatobiliary center, impact of MDT approach including hepatobiliary surgeon O-138 on the treatment outcomes of synchronous liver metastases was MANAGEMENT OF COLORECTAL CANCER WITH SYNCHRONOUS investigated by comparing the estimated clinical results based on LIVER METASTASES the initial treatment plans offered by colorectal surgeons and the actual clinical results based on the treatment plans modified by Siriwardena Ajith hepatobiliary surgeons. Results: Among 689 patients who underwent curative resections O-139 for primary colorectal lesions between April 2014 and October 2015, 42 (6.1%) patients presented synchronous liver metastases SURGERY FOR ADVANCED COLORECTAL CANCER with (n=14) or without (n=28) extrahepatic disease. Proportion of patients who were diagnosed with resectable or potentially M. Levy, L. Lipska, K. Veskrna, M. Mracek, J. Simsa, V. Visokai. resectable disease at initial assessment was 40.5% (17/42) by Surgical Department, Thomayer Hospital, First Faculty of colorectal surgeons and 61.9% (26/42) by hepatobiliary surgeons Medicine, Charles University, Prague, 14059, Czech Republic. (P=0.049). With adequate combination of preoperative chemo- Background: The recent more effective chemotherapy and the therapy and advanced hepatobiliary surgical approach, 54.7% development of surgical procedures have expanded the possibilities (23/42) patients eventually underwent curative surgical resection of treatment patients with advanced colorectal cancer – locally and including 4 conversion cases. Based on the outcome-based

Surgery, Gastroenterology and Oncology, 22 (3), 2017 171 ABSTRACTS

estimation, approximately 20% of patients would have benefit O-143 from curative surgical options with 10% of conversion rate among initially unresectable population by including hepatobiliary TREATMENT STANDARD OF RECTAL CANCER FOR ORGAN surgeons in MDT. PRESERVATION Conclusion: MDT approach including hepatobiliary surgeons Watanabe Toshiaki « In Memorium » significantly improves resection rate and may offer potential survival benefit even for patients with initially unresectable disease. O-144 O-141 LONG-TERM SURVIVAL FOR COLORECTAL CANCER WITH LIVER LAPAROSCOPIC COMBINED COLORECTAL AND LIVER RESECTIONS METASTASES FOR PRIMARY COLORECTAL CANCER WITH SYNCHRONOUS LIVER A.A. Burlaka, O.V. Vasiliev, V.I. Dorozhynskyi, V.V. Zvirych METASTASES. O.O. Kolesnik. Vladov Nikola National Cancer Institute, Kyiv, Ukraine. Background: Despite the introduction into clinical practice O-142 calculating the volume of future liver remnant as well as application of portal vein embolization (PVE) or associating of liver partition and MANAGEMENT OF THE SYNCHRONOUS COLO-RECTAL TUMORS portal vein ligation, ALF remains to be the leading cause of compli- (BENIGN AND MALIGNANT) cations and mortality after liver resection. Method: Researches are based on retrospective analysis of (406 Chr. Petkov, K. Zarkov. patients) colorectal cancer patients with synchronous and First Surgical Department, Fifth General Hospital, Sofia, metachronous liver metastases (mCRC), (pT1-4N0-2M0-1 cancer of Bulgaria. the colon and pT1-3N0-2M0-1 rectal cancer) period from 2007 to Background: The advance and wide-spread of bowel endoscopy 2017 in National Cancer Institute (Ukraine). resulted in early diagnostics of colo-rectal tumors (SCRT)-benign Results: Ten-year overall survival rate of mCRC was 23% and 38% and malignant; as well as encountering synchronous tumors. for rectal and colon cancer primary respectively. Total level of Aims: We discuss the diagnostics of the found synchronous colo- complications registered for 30 days post-operative period was rectal tumors regarding histopathology (benign and malignant); 17.9%. Most serious complications registered in patients who treatment tactics – performed procedures; follow-up. underwent "major" liver resection (12.5%). ALF was the second Patients: We retrospectively analyze 148 patients with SCRT lead reason of complication in patients with simultaneous and treated in the Surgical Departments and Gastroenterology of our combined surgical tactic. hospital for 2010-2015. Colonoscopies are performed in First Conclusions: And new principles of ALF diagnosis and manage- Surgical Department by surgeon; in Gastroenterology by gastro- ment should develop. enterologist. Assessed are: number of synchronous tumors per patient; localization; histopathology; TNM stage of malignant; O-145 performed procedures – endoscopic and/or surgery. Results: Histopathology of synchronous tumors: Benign–12; SIMULTANEOUS LAPAROSCOPIC RIGHT HEPATECTOMY AND Benign and malignant–19; Malignant–8 cases. Number of SCRT per EXTENSIVE RIGHT COLECTOMY FOR CRC WITH SYNCHRONOUS patient: 2 tumors-94; 3 tumors-32; 4 tumors-20; 10 and more LIVER METASTASES tumors-2 patient. Localization of polyps: rectum–68; sigmoid–175; descendens–23; transversum–36; ascendens–27; cecum-9. I. Takorov, Ts. Trichkov, M. Iakova, I. Vasilevski, V. Mihaylov, Performed procedures: Biopsy–5%; Biopsy and endoscopic Ts. Lukanova, E. Odisseeva, N. Vladov. polypectomy–48%; Endoscopic polypectomy–26%; Surgery and Department of Hepato-Pancreato-Biliary and Transplant endoscopic polypectomy–3%; Surgery–9%. The tactics for diagnos- Surgery – Military Medical Academy, 1606 Sofia, Bulgaria. tics and treatment of SCRT comprises: • Total colonoscopy is Objectives: Nowadays laparoscopic liver and colorectal resections as performed in all cases. • If synchronous polyps are found small and separate procedures are accepted as feasible, safe and oncological not proper to be removed, biopsy of every tumor is performed; and equivalent to open ones in the treatment of colorectal cancer. patient is included in follow-up. • Pediculated polyps are removed However, there is still no consensus, regarding its applicability as during colonoscopy. If not possible - subjected to open surgery – simultaneous procedures in cases with synchronous liver metastases laparotomy, colotomy, polypectomy and suture. • When synchro- from colorectal cancer. A case of a 65-year-old male patient with nous benign and malignant tumors are found –is possible to: 1) cancer of transverse colon and two synchronous metastatic lesions Remove the benign during colonoscopy and surgery for the malig- (8 and 7 cm) in the right liver is presented. The disease was nant to follow. 2) Remove one of benign during colonoscopy and confirmed by colonoscopy and CT scan. surgery for the malignant and the remaining benign (if close) to Methods: After a laparoscopic exploration of the abdomen, a follow. 3) Surgery. simultaneous right hepatectomy and extensive right colectomy Conclusions: We aim to remove the benign colo-rectal tumors were performed, using six trocars for the entire procedure. endoscopically. Colo-rectal cancers are submitted to surgery after The specimens were extracted through an upper midline mini- endoscopic diagnosis. laparotomy. Results: Total operative time was 320 minutes, with minimal intra- operative blood loss. Blood transfusions after the procedure were not performed. Per oral feeding was started on the third day after

172 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

surgery. The postoperative hospital stay was 6 days without any comprise several other GI surgeries, i.e., gastrectomy, colectomy complications. and distal pancreatectomy. However, resection of uncinate process Conclusions: In this case we can see the feasibility of the laparos- is unique process required exclusively for LPD. IPDVs are linker of copic approach to simultaneous liver and colorectal resections for uncinated process and SMV, and also one of major sources of colorectal cancer with synchronous liver metastases. The well bleeding during resection. The early recognition of IPDVs and their known advantages of the mini-invasive surgery make such complex resection broaden the operation field between uncinated process, procedures more reliable. They must be performed when the SMV and SMA in a safe way. Addition to the recognition of IPDVs, surgical team has enough experience and in properly selected anatomy of Treitz’s ligament is also important to make LPD more cases. feasible. These anatomical findings and laparoscopic techniques will be discussed. O-146 O-148 PURE LAPAROSCOPIC RIGHT HEPATECTOMY USING ANTERIOR APPROACH FOR METASTATIC SHORT-TERM OUTCOME OF LAPAROSCOPIC DISTAL PANCREATECTOMY; COMPARISON BETWEEN N. Vladov, Ts. Trichkov, I. Takorov, I. Vasilevski, V. Mihaylov, SPLEEN-PRESERVING AND EN-BLOC SPLENECTOMY Ts. Lukanova, M. Iakova, E. Odisseeva. Department of Hepato-Pancreato-Biliary and Transplant T. Morikawa, M. Iseki, M. Ishida, T. Takadate, T. Hata, S. Maeda, Surgery – Military Medical Academy, 1606 Sofia, Bulgaria. K. Ariake, K. Masuda, T. Aoki, K. Fukase, H. Ohtsuka, M. Mizuma, N. Sakata, K. Nakagawa, H. Hayashi, F. Motoi, T. Naitoh, T. Kamei, Objectives: Pure laparoscopic hepatectomy is a minimally invasive M. Unno procedure that leads to fast recovery. This still can be a challenging Department of Surgery, Tohoku University Graduate School procedure, especially if anterior approach is required. A case of a 58 of Medicine, Sendai, Miyagi, 980-8574 Japan. years old female in a good general condition, suffering from metastatic lesion (7 cm) in the right part of the liver is presented. Introduction: Laparoscopic distal pancreatectomy is now the She has had left radical mastectomy for breast cancer combined standard treatment for low-malignant tumor in the pancreas with adjuvant chemotherapy. On follow-up PET/CT scan, 21 months body or tail. Although many institutes perform laparoscopic after the breast operation, a metastatic lesion was detected. spleen-preserving distal pancreatectomy (LSPDP), its benefit is still Methods: After open-laparoscopy and exploration of the abdomen controversial. The aim of this study is to compare LSPDP with laparo- we focused on the liver, which presented with heavy steatosis and scopic distal pancreatectomy with splenectomy (LDP) in the light of a huge solitary metastatic lesion. This is the reason why we have safety. chosen anterior approach. We started with dissection of the Methods: We evaluated the characteristics and the operative hepatoduodenal ligament, then divided the right hepatic artery outcomes of all patients who underwent LSPDP or LDP at our and right hepatic vein. The parenchyma was transected with institution from July 2009 to January 2017. minimal blood loss and the right hepatic pedicle and the right vein Results: We performed 55 LDPs (LSPDP, n = 12; LDP, n = 43) during were transected with linear endoscopic stapler (45 mm). The the study period. There was no significant difference in the specimen was extracted through a mini-Pfannenstiel laparotomy. characteristics such as age, sex, body mass index and ASA score. Results: The operative time was 210 minutes and the blood loss The operation time of LSPDP was significantly longer than LDP was under 100 ml. No additional blood transfusion was required. (LSPDP, 470 ± 43 minutes; LDP, 352 ± 22 minutes, p=0.018), The entire procedure was totally laparoscopic. The postoperative meanwhile blood loss of each group was similar (LSPDP, 203 ± 74 hospital stay was 5 days without any complications. ml; LDP, 207 ± 39 ml, p=0.96). Only 1 patient who received LDP was Conclusions: Laparoscopic liver resection enable the patient to converted to open surgery because of strong adhesion. The rate of have early discharge from the hospital with minimal percent of postoperative complications, including pancreatic fistula were not postoperative complications. Performed by experienced surgeon, significantly different between the 2 groups. Splenic infarction was laparoscopic liver resections using anterior approach show not observed in all patients at the time of discharge. The length of excellent short- and long-term outcomes. hospital stay was not different significantly (LSPDP, 19.3 ± 3.8 days; LDP, 17.5 ± 2.0 days, p=0.69). Ten of 12 patients who were treated by LSPDP, were histologically diagnosed as NET. O-147 Conclusion: According to our data, LSPDP is feasible and almost ADVANCED LAPAROSCOPIC PANCREATECTOMY has similar outcomes to LDP. Masafumi Nakamura O-149 Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University HOW TO REDUCE POPF AFTER PPPD? LDP becomes one of the common surgical methods in the field of Yoon Dong Sup pancreatic surgery. However, splenic-vessels preservation is still challenging. Preservation of spleen was performed in 32% of patients who underwent laparoscopic distal pancreatectomy (LDP) O-150 in Japan, and 85.9% of spleen preserving LDP was performed by preserving splenic vessels. Our anatomical findings concerning LEARNING CURVE OF MINIMALLY INVASIVE PANCREATIC splenic vein contributed to the dissemination of vessel-preserva- RESECTION tion method. Recognition of portal-vein system is also important Richard Schulick in the field of laparoscopic pancreatoduodenectomy (LPD). LPD

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O-151 significantly the overall rate of POPF. However, this classification doesn’t change the criteria of grade B POPF, that continue to be LAPAROSCOPIC SURGERY FOR PANCREATIC CANCER too much dependent to the post-operative management policy (antibiotics administration, timing of drain removal) and to group Y.S. Yoon. cases with different clinical severity. Department of Surgery, Seoul National University Bundang Hospital Seongnam-si, 13620, Korea. O-154 Laparoscopic surgery is associated with less blood loss and shorter hospital stay compared with open surgery. In case of laparoscopic UNJUSTIFIED AND POTENTIALLY AVOIDABLE PREOPERATIVE distal pancreatectomy, these results have been recently reproduced BILIARY DRAINAGE: IMPACT ON PERIOPERATIVE OUTCOMES by higher quality studies such as large-scale multicenter or OF RESECTABLE PERIAMPULLARY TUMORS propensity score matching studies. In comparison, laparoscopic pancreatoduodenectomy for pancreatic cancer still has a very low Jean-Baptiste Cazauran1, Julie Perinel1, Michel El Bechwaty1, level of evidence. The current evidence on the safety and effective- Gennaro Nappo1, Mathieu Pioche2, Thierry Ponchon2, Mustapha ness of laparoscopic surgery for pancreatic cancer is limited in well- Adham1. selected patients by experienced surgeons. To support the extended Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon application and generalization of laparoscopic surgery in the 69001, France. treatment of pancreatic cancer, well-designed studies with good Objective: Preoperative endoscopic biliary drainage (PEBD) should quality of evidence are necessary. However, considering the not be performed systematically for malignant periampulary aggressive biology of this cancer and the inherent technical challenge tumors (MPT) with uncomplicated obstructive cholestasis, yet of minimally invasive pancreatectomy, there is a long way to go until many patients still receive routine PEBD. Herein were assessed laparoscopic surgery for pancreatic cancer is accepted as a safe perioperative outcomes of routine PEBD in resectable MPT with alternative treatment to open surgery. uncomplicated biliary obstruction. Methods: Avoidable-PEBD (despite recommendations), Necessary- O-152 PEBD (following recommendations), and Upfront-Surgery groups were identified among patients undergoing surgery for resectable RISK FACTORS FOR SURVIVAL IN PDAC PATIENTS FOLLOWING MPT (2008-2014). The first two groups were compared on referral PANCREATODUODENECTOMY patterns, drainage procedure, and post-PEBD complications; Avoidable-PEBD and Upfront-Surgery groups were compared on Barauskas Giedrius perioperative outcomes. Results: A total 140 patients underwent surgery for resectable MPT; O-153 34 had cholestasis with clear PEBD indication (Necessary-PEBD). A further 70 presented uncomplicated obstructive cholestasis with TEN YEARS OF POST-OPERATIVE PANCREATIC FISTULA (POPF) total bilirubin<300μmol/l, of whom 30 had Avoidable PEBD and 40 DEFINITION (2005-2016). DOES THE NEW CLASSIFICATION REALLY underwent upfront surgery. In total 46.9% of PEBD were avoidable CHANGE SOMETHING? and 64.1% were performed before surgical consultation. Time-to- Nappo G., Capretti G., Gavazzi F., Ridolfi C., Uccelli F., Cereda M., surgery was significantly increased in the Avoidable-PEBD group by a Zerbi A. mean±SD 33±5.2 days as compared to Upfront-Surgery group (95%CI Pancreatic Surgery Unit, Humanitas University [22.9-43.6]; p<0.001). The Avoidable-PEBD group had a complication Humanitas Research Hospital, Rozzano (MI) – Italy. rate of 43.3%, and 10.0% were unresectable due to severe fibrosis following PEBD-induced acute pancreatitis. Perioperative severe Introduction: In 2005 International Study Group of Pancreatic complication rate was higher in the Avoidable-PEBD (73.3%) than in Surgery (ISGPS) classified POPF into 3 different grades of severity the Upfront-Surgery group (37.5%, p=0.003), as was Clavien-Dindo (A, B, C) and it has been universally adopted. Recently, ISGPS grade>II postoperative complication rate (63.3% and 37.5%; p=0.03). updated this classification. The aim of this study was to compare Conclusion: Routine preoperative biliary drainage is deleterious the incidence and severity of POPF in our series of Pancreatico- and persists despite recommendations against its use, and most Duodenectomies (PDs) using the two classifications. stenting is performed before surgical consultation. Early multi- Material and methods: All consecutive PDs performed from 2010 disciplinary team discussions could be implemented with an aim to to 2016 were retrospectively evaluated from a prospective reduce unnecessary stenting and improve patient outcomes. database. Incidence and grade of POPF strictly adopting the two classifications were recorded. Results: A total of 502 patients were included in the study. The O-155 overall incidence of POPF was 35.2% and 30.7% in the old and new classification, respectively (p < 0.01). POPF was classified as grade LAPAROSCOPIC DOUDENOPANCREATECTOMY(LPD)-OUR A, B and C in 4.6%, 26.1% and 4.6%, respectively, according to the APPROACH. HOW TO DO IT? old classification, while was classified as grade B and C in 26.1% and 4.6%, respectively, according to the new one (biochemical leak was Belev N., Penkov R., Krastev P., Popov Sht., Kolarov H., observed in 4.6% of cases). Reasons of grade B POPF were Dgarov G., Moshekov E. extremely heterogeneous: antibiotic administration (10.7%), drain UMHAT-Eurohospital, Plovdiv-4000, Surgical Department. > 3 weeks (67.9%) and radiological procedures (drainage/emboliza- Introduction: Laparoscopic procedures have advanced to represent tion) (21.4%). the new gold standard in many surgical fields. Laparoscopic Discussion: The updated classification deletes grade A POPF, intro- pancreatoduodenectomy and laparoscopic distal pancreatectomy ducing the concept of biochemical leak. Consequently, it reduces (LDP) are advocated to improved perioperative outcomes,

174 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

including decreased blood loss, shorter length of stay, reduced of the gastric drainage veins should undergo preservation or recon- postoperative pain and expedited time to functional recovery. struction, and anastomosis between the right gastroepiploic vein However, the indication to minimally invasive approach for and left ovarian vein may be beneficial. pancreatic surgery is often benign or low grade malignances. Material and Method: The steps of LDP procedures are similar to O-157 the open procedure. We perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of LYMPHADENECTOMY ISSUES IN ESOPHAGEAL CANCER procedure using hand-assisted techniques. For the period 2014- 2016, we have been perform 46 PD, 14(30%) we have done with Vashist Yogesh laparoscopic approach. 4(28,5%) of patients were operated totally laparoscopic and 10(71%) of patients were operated by hand- O-158 assisted techniques. Results: We found longer operative time in laparoscopic group, FLUORESCENCE GUIDED SURGERY FOR GI CANCERS 385min. vs 210 min in open group. Mean blood loss was 260ml in Bouvet Mike laparoscopic operated patients and 430 ml in open group. Mean length of stay was 8 days in laparoscopic group vs 14 days in open O-159 group. Overall morbidity in laparoscopic group was 21%. One patient with superior vein thrombosis (Clavien-Dindo-II), One patient with ADENOCARCINOMA OF THE ESOPHAGOGASTRIC JUNCTION postoperative acute necrotizing pancreatitis (Clavien-Dindo-IVa), a SIEWERT II: TOTAL GASTRECTOMY OR SUPERIOR POLAR patient with low debit pancreatic fistula (Clavien-Dindo-II). Mortality ESOGASTRECTOMY? rate was 7% (1 patient was died in early postoperative period from T. Voron 1, C. Gronnier2, A, Pasquer3, J. Théreaux4, J. Gagnière5, G. venous mesenterial thrombosis and multiorgan dysfunction. Lebreton6, B. Meunier7, D. Collet2, C. Mariette8, F. Paye1, on behalf Conclution: LPD can be done laparoscopically in selected patients of FREGAT working group, FRENCH and AFC associations. by experienced surgeons (in laparoscopic and open surgery too), 1CHU Saint-Antoine, APHP, 75012 Paris, France. but clear advantages remain to be defined. 2CHU Bordeaux, 33300 Bordeaux, France. 3CHU Edouard Herriot, 69000 Lyon, France. O-156 4CHU Brest, 29200 Brest, France. 5CHU Clermont Ferrand, 63000 Clermont Ferrand, France. GASTRIC VENOUS CONGESTION AND BLEEDING IN ASSOCIATION 6CHU Caen, 14000 Caen, France. WITH TOTAL PANCREATECTOMY 7CHU Rennes, 45000 Rennes, France. A. Nakao1, S. Yamada2, T. Fujii2, H. Tanaka2, K. Iede2, K. Oshima1, 8CHU Lille, 59000 Lille, France. 2 Y. Kodera . Objective: Optimal surgical approach for patient with type II AEG is 1 Department of Surgery, Nagoya Central Hospital. still debated although these tumors are now considered as 2 Department of Gastroenterological Surgery, Nagoya University esophageal cancers in the seventh edition of TNM classification. Hospital, Department of Surgery, Nagoya Central Hospital The objective of this study is to assess and compare surgical and Nagoya, 453-0801, Japan oncological outcomes of two surgical approaches (superior polar Background: We sometimes encounter gastric venous congestion esogastrectomy (SPE) or total gastrectomy(TG) in patients with and bleeding in association with total pancreatectomy (TP). The type II adenocarcinoma of the esophagogastric junction (AEG). possibility of whole or subtotal stomach preservation and the Methods: 183 patients with type II AEG treated from 1997 to 2010 necessity of gastric resection combined with TP are unclear. in 21 French centers by SPE or TG were included in a retrospective Methods: Thirty-eight patients who had undergone TP were retro- study. The surgical and oncological outcomes were compared spectively analyzed to evaluate gastric venous congestion and between these two surgical approaches. bleeding. TP was classified as TP with distal gastrectomy (TPDG), Results: A TG was performed in 64 (35%) patients whereas 119 pylorus-preserving TP (PPTP), subtotal stomach-preserving TP (65%) patients were treated by SPE with transthoracic approach in (SSPTP), and TP with segmental duodenectomy (TPSD). 100 patients (83.2%), transhiatal approach combined with cervico- Results: Portal vein or superior mesenteric vein resection and tomy in 19 patients (16.8%). Surgical outcomes were comparable reconstruction was performed in 24 patients (62.2%). Gastric between the two approaches with a postoperative mortality rate of bleeding occurred immediately after tumor resection in one of 4.9% and a severe operative morbidity within 30 days observed in eight patients who underwent SSPTP, and urgent anastomosis 28 patients (15.3%). Median survival in patients operated on by TG between the right gastroepiploic and left ovarian vein stopped the was of 46 months compared to 27 months in patients treated by bleeding. Another case of gastric bleeding was observed a few SPE (p=0.118). At multivariate analysis, TG approach appears being hours after TP in one of nine patients who underwent PPTP, an independent good prognostic factor compared with SPE and hemostasis was achieved after conservative therapy. Gastric approach (HR=1.847; p=0.008). However, TG was also associated bleeding was not observed in 16 patients who underwent TPDG with a higher rate of incomplete resection, (12.5% vs 5.9%; and 5 who underwent TPSD. Some patients underwent preserva- p=0.120). tion of gastric drainage veins (left gastric vein, right gastric vein, or Conclusion: When TG allows obtaining tumor-free resection right gastroepiploic vein). Neither patient with bleeding underwent margins, this approach should be preferred to SPE approach. A new preservation of a gastric drainage vein. pragmatic classification of AEG is proposed to facilitate the pre- Conclusions: Distal gastrectomy may be a safe method with which operative choice of the optimal surgical approach. to prevent gastric venous congestion and bleeding after TP. To preserve the subtotal or whole stomach when performing TP, one

Surgery, Gastroenterology and Oncology, 22 (3), 2017 175 ABSTRACTS

O-160 underwent a transthoracic esophagectomy. Methods: 34 patients who underwent a transthoracic esophagec- MILESTONES IN OESOPHAGEAL RESECTION FOR OESOPHAGEAL tomy were enrolled into the Enhanced recovery after surgery CARCINOMA IN THE SUDAN. (ERAS) program that included early post-operative enteral nutrition Ahmed Mohamed ElMakki and mobilization. Each patient was evaluated using CPX on both the day of an admission day (pre) and day of discharge (post). On O-161 the other hand, 22 patients were enrolled into this program using SWT. The program was started on the first postoperative day (POD ANTETHORACIC FREE JEJUNUM RECONSTRUCTION FOR 1). Routine postoperative bronchoscopy for toileting sputum and ESOPHAGEAL CANCER mechanical bowel preparation (MBP) before surgery were only performed when considered to be necessary. Outcome metrics N. Iwata, M. Koike, H. Oya, M. Kanda, D. Kobayashi, C. Tanaka, comprised peakVO2, peak workload, and anaerobic threshold (AT) M. Fujiwara and Y. Kodera. in CPX, the distance in SWT. Department of Gastroenterological Surgery (Surgery II), Results: In CPX, PeakVO2 (mL/kg/min) was 21.9 ± 4.4 (pre) and Nagoya University Graduate School of Medicine, Nagoya, 17.0 ± 3.7 (post) (p < 0.01). Peak workload (watt) was 101.8 ± 23.5 466-8550, Japan. (pre) and 76.5 ± 22.0 (post) (p < 0.01). AT(mL/kg/min) was 12.6 ± Background: Gastric tube is the first choice as an esophageal 2.2 (pre) and 11.3 ± 1.7 (post) (p < 0.01). The rates of decrease for substitute for reconstruction after esophagectomy. Colon or peak VO2 and workload were 26.4% and 24.9%, respectively. In jejunum is selected for patients in whom stomach cannot be used. SWT, 521.4m in preoperative status, 477.1m in postoperative However, due to anatomic reason, pedicled jejunum reconstruc- month 6 (POM 6), and 491.4m in POM 12. tion has a weakness in the limited access to upper thorax. To solve Conclusions: Physical activity on the day of discharge decreased by this issue, the authors adopted free jejunum reconstruction as the approximately 25% and 4.9 METS which was calculated based on operation in patients with esophageal cancer who had no stomach peakVO2. This level is not limited in daily usual life, but not enough to use as an esophageal substitute and limitation to harvest to keep quality of life. The data of SWT indicated about 94% in sufficient pedicled jejunum flap. POM12 compared with preoperative status. Objectives: The aim of this presentation is to review our experience with this technique. O-163 Method: From 2004 to 2011, esophagectomy and anterhoracic free jejunum reconstruction was performed in 5 patients at the EARLY RESULTS OF LAPTHORACOSCOPIC ESOPHAGECTOMY Department of Gastroenterological Surgery (Surgery II), Nagoya WITH CURATIVE THREE FIELD LYMPHADENECTOMY FOR University Hospotal. Medical records of these 5 patients were ESOPHAGEAL CANCER retrospectively reviewed to determine demographic data, diagnosis V. Trung Lam, P.D. Tien Tran, D. Ai Bui, V. V. Loc Nguyen, V. Duc Tran. and perioperative course. Digestive surgery Department, ChoRay hospital, Vietnam. Surgical technique: A skin flap of the chest wall was created as far as the medioclavicular line by dissecting along the fascia of the Objective: Esophageal cancer (EC) is one of popular cancers in greater pectoral muscle to accommodate the jejunum. In the Vietnam. Some studies recently showed better survival rate with abdomen, we commonly used first or second branch vessel as three field lymphadenectomy (TFL). We conduct this study to donor vessel and harvest free jejunum flap 20 cm in length. After evaluate the feasibility and results of lapthoracoscopic esophagectomy esophagojejunum anastomosis revascularization was performed (LTE) with curative TFL for EC at Choray hospital Vietnam. by plastic surgeons, after removing the third rib cartilage and Method: Prospective study. Patients with squamous cell carcinoma isolate right internal mammary artery and vein. (SCC) of esophagus will be included. Patients with cervical EC or Results: Median operating time, blood loss and hospital stay were distal metastasis will be excluded. 540 min, 520 ml and 28 days, respectively. There were no in-hospi- Results: From 11/2015 to 5/2017, 56 patients with SCC of esophagus tal death. Anastomotic leakage occurred in 2 patients. have been included into the study. There was 52 male and 4 female Conclusion: Although antethoracic free jejunum reconstruction is with mean age of 60 ± 4,3 (45 – 75). Eight patients had neoadjuvant technically demanding, it is reliable technique for patients in whom chemoradiation. 5 patients with stage I, 26 with stage II and 25 with pedicled jejunum flap is not available for reconstruction. stage IV. Tumor located in middle 1/3 was 50 (59.5%), lower 1/3 was 21 (25%) and upper 1/3 was 1 case. Mean operation time was 6 hours with minimal blood loss. Mean hospitalisation was 9.5 ± 2.8 O-162 days (7 – 22). Mean lymph nodes harvested in cervical, mediastinal and abdominal fields was 9, 14 and 8 respectively. Mean metastatic TO EVALUATE THE OUTCOMES OF PHYSICAL ACTIVITY IN lymph nodes in cervival, mediastinal and abdominal fields was 3, 2 PATIENTS WHO HAVE UNDERGONE THORACIC ESOPHAGEAL and 4 respectively. Postoperative mortatily was 1.7% (1 case) due to CANCER SURGERY severe pneumonia. Overall morbidity was 35.7% included 4 cases H. Sato, Y. Miyawaki, H. Gunji, S. Sakuramoto, M. Aikawa, with pneumonia, 4 cases with anastomotic leak (conservative treat- K. Okamoto, S. Yamaguchi, I. Koyama. ment), 1 case with cervical lymph leak which required reoperation, 6 Division of Gastroenterological Surgery, International Medical cases with temporary coarse voice. Center Saitama Medical University, Hidakashi, 350-1298, Japan Conclusion: LTE with curative TFL for EC is feasilbe and safe with good capacibility of lymphadenectomy. It need longer follow-up Objective: Cardiopulmonary exercise testing (CPX) and Shuttle time to better evaluate oncological and functional outcomes of this walking test (SWT) are non-invasive, objective methods of assessing operation. integrated response of the heart, lungs, and musculoskeletal system to incremental exercise. This study aimed to evaluate the impact of physical activity using CPX or SWT in patients who

176 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-164 ratio (MLR), platelet-lymphocyte ratio (PLR), lymphocyte-white cell ratio (LWR), monocyte-white cell ratio (MWR), platelet-white cell ratio A PILOT TRIAL OF S1 AND PACLITAXEL IN ESOPHAGEAL (PWR) and lymphocyte-monocyte ratio (LMR). CARCINOMA PRETREATED BY 5FU, CISPLATIN AND DOCETAXEL Results: One hundred and forty patients, 65 females and 75 males, – FOLLOW-UP REPORT median age 66, were included in the study. Most GISTs were located in the stomach (70,7%), while the remaining were found in the Y. Nakajima, K. Kawada, Y. Tokairin, A. Hoshino, T. Okada, duodenum (12,1%), ileum (9,3%), esophagus (2,9%), jejunum (2,9%) T. Ryotokuji, M. Okuda, Y. Kume, Y. Kawamura, K. Yamaguchi. and sigma (2,1%). Ninety-seven patients were asymptomatic; 39 had Department of Esophageal Surgery, Tokyo Medical and Dental concomitant cancers. Neoadjuvant therapy was administered to 9 University, Tokyo, 118519, Japan. patients. Median follow-up was 58,5 months. Three and 5-year Objectives: This study is the follow-up study demonstrating the overall survival (OS) were 83,5% and 78,7%, respectively; 3 and 5- clinical efficacy and toxicity of S1 and paclitaxel (S1/PTX) in patients year disease free survival (DFS) were 89,7% and 86,9%. Median OS with unresectable or postoperative recurrent esophageal and DFS were not reached. On univariate analysis, factors associated squamous cell carcinoma (ESCC) who had been previously treated to DFS were tumor diameter (p=0,003), gastric location (p=0,024), with 5FU, cisplatin and docetaxel. cell type (p=0,024), mitosis (p<0,001), MLR (p=0,014), NLR (p=0,016), Methods: Thirty-one ESCC patients treated using S1/PTX at our LMR (p=0,029). Independent prognostic factors on multistep multi- institute since 2010 were enrolled in this study. S1 was adminis- variate analysis (DFS) were: mitosis (p=0,001), NLR (p=0,015), MLR tered orally at a dose of 80 mg/m2/day from days 1 to 14, and (p=0,015), PLR (p=0,031). Correlations were found between MLR, paclitaxel was administered intravenously on days 1 and 8 at a dose NLR, PLR and tumor diameter, and between PLR and number of of 80-100 mg/m2. To compare the clinical outcomes, 35 patients mitosis. who did not receive aggressive treatment (BSC group) and 33 Conclusions: Serum inflammation indexes such as NLR, MLR and patients who were treated with chemotherapeutic regimens other PLR are independent prognostic factors for DFS in GIST. They can than S1/PTX (non-S1/PTX group) at our institute during the same be used as markers to preoperatively stratify patients. Inclusion of period were enrolled. NLR, MLR, PLR in GIST management should be considered to Results: A total of 117 cycles (median 3.0 cycles, range 1-12 cycles) improve the accuracy of risk estimation. were administered. The response rate was 20.0%, including 3 complete responses (CR). The median progression-free survival O-167 time (PFS) was 139 days, and the median overall survival time (OS) was 306 days. Severe neutropenia occurred in 14 patients, and 3 BILE DUCT INJURY DURING CHOLECYSTECTOMY -WHAT TO DO? showed febrile neutropenia. All non-hematological toxicities were AND WHAT NOT? mild, and peripheral nerve paralysis was observed in two patients. Regarding the clinical results of the non-S1/PTX group, 1 patient Rajneesh K Singh achieved CR, and the overall response rate was 6.3%. The median PFS was 85.5 days, and the median OS was 336 days. Compared O-168 with S1/PTX, although there was no significant difference in the best overall response, PFS and OS, S1/PTX showed higher CR rate. MANAGEMENT OF BILIARY INJURES & STRICTURES DURING Regarding the BSC group, the median OS was 71 days, and S1/PTX CHOLECYSTECTOMY A JORDANIAN EXPERIENCE /BILIARY resulted in a significantly better prognosis. Conclusion: S1/PTX was found to have tolerable clinical efficacy in Breizat Abdelhadi terms of the response rate, survival and toxicity in patients with unresectable or postoperative recurrent ESCC who had previously O-169 been treated with 5FU, cisplatin and docetaxel. PROSPECTIVE COMPARISON OF SYSTEMIC INFLAMMATORY RESPONSES IN CHOLECYSTECTOMY BY MEANS OF ACCESS; O-165 SINGLE-PORT UMBILICAL INCISION, TRANSVAGINAL NOTES, LAPAROSCOPY AND LAPAROTOMY ACCESS. PROGNOSTIC VALUE OF SERUM INFLAMMATION MARKERS Kumar Rahul. IN GASTROINTESTINAL STROMAL TUMOR King George’s Medical University, Lucknow, India, 800001. F.C.M. Cananzi, E.M. Minerva, L. Conti, A. Marzorati, L. Samà, Objectives: Surgical injury is associated with inflammatory stress, F. Sicoli, V.L. Quagliuolo. often due to ischemia/reperfusion injury. This study was designed to Humanitas Clinical and Research Center, Rozzano, 20089 (MI), evaluate and compare clinical and inflammatory responses to Italy. surgical trauma caused by cholecystectomy through various access Objectives: Treatment of Gastrointestinal Stromal Tumors (GISTs) approaches: single-port umbilical incision (SILS), transvaginal natural is driven by well-known characteristics such as tumor size and orifice transluminal endoscopic surgery (NOTES), laparoscopy, and mitosis number. Several inflammation markers have been linked to Laparotomy access. development and prognosis of GISTs. The aim of this study was to Methods: This prospective study enrolled 60 patients equally investigate the value of preoperative serum inflammation markers divided into four groups with symptomatic cholelithiasis, of whom in determining GIST prognosis. 11 underwent open, 32 laparoscopic, 10 single-port umbilical Methods: Clinical and pathological features of patients who under- incision and 7 transvaginal natural orifice transluminal endoscopic went surgery at our institution for primary GIST between 2000 and surgery cholecystectomy. Patients were monitored perioperatively 2014 were reviewed. Peripheral blood inflammation markers were regarding anesthesia, surgical procedure times and surgical compli- calculated: neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte cations. Postoperatively, patients were assessed regarding ambula-

Surgery, Gastroenterology and Oncology, 22 (3), 2017 177 ABSTRACTS

tion time, feeding and for presence of clinical complications. Ayman El Nakeeb, Waleed Askar. Peripheral venous blood was collected to measure Procalcitonin, C- Gastroenterology surgical center, Mansoura University, Egypt. reactive protein (CRP) and Interferon-gamma (IFN-γ) preoperative- Introduction: The time interval between ERCP and laparoscopic ly, immediate post operative period and on day 2 and 7. cholecystectomy (LC) is a matter of debate that may vary from days Results: All procedures were successfully performed. Only minor to months. This study was planned to compare early LC (within complications, such as gallbladder perforation and bleeding from admission) versus late LC (after 1 month) after ERCP as regard the liver bed, were observed during surgery in all groups. The technical difficulties and surgical outcomes vaginal NOTES group showed higher anesthesia and surgical Patient and methods: This is a prospective randomized study on procedure times compared to the other groups (p<0.001). It was patients who are presented with concomitant gall bladder (GB) and found that inflammatory markers were significantly raised in post common bile duct (CBD) stone. The study population was divided operative period in open cholecystectomy group as compared to into two groups; group (A) managed by early laparoscopic chole- minimally invasive cholecystectomy groups. No other between- cystectomy (LC) within 3 days after ERCP and group (B) managed by group differences in perioperative or postoperative times, clinical late LC one month after ERCP. The primary outcome is the conver- evolution, or serum inflammatory markers were observed. sion to open surgery. Secondary outcomes will include recurrent Conclusion: On the basis of these findings, it can be hypothesized biliary symptoms, degree of adhesions, blood loss, postoperative that open cholecystectomy causes more tissue responses as morbidity, and hospital stay. compared to its laparoscopic alternative. The single-port umbilical Results: 110 patients included in this study. The conversion rate from and transvaginal NOTES access approaches were feasible and safe LC to open occurred in 11 (10%) cases. No significant difference compared to laparoscopic and laparotomy for cholecystectomy between both groups as regards the conversion rate, the degree of adhesion, cystic duct diameter, and intraoperative CBD injury or O-170 bleeding. Recurrent biliary symptoms were significantly more in delayed LC group in 7 (12.7I%) patient versus one patient in early LC EARLY CHOLECYSTECTOMY IMPROVES OUTCOMES IN ACUTE (P=0.03). Four (7.3%) patients developed postoperative bile leakage CHOLECYSYTITIS IN PREGNANCY. MULTICENTER STUDY. from the cystic duct stump in delayed LC group and all patients managed conservatively. Baraket O., Triki W., Ayed K., , Baccar A., Abbassi I., Itami A., Conclusion: LC after ERCP and ES is more difficult, it must be Lahmidi A, Bouchucha S. operated by an experienced laparoscopic surgeon to reduce the Department of general surgery. conversion rate and decrease the morbidity rate. No significant Hospital Habib BougatfA de Bizerte. 7000 Bizerte difference between both groups as regards the conversion rate. Faculty of Medicine of Tunis, University Tunis El Manar, Tunisia. Recurrent biliary symptoms were significantly more in delayed LC Objectives: Acute cholecystitis is rare in pregnancy with an while waiting LC. Morbidity was significantly more in delayed LC. estimated incidence of 0.2–0.5 per 1,000 pregnancies. Different methods of management have been reported, ranging from O-172 conservative treatment with antibiotic, percutaneous transhepatic gallbladder drainage, laparoscopic cholecystectomy. The aim of this LEFT SIDED GALLBLADDER: TECHNICAL CHALLENGES FOR study is to determine the benefit and outcomes of early cholecystec- LAPAROROSCOPIC CHOLECYSTECTOMY tomy in these patients. Methods: A multicenter retrospective study of pregnant women Th. Piperos, M. Zoulamoglou, E. Konstantinou, D. Kakaviatos, with acute cholecystitis including 15 centers from 2009 to 2015 was Th.Troupis, M. Sgantzos, Th. Mariolis-Sapsakos. done. We have not includes patients with non complicated sympto- Aim: The aim of our study is the presentation of technical aspects matic cholelithiasis, choledocholithiasis, gallstone pancreatitis. at resection for left sided gallbladder. Results: One hundred and seven pregnant women were admitted. Material-method: The study presents two cases of left-sided 99 patients underwent surgical treatment during pregnancy (30 in gallbladder and their intraoparative management. We had two first trimester, 45 in second trimester and 24 in the third trimester) cases during the last three years, one man 31 years-old and one and 3 after deliverance. Laparoscopic approach was done in 72 woman 45 years old. Both patients had gallstones with history of cases with 3 conversions. Median delay between admission and biliary colic. Preoperative imaging was done with ultrasound. surgery was 2 days. 66 patients were operated before 72 hours. No Results: During laparoscopy after the placement of umbilical trocar, death was observed in our study. Overall maternal morbidity was we identified an anatomic variation to the position of gallbladder. 6, %. Predictive factors of morbidity were: age >35 years, delayed The position was under the Liver segment III, to the left of round cholecystectomy CRP>150 and biliary peritonitis. After multivariate ligament. Therefore it was appropriate the modification of trocar’s analysis only delayed cholecystectomy and biliairy peritonitis were placement. The subxiphoid trocar placed more laterally under the predictive factors of morbidity. left subcostal region for easy maneuvers. The other two trocars Conclusion: Early surgical treatment of acute cholecystitis reduces placed to the traditional sites under the right hypochondrium. The morbidity of acute cholecstitis in pregnant women. Laparoscopic operation was performed with the standard technique of critical approaches is safe when we respect some rules and we have view. We hadn’t intraoperative or postoperative complications. experience. Conclusions: The left-sided gallbladder is a rare condition with prevalence of 0.3%. It’s surprising for a surgeon the identification of O-171 such variation intaoperatively. It’s needs modification to trocar’s placement with transposition of the hypoxiphoid trocar laterally EARLY VERSUS LATE CHOLECYSTECTOMY AFTER CLEARANCE OF under the left subcostal region. Because of the many variation at COMMON BILE DUCT STONES BY ENDOSCOPIC RETROGRADE biliary anatomy, this rare condition results to change the standard CHOLANGIOPANCREATOGRAPHY: A PROSPECTIVE RANDOMIZED trocar’s position to achieve the maximum safety for cholecystectomy. STUDY

178 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-173 clearance was obtained endoscopically. Endoscopic papilla cannu- lation was feasible in 161 patients (76.7%) whereas in 49 (23.3%) a LONG-TERM OUTCOME OF SMALL DIAMETER trans-cystic guide wire was needed. The overall LERV feasibility was HEPATICOJEJUNOSTOMY FOR TREATMENT OF 96.6%. The conversion rate to open surgery was 3.3%. Minor POST-CHOLECYSTECTOMY BILE DUCT INJURIES. morbidity was observed in 1.9% of cases, mortality in 0.47% and Waleed Askar1, Ahmad M. Sultan2. the mean hospital stay was 4.3 days. 1Assistant professor, Gastroenterology surgical Center (GEC), Conclusions: These results confirm the high effectiveness of LERV. Department of Surgery, Mansoura University This approach to treat cholecystocholedocholithiasis should be 2Assistant professor, Gastroenterology surgical Center (GEC), preferred and therefore implemented where a strong collaboration Department of Surgery, Mansoura University. between surgeons and endoscopists is possible. Background/Aims: Bile duct injury (BDI) is the most dreadful complication of cholecystectomy. The aim of this study is to O-175 evaluate the long-term outcome of patients presented with post- LONG TERM OUTCOMES OF CHOLEDOCHODUODENOSTOMY cholecystectomy BDI and treated with small diameter hepatico- FOR COMMON BILE DUCT STONES IN THE ERA jejunostomy (HJ) Roux-en-Y. OF LAPAROSCOPY AND ENDOSCOPY Method: Between January 1992 and September 2016, all patients who underwent HJ Roux-en-Y for treatment of post-cholecystectomy Rami Said, Ayman El Nakeeb, Talaat Abd Allah. BDI were retrospectively studied. Group A (HJ with a diameter 10mm or less) and group B (HJ with a diameter more than 10mm). Long- Background: Choledochoduodenostomy (CDD) has been reported term follow up was done for detection of the rate of anastomotic as an effective treatment of Common bile duct stones (CBDS). This stricture. study was designed to analyze short term and long term outcomes Results: A total number of 353 patients were included in the study of CDD for CBDS with 35 patients (9.9%) were missed during long-term follow up. Methods: Demographic data, preoperative, intraoperative and Group A included 66 (18.7 %) patients while group B included 287 postoperative variables were collected. The long term assessment (81.3%) patients. There was a significant difference in the level of was done in a prospective manner included clinical examination, injury between 2 groups (P= 0.034).The long-term follow up was liver function, abdominal ultrasound, MRCP, upper GIT endoscopy performed after a median 75 months, range (2-246) for 318 and assessment of quality of life using Gastrointestinal Quality of patients. The overall long-term complications were higher within Life Index (GIQLI). group A (16/64-25%) than group B (32/254-12.6%), (P = 0.009). The Results: A total of 388 consecutive patients underwent CDD, the incidence of anastomotic stricture within group A was higher than mean age was 57.92 ± 13.25 years. The mean CBD diameter was group B (P= 0.015). 18.22±4.01 mm. The mean operative time was 81.21±20.23 Conclusion: The incidence of anastomotic stricture is higher in minutes. Two patients had recurrent stone (0.06%) and managed small diameter hepaticojejunostomy. Technical skills are important successfully by endoscope. Gastritis was observed in 16.9% to ensure wide patent mucosa-to-mucosa hepaticojejnostomy to patients. No patient developed sump syndrome, deterioration in avoid development of anastomotic stricture. liver function or cholangiocarcinoma. Total and subgroup scores on the GIQLI before and after CDD differed significantly at follow-up (P=0.0001). O-174 Conclusion: CDD is a safe and effective method of drainage of CBD after clearance of CBDS. Long term outcomes are acceptable with EFFICACY OF THE LAPAROENDOSCOPIC “RENDEZ-VOUS” TO good quality of life. Sump syndrome is extremely rare; CDD may be TREAT BILE DUCT STONES IN 210 CONSECUTIVE PATIENTS. associated with mild to moderate gastritis. CDD doesn't lead to A SINGLE CENTER EXPERIENCE. development of cholangiocarcioma. A. Pesce, G. La Greca, F. Di Marco, M. Di Blasi, S. Puleo, Key words: Common bile duct stone, cholangiocarcinoma, biliary D. Russello, S. Latteri. drainage. Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, Via S. O-176 Sofia 84, 95123 Catania, Italy. MANAGEMENT AND OUTCOME OF BORDERLINE COMMON BILE Objectives: The simultaneous laparo-endoscopic “rendez-vous” DUCT WITH STONES: A PROSPECTIVE RANDOMIZED STUDY. (LERV) represents an alternative to sequential or totally laparo- scopic approaches for patients affected by cholecystocholedo- Ayman El Nakeeb, Waleed Askar. cholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients. Introduction: Management of common bile duct stones (CBDS) in Methods: From 2002 to 2016 all patients affected by cholecystoc- patients with borderline CBD presents a surgical challenge. The aim holedocholithiasis were treated with a standardized “tailored” of this study was to compare conservative treatment with LERV. The relevant technical features of the procedure were endoscopic stone extraction for the treatment of borderline CBD recorded. An analysis of feasibility, effectiveness in stone clearance with stones. and safety was performed. Patients and methods: This prospective randomized controlled Results: Among 214 patients with CBD stones, 210 were treated trial includes patients with CBDS in borderline CBD (CBD <10 mm) with LERV and 4 with open rendez-vous approach. Intra-operative associated with gallbladder stones who were treated with conserva- cholangiography (IOC) confirmed common bile duct (CBD) stones tive treatment or endoscopic stone extraction followed by laparo- in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone scopic cholecystectomy (LC) and intraoperative cholangiogram (IOC).

Surgery, Gastroenterology and Oncology, 22 (3), 2017 179 ABSTRACTS

The primary outcome was successful CBD clearance. The secondary hanging maneuver by three Glisson’s pedicles and three hepatic outcomes were the overall complications, cost, and hospital stay. veins. Results: LC and IOC revealed complete clearance of CBDS in 48 (96%) cases in the endoscopic retrograde cholangiopancreatography (ERCP) O-179 group (52% of patients by ERCP, and 44% of patient passed the stone spontaneously), and in the remaining two patients, the CBDS was ALL ABOUT GLISSONEAN APPROACH TECHNIQUE removed by transcystic exploration. In the conservative group, LC and FOR LAPAROSCOPIC LIVER RESECTION IOC revealed complete clearance of CBDS in 90% of cases, and in the remaining 10% of patients, the CBDS was removed by transcystic Chanwat Rawisak exploration. Post-ERCP pancreatitis (PEP) is noticed significantly in the ERCP group (2 [4%] versus 8 [16%]; P = .04). The average net cost was O-180 significantly higher in the ERCP group. Recurrent biliary symptoms developed significantly in the ERCP group after 1 year (10% versus POSTOPERATIVE LIVER FAILURE AFTER MAJOR HEPATECTOMY 0%; P = .02) in the form of recurrent cholangititis and recurrent WITH EXTRAHEPATIC BILE DUCT RESECTION: VALIDATION STUDY CBDS. OF CLINICAL DEFINITIONS OF PHLF FOR DETECTING MORTALITY. Conclusions: Management of CBDS in patients with borderline CBD represents a surgical challenge. Borderline CBD increases the tech- T. Kawamura, T. Noji, K. Okamura, K. Tanaka, Y. Nakanishi, nical difficulty of ERCP and increases the risk of PEP. Conservative T. Asano, Y. Ebihara, Y Kurashima, T. Nakamura, S. Murakami, management of CBDS in borderline CBD not only avoids the risks T. Tsuchikawa, T. Shichinohe, S. Hirano. inherent in ERCP and unnecessary preoperative ERCP, but it is also Hokkaido University Faculty of Medicine, Gastroenterological effective in clearing CBDS. The hepatobiliary surgeon should Surgery II Sapporo, 060-8638, Japan. consider a conservative line of treatment in CBDS in borderline CBD Background: Postoperative liver failure (PHLF) is the most serious in order to decrease the cost and avoid unnecessary ERCP. complication after major hepatectomy (Hx) with extrahepatic bile duct resection (EBDR), and could be a cause of hospital mortality in O-178 its severe cases. The purpose of this study was to evaluate several PHLF criteria as predictors of PHLF related mortality following Hx OPEN LIVER SURGERY: SURGICAL ANATOMY AND ANATOMICAL with EBDR for perihilar cholangiocarcinoma (PHCC). SURGERY OF GLISSONEAN APPROACH Methods: 183 PHCC patients who had undergone Hx with EBDR were evaluated. The study protocols were approved by our institu- A. Karamarkovic. tional review board (016-0405) and this study was enrolled in Faculty of Medicine University of Belgrade, University Clinical UMIN-CTR (No: UMIN000025709). Center of Serbia, HPB Service, Belgrade 11000, Serbia. Results: Seven patients (3.8%) died of PHLF-related causes. We The extrafascial dissection of Glissonean pedicle is a very important compared several criteria for PHLF: a) 3-50-50 criterion (Total bilirubin: technique that can be extremely useful in particular circumstances T-Bil > 3 mg/dl and prothrombin time: PT% < 50% on POD 3); b) 65-50 during liver surgery, such as in multi-operated patients or in criterion (T-Bil > 3.5 mg/dl and PT% < 65% on POD 5); 3) Max T-Bil patients with cirrhotic liver or anomalous vascular and biliary criterion (T-Bil > 7.3 mg/dl before POD 7); c) International Study variations. Regarding this technique some terminology confusion Group of Liver Surgery (ISGLS) criterion; and d) 50-50 criterion. The still exists (Glissonean approach, extra-Glissonean approach, 3-50-50 and Max T-Bil criteria showed higher positive predictive Glissonean pedicle transection method, posterior intrahepatic values (25.0% and 23.1%, respectively) and accuracies (88.5% and approach, suprahilar Vascular control, perihilar posterior approach, 90.7%, respectively) than other criteria. superficialisation of Glissonean pedicles). Nevertheless, despite Conclusions: The 3-50-50 and Max T-Bil criteria were proved to be many titles the main surgical concept is the same, and it’s based on useful for defining PHLF-related death after Hx with EBDR for PHCC. the anatomical fact and observation of Couinaud that portal triad elements inside the liver substance, are enveloped with fibrous O-181 Glissonean sheet, thus representing an important structure of internal architecture of the liver. The extrafascial-Glissonean STAPLER HEPATECTOMY VERSUS LIGASURE TRANSECTION IN pedicle approach in liver surgery provides new knowledge of the ELECTIVE HEPATIC RESECTION: A RANDOMIZED CONTROLLED surgical anatomy of the liver and advances the technique of liver TRIAL surgery. Opposite to “classic” intrafascial dissection, this technique includes extrafascial isolation of the whole sheet of Glissonean N. Rahbari, J. Kirchberg, J. Fritzmann, D. Sturm1, M. Büchler, pedicle and its division “en masse”. Glissonean pedicles can be J. Weitz, C. Reißfelder. 1 approached intrahepatically or extrahepatically. The use of vascular Department of Visceral-, Thoracic-and Vascular Surgery, staplers in this situation allows quick and safe transection of the University Hospital Carl Gustav Carus, TU Dresden, 01307, pedicle, as well as appropriate hepatic vein. The second advantage Germany 2 of this technique presents the quick and easy definition of the Department of General, Visceral and Transplantation Surgery, anatomic territory of the liver to be removed. Selective clamping of University of Heidelberg, 69120, Germany the appropriate isolated pedicle demonstrates the further ischemic Objectives: Earlier studies have demonstrated stapler hepatectomy demarcation of anatomical liver part of interest (hemiliver, section and various energy devices as safe alternatives to the clamp-crushing or even segment) as well as delineation of resectional planes. technique in elective hepatic resection. In this randomized trial the Recent advances of presented surgical technique includes liver effectiveness and safety of stapler hepatectomy was compared to hanging maneuver and some modifications with two tapes to parenchymal transection with the LigaSure vessel sealing system. control the main fissure of the liver or various liver resections using Methods: Patients scheduled for elective liver resection at two

180 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

tertiary care centers were randomized intraoperatively to stapler O-183 hepatectomy or transection with the LigaSure device. Total intra- operative blood loss was the primary efficacy endpoint. PREVENTING MISSING LIVER METASTASES: EVALUATION Transection time, operating time, perioperative complications and OF A PRETHERAPEUTIC STATEGY USING FIDUCIAL PLACEMENT length of hospital stay were recorded as secondary endpoints. Results: A total of 138 patients were randomized, 69 to the LigaSure V. Kepenekian, A. Muller, PJ. Valette, P. Rousset, T. Walter, and 69 to the Stapler hepatectomy group. Baseline characteristics M. Adham, O. Glehen and G. Passot. were balanced well between groups. Intraoperative blood loss was Hospices Civils de Lyon Lyon, 69003, France significantly higher in the LigaSure (850 [100-4000] ml) vs. stapler hepa- Objectives: Surgery offers prolonged survival in selected patients tectomy group (600 [30-4200] ml) (p = 0.03). Duration of parenchymal with colorectal liver metastases (CRLM). A large part of these transection was significantly lower in the stapler hepatectomy groups patients receives preoperative chemotherapy, in neoadjuvant or (23 ± 12 min vs. 8 ± 5 min; p = 0.03), as was the total operating time conversion intent. The incidence of metastases disappearing from (199 ± 86 min vs. 168 ± 70 min; p = 0.03). Surgical morbidity did not pretherapeutic cross-sectional imaging is increasing. At least half of differ between the LigaSure and the Stapler hepatectomy groups these lesions are still active. It asks the question of their elective (27 [39%] vs. 30 [44%]; p = 0.37), nor did the grade of complications treatment when they are part of the future remnant liver. This (p = 0.14). retrospective study aimed to evaluate the pretherapeutical Discussion: Stapler hepatectomy is associated with reduced blood marking of these missing metastases using fiducial placement. loss and shorter operating time compared to the LigaSure device Methods: Patients with CRLM treated in curative intent between for parenchymal transection in elective partial hepatecomy. 2009 and 2016 were included. According to multidisciplinary team decision, lesions of less than 25mm, more than 10mm deep in O-182 hepatic parenchyma and located out of the field of a planned resection were marked. The fiducial was placed at the edge of the OVERVIEW OF THE LEARNING CURVE IN LAPAROSCOPIC LIVER lesion, with US-or CT-guiding. Rate of complication by procedure, SURGERY: WHAT ARE THE CHALLENGES? clinical and pathologic data were analysed. Tomassini F., Berardi G., Troisi R.I. Results: We marked 76 CRLM in 43 patients. Twenty-three marked Dept. of General, Hepatobiliary and Liver Transplantation CRLM (30 per cent) did disappear. Their mean size at diagnosis was Surgery. Ghent University Hospital, 9000 Ghent, Belgium. 11mm (8-25). After a median follow-up of 26,5 months (3,9-76,2), 4 complications occurred on 89 procedures (4,5 per cent) (2 hepatic Objectives: The learning curve (LC) for laparoscopic liver surgery hematomas, 1 fiducial migration and 1 misplacement). They were all (LLS) is longer and demanding and it’s difficult to draw final of Clavien-Dindo grade 1. No needle-track seeding was noted. Four conclusions because many factors influence outcomes, such as MM were treated by surgery with persistent disease in half of center experience and individual surgical skills. We here present a them. The others MM were treated by thermal ablation. review on the definition of the LC for LLS. Conclusion: This technique does not lead to major complications Methods: A literature review was performed regarding different and seems usefull in the CRLM curative intent strategy aiming at aspects related to the LC in LLS with no specific restriction. Because treating all initial metastatic site with parenchymal-sparing. the published evidence has focused on single centers experience with different surgeons and specific procedures, we defined the single surgeon learning curve (SSLC) as a continuously evolving O-184 process by analysing our 11 years experience. Results: Vigano et al. described the LC based on a CUSUM analysis ONCOLOGICAL AND SURGICAL OUTCOMES OF HEPATOCELLULAR of conversions, comparing three different periods. They concluded CARCINOMA AFTER ROBOTIC HEPATECTOMY: A COMPARISON the 60 procedures are needed to attain a minimal conversion rate. STUDY TO CONVENTIONAL OPEN HEPATECTOMY However, four different surgeons shared this experience. Cai et al. described a single center experience on four specific procedures, King-Teh Lee, Kung-Kai Kuo, Shen-Nien Wang claiming 15-30 left hemihepatectomy, 43 left lateral sectionectomy, Division of General and Digestive Surgery, Department 35 non-anatomic and 28 segmentectomies as the numbers needed of Surgery, Kaohsiung Medical University Hospital, to achieve best results. Nomi et al. recently published a paper Kaohsiung Medical University, Kaohsiung, Taiwan. focusing on laparoscopic major hepatectomies analysing the OT. Most liver resections are currently performed using an open They suggested that 45 procedures were required to reduce the approach. Minimally invasive surgery gradually became mainstay OT. According to our analysis based on 319 different laparoscopic for liver surgery in recent decade. Robotic hepatectomy has been liver resection (LLR) performed by a single surgeon during 11 years, suggested to be a safe and effective approach for hepatocellular the SSLC could be considered completed after 160 cases, in carcinoma (HCC); however, studies regarding oncological and which the surgeon progressively challenged himself with various surgical outcomes are still limited. Accordingly, we performed this procedures through stepwise difficulties; the gradual increase in study to compare the surgical and oncological outcomes between the types of procedures and degree of difficulty has led successively robotic and open hepatectomy. to the safe management of major hepatectomies and resections of Methods and Materials: Between June, 2013 and July 2016, a total postero-superior segments. of 63 patients with primary HCC underwent robotic hepatectomy Conclusions: A long LC should be anticipated to broaden the (RH), and 177 patients underwent open hepatectomy (OH) by the indications for LLR. Certainly, in LLS, the continuous monitoring of same surgical team in our department, were included in this study to performance and results is a crucial step in completing the LCs of assess the surgical and oncological outcome after a liver resection. younger fellows, who will master laparoscopic techniques in the These patients were followed up regularly in outpatient department future. of this hospital, the follow-up period is 726.10±248 days for the open group an 791.05±323.48 days for the robotic group. Pre, peri-and

Surgery, Gastroenterology and Oncology, 22 (3), 2017 181 ABSTRACTS

post-operative data of all patients with undergoing a liver resection O-186 for HCC were collected prospectively and analyzed retrospectively. Results: The demographic and clinical features of patients with HCC LAPAROSCOPIC ANTERIOR RECTAL RESECTION in both groups are statistically comparable. The postoperative com- WITH SYNCHRONOUS HEPATIC SEGMENTECTOMY plications rate is slightly lower in robotic group (11.1% vs. 15.3%, p=0.418). The rate of Ro resection is similar in both groups (92.1% Correia, M.L. Matos, L. Carvalho, I. Bessa, J. Costa, vs. 96%, p=0.56).The length of hospital stay is significantly shorter A.C. Soares, M.R. Sousa, J. Costa Pereira, Gonçalves, M. Nora. in robotic group (6.21±2.06 days vs. 8.18 ±6.99 days, p=0.001). The Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da overall recurrence rate of HCC is lower in robotic group although Feira, 4520-211, Portugal. the difference is not significant (27% vs. 37.3%, p=0.140). The 1,2,3 The mainstay of surgical treatment for colorectal cancer with year disease free survival is 72.5%, 64.3% and 61.6%, respectively, synchronous hepatic metastases has been under discussion and for open group, while it is 79.5%, 71.9% and 71.9% respectively for remains controversial. Although some studies recommend a robotic group, (p=0.325). The 1,2,3 year overall survival rate is staged approach advocating that the timing of metastatic resection 95.4%, 92.3% and 92.3% respectively for open group, while it is (synchronous versus staged) does not affect the prognosis, it is 100%, 97.7% and 97.7%, respectively, for robotic group (p=0.137 ). known that 15-30% of patients fail to complete the treatment plan. Multivariate analysis using Cox regression model showed Child- Thus, the synchronous resection has been emerging as a valid and Pugh B, satellite module, Ishak’s score and α-FP are independent safe option, with proven short-term outcomes similar to the staged risk factors for HCC recurrence. approach regarding morbidity and mortality. This is true for selected Conclusion: The robotic surgery is a safe and feasible procedure for patients that require a minor hepatic resection in experienced high- liver resection. The oncological and surgical outcomes of robotic volume centers. We present a video of a laparoscopic anterior hepatectomy are comparable to open surgery. The robotic hepatec- rectal resection with synchronous hepatic segmentectomy (II and tomy, however, carried a benefit of significantly shorter length of III). The patient was a 50-year-old man diagnosed with colorectal hospital stay. cancer (rectal-sigmoid transition) and synchronous single hepatic metastasis (segment II). Pre-operative CEA and CA 19.9 were 14,02 O-185 ng/mL and 83,4 U/mL, respectively. Total operative time was 245 minutes, without noteworthy complications on postoperative LIVER ARTERIAL BLOOD SUPPLY AFTER CLAMPING OF COMMON period. The patient was discharged at the 6th postoperative day HEPATIC ARTERY. US DATA OF 110 CASES. and is being submitted to adjuvant FOLFOX chemotherapy. Egorov V.I., Petrov R.V., Starostina N.S.,Zhurina Ju.V. 1Bakhrushins Brothers Moscow City Hospital. O-187 2 Moscow Clinical Scientific Centre, Russia, 107076 KASAI-LIKE PROCEDURE FOR MULTIPLE BILIARY DUCT Aim: To study liver collateral arterial supply after temporary RECONSTRUCTION AFTER EXTENDED LIVER RESECTION occlusion of the common (CHA), right gastroepiploic (RGEA) and FOR PERIHILAR CHOLANGIOCARCINOMA. accessory/replaced left hepatic arteries (a/rLHA). A. Mimmo, S. Tzedakis, E. Ferreri, H. Jeddou, A. Merdrignac, Background: Distal pancreatectomy with celiac artery resection K. Boudjema. (DPCAR) is in use for borderline-resectable pancreatic cancer. It is Service de Chirurgie Hépatobiliaire et Digestive, believed that considerable reduction of the liver arterial supply Centre Hospitalier Universitaire de Rennes, Université de after DPCAR may cause severe liver ischemia. Although the artery Rennes 1, 35033 Rennes cedex 9, France. reconstruction is not a problem anymore the decision to recon- struct СHA has to be justified. Introduction: In patient with perihilar cholangiocarcinoma (PCC), Patients and methods: Arterial anatomy, diameters of CHA, proper complete resection of tumour remain the best therapeutic option hepatic (PHA), gastroduodenal (GDA) and pancreatoduodenal for a long term survival. In patient with Bismuth type IV lesions, left arteries (PDA) were registered before surgery in 110 consecutive or right extended liver resection has been shown to be feasible. patients with pancreatic body/tail cancer (n35), gastric cancer with The Achilles heel of the procedure remain biliary reconstruction pancreatic involvement (n30) and liver tumors (n45) by CT. For due to multiplicity and small diameter of remnant liver ducts. In DPCAR (n20) the data were obtained after surgery as well. Arterial this video, we show how a Kasai-like portoenterostomy allow to blood flow in the liver and mean systolic velocity in hepatic arteries circumvent this difficult. before and after clamping were measured intraoperatively by Method: A 57-years-old Caucasian female with a PCC type IV, Doppler ultrasound. underwent right trisectionectomy, using “no-touch technique”. Results: Classical arterial anatomy was identified in 67% and Cross section of the left biliary plate was tumour free at frozen replaced right hepatic artery (rRHA) from the SMA in 24% of cases. section analysis, but it showed three small biliary duct for segment Pulse had disappeared in 9(8%) cases after clamping of CHA, RGEA II (x1), segment III (x1) and remnant segment IVb. The biliary plate and aLHA/rLPA. Collateral arterial blood flow in the liver parenchyma was large (2,5 cm) a distance between each duct was too large to was revealed in all cases. DPCAR led to increase of GDA, rRHA, PDA allow unification. Roux-en-Y portoenterostomy, with interrupted and RGEA blood flow in 0,9-12 times; PD arcades were detected only 5/0 PDS suture, was performed between the left biliary plate level once before DPCAR and every time afterwards. and extramucosa wall of efferent Roux-en-Y jejunal limb. Two Conclusion: Doppler ultrasound is a reliable modality for intra- trans-portoenterostomy drains were placed according to the operative assessment of liver arterial blood supply after DPCAR; Voelker technique. Hepatic artery reconstruction may be necessary after DPCAR if Results: The post-operative course was uneventful. The patient arterial Doppler signal disappeared upon the liver parenchyma. was discharged on 8th post operative day. The two trans- portoenterostomy drains were removed after six weeks.

182 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Conclusions: In extended PCC, Kasai-like portoenterostomy may O-193 broaden the indication for liver resection. HEPATECTOMY FOR INTRAHEPATIC STONE DISEASE: THE ROBOTIC APPROACH O-189 K.F. Lee, A. Fong, C. Chong, S. Cheung, J. Wong, P. Lai. ADVANCED LAPAROSCOPIC LIVER RESCTION IN PATIENTS WITH Prince of Wales Hospital, Hong Kong SAR, China. LIVER CIRRHOSIS Objectives: Management of intrahepatic stone disease is difficult. Cheung Tan To Liver resection has emerged in recent years as a promising treatment option. Methods: Robotic liver resection (RLR) has been adopted in our O-190 center for the management of patients with intrahepatic stone disease. The operative and short-term outcomes of this cohort of CHALLENGING AND UPDATES IN LAPAROSCOPIC LIVER SURGERY patients were compared with those of a historical cohort of Troisi Roberto patients in whom an open approach (OLR) was used. A subgroup analysis was performed for patients who underwent left lateral sectionectomy, which was the most common type of liver resection O-191 done for intrahepatic stone disease. Results: Between September 2010 and April 2015, 15 RLR proce- CONTRO.VERSIES OF ROBOTIC LIVER RESECTION dures were performed in patients with intrahepatic stone disease. The historical cohort consisted of 42 patients who underwent OLR CN Tang between January 2005 and January 2014. No differences were found Chief of Service, Department of Surgery, Director of MAS in patient demographics, disease characteristics, or types of Training Centre, Deputy Hospital Chief Executive, Pamela resection. No operative deaths occurred, and no difference was seen Youde Nethersole Eastern Hospital, HKSAR. in the complication rates. The RLR procedures had significantly less Interest in laparoscopic liver surgery has increased in last two decades. blood loss (100 ml vs. 235 ml; p = 0.011) and shorter hospital stays (6 Previous series have demonstrated the safety and feasibility of days vs. 8 days; p = 0.003). After a median follow-up of 19.4 months laparoscopy for minor hepatectomies. Laparoscopy is now for the RLR group and 79.2 months for the OLR group (p < 0.001), considered a standard approach for left lateral sectionectomy and there were no differences in the residual stone rate, the recurrent minor resections. Comparative studies have suggested that stone rate, or the rate of recurrent cholangitis. The subgroup analysis laparoscopy is associated with less bleeding, fewer complications, of patients who underwent left lateral sectionectomy (10 RLR vs. 27 and a better subsequent quality of life than open liver surgery. OLR) revealed similar outcomes, i.e., less blood loss and shorter However, there are still a lot of limitations of conventional laparo- hospital stays in the RLR group. scopic hepatectomies, such as tumor location, tumor size and Conclusions: RLR reduces blood loss and shortens hospital stays extent of liver resection. The recent introduction of robotic surgical compared with OLR. A longer follow-up period is needed to systems has revolutionized the field of minimally invasive surgery. assess the long-term outcomes of RLR regarding the prevention of It was developed to overcome the disadvantages of conventional recurrent stones and cholangitis. laparoscopic surgery. Robotic surgical systems can enhance a surgeon’s dexterity in the surgical field through a magnified three- dimensional view, instruments with seven degrees of freedom, and O-194 intuitive hand-control movements. The robotic devices can also shorten the learning curve of difficult laparoscopic procedures for CRITICAL APPRAISAL OF THE IMPACT OF INDIVIDUAL SURGEON inexperienced laparoscopic surgeons and enable expertise to con- EXPERIENCE ON THE OUTCOMES OF LAPAROSCOPIC LIVER duct more complex laparoscopic procedures easily. Early outcomes RESECTION IN THE MODERN ERA: COLLECTIVE EXPERIENCE from robotic hepatectomies are comparable with those of laparo- OF MULTIPLE SURGEONS AT A SINGLE INSTITUTION WITH scopic and open approaches. In clinical practice, the robotic system 324 CONSECUTIVE CASES has broadened the indications of minimally invasive surgery into B.K. Goh, J.Y. Teo, S.Y. Lee, A.Y. Chung, C.Y. Chan. the more complex liver surgeries such as major hepatectomy with Singapore General Hospital, Singapore 169608. biliary reconstruction, donor hepatectomy. Technological innova- tions and increased surgeon familiarity with this approach will Background: Most studies analyzing the learning experience of improve, likely leading to greater adoption and acceptance. laparoscopic liver resection (LLR) focused on the experience of 1 or 2 expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of O-192 LLR based on the contemporary collective experiences of multiple EARLY ENTERAL VERSUS TOTAL PARENTERAL NUTRITION IN surgeons at single institution. Methods: Retrospective review of 324 consecutive LLR from 2006 PATIENTS UNDERGOING PANCREATICODUODENECTOMY: A to 2016. The cases were performed by 10 surgeons over various RANDOMIZED MULTICENTER CONTROLLED TRIAL (NUTRI-DPC) time periods. Four surgeons had individual experience with < 20 J Perinel, C Mariette, B Dousset, I Sielezneff, A Gainant, cases, 4 surgeons with 20-30 cases and 2 surgeons with > 90 cases. JY Mabrut, S Bin-Dorel, M El Bechwaty, D Delaunay, L Bernard, The cohort was divided into 2 groups: comparing a surgeon’s A Sauvanet, M Pocard, E Buc, M Adham experience between the first 20, 30, 40 and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions and major hepatectomies.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 183 ABSTRACTS

Results: As individual surgeons gained increasing experience, this O-196 was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver LAPAROSCOPIC HEPATECTOMY FOR SEGMENT I, IV, V AND VIII reresections, increased major resections and increased resections of tumors located at the posterosuperior segments. This resulted in Hongyu Li, Yonggang Wei, Bo Li. significantly longer operation time and increased use of Pringle West China Hospital, Sichuan University, Chengdu 610041, maneuver but no difference in other outcomes. Analysis of LLR for Sichuan Province, China PR. tumors in the posterosuperior segments demonstrated that there Objectives: According to difficulty scoring system, laparoscopic was a significant decrease in conversion rates after a surgeon had hepatectomy (LH) for caudate lobe and middle segments should be experience with 20 LLR. For major hepatectomies, there was a considered as the most difficult case. We here report the first case significant decrease in morbidity, mortality and length of stay after of LH for segment I, IV, V and VIII in China. acquiring experience with 20 LLR. Methods: The patient was a 31-year-old man without hepatitis Conclusion: LLR can be safely adopted today especially for lesions history. Preoperative MRI revealed a 5.0cm×5.2cm mass located in in the anterolateral segments. LLR for lesions in the difficult the paracaval portion. Preoperative liver function tests and tumor posterosuperior segments and major hepatectomies especially in markers were normal. Preoperative diagnose was hepatic adenoma. cirrhosis should only be attempted by surgeons who have acquired Informed consents were obtained from the patient himself and his a minimum experience with 20 LLR. parents. The West China Hospital administration and the ethics committee authorized the surgery. Results: After cholecystectomy, the right hemi-liver was mobilized. O-195 Intraoperative ultrasonography was used to locate the tumor precisely. A rubber tube was placed through the tunnel between LAPAROSCOPIC FORMAL RIGHT AND LEFT HEPATECTOMY VERSUS liver and vene cava for the preparation of Hanging maneuver. OPEN APPROACH: A PROPENSITY SCORE MATCHING ANALYSIS Parenchymal transection started from segment IV under Pringle Francesca Tozzi F., Giammauro Berardi, Maaike Vierstraete, maneuver. The superficial of liver was dissected by ultrasonic Marco Vivarelli, Roberto Montalti, Roberto Ivan Troisi. shears and the deeper tissue was dissected by ultrasonic aspirator. Ghent University Hospital and Medical School, De Pintelaan The hemi-hepatic vascular inflow occlusion was then adopted after 185, 2K12 IC, Ghent 9000. dissection of hepatic hilum. The caudate lobe was completely separated from the left lateral lobe and the right posterior lobe. Objective: To analyse intra-operative and post-operative outcomes The root of middle hepatic vein and the right anterior Glisson’s of pure laparoscopic right and left vs. open hepatectomy matched branch were transected by linear stapler. The cephalic transection by the propensity score analysis. The aims of the study were peri- was carefully performed along the root of right hepatic vein. Finally, operative and short-term outcomes of laparoscopic right and left the transection was completed after an exposure of right and left hepatectomy. hepatic vein and vene cava, as well as hepatic hilum. The specimen Methods: From 2006 to 2014, 201 pure formal right hepatec- was put into a retrieval bag and removed from suprapubic incision. tomies and left hepatectomies were performed of which 48 were The operation time was 410 minutes and blood loss was 300ml. laparoscopic. After a 1:1 propensity score matching, right hepatec- Hepatic adenoma was postoperatively diagnosed. The postopera- tomies and left hepatectomies were compared to 34 open right tive course was uneventful for the patient. and left hepatectomies. The matching was based on the following Conclusions: LH for segment I, IV, V and VIII can be safely parameters: age, gender, BMI, ASA score, underlying liver disease, performed in selected patient in experienced center. previous abdominal surgery, type of hepatectomy, preoperative chemotherapy, number, dimension and nature of lesions. An Intention-to-treat and a Per-protocol analysis were carried out. O-197 Results: Mean overall surgical time was 344.3±109 minutes in the laparoscopic group and 300.8±69 in the open group (p=0.058); LAPAROSCOPIC HYBRID NOTES LIVER RESECTION WITH conversion rate in laparoscopy was 20.6%; median blood loss was NATURAL ORIFICE SPECIMEN EXTRACTION (NOSE) FOR 300 ml (50-3000) vs. 500 ml (50-2500) respectively for laparoscopic COMPLEX CYST AT SEGMENT 6 and open (p=0.534). Pringle manoeuvre was used in 8.8% of cases in Thanadeth Vongjarukorn, Akkaraphorn Deeprasertvit. the laparoscopic group and 12.1% of cases in the open group Department of Surgery Police General Hospital, (p=0.709). Lengths of post¬operative analgesia and hospital stay Bangkok,10330, Thailand. were significantly shorter in the laparoscopic group (p=0.03 and p=0.0001, respectively). Post-operative complications occurred in Background: Laparoscopic liver surgery is upcoming surgical 11.8% of laparoscopic cases and in 32.4% of open cases (p=0.410). technique. Multiple series have reported on the safety and efficacy Median Complication Comprehensive Index was 20.9 (20.9 – 33.5) of laparoscopic liver surgery. Nevertheless, extension of port site is in the open group vs 20.9 (8.7 – 26.2) in theopen group (p=0.571). needed for specimen retrieval. This abdominal wound extraction Per protocol analysis (only patients without conversion in lap group site remains to be a major source of morbidity after laparoscopic were compared to patients with standard approach), showed a liver surgery. The common incisions for transabdominal specimen better trend in favour of laparoscopy concerning postoperative retrieval are lower quadrant, midline, or transverse suprapubic hospital stay, blood loss, days of analgesia and complications. incision. This case shows the alternative method of specimen Conclusions: Laparoscopic formal right and left hepatectomies are extraction after laparoscopic liver surgery. safe and feasible procedures allowing a similar complication rate Objectives: To evaluated the effectiveness and benefit of the with a shorter hospital stay and diminished post-operative pain alternative method of specimen extraction after laparoscopic liver respect to the standard approach. surgery. Materials & Methods: A 69-year-old Thai woman with incidental

184 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

and asymptomatic complex cyst lesion at liver segment 6 during hospital based study carried out at Soba University Hospital, annual ultrasonographic checkup was presented. The magnetic Khartoum, Sudan, from January to July 2016. All patients referred resonance imaging showed complex cyst at liver segment 6. A for colonoscopy during the study period were included in the study combined laparoscopic-transvaginal approach was applied with 10- after obtaining an informed consent. Those under 18 years or mm camera port placed at her vaginal posterior fornix. The 10-mm those who declined to participate were excluded. The ASGE guide- and two 5-mm ports were placed at her abdomen. The liver lines were used to assess the appropriateness of colonoscopy. Data parenchyma was divided using the Cavitron Ultrasonic Surgical was collected using a special data sheet and analyzed using SPSS Aspirator (CUSA) and vessel sealing device. The specimen was version 20. placed in the Endobag and extracted transvaginally. Results: A total number of 222 patients were included in the study Results: Operative time was 135 minutes and blood loss was 120 with a mean age of 50.2 years +/-16. 217 patients (97.7%) were ml. The patient was discharged on postoperative day 3. She outpatients and 121 patients (54.5%) were males. The examination complained of a pain at incisional wound which was relieved was completed up to the caecum in 206 patients (92.8%). Bowel without intravenous analgesia. No postoperative complication was preparation was described by the endoscopyst as optimal in 80.6% found after 30 days. and suboptimal in 15.3%. There were (62.6%) appropriate referrals, Conclusion: Our technique of transvaginal specimen retrieval (27%) inappropriate referrals and 10.4% not listed referrals. The effectively prevents wound-related complications by completely diagnostic yield of colonoscopy was 35.1% and was highly eliminating mini-laparotomy for specimen extraction. NOSE dependent on appropriate colonoscopies. technique results in shorter recovery period, less postoperative Conclusion: ASGE guideline for colonoscopy revealed high rate of pain, and fewer potential wound-related complications. This diagnostic yield and can be adopted in our settings with some technique is safe and effective with excellent aesthetic results. modification regarding certain indications which were not listed in the guidelines and found to be associated with small but significant pathology. O-198

MODERN MINIMALLY INVASIVE SURGICAL TREATMENT OF ULCERATIVE COLITIS, SHORT AND LONG TERM RESULTS

Lázár György O-202

O-199 EFFICACY AND SAFETY OF INFLIXIMAB TOLERANCE INDUCTION IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES WHO ATTITUDE OF SURGEONS FOR MINIMALLY INVASIVE SURGERIES EXPERIENCED ACUTE INFUSION REACTIONS IN RESOURCE LIMITED COUNTRIES. I. Pauchard1, S. Nancey1, F. Hacard1, N. Williet2, X. Roblin2, Haile Henok F. Berard1, B. Flourie1, G. Boschetti1. 1 Pierre Benite/FR. 2 Saint-Etienne/FR O-200 Introduction: Immediate hypersensitivity reactions (IHR) are one of the reasons of infliximab (IFX) failure. We aimed to report efficacy ROBOTIC RESECTION OF PRESACRAL (RETRORECTAL) MASSES and safety of a tolerance induction protocol in inflammatory bowel diseases (IBD) patients who had previously experienced IHR during Akmal Yasir IFX infusions. Aims & Methods: We reported all cases of IBD patients who had O-201 previously experienced IHR to IFX and who were submitted to a standardized protocol of drug immune tolerance induction to IFX AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY from 2010 to 2015. GUIDELINES FOR COLONOSCOPY INDICATIONS: ARE THEY Results: Sixteen patients were included in our study. IHR occurred SUITABLE FOR AFRICAN PATIENTS. in a majority of patients (69%) during the first 3 infusions and for half of them after a period of IFX withdrawn. Seventy-five percent H.D.Elsiddig, A.Dawoud, O.EL. Salim, A.H.Widatalla, S.ZIbrahim, of the patients exhibited moderate symptoms. All skin Prick tests H.M. Mudawi, M.A.Eltahir, S.H. Suliman were negative and only 2 intradermal tests were positive. Basophil Soba University Hospital, Departments of GI Surgery, activation tests and anti-drug antibody measurements were per- Endoscopy and Gastroenterology University of Khartoum, formed in 8 out 16 patients and were positive in 3 and 4 patients, Khartoum, postal code 8081 Sudan. respectively. The IFX induction of tolerance was successful in 69% Objectives: The need for colonoscopy as a diagnostic and therapeu- of patients without safety issue and IFX was pursued with clinical tic modality is increasing worldwide. In country like Sudan with efficacy for more than a year in 7 patients (44%). No link between limited resources, this may increase the work load of the endoscopy the results of the allergologic investigations and the success of the units and the waiting time of patients with an adverse effect on tolerance induction was found. disease progression. So, we need defined criteria for colonoscopy Conclusion: A majority of acute reactions to IFX infusions occurred referrals. The objectives of this study were to: investigate the during the beginning or restarting of treatment and was related to appropriateness of colonoscopy referrals to Soba University a non-allergic hypersensitivity mechanism. Induction of tolerance Hospital using the ASGE guidelines and to evaluate the diagnostic to IFX is feasible and effective and may safely allow retreatment of yield of appropriate and inappropriate referrals according to these IFX in almost 70 % of IBD patients. guidelines. Methods: This is a prospective, descriptive, cross-sectional,

Surgery, Gastroenterology and Oncology, 22 (3), 2017 185 ABSTRACTS

O-203 O-204

ENRICHMENT OF CIRCULATING DOUBLE POSITIVE INTERLEUKIN-17 IBD-INFO QUESTIONNAIRE: A MULTICENTER FRENCH UP-TO-DATE PRODUCING FOXP3+ CD4+ T CELL SUBSETS ARE ASSOCIATED WITH SURVEY OF PATIENT KNOWLEDGE IN INFLAMMATORY BOWEL A HIGHER RISK OF FURTHER RELAPSE IN CROHN’S DISEASE IN DISEASE REMISSION P. Danion1, A. Buisson2, X. Roblin3, N. Mathieu4, A.-L. Charlois1, 1 1 2 2 1 G. Boschetti , B. Flourie , X. Roblin , S. Paul , J. Bienvenu , N. Williet3, E. Del Tedesco3, B. Flourie1, S. Nancey1, G. Boschetti1. 3 4 2 5 G. Bommelaer , A. Buisson , E. Del Tedesco , C. Josson , 1Pierre Benite/FR; 2Clermontferrand/FR; 3Saint-Etienne/FR 5 1 S. Legastelois , S. Nancey . 4Grenoble/FR 1Pierre Benite/FR; 2Saint-Etienne/FR; 3Clermont-Ferrand/FR 4Clermont-ferrand/FR, 5Lyon/FR Introduction: It has been demonstrated in many chronic condi- tions, including inflammatory bowel disease (IBD), that better Introduction: The balance between Foxp3+ regulatory T cells patients’ knowledge about pathology and treatment improves the (Tregs) and effector T cells, including Th1 and Th17 CD4+ T cell course and management of disease. The aim of this study was to subsets are critical for protecting the host from infection while develop an updated self-questionnaire to assess patients' level of maintaining gut homeostasis. All these T cell subsets contribute to knowledge of IBD. the pathogenesis of Crohn’s disease (CD). The dynamics of most of Aims & Methods: The IBD-INFO included 3 parts: an original part the peripheral effector and regulator T cell subsets during the (Q1), and 2 parts from the translation of the pre-existing question- course of CD in remission and their relationships with the risk of naires Crohn’s and Colitis Knowledge score (CCKNOW) (Q2) and relapse remain unknown. We aimed to systematically analyse the Crohn’s and Colitis Pregnancy Knowledge score (CCPKNOW) (Q3). The evolution of frequencies of circulating Th1, Th17 and Tregs with reliability and discriminatory ability of the questionnaire were respect to disease remission -relapse in CD. validated with 3 groups of non-IBD volunteers with various theoreti- Aims & Methods: A cohort of 113 CD patients in clinical remission cal knowledge levels. The final questionnaire (64 validated questions) were regularly followed up on a 3-month basis. Blood samples was then tested on 364 in-and out-IBD patients from 4 French were collected at each visit for routine monitoring inflammatory university hospitals. The score for each part of the questionnaire was markers, including ultrasensitive CRP and for measurements of calculated and factors associated with low scores were identified by various serum cytokines, including IL-6, IL-8, IL-10, IL-13, IL-17A, uni-and multivariate logistic regression analyses. IL-23, TNFa, IFNg, TGFb, by an ultrasensitive Erenna method. The Results: The scores obtained by the 3 non-IBD volunteer groups frequencies of circulating single positive Th1, Th17 and Tregs CD4+ differed significantly (p < 0.0001) and the IBD-INFO questionnaire T cell subsets, as well as double positive CD4+ T cell subsets co- showed excellent internal reliability and consistency (α = 0.98). The expressing IFNg¬IL17, Foxp3-IFNg and Foxp3-IL-17 were analysed median total score obtained by the IBD patients was 27/64 [0-59], by multicolour flow cytometry. and scores for Q1, Q2 and Q3 were, respectively, 10/23 [0-21], Results: Among the whole cohort, 34 (30%) out of 113 patients 11/24 [0-23] and 4/17 [0-16]. In multivariate analysis, lack of a relapsed within the follow-up period. The prevalence of circulating university degree, not being a member of a patient association, not IFNg-secreting CD4+ T cells (Th1), IL-17-secreting CD4+ T cells receiving anti-TNFα treatment, duration of IBD ≤ 3 years, male sex (Th17) and Foxp3-expressing CD4+ T cells (Treg) as well as the and age > 38 years and were independent risk factors of poor IBD- concentrations of a wide broad of cytokines (IL-6, IL-8, 17A, TGFb, INFO knowledge score. The areas of knowledge least mastered TNFa, IFNg, IL-13, IL-23) measured in the serum were not signifi- were vaccination, IBD-related cancers, treatments and pregnancy. cantly different all over the time between patients who relapsed Conclusion: Using the IBD-INFO, an updated self-administered and those who stay in clinical remission. Various circulating double questionnaire built to assess IBD patients’ knowledge, several risk positive CD4+ T cell subsets co-expressing Foxp3 and IL-17, Foxp3 factors have been highlighted that allow better targeting and IFNg and triple positive Foxp3+ IL-17+ and IFNg+ were of patients and areas requiring an improvement in the level of detectable in CD patients in remission. The subset of CD4+ T cells information. co-expressing IL-17 and Foxp3 was found significantly enriched (≈ 2-fold increase) in the circulating compartment in the cohort of O-205 patients in remission who further experienced a clinical relapse 3 months later compared with that of CD patients who stayed in NOVEL METHODS OF INTERVENTIONAL MANAGEMENT FOR remission all over the follow-up period. In a multivariate analysis, HEPATOCELLULAR CARCINOMAS elevated serum usCRP, low serum IL-10 and high number of double positive IL-17 and Foxp3 CD4+ T cells were 3 independent factors S. Murata, D. Yasui, F. Sugihara, T. Ueda, H. Saito, S. Onozawa, significantly associated with the risk of further clinical relapse in CD S. Kumita. patients in remission. Dept. of Radiology, Nippon Medical School, Tokyo 113-8603 Conclusion: Detectable circulating crossover immune CD4+ T cell Japan. subsets co-expressing Foxp3, IL-17 and IFNg in CD patients in Objective: There are several treatment modalities for advanced- remission argues in favour of the recent concept of T cell plasticity. A stage HCC patients. Usually, many clinicians select sorafenib. significant enrichment of a unique CD4+ T cell subset co-expressing However, sorafenib does not have survival benefit for HCC with Foxp3 and IL-17 that preceding the occurrence of a flare suggests the portal vein tumor thrombus (PVTT). On the other hand, portal vein potential contribution of this double positive T cell subset in the invasion easily occurs arterioportal shunts (APS). The aim of this pathogenesis of CD. study was to assess the efficacy of TACE during corresponding portal vein occlusion (TACE-PVO) in patients with hepatocellular carcinoma (HCC) and marked arterioportal shunts (APS).

186 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Methods: The study design was a prospective, non-randomized better background liver function than those in high HA group. In study of TACE-PVO vs. TACE with embolization of APS. The subject contrast, patients in low HA group showed larger median tumor comprised 47 patients (24 pts for TACE-PVO, 23 for TACE with size than those in high HA group (3.3cm vs. 2.6cm, p<0.001). After embolization of APS). We evaluated effectiveness of APS treat- propensity score matching, two comparable groups consisting of ment, tumor response, adverse events, and survival. 139 patients were obtained. There were no significant differences Results: Both the effectiveness of AP shunts treatment (p = 0.002) in clinicopathological characteristics between the two groups. and target tumor response (p < 0.001) were significantly better in However, both the 5-year OSR and RFSR in low HA group were still TACE-PVO group than in TACE with embolization of APS. significantly better than those in high HA group (57.4% vs. 38.3%, Concerning complications, no major procedure-related complica- p=0.006 and 22.5% vs. 14.7%, p=0.003). tions occurred in either group. The median survival time was Conclusion: High preoperative HA level predicts poor postoperative significantly better (p = 0.00164) in the TACE-PVO group (31.0 survival of HCC patients. months) than TACE with embolization of APS (16.8 months). Conclusion: TACE-PVO may be a safe and useful therapy for O-209 selected patients with unresectable HCC and marked APS. THE USEFULNESS OF ALBUMIN-BILIRUBIN GRADE FOR PREDICTING O-206 THE LATE RECURRENCE OF HEPATOCELLULAR CARCINOMA AFTER CURATIVE THERAPY RESULTS OF NEOADJUVANT HEPATIC ARTERIAL INFUSION H. Matsushima1,2, Y. Takami1, T. Ryu1, M. Yoshitomi1, CHEMOTHERAPY IN INOPERABLE HCC PATIENTS WITH M. Tateishi1, Y. Wada1, S. Eguchi2, H. Saitsu1. CHILD-PUGH CLASS A 1Department of Hepato-Biliary-Pancreatic Surgery, Clinical Yun Sung Su Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan, 810-8563. 2Department of Surgery, Nagasaki University Graduate School O-207 of Biomedical Sciences, Nagasaki, Japan, 852-8501. UPDATES IN MANAGEMENTS OF HCC Background: The predictive factors for late recurrence of hepato- cellular carcinoma (HCC) after 5 years from curative therapy are still Masatoshi Kudo unknown. In recent years, the albumin-bilirubin (ALBI) grade (ranging from 1 to 3, higher grade representing worse liver func- O-208 tion), which can be calculated simple from serum albumin and bilirubin level, has been proposed as a useful assessment model of PROGNOSTIC SIGNIFICANCE OF PREOPERATIVE HYALURONIC liver function. We aimed to investigate the usefulness of ALBI grade ACID LEVEL IN PATIENTS WITH HEPATOCELLULAR CARCINOMA as a predictive factor for the recurrence of HCC after 5 years from Takatsugu Matsumoto, Takashi Suzuki, Takayuki Shimizu, Keigo curative therapy. Tani, Kyung Hwa Park, Takayuki Shiraki, Shozo Mori, Yukihiro Methods: Among consecutive 849 HCC patients who underwent Iso, Masato Kato, Mitsuru Ishizuka, Taku Aoki, Keiichi Kubota. liver resection or ablative therapies with curative intent between Department of Gastroenterological Surgery, Dokkyo Medical January 2000 and June 2011, the patients who survived for 5 years University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293 Japan. without recurrence after curative therapy were investigated retro- spectively. The relationships between clinicopathological parame- Background: It is known that serum hyaluronic acid (HA) levels are ters including ALBI grade and late recurrence were analyzed. increased in patients with various tumors and serum high HA level Results: A total of 184 patients survived for 5 years without recur- predicts the prognosis for such cohort. However, as HA also rence. Of these, 61 (33.2%) patients had developed recurrence at correlates with liver fibrosis, the prognostic significance of serum the time of the final evaluation. In univariate analysis, indocyanine HA in patients with hepatocellular carcinoma (HCC) is still unclear. green retention rate at 15 min and number of tumors were related The aim of this study is to investigate the impact of preoperative to a late recurrence as a pre-treatment parameter. Although pre- serum HA level on postoperative prognosis for HCC patients. treatment aspartate aminotransferase level, alanine aminotrans- Methods: A total of 837 consecutive patients who underwent ferase level, Child-Pugh class and ALBI grade were not related to a hepatic resection for HCC between April 2000 and April 2015 were late recurrence, those at five years after treatment were enrolled to this study. One hundred and eighty patients were related to a late recurrence significantly. By multivariate analysis, excluded because preoperative HA levels were not available. Then ALBI grade 2-3 was an independent factor for a late recurrence the patients were divided into two groups according to the levels of (RR5.17, P < 0.0001). Moreover, the increasing of ALBI grade during serum HA (high HA (>=200) group: n=248, low HA (<200) group: 5 years after initial treatment was related to poor recurrence-free n=408). The clinicopathological characteristics and postoperative survival significantly. survivals were compared between the groups. Moreover, additional Conclusions: Post-treatment ALBI grade was a more useful factor propensity score matching analysis was performed to adjust the for the late recurrence of HCC after 5 years from curative therapy characteristics between the groups. compared to pre-treatment ALBI grade. This finding suggests that Results: Both the 5-year overall and relapse-free survival rates (OSR the preservation of liver function after therapies may decrease the and RFSR) in low HA group were significantly better than those in late recurrence. high HA group (59.8% vs. 38.6%, p<0.001 and 24.5% vs. 13.1%, p<0.001). However, patients in low HA group showed significantly

Surgery, Gastroenterology and Oncology, 22 (3), 2017 187 ABSTRACTS

O-210 tion at the point where MHV branch of segment 5(V5) joining the main trunk. Test clamping of G8 helps to define the whole S8. PURE LAPAROSCOPIC RIGHT HEPATECTOMY USING INDIVIDUAL Then parenchyma dissection continues to complete anatomical S8 INFLOW VASCULAR CONTROL FOR HCC FOLLOWING TACE -PVE resection. Results: Total 5 patients received laparoscopic anatomical S8 W. Taesombat, M. Sutherasan, B. Nonthasoot, S. Nivatvongs, segmentectomy by this technique has been collected from May B. Sirichindakul. 2016 to April 2017. The mean age is 66.4 years (54~76). The peri- Department of Surgery, Faculty of Medicine, King operative outcome included the following: mean tumor size: 2.9 Chulalongkorn Memorial Hospital, Chulalongkorn University, cm (1.7~4.6), estimated blood loss: 290 c.c. (50~580), no patient Bangkok, 10330 Thailand. needed blood transfusion, operation time: 255 min (195~375), Objectives: Laparoscopic right hepatectomy is technically demanding postoperative hospital stay: 4.8 days (3~7). No open conversion procedure particularly for liver tumor following sequential TACE -PVE. happened in this series. Postoperative pleural effusion developed Because of shifting of parenchymal transection plane from atrophy- in one patient. hypertrophy phenomenon of PVE, parenchymal transection is more Conclusions: Opening the liver parenchyma along the Cantlie’s line difficult. Besides, TACE -PVE induce inflammation around right in laparoscopic S8 segmentectomy improves the surgical exposure. portal pedicle making individual inflow vascular control is more Dissection of G8 and anatomical resection could be completed challenging. We present the case of pure laparoscopic right more reproducibly. hepatectomy using individual inflow vascular control for patient with hepatocellular carcinoma (HCC) with tumor thrombus in right anterior portal vein who underwent preoperative TACE -PVE. O-212 Methods: After careful searching for intra-and extra-hepatic metastases, cholecystectomy was performed to facilitate right SCREENING PROGRAMS FOR PANCREATIC CANCER IN HIGH-RISK portal pedicle exposure. Individual dissection and ligation of right INDIVIDUALS: SCREENING GOALS ACHIEVEMENT, OVERALL AND portal vein and right hepatic artery were performed sequentially. UNNECESSARY SURGERY -A META-ANALYSIS Limited liver mobilization was performed to facilitate parenchymal S. Paiella, M. De Pastena, T. Pollini, G. De Marchi, L. Landoni, transection. Ultrasonic device and Cavitron Ultrasonic Surgical L. Casetti, D. Ciprani, E. Secchettin, C. Bassi, R. Salvia. Aspirator were used for transection. Branches of middle hepatic General and Pancreatic Surgery Unit, Pancreas vein and small glissonean pedicles were clipped. Right hepatic duct Institute,University of Verona. Verona, Italy. was encircled and then divided. After complete parenchymal transection, right hepatic vein was divided by using stapling Background: Surveillance programs based on EUS or MRCP have devices. Right lobe liver was mobilized completely and placed in been able to detect pancreatic cancer (PDAC) or premalignant plastic bag and removed through Pfannelstiel incision. lesions (PanIN3, high-grade dysplasia/carcinoma in situ IPMNs) in Results: Pure laparoscopic right hepatectomy was performed familial high-risk individuals (FPC-HRI). However, the pooled rate of successfully without intra-operative complications or blood trans- screening goals achievement (SGA) has never been reported to fusion. Operative time was 360 minutes and estimated blood loss date. In addition, screening programs exposes FPC-HRI to a certain was 150 ml. Pathology revealed HCC 5.5 cm in diameter with tumor risk to receive surgery at a time point and, possibly, to receive thrombus in right anterior portal vein and uninvolved resected unnecessary surgery. The aim was to assess the prevalence of SGA, margins. Patient was discharged on postoperative day 6 without as well as the prevalence of surgery and unnecessary surgery rates, peri-operative complications. through a systematic review and a meta-analysis of proportions. Conclusions: Pure laparoscopic right hepatectomy using individual Methods: We searched MEDLINE and EMBASE from January 2000 inflow vascular control is feasible procedure for hepatocellular to September 2016 to identify controlled or uncontrolled studies of carcinoma following sequential TACE -PVE. FPC-HRI enrolled in surveillance/screening programs based on EUS and/or MRI/MRCP. The main outcome measures were pooled proportion of SGA (resectable PDAC, PanIN3, HGD-IPMNs), overall O-211 and unnecessary surgery, using a random effects model. Results: In a meta-analysis of 16 studies reporting of 1662 FPC-HRI LAPAROSCOPIC S8 ANATOMICAL SEGMENTECTOMY the pooled proportion of surgical procedures (including explorative – A MODIFIED APPROACH TO IMPROVE EXPOSURE laparotomy) was 6.4% (CI 95% 4.25-8.97; I2=72.79; p<0.0001). The K.H. Chen, T.F. Siow, U.C. Chio, Y.D. Chen, Y.J. Chang, T.C. Lin, pooled proportion of SGA was 2.12% (CI 95% 1.31-3.12; I2=35.59%; S.Y. Huang, J.M. Wu, K.S. Jeng. p=0.073). In 73 out of 106 FPC-HRIs submitted to surgery, the final Far-Eastern Memorial Hospital, New Taipei City, 220, Taiwan. pathology revealed a diagnosis not in line with the SGA. The pooled proportion of unnecessary surgery was 63.17% (CI 95% 40.16- Objectives: Laparoscopic anatomical S8 resection has been a 83.39; I2=87.26; p<0.0001), the most frequent diagnoses being surgical challenge. Standard technique remains to be established low-grade IPMNs and serous cystadenoma (23 and 19 cases, even by open approach. respectively). Methods: A retrospective review of a prospectively established Conclusions: Despite the bias of the heterogeneity among the database of 745 laparoscopic liver surgery had been done to collect studies considered, this meta-analysis suggests that the pooled patients receiving laparoscopic anatomical S8 segmentectomy. proportion of SGA is higher than the lifetime risk of pancreatic Surgical techniques: Test Clamping of the right anterior Glissonean cancer in non-HRI. However, being included in a surveillance pedicle was applied to define the demarcation along the Cantlie’s program means also to accept either a low risk of receiving surgery, line. After opening the liver parenchyma, the main trunk of MHV often unnecessary. Several efforts should be made to avoid the was identified by tracing down along MHV branches of segment 4. overtreatment of pancreatic anomalies found during the screening. Glissonean pedicle to segment 8(G8) can be identified by dissec-

188 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-213 The aim of this study was to evaluate the indication for surgery, the previous treatment modalities used and the long-term follow-up, CLINICAL IMPACT OF VENOUS INVASION IN PANCREATIC CANCER considering complications, quality of life, pain coping and this in Addeo Pietro relation with the abstinence of alcohol and tobacco. Several questionnaires were used including the EORTC QLQ – PAN28, the PCCL, the McGill and EQ-5D. O-214 Results: In total 45 patients were surgically treated with chronic pancreatitis as the main indication. Only 19 patients agreed on EXVIVO RESECTION AND INTESTINAL AUTOTRANSPLANTATION participation and a free outpatient visit. Seven patients died during FOR THE TREATMENT OF TUMORS AT THE ROOT OF THE the follow-up period. Six patients had a drainage procedure, while MESENTRY 13 had a classical or pyloruspreserving pancreaticoduodenectomy. Mean age was 50 years with a range in follow-up from 2 till 10 A.A. Ahmed1, Saman NikIgbalian2, Alireza Shamsaeefar3, years. The overall outcome considering QoL was 69% with no Amin Bahraini4 difference between drainage and resection procedures. As soon as 1HPB &organ transplantation fellow, Shiraz center of organ a complete alcohol abstinence was achieved patients had a signifi- transplantation, Shiraz, Iran. cantly better EQ-5D score than alcoholic patients. As only 2 2Associate professor of Surgery, Shiraz University of Medical patients stopped smoking completely, no correlation could be Science, Shiraz, Iran. detected between QoL and tabacco use after surgery. Using the 3HPB & organ transplant surgeon.Shiraz Center of Organ PCCL questionnaire for coping, surgery showed that the mean transplantation, Shiraz, Iran. score for internal coping was 3.16 (out of 6-scale), but most 4HPB & organ transplant surgeon. Ahwaz University of Medical patients still have some degree of pain. Science, Ahwaz, Iran. Conclusions: Patient outcomes after surgical treatment for chronic Background: Pancreatic tumors involving the root of the mesentry pancreatitis are acceptable but longterm multidisciplinary continue to be a management problem in hepatopancreaticbiliary guidance and follow-up are essential to improve quality of life and field, these tumors constitute a wide spectrum of pathology NET, coping. PDAC, GIST. Previously these tumors were labeled as irresectable tumors,late stage and untouchable. O-216 Material and Method: Between the period January 2015-June 2016, Twenty one patient underwent exvivo resection and auto- IS SPLENECTOMY STILL JUSTIFIED FOR LEFT-SIDED PANCREATIC transplantation of the small bowel for tumors of the pancreatic CANCER? A HISTOLOGICAL REAPPRAISAL. head, neck involving the root of the mesentry, in Shiraz Center for Organ Transplantation, Namazi hospital, Islamic Republic of Iran. T. Marchese, M. Collard, N. Guedj, M. Ronot, A. Sauvanet. Tumors and mesentricvessels were evaluated using triphasic CT Department of Hepato-Pancreatico-Biliary Surgery, Beaujon and MRV. Internal jugular, great saphenous veins and Deep venous Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), system of the lower limbs were assessed preoperative by duplex Université Paris VII, Clichy, France. examinationfor venous graft of the resected portal vein Background: Splenectomy is recommended during resection for Results: Mean operative time 780 ã 46 min, mean blood loss 1900 left-sided pancreatic ductal adenocarcinoma (PDAC) to perform ml, short term mortality 14%, three patients. Main cause of death lymphadenectomy of station 10 (splenic hilum), but there is no is respiratory complications (pneumonia, ARDS). Mean cold level I evidence available to justify this procedure. Our objective ischemic time 110 ã 25 min. Exploration rate 42%, nine patients was to evaluate the rates of lymph node involvement and contigu- were explored for different causes. R0 resection could be achieved ous involvement of the splenic hilum in resectable distal PDAC. in most of the cases, and symptoms relief was pleasantly accepted Methods: We retrospectively reviewed all patients who underwent by the patients. splenopancreatectomy for PDAC from January 2008 to March Conclusion: Exvivo resection and autotransplantation of small 2017. A pathologist reinterpreted all the microscopic slides of bowel is good and justifiable option for pancreatic tumors involving station 10 lymph nodes. CT-scans of patients with a tumoral the root of the mesentry. It provides good relief of symptoms, long involvement of the spleen or of the splenic hilum by contiguity disease free survival and potential cure. (TISOSH) and those with a distance between tumor and spleen <10 mm at pathologic examination were reviewed blindly by a radio- O-215 logist to measure the capacity of the CT-scan to diagnose TISOSH. Results: We included 110 consecutive patients, including 104 with MULTIDISCIPLINARY APPROACH IS ESSENTIAL AFTER SURGERY analysable nodes at station 10. Tumor was N+ in 59 patients (54%). FOR CHRONIC PANCREATITIS TO ACHIEVE BEST PATIENT OUTCOME The median number of nodes identified at station 10 was 2.0 ± 3.0 (range: 0-12). No patients had tumor-positive lymph nodes at Berrevoet F., Craeynest A., Ververken F., Vanlander A. station 10 (0/104). A TISOSH was found in 9 patients (8%). A TISOSH Department of General and HPB Surgery and Liver was significantly associated with tumor size (p=0.005) and Transplantation, Ghent University Hospital, Ghent, Belgium. multivisceral involvement (p=0.045). Sensibility and specificity of Introduction: Adequate treatment for chronic pancreatitis includes the evaluation of the TISOSH by CT-scan were respectively 89% and a wide variety of options being conservative management, endo- 95%. scopic and surgical treatment. In recent years the role of surgery for Conclusion: Splenic conservation seems possible in case of these patients increased with several publications showing better left-sided PDAC in selected patients without suspected TISOSH at outcome than after endoscopic treatment in selected patients. preoperative CT. Methods: Retrospective assessment of the patients surgically treated for chronic pancreatitis from 2005 till 2013 was performed.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 189 ABSTRACTS

O-217 resection (1) were performed for 19 neuroendocrine (NEN), 3 solid- pseudopapillary, 3 serous and 29 mucinous cystic tumors. Fifteen SPLENIC VESSEL INVASION OF PANCREATIC CANCER OF THE pancreas-preserving duodenectomies were performed for (GIST) (10), BODY AND TAIL: IMPACT ON PROGNOSIS AND PATTERNS OF villous adenoma (2), gigantic leiomyosarcoma (1), gangliocytic para- RECURRENCE ganglioma (1) and solitary metastasis of endometrial cancer. In 3 cases duodenectomy was subtotal with replantation of pancreatic and T. Mizumoto, H. Toyama, S. Terai, H. Mukubo, H. Yamashita, common bile ducts and in 13 cases the procedure was infrapapillary, S. Shirakawa, Y. Nanno, Y. Ueda, D. Lee, Motofumi Tanaka, once associated with aorta and IVC resection. Pancreatic tumors were M. Kido, K. Ueno, T. Ajiki, T. Fukumoto, and Y. Ku. diagnosed before surgery in 51 of 55 and duodenal tumors in 10 of 15 Division of Hepato-Biliary-Pancreatic Surgery, Department of cases. The most precise tools were EUS and CT. For pancreatic Surgery, Kobe University Graduate school of Medicine, 7-5-2, diseases the maim symptoms were pain or discomfort (35) or NEN Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan. functioning (7), пfor duodenal tumors–bleedings (6) and obstruction Objectives: Prognostic impact of pancreatic adenocarcinoma (3). Ninety days mortality was 0. Morbidity rate -44%. There were no (PDAC) invasion to the splenic vessel is unclear. The aim of cases of local relapses and new diabetes. Three patients were treated this study was to assess the clinical value of pathological and by liver resection in 1,5-3,5 years after duodenal resections for GIST radiological splenic vessel invasion in PDACs of the body and tail. and target therapy. Methods: Medical records of patients with PDAC of the body and Conclusion: OPP is safe and oncologically justified for treatment of tail who underwent distal pancreatectomy between 2003 and pancreatic and duodenal tumors with low and indefinite malignant 2016 at Kobe University Hospital were retrospectively analyzed potential. with attention to pathological splenic vessel invasion. Moreover, preoperative computed tomography (CT) images were reviewed in correlation with pathological splenic vessel invasion. O-219 Results: Seventy patients (32 females and 38 males) were enrolled. Twenty-two patients (31.4%) were identified on pathological OMISSION OF ADJUVANT THERAPY AFTER PANCREATIC SURGERY studies as having splenic vein (SV) invasion, while 6 (8.6%) had IS CORRELATED WITH POST-OPERATIVE COMPLICATIONS, AGE splenic artery (SA) invasion. Pathological SV invasion (but not SA AND MARIETAL STATUS invasion) was an independent prognostic factor on multivariate Berrevoet F, Craeynest A., Ververken F., Vanlander A., Troisi R. analysis (P = 0.049). On analysis of recurrence patterns, patients Dept. of General and HPB Surgery and Liver Transplantation with PDAC positive for SV invasion were at higher risk of liver Ghent University Hospital, Gent, Belgium. metastasis (P = 0.007); the associations were not significant for lung metastasis and local/peritoneal recurrence. SV deformity/ Objective: A quality parameter after pancreatic surgery might be stenosis/occlusion on preoperative CT effectively predicted patho- the receipt of adjuvant therapy post-surgery. The aim of this study logical SV invasion with a sensitivity of 95.5% and specificity was to evaluate postoperative complications in relation to receipt of 79.2%. Radiological SV invasion was associated with liver metas- of adjuvant chemotherapy and survival in patients treated for pan- tasis and shorter postoperative survival, reflecting pathological creatic cancer in a tertiary referral hospital. invasion. Methods: All consecutive pancreatic adenocarcinoma patients Conclusions: Pathological SV invasion was independently associated (2009-2015) undergoing surgical resection were included. Receipt with poor survival in consequence of liver metastasis in patients of adjuvant therapy was compared between patients with and with PDAC of the body/tail. Radiological SV involvement may be a without postoperative complications according to Clavien Dindo surrogate marker for pathological invasion. classification, age and marital status. Results: 153 patients were identified (median age 66 years), of which 42.5% had at least 1 postoperative complication. Only 3% of the O-218 patients with complications had Clavien Dindo IV. 6.5% of all patients needed surgical or radiological intervention due to a pancreatic ORGAN-PRESERVING SURGERY FOR PANCREATIC fistula, chyle leakage, collections or abscess formation. Omission of AND DUODENAL TUMORS. EXPERIENCE OF 70 PROCEDURES adjuvant therapy is more frequent in patients with complications (21.7% vs. 9.9%; p=0.039). Other factors significantly associated Egorov V.I., Petrov R.V. with omission were age > 65 and single status. 2-year survival is Bakhrushins Brothers Moscow City Hospital, Moscow Clinical significantly improved for patients who received adjuvant therapy Scientific Centre, Sklifosovsky Emergency Institute, Russia, versus no therapy (51.9% vs. 25.0%; p=0.049). The presence of post- 107076. operative complications versus none did not affect long-term Background: Modern pre-and intraoperative diagnostics of survival (45.0% vs 41.4%, 2009-2013, with follow-up trough 2015). pancreatic and duodenal tumors with low and indefinite malignant Patients’ own choice to refuse adjuvant therapy was the main reason potential makes organ-preserving surgery justified for these entities. for omission (38.8%). Medical reasons for omission counted for 22%. Aim: To assess the efficacy of organ–preserving procedures (OPP) Conclusions: Although standardized surgical techniques and for treatment of pancreatic and duodenal tumors. postoperative management lead to low 30-day morbidity and Method: Retrospective analysis of short-and long-term results of mortality in our series, patients’ own choice, higher age and single 70 consecutive OPP (2007–2016). status seem to be the most frequent reasons for omission of a Results: Distal pancreatectomies with spleen preservation with (6) djuvant therapy. It is important to identify these subgroups to and without (29) spleen vessels preservation (Sutherland-Warsaw achieve best outcomes in terms of survival. procedure), central pancreatic resections(15), duodenum-preserving total pancreatic head resections (4) and center-preserving pancreatic

190 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-220 as FRLV was ≥ 30% of the total liver volume (healthy liver tissue), or ≥ 40% in patients with more than 6 series of chemotherapy. The HEPATIC STELLATE CELLS: UNIQUE CHARACTERISTICS IN CELL adjuvant chemotherapy, patient´s age, number and volume of BIOLOGY CLMs, FLRV and contralateral liver volume changes were evaluated as factors for overall (OS) and disease free survival (DFI). D. Tophuria, M. Matoshvili. Results: All procedures were without any complications. In all Human Normal Anatomy, Dermato-Venerology Departments patients, FLRV growth was sufficient in interval of 2-3 weeks Tbilisi State Medical University after HSC applications. FLRV (cm3) before, 2 and 3 weeks after Hepatic stellate cells (HSCs), a mesenchymal cell type in hepatic procedure was 545.5± 175.1; resp. 645.2± 155.5 and 684.2 ± 154.5 parenchyma, have unique features with respect to their cellular (p< 0.0001). R0 hepatectomy (right, or extended right hepatectomy) origin, morphology, and function. Normal, quiescent HSCs function was performed in 16 patients (80 %), exploratory laparotomy in four as major vitamin A-storing cells containing over 80% of total patients (3x tumor progression, 1x severe adhesions). One and two vitamin A in the body to maintain vitamin A homeostasis. HSCs are years OS was 76.6, resp. 50.3%, DFI was 67.2, resp.32.1% in located between parenchymal cell plates and sinusoidal endothelial patients after liver resection. More than three CLMs were only cells, and extend well-developed, long processes surrounding significant factor for DFI (p<0.04) not for OS. The growth of CLMs sinusoids in vivo as pericytes. However, HSCs are known to be volume was found in 17(85%) of patients (p< 0.003), but it was 'activated' or 'transdifferentiated' to myofibroblast-like phenotype significant neither for OS nor for DFI. Four patients (20 %) died in lacking cytoplasmic lipid droplets and long processes in pathological the interval of 9 to 13 months after R0 hepatectomy due to tumor conditions such as liver fibrosis and cirrhosis, as well as merely progression. Ten patients are without any tumor recurrence in the during cell culture after isolation. HSCs are the predominant cell type interval of one and 38 months after R0 liver resection. Pulmonary producing extracellular matrix (ECM) components as well as ECM metastasis was diagnosed in one patient after nine months. It was degrading metalloproteases in hepatic parenchyma, indicating that successfully treated with laser metastasectomy. Six patients had they play a pivotal role in ECM remodeling in both normal and patho- CLMs recurrence (6-9 months) in the resection line. In two patients logical conditions. Recent findings have suggested that HSCs have a the recurrences were solved by radiofrequency ablation under neural crest origin from their gene expression pattern similar to CT guidance. In four patients we were not able to perform any neural cell type and/or cells and myofibroblasts. The surgical procedure and patients were treated by oncologists. morphology and function of HSCs are regulated by ECM components Conclusion: Combination of PVE with application of autologous as well as by cytokines and growth factors in vivo and in vitro. Liver HSC appears to be save and promising method for stimulation of regeneration after partial hepatectomy might be an invaluable FLRV growth with a subsequent possibility of radical liver resection model to clarify the HSC function in elaborate organization of liver in patients with primary non-resectable CLM. The unresolved issue tissue by cell-cell and cell-ECM interaction and by growth factor and is a danger of CLMs progression in the liver parenchyma following cytokine regulation. the PVE with HSC application.

O-221 O-222

PORTAL VEIN EMBOLIZATION AND STEM CELLS APPLICATION PREOPERATIVE RIGHT PORTAL VEIN EMBOLIZATION (PVE) AFTER IS A GOOD OPTION FOR ENLARGEMENT OF FUTURE LIVER INTRA¬ARTERIAL CHEMOTHERAPY (IAC) REMNANT VOLUME. A.A. Polikarpov, P.G.Tarazov, D.A.Granov. Vladislav Treska, Jakub Fichtl, Daniel Lysak, Bruha Jan, Russian Scientific Center of Radiology and Surgical Duras Petr, Mirka Hynek, Skalicky Tomas, Finek Jindrich Technologies, St.Petersburg, 197758, Russia. Supported by the Research Project PROGRES Charles Aim: To evaluate effectiveness of PVE for inducing preoperative University in Prague. hypertrophy of small (<30%) future remnant liver (FRL) in patients Objectives: Insufficient future liver remnant volume (FLRV) is one previously treated with IAC. of the main causes of colorectal liver metastases (CLMs) non- Methods: Between 2003 and 2015, PVE was performed in 42 pts resectability in majority of patients. Recently some methods are (Group 1) with previous IAC (HAI or TACE; 1 to 6, mean 1.7 used for the enlargement of FLRV. Portal vein embolization (PVE) treatments) of their colorectal liver Mts (n=29), HCC (n=7) or other together with application of autologous hematopoietic stem cells liver malignancy (n=6). In control Group 2, PVE was done in 27 (HSC) can be the useful method of FLRV growth stimulation. chemo-naïve pts with colorectal Mts (n=19), HCC (n=6) or other Method: PVE with autologous HSC application have been used in tumor (n=2). Lipiodol, ethanol, and Gelfoam were used for 20 patients with primary non-resectable CLMs (3/2011 – 8/2015). occlusion. Indications for PVE with HSC were: FLRV<30%, no extrahepatic Results: IAC resulted in partial tumor response (n=20) or stabilization metastases and no general contraindication for liver surgery. PVE of tumor growth (n=22) in all Group 1 pts, and the decision of poten- was performed on the site of CLMs (in all cases on the right lobe) tial resectability was made by multi-disciplinary team. After PVE, FRL by mixture of lipiodol and histoacryl. Next day after PVE autologous became 38% (+52%) in Group 1 and 39% (+60%) in Group 2 (NS). In HSC were applied via vena ileocolica to the contralateral liver lobe. 28-50 (median 31) days, right or extended right hepatectomy was HSC were used from peripheral blood in 12 patients, and from made in 23/42 (55%) and 15/27 (56%) pts, respectively. One patient bone marrow in 8 patients. Metastasectomy or radiofrequency of Group 2 with FRL=32% died from hepatic failure on the 21st day. ablation (RFA) of CLMs in the left liver lobe was performed in six No significant hepatic insufficiency was seen in 38 other pts. The (28.6%) patients as the first step before PVE and application of HSC. remaining pts were not resected because of intra-or extrahepatic The growth of FLRV was examined each week after procedure by metastases or small FRL, and they received IAC. computed tomography (CT). Liver resection was performed as soon Conclusion: PRPVE is a safe and well-tolerated procedure

Surgery, Gastroenterology and Oncology, 22 (3), 2017 191 ABSTRACTS

decreasing risk of postoperative liver failure including patients with after operation. Group VI; 70% hepatectomized, injected CCl4 four previous IAC. weeks after operation, sacrificed 31 days after operation. CCl4 injected intraperitoneal "3ml/kg" Results: Hematoxylin & Eosin revealed extensive hepatocyte loss in O-223 group II, marked loss in group VI, mild loss in group V. Masson's trichrome revealed that fibrosis grade was grade six in group II, CELLULAR CHARACTERISTICS OF THE LIVER TOXIC INJURY AND grade three in group V, grade four in group VI. Alpha-fetoprotein REGENERATION Immuno-expression was mild positive in groups II and IV, moderately positive in group VI, strong positive in group III and very D.Tophuria, M.Matoshvili. strong positive in group V. Transmission electron microscope Tbilisi State Medical University, Human Normal Anatomy, revealed that group VI hepatocytes more damaged than group V Dermato-Venerology. and both less affected than group II. Hepatocytes nuclei were Background: The morphological basis of liver,s acute insuficiency is pyknotic. Fat globules markedly deposited. Large electron lucent cytological syndrome, which leeds to cell membrane and cell areas and scanty glycogen. Endoplasmic Reticulum dilated with structures distruction leading organ,s functional insuficiency. As dispersion of ribosomes. Bile canaliculi dilated with atrophic already known liver has unique ability of reparative regeneration, microvilli. Liver enzymes &bilirubin showed high significant which is manifested by increasing in number of the peroxisomes, oval increase in groups II, III, V and VI. Groups II &VI showed high shaped mitochondrias and endoplasmic reticulum. Study and research significant increase as compared to V which showed high significant of livers tremendous regeneration ability is highly important in study increase as compared to group III. Liver weight showed high already known methods of liver,s treatment methods and significant increase in groups III, IV, V and VI. in developing new ones (cell transplantation). Conclusion: Hepatic stimulator substance extracted from Methodology: Hepatic stem/progenitor cells also known as “oval regenerating rat liver 96 hours after partial hepatectomy protecting cells” in rodents have been implicated in liver tissue repair, at a time it against hepatotoxic effects of CCl4. Early regenerating liver tolerate when the capacity for hepatocyte and bile duct replication is CCl4 toxicity better than late regenerating liver. exhausted or experimentally inhibited (facultative stem/progenitor cell pool).white Wister line rats were been selected as experimental animals. They were divided into the 4 groups. I group animals used O-225 for modelling of acute liver failure by injection hepatocytotoxic agent CCL4 “carbon tetrachloride”. In II group were performed 60% liver CLINICOPATHOLOGICAL STUDY OF IGG4 CHOLANGITIS AND resection. III group hepatocyte donors (progenitor hepatocytes) for AUTOIMMUNE PANCREATITIS – A SINGLE CENTER EXPERIENCE antihepatocytotoxic serum. On the fourth day after liver toxic Chun-Yi Tsai, Yu-Yin Liu, Keng-Hao Liu, Jeng-Huei Tseng, damage and hepatic injury by 60% liver resection, was starting Tze-Chin Chen, Chun-Nan Yeh, Yi-Yin Jan, Ta-Sen Yeh. treatment by antihepatocytotoxic serum which was made from Chang Gung Memorial Hospital, Linkou branch, Taoyuan City, progenitor hepatocytes which were on reparative regeneration 333, Taiwan. activity. Liversections was studied by morphometric analysis. Results: The performed research has shown that antihepatocyto- Objectives: IgG4 sclerosing cholangitis (IgG4-SC) and autoimmune toxic serum prevents liver-cell necrosis, promotes reparative pancreatitis (AIP) are hepatobiliary presentations of systemic IgG4 regeneration process in damaged liver cells, and helps in organ related disease (IgG4-RD). They are recognized increasingly owing function restoration. Morphological evaluation have shown to their distinct clinicopathological characteristics. We try to clarify regeneration process increasing of bipolar hepatocytes number, the demographic features, reliable diagnostic modalities, and increasing of hepatocytes mitogenic activity. response to treatment. Key words: Liver, toxic damage, regeneration. Methods: We recognized 46 patients with IgG4-RD from January 2009 to December 2016 in our institute. Thirty-four of the cohort (74%) present with either solitary IgG4-SC (group A, n=8), solitary O-224 AIP (group B, n=14), or both (group C, n=12). The diagnoses were achieved according to the JPS2011 criteria and the HISORt criteria, REACTION OF REGENERATING RAT LIVER AFTER 70% HEPATECTOMY respectively. TO CARBON TETRACHLORIDE TOXICITY: IMMUNO-HISTOCHEMICAL Results: 40% of group C patients were designated as autoimmune AND ELECTRON MICROSCOPIC STUDY. disease by CT scan whereas none of the group A and B was. However, MRCP achieved the impression of autoimmune disease in 92% of the W. Hamid, M. El-Shobary, A. El-Hawary, R. Fekry, S. Alber. cohort. Among the group A patients, 75% of them were designated Wesam H. El-Sayed, Anatomy Department, Faculty of Medicine, as hilar cholangiocarcinoma as the initial diagnosis. For serology, 85% Mansoura University, Mansoura, Egypt. patients have elevated IgG4 serum level (median 453 ng/dL). Twenty Objectives: Evaluate tolerance of regenerating rat liver after patients (59%) disclosed relapse of disease during follow up. 70% hepatectomy to CCl4 toxicity early and late throughout Univariate analysis demonstrated that pancreaitis and primitive level regeneration. of IgG4 are risk factors related to disease relapse after treatment. Methods: In Mansoura Experimental Research Center, from 2015 Conclusions: The diagnosis of IgG4-SC and AIP remained a distinct to 2016, 60 male albino rats divided equally into 6 groups. Group I; category requiring multi-modalities. MRCP demonstrated high sham operated. Group II; sham operated, injected CCl4. Both sensitivity in diagnosis than CT among our cohort. Primitive level of groups sacrificed 3 days after operation. Group III; 70% hepatec- IgG4 and pancreatic involvement are factors related to relapse of tomized, sacrificed 6 days after operation. Group IV; 70% hepatec- disease. tomized, sacrificed 31 days after operation. Group V; 70% hepatec- tomized, injected CCl4 three days after operation, sacrificed 6 days

192 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-226 O-230

LIVER FIBROSIS AND CIRRHOSIS: ROLE OF THE FIBROBLASTIC LAPAROSCOPIC VERSUS OPEN RESTORATION OF THE GUT CELL SUBPOPULATIONS CONTINUITY AFTER HARTMANN‘S PROCEDURE Tophuria Davit Wael Barakaat, Ahmed Mohamed, Alaa Ahmed Redwan. Sohag University Hospitals, Sohag, Egypt. O-227 Aim: The aim of this study was to compare the outcome of the laparo- scopic and open restoration of the gut continuity after Hartmann CRIAL (COLORECTAL INTRACORPOREAL ANASTOMOSIS BY operation as regard operative and post-operative complication. LAPAROSCOPY). - A SAFE WAY TO AVOID AN DERIVATIVE Methods: All patients who underwent restoration of the gut STOMA IN THE LOW ANTERIOR RESECTION OF RECTUM continuity after Hartmann‘s procedure either laparoscopic AFTER NEOADJUVANT RADIOTHERAPY. Hartmann’s closure or open Hartmann’s reversal between December Costa Pereira Joaquim 2013 and December 2016 were included. Results: Between December 2013 and December 2016, 32 patients underwent restoration of the gut continuity after Hartmann‘s O-228 procedure in Sohag university hospitals, Egypt, were enrolled in this study. 14 patients had a laparoscopic reversal of Hartmann’s A NEW DEVICE FOR INTRACORPOREAL INTESTINAL ANASTOMOSIS colostomy and 18 had an open reversal of Hartmann’s colostomy. DURING LAPAROSCOPIC COLO-RECTAL SURGERY There was no significant difference between both groups as regard Tanaka Jun-ichi age, sex, body mass index, length of remaining rectal stump or time interval between primary operation and Hartmann reversal. The most common indication for Hartmann’s colostomy was obstructed O-229 rectosigmoid cancer [13/32]. The operative time was significantly shorter in LHR group (107 minutes versus 124 minutes LAPAROSCOPIC COLONIC RESECTION WITHOUT URINARY p=0.031),time to pass flatus was significantly earlier in LHR (1.70 DRAINAGE: IS IT BFEASIBLE ? days versus 3.33 days p=0.000) , wound complications were significantly lower in LHR (1 case versus 8 cases p= 0.044) , LHR had M. Alyami, P. Lundberg, G. Passot, Olivier Glehen, E. Cotte less post-operative pain 24 hours after procedure (VAS was 5.93 The Department of Surgical Oncology, CHU Lyon Sud, Hospices versus 8.72 p= 0.000).The length of hospital stay was significantly civils de Lyon University of Lyon, 69495, Pierre Bénite, France. shorter in the LHR group (6.55 days versus 12.14 days P = 0.038)no Background: Urinary retention following colorectal surgery is a significant difference between both group as regard intraoperative known and costly morbidity. Increasing effort is being made to complications, leakage, reoperation or postoperative complica- streamline patient recovery following colon resection, though the tions no mortality was detected in this study. ideal timing and duration of urinary catheterization (UC) and its Conclusion: Laparoscopic reversal of Hartmann’s operation is safe effect on urinary retention (UR) and urinary tract infection (UTI) as open surgery and had less postoperative pain, wound infection remain controversial. and shorter hospital stay .it should be the procedure of choice for Methods: Our program prospectively enrolled patients undergoing reversal of Hartmann’s operation. elective segmental colon resection through our Bfast track protocol, in which UC is completely avoided unless required for fluid management or to facilitate dissection. Patient demographics O-231 and perioperative data including type of analgesia, duration of anesthesia, timing of UC, and rates of perioperative UR and UTI INTRACORPOREAL VERSUS EXTRACORPOREAL ANASTOMOSIS were prospectively recorded. FOLLOWING LAPAROSCOPIC RIGHT COLECTOMY: SHORT-TERM Results: Sixty-five patients met inclusion criteria. Sigmoid colectomy OUTCOMES was the most common procedure (76.9 %). The average duration of I. Gil, N. Rama, D. Parente, I. Sales, P. Alves, P. Clara, S. Amado, anesthesia was 274 min, and epidural analgesia was employed in 32 M. Coelho, V. Faria. (49.2 %). Twenty-two patients (33.8 %) required temporary peri- Colorectal Unit – Centro Hospitalar Leiria, 2410-197 Leiria, operative UC. All patients left the operating room without a urinary Portugal. catheter. Urinary retention occurred in six patients (9.2 %, three with and three without epidural analgesia). One patient who was not Background/Objectives: There has been a growing enthusiasm in catheterized developed a UTI (1.5 %). There was no perioperative developing new techniques of intracorporeal anastomosis following mortality. Overall, 39 (60.0 %) patients successfully underwent laparoscopic colectomy, more challenging than extracorporeal segmental colon resection and hospital discharge without any UC. techniques. We have two aims: to evaluate the feasibility and Conclusions: Fast track enhanced recovery after elective segmental safety of intracorporeal anastomosis following laparoscopic right colon resection without requiring UC is safe and feasible. Epidural colectomy; to compare post-operative outcomes of intracorporeal analgesia does not mandate the use of UC. In light of the and extracorporeal anastomosis following laparoscopic right considerable morbidity and cost of UR and UTI, this approach merits colectomy. further investigation for this patient population. Methods: We designed a retrospective study comparing intra- corporeal and extracorporeal anastomosis following laparoscopic right colectomy. A total of 115 consecutive patients operated for

Surgery, Gastroenterology and Oncology, 22 (3), 2017 193 ABSTRACTS

right colon disease were identified, during the period from O-233 September 1st 2014 to 31st May 2017. Patient demographics included age, sex, ASA score, past abdominal surgery, anticoagu- LAPAROSCOPIC LEFT NEPHRECTOMY COMBINED WITH lant and steroid therapy, Diabetes Mellitus and pre-operative ABDOMINO-PERINEAL RESECTION OF THE RECTUM FOR diagnosis. The analysed outcomes included length of stay, opera- SYNCHRONOUS PRIMARY MALIGNANCIES tive time, blood loss, extraction site, post-operative complications (ileus, anastomotic failure, abdominal abscess and surgical site I. Takorov, Ts. Trichkov, R. Kostadinov, M. Iakova, I. Vasilevski, infection), and 30-day mortality. V. Mihaylov, Ts. Lukanova, E. Odisseeva, N. Vladov. Results: The extracorporeal group included 84 patients and the Department of Hepato-Pancreato-Biliary and Transplant intracorporeal group 31 patients. Mean length of stay was signifi- Surgery – Military Medical Academy, 1606 Sofia, Bulgaria. cantly shorter for the intracorporeal group (10,5 versus 8,5 days). Objectives: Synchronously occurring primary malignant lesions of There was no statistically significant differences in operative tome, the colon and kidney are rare, occurring in 0.03-0.5% of the cases. blood loss, ileus, anastomotic failure, infection or mortality. Data on this topic is scarce and consists mainly of case reports with Conclusion: Our study reveals similar outcomes for both intra and small sample sizes. We demonstrate a technique for combined extracorporeal anastomosis following laparoscopic right colectomy. laparoscopic abdomino-perineal resection and left nephrectomy Therefore, intracorporeal anastomosis presents as a feasible and for concomitant low rectal and renal cell cancers. To the best of our safe technique in the hands of experienced laparoscopic surgeons. knowledge this is the first peer to peer presentation of this original surgical approach. Methods: Sixty-three-year-old male was referred to our unit with O-232 histologically verified symptomatic rectal cancer, lying in close proximity to the internal anal sphincter. The diagnostic work-up OPTIONS FOR PERINEAL DEFECT CLOSURE FOLLOWING revealed synchronous lesion in the left kidney. After multidisciplinary EXTRALEVATOR ABDOMINOPERINEAL EXCISION IN guided decision, the patient was subjected to laparoscopic RESOURCE-LIMITED SETTING abdomino¬perineal resection, combined with left nephrectomy. He Mariam Baig1, Syed Hasan Raza1,Raza Sayyed2, Shahid Khattak1, was placed supine, in lithotomy position. Open laparoscopy was Aamir Ali Syed1. performed supra-umbilically and in total 6 trocars were inserted. 1Department of Surgical Oncology, Shaukat Khanum Memorial After transection of inferior mesenteric artery and vein, colon was Cancer Hospital and Research Centre, Lahore, Pakistan. mobilized to allow access to the left kidney. The nephrectomy was 2Surgical Oncologist, Patel Hospital, Karachi, Pakistan. done initially, followed by abdomino-perineal resection with total mesorectal excision and paraaortic lymphatic dissection. Both Objectives: Extralevator AbdominoPerineal Excision (ELAPE) is an specimens were extracted through the perineal incision, sparing the oncologically acceptable surgical procedure for the management need for an abdominal one. of low rectal cancer involving the sphincters. Management of the Results: The operative time was 330 min and the estimated blood perineal defect resulting from wider resection at the level of leva- loss 150 ml. The post-operative period was uneventful, and the tor muscle remains a challenge for the surgeon. This is especially patient was discharged on the 5th day. Currently he is healthy, with true in resource limited settings where biological mesh or a flap no sign of recurrence 6 months after the procedure. closure of these defects may not be readily available. We report Conclusions: Combined multi-visceral laparoscopic resection for our institutional experience in management of the perineal wound synchronous neoplasia is feasible in selected patients. When defect following ELAPE at a specialist cancer hospital. performed by an experienced team, it offers similar oncologic Methods: Cases undergoing ELAPE between October 2014 and outcomes, compared to the conventional approach, yet having the June 2016 were included. Clinical details, operative data and post- advantage of fast recovery, with less surgical complications. operative outcomes were retrieved from electronic case records. Management of the perineal defect and perineal wound infection as outcome was recorded. O-234 Results: A total of 52 patients underwent ELAPE during the study period. The mean age was 52 years (IQR 31-57). Median duration ABDOMINOPERINEAL EXCISION OF THE RECTUM. of surgery was 325 minutes (IQR 300-368). Median blood loss was FIRST EXPERIENCE. 75 ml (IQR 50-150). The perineal defect was closed in 45 patients Kostyantyn Mylytsya (86.5%) using omentoplasty. One patient had the defect closed by Zaporizhzhya medical academy of postdiploma education. gracilis muscle rotational flap. Non-biological mesh was used in 27 Zaporizhzhya. 69096. Ukraine. patients (51.9%). Dual mesh was used in one patient, while in the remaining patients polypropylene or composite mesh containing Laparoscopic surgery appeared on the territory of Ukraine almost polypropylene were used. Perineal wound healed well in 35 simultaneously in the mid-90s of the last century. Spectrum of such patients (67.3%) while 17 patients (32.6%) required wound techniques as appendectomy and cholecystectomy was mastered opening and care with dressing. Re-exploration of perineal wound by all the centers, and further expansion of the spectrum of was required in 2 patients (3.8%). Median hospital stay was 6 (IQR operations (primarily operations on the intestine) was overcome 5-6.25). only by single centers. One of the reasons for this is that the cost of Conclusion: Non-biological mesh is a good alternate option for consumables for laparoscopic appendectomy or cholecystectomy perineal wound closure in ELAPE in limited resource settings. is about $ 10, and for example, laparoscopic anterior resection with Omentoplasty can be safely performed with overlying placement the application of colorectoanastomosis is at least $ 700. In of synthetic mesh for closure of perineal defect in ELAPE. This colorectal surgery exist not a frequent operation that does not avoids the use of expensive biological mesh or plastic surgery for require significant material costs. This is laparoscopic abdomino- closure of defect. perineal excision of the rectum (Miles operation). This operation is

194 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

not only possible, but it should also be performed laparoscopically, O-238 because tumor can be extracted through the perineal hole without injuring the anterior abdominal wall. 14 laparoscopic operations COMBINED IPSILATERAL LIVER LOBE DEVASCULARIZATION AND were done in chair surgery and proctology if Zaporizhzhya medical ALCOHOL TREATMENT (CILDAT) FOR THE LARGE HEPATOCELLULAR academy of postdiploma. The advantages of laparoscopic surgery CARCINOMA (HCC) are a reduction in the cost of treatment, as well as an easier post- O. M. Elsanousi, F. H. Salim, M. A. Mohamed, E. A. Adam. operative rehabilitation of the patient Faculty of Medicine. Department of Surgery, The National Ribat O-235 University, Khartoum. 11111. Sudan. Objectives: This study aims to evaluate the long term outcome of DEVELOPING NEW COMBINATION THERAPIES FOR LIVER CANCERS the combined ipsilateral liver lobe arterial devascularization aug- Duda Dan mented postoperatively, by percutaneous ethanol alcohol injection (PEI) for the patients with large hepatocellular carcinoma (HCC). O-236 Methods: The clinical data was reviewed for the adult patients suffering from large HCC and underwent surgical ligation of the HCC: NEW THERAPEUTIC TARGETS ipsilateral hepatic artery as well as isolation of their extrahepatic collateral arteries; followed four weeks later by a complimentary Kaseb Ahmed PEI. Results: 16 patients were subjected to the combined treatment. O-237 Their mean age was 62.6 years. 12 (75.0%) patients were ASA grade III. Two patients (12.5%) were classified as intermediate and 10 ANTERIOR APPROACH WITH HANGING MANEUVER CAN (62.5%) patients were advanced stage. The mean size of their IMPROVE LONG-TERM OUTCOME FOR HEPATOCELLULAR tumors was 12.9 centimeters. Nine patients (56.3%) had tumor CARCINOMA: A MULTI-INSTITUTIONAL PROPENSITY sizes > 10 cm. The mean operative blood loss was 279.4 mls, where SCORE-MATCHING STUDY the mean postoperative hospital stay was 7.69 days. The 30 days`

1,2 1,2 1 2 operative mortality was encountered in one patient (6.25%) due to T. Beppu , K. Imai , K. Okuda, S. Eguchi S , H. Baba , postoperative pulmonary embolism. The mean number of alcohol H. Fujioka1, Kyushu Study Group of Liver Surgery1, Japan. 1 sessions was 5.7, and the mean alcohol volume was 78.1 mls. Project Committee of the Multi-Institutional Study by the The mean follow up duration was 14 months. The mean survival Kyushu Study Group of Liver Surgery, Japan. 2 duration was 14.7 months. The one, three and five years` survival Department of Gastroenterological Surgery, Kumamoto rates were 40%, 13.4% and 6.7%, respectively. One patient (6.3%) University, Japan. underwent a major complication (Clavien-Dindo grade ≥ III). Grade Objectives: Anterior right-side hepatectomy with hanging maneuver 3/4 and 4 Common Toxicity Criteria for Adverse Effects (v4.03) were (ARH-HM) for large hepatocellular carcinoma (HCC) is gradually met in 11 (68.8%) and one (6.3%) patients, respectively. The objec- increasing; however its efficacy is still unknown. This study was tive response rate was 62.6%, while the mean objective response designed to assess the short-term and long-term benefits of ARH-HM duration was 13.8 months. compared with conventional right-side hepatectomy (CRH). Conclusions: These preliminary findings show that our combined Methods: Between January 2000 and December 2012, 306 patients treatment can be a good alternative to the HCC treatment to the with HCC ≥ 5 cm were divided into two groups: ARH-HM (n = 104) patients with large sizes. and CRH (n = 202). "ARH without hanging maneuver’ or ‘ARH with hanging maneuver after liver mobilization’ were excluded. A one-to- one propensity-score matching analysis was applied to balance O-239 the perioperative background factors. Subgroup analyses were additionally performed. CLINICOPATHOLOGICAL FEATURES AND SURGICAL OUTCOME OF Results: 1) In the propensity-score matching cohort, 72 ARH-HM PATIENTS WITH FIBROLAMELLAR HEPATOCELLULAR CARCINOMA. and 72 CRH patients showed equivalent clinicopathological Ehab El Hanafy, Mohamed Abdel Wahab. characteristics. 2) In comparison with CRH group, patients in the Gastrointestinal surgical center, Mansoura University, 35516, ARH-HM group demonstrated significantly less intraoperative Egypt. blood loss (480 g vs. 1242 g, P < 0.001; a lower frequency of red cell concentrate transfusion (21.1% vs. 50.7%, P < 0.001); and similar Objectives: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a operation time, morbidity (Clavien-Dindo classification ≥ III) and rare histologic variant of hepatocellular carcinoma (HCC) which mortality. The recurrence-free survival rates were equivalent in the arises in young individuals and has been considered to be less two groups; however, the overall survival rate was significantly aggressive than common HCC. The aim of this study was to better in the ARH-HM group (5-year survival rates: 50.2% vs. 31.4%, evaluate the clinicopathological features and the surgical outcomes P = 0.021). 3) In the subgroup of HCC ≥10cm, 5-year recurrence- of patients with FL-HCC over a 15-year period. free survival (16.6% vs. 10%, P = 0.049) and 5-year overall survival Methods: This is a retrospective study including 22 patients with a (44.7% vs. 23.4%, P = 0.005) was significantly better in the ARH-HM pathologic diagnosis of FL-HCC who underwent hepatectomy over group. a 15 year period. Tumor characteristics, survival and recurrence Conclusions: Compared to the CRH, ARH-HM can provide better were evaluated. overall survival rates with a decrease in intraoperative blood loss Results: There were 11 male and 11 female with a median age of and transfusion rates for large HCC. Survival impact was evident 29 years (range from 21 to 58 years). Two (9%) patients had hepa- especially in patients with HCC ≥ 10 cm. titis C viral infection and only 2 (9%) patients had alpha-fetoprotein level >200 ng/ml. The median size of the tumors was 12 cm (range

Surgery, Gastroenterology and Oncology, 22 (3), 2017 195 ABSTRACTS

from 5 – 20 cm). Vascular invasion was detected in 5 (23%) A.O. Kaseb, R. Abdel-Wahab, R. Murthy, M. Hassan, K.P.S. patients. Four (18%) patients had lymph node metastases. The Raghav, L. Xiao, J. Morris, R. Avritscher, B.C. Odisio, C. Ohaji, median follow up period was 42 months and the 5-year survival R.A. Wolff, J.C. Yao, A. Mahvash. was 65 %. Five (23%) patients had a recurrent disease, 4 of them GI Medical Oncology Department, The University of Texas MD had a second surgery with 36 months median time interval. Anderson Cancer Center, Houston, TX, USA. Vascular invasion is the only significant negative prognostic factor Clinical Oncology Department, Assiut University, Assiut, Egypt. Conclusion: FL-HCC has a favorable prognosis than common HCC Department of Interventional Radiology, The University of and should be suspected in young patients with non cirrhotic liver. Texas MD Anderson Cancer Center, Houston, TX, USA. Aggressive surgical resection should be done for all patients. Department of Biostatistics, The University of Texas MD Repeated hepatectomy should be considered for these patients as Anderson Cancer Center, Houston, TX, USA. it has a relatively indolent course. Objectives: Combined use of sorafenib and local therapy for treating unresectable hepatocellular carcinoma (HCC) is not well O-240 established. Our study aimed to assess the efficacy and safety of combined use of sorafenib and yttrium-90 resin microspheres (Y90 ABILITY OF IGF-1 SCORE TO SUB-STRATIFY CTP CLASSES AND RMS) in unresectable HCC defined as Barcelona Clinic Liver Cancer PREDICT RESPONSE TO SYSTEMIC THERAPY IN HEPATOCELLULAR class C. CARCINOMA Methods: Between October 2013 and August 2016 we enrolled 40 advanced stage HCC patients, 38 patients were treated with A.O. Kaseb, R. Abdel-Wahab, M. Hassan, L. Xiao, K.P.S. Raghav, sorafenib followed (after 4 weeks) with Y90 RMS at MD Anderson L. Girard, H.M. Amin, J. Morris, R.A. Wolff, J.C. Yao. Cancer Center. Survival analysis was done to evaluate median GI Medical Oncology Department, The University of Texas MD overall survival (OS) and progression-free survival (PFS). We used Anderson Cancer Center, Houston, TX, USA. modified Response Evaluation Criteria in Solid Tumors (RECIST) to Clinical Oncology Department, Assiut University, Assiut, Egypt; assess response to treatment and the Common Terminology Department of Biostatistics, The University of Texas MD Criteria for Adverse Events (CTCAE) v4.0 to evaluate the grading of Anderson Cancer Center, Houston, TX, USA. treatment related toxicity. Hematopathology Department, The University of Texas MD Results: The majority of our patients were males (74%), white Anderson Cancer Center, Houston, TX, USA. (47%), 66% had underlying liver cirrhosis, 26% had vascular Objectives: Our recent studies showed that lower insulin like invasion, and 26% had extrahepatic disease. The estimated median growth factors-I (IGF-I) associated with shorter overall survival (OS) OS and 95% confidence interval (CI) in months was 18.46 (12.29 – in HCC. Furthermore, integrating IGF-I into Child Pugh Score (CTP) NA) and the estimated PFS was 12.29 months (5.72 – 18.79). Stable (IGF-CTP) led to better prognostic stratification (Kaseb et al., JNCI disease (SD) was observed in 44.74% of patients, while 28.95% 2014). Since CTP class A is the standard criterion for active therapy achieved partial response (PR). Grade III-IV adverse events and trials entry, we aimed at assessing the ability of IGF-CTP to included fatigue (n = 3), hyperbilirubinemia (n = 2), thrombocy- predict systemic therapy outcome. topenia (n = 1), proteinuria (n = 1), hyponatremia (n = 1), elevated Methods: 78 patients were prospectively enrolled and treated with liver enzymes (n = 4), hypertension (n = 4), diarrhea (n = 1), nausea sorafenib. Pre-treatment blood sample were tested for IGF-I and (n = 1) and vomiting (n = 2). IGF-CTP was calculated after study completion. Survival analysis Conclusions: This is the first prospective study to evaluate was done to measure the estimated median OS and progression sorafenib followed by Y90 in HCC. Our study included patients with free survival (PFS), and log rank test was used to compare PFS and metastatic HCC and showed that combined use of sorafenib and OS between subgroups of IGF-CTP score of patients. Y90 was tolerable and was associated with longer OS and PFS Results: For CTP A patients, the estimated median OS in months compared to previous studies which evaluated sorafenib alone. (95% confidence interval, CI) was 9.1m (5.3 – 19.7) and PFS was However, future randomized phase III studies are warranted to 5.6m (3.8 – 7.9). Patients who were reclassified as IGF-CTP (B) assess sorafenib+/-Y90 in metastatc disease setting. (OldA/newB = AB) had significantly shorter OS 5.2m (2.8 -NA) and PFS of 4.3m (2.1 – NA), as compared to patients’ who classified as O-242 class A by both scoring systems (AA), who had OS of 11.1m (5.7 – 21.3) and PFS of 7.2 m (3.9 – 15.1), P < .001. Interestingly, patients TREATMENT OUTCOME OF RUPTURE HEPATOCELLULAR who classified as CTP-B but IGF-CTP-A ( = BA) had significantly CARCINOMA; A SINGLE CENTER EXPERIENCE longer OS 10.2 (2.89 – NA) and PFS 8.1 (2.9 – NA), as compared to (BB) patients who had OS of 5.8 (3.2 –NA) and PFS of 5.1 (3.19 – S. Junrungsee, W. Lapisatepun, T. Sandhu, A. Chotirosniramit. NA), P < .001 Division of Hepatobiliarypancreas Surgery, Department of Conclusions: Our study concluded that IGF-CTP score was more Surgery, Faculty of Medicine, Chiang Mai University, 50200, accurate than original CTP score in predicting survival outcomes of Thailand. systemic therapy in HCC. If validated, this approach may change the Objectives: Ruptured tumor is one of the leading cause of death standard stratification criteria for active therapy in routine clinical in hepatocellular carcinoma (HCC) patients. The best strategy of practice and patient selection for clinical trial entry in HCC. treatment is still a matter of debate. Herein, we evaluate and discuss the outcomes of different treatment modalities in our O-241 center for ruptured HCC. Methods: A retrospective review was performed of all patients A PHASE II STUDY OF SORAFENIB AND YTTRIUM-90 GLASS who presented with ruptured HCC between 2006 and 2015. Data MICROSPHERES FOR ADVANCED HEPATOCELLULAR CARCINOMA, on clinical features, treatment strategies, and survival outcomes BCLC STAGE C were collected.

196 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Results: 187 (7.6%) from 2557 HCC patients were diagnosed overall survival of 86.6%, and no one patient experimented local ruptured HCC during study period. Hemostasis was achieved by recurrence. transarterial embolization (TAE) in 74 (40%) and by emergency laparo- Conclusions: Robotic PD with vascular resection is still a complex tomy for stop bleeding in 10 (5%) patients. Fifteen (8%) patients were and technically advanced procedure that requires a specific underwent emergency or urgency liver resection and 9 (5%) patients training, but it seems to be safe and feasible in hands of expert received staged approach (TAE first and liver resection later). There surgeons. Despite our initial experience, we achieved a good were 74 (42%) patients who received best supportive care (BSC). The control of haemostasis obtaining an oncologic adequacy. resectabililty rate in this cohort is 13%. The overall median survival is 3.2 months. The best outcome was observed in emergency O-246 liver resection group. The 1, 3 and 5 years survival is 50, 50, 30% respectively. The staged approach is also a favorable option. The 1, 3 THE COMPLICATIONS IN ROBOTIC PANCREATIC SURGERY: OUR and 5 years survival is 69.2, 30.8, 15.4% respectively. The median EXPERIENCE survival in TAE and BSC group is only 3.8 and 2.2 months. Conclusion: The good outcome can be expected in ruptured HCC M.V. Marino1, G. Shabat1, G. Gulotta1, A. Komorowski2. patients who can received liver resection especially in emergency 1P.Giaccone Hospital, Palermo, 90127, Italy. liver resection group. Median survival in patients who treated with 2Maria Skłodowska-Curie Memorial Institute of Oncology surgery was significant better than that observed in patients who Cancer Centre, Kraków, 31-115, Poland. underwent TAE or BSC. Objective: Despite its potential benefit, the acceptance of robotic approach in pancreatic surgery is still poor due to the complexity of O-243 the procedures and the potential fatal complications. We analyzed all complications occurred in our 5 years experience in robotic pan- ROBOTIC PANCREATICODUODENECTOMY: HOW TO OVERCOME creatic surgery. DIFFICULT CASES Methods: We have performed a retrospective evaluation of a prospectively maintained database on robotic pancreatic surgery Liu Rong since 2012 to 2017. Results: A total of 36 patients (20 male) underwent to robotic O-244 pancreatic surgery. We performed 16 pancreatoduodenectomies (PD 44.4%), 12 distal pancreatectomies (DP 33.3%), 6 tumor TECHNICAL EVOLUTION OF ROBOTIC WHIPPLE -A PERSONAL enucleations (16.6%) and 2 pseudocyst-gastrostomy (5.5%). The EXPERIENCE overall operative time was 425±140 min, the median blood loss was 150 ml (70-600). The morbidity rate we observed was 12/36 Yiengprugsawan Anusak (33.3%), and 5 event were classified like major according to Clavien-Dindo score. The pancreatic fistula rate was 7/36 (19.4 %): 3 O-245 in the DP group, 2 in the PD group and 2 in the enucleation group. The reoperation rate was 2/36 (5.5 %) all in the PD group, while the VASCULAR RESECTION DURING ROBOTIC readmission rate was 11%. There was one postoperative death PANCREATICODUODENECTOMY: OUR INITIAL EXPERIENCE during 30 days post surgery in the PD group. M.V. Marino1, G. Shabat1, A. Frontali2, G. Gulotta1, Conclusion: The robotic pancreatic surgery seems to be associated A. Komorowski3. with an acceptable risk of complications rate, it offers a low blood 1P. Giaccone Hospital, Palermo (PA) 90127, Italy. loss and conversion rate also in case of pancreatic surgery. 2IRCCS Multimedica, Sesto San Giovanni (MI) 20099, Italy. 3 Maria Skłodowska-Curie Memorial Institute of Oncology O-247 Cancer Centre, Krakow 31115, Poland Objectives: Firstly described in 2003, the robotic approach for ROBOTIC DISTAL PANCREATECTOMY WITH SPLEEN-PRESERVA - pancreatic surgery is nowadays applied for complex vascular TION BY WARSHAW TECHNIQUE AND SPLENECTOMY reconstruction and for pancreatic transplant. Unfortunately the Shin-E Wang, Yi-Ming Shyr. wide acceptance of this technology is still low due to its high costs Departments of Surgery, Taipei Veterans General Hospital, and the lack of a standardized training program. We evaluated the National Yang Ming University, Taipei, Taiwan. potential benefits of the robotic surgery when a vascular resection is deemed necessary. Background: Outcomes after robotic distal pancreatectomy with Methods: Since August 2015 to May 2016, a total of 15 patients spleen preservation (RDP-SP) by Warshaw technique and with underwent to robotic pancreatico-duodenectomy (PD) for border- splenectomy (RDP-S) were compared. line resectable tumors. Methods: All the data for patients undergoing robotic distal Results: We performed 10 cases of latero-tangential portal vein pancreatectomy (RDP) were prospectively collected. resection, 3 end-to-end venous direct anastomosis and 2 cases Results: A total of 66 patients were included, with 33 in each group. employing a synthetic graft. The overall operative time was 450 ± The console time was significantly shorter in RDP-SP group than 170 min while the estimated blood loss was 180 ml (70-520 range). that in RDP-S group (165 vs. 220 min.). The median blood loss was We had an acceptable postoperative morbidity rate (20%). We 50 c.c. in RDP-SP group and 100 c.c. in RDP-S group. The surgical observed one pancreatic fistula and one biliary leakage both morbidity was significantly lower in RDP-SP group (18% vs. 58%). treated conservatively, and one massive bleeding which required a Spleen infarction (15%), gastric (6%) varices and perigastric (45%) conversion to open surgery. The readmission rate was 6.6%, and varices after RDP-SP were not associated with any subsequent the overall length of stay was 12 days. We achieved a 1-year complication. Postoperative platelet count and white blood cell

Surgery, Gastroenterology and Oncology, 22 (3), 2017 197 ABSTRACTS

(WBC) count were significantly higher in RDP-S group. data and post-operative results were collected and evaluated. Conclusions: Both RPD-SP and RPD-S are feasible in selected Results: From January 2010 to May 2017 forty-five patients under- patients. RPD-SP is feasible and time-saving. Although gastric/peri- went to pancreas-preserving surgery for duodenal and ampullary gastric varices and spleen infarction are not uncommon after lesions: ampullectomy and duodenectomy were performed in 26 RPD-SP, they appear to be clinically irrelevant. (57.8%) and 19 (42.2%) cases, respectively. Surgical indications were: duodenal cancer (4 cases, 8.9%), benign duodenal lesion (16 cases, 35.5%), ampullary cancer (7 cases, 15.5%) and benign O-248 ampullary neoplasm (18 cases, 40%). Mean time of surgical procedures was 251.3 minutes. Overall post-operative morbidity ROBOTIC PANCREATIC SURGERY- FROM DISTAL was 38% and 42% for ampullectomy and duodenal resection, respec- PANCREATECTOMY TO PANCREATICODUODENECTOMY tively. Severe complications (grade IIIb-V according Clavien-Dindo classification) occurred in only 1 case (3.8%) of ampullectomy and 1 Shin-E Wang, Yi-Ming Shyr. case (5.3%) of duodenal resection. Reoperation was necessary in From the Departments of Surgery, Taipei Veterans General only in 2 cases (1 in case of ampullectomy (3.8%) and 1 in case of Hospital, National Yang Ming University, Taipei, Taiwan. duodenal resection (3.8%)) for abdominal bleeding. Median hospital Objective: This study was to identify the learning curve of console stay was 9 (8-24) and 10 (7-39) days for ampullectomy and duodenal time (CT) for robotic distal pancreatectomy (RDP) and robotic resection. No post-operative mortality was recorded. pancreatectomy (RPD). Perioperative outcomes were compared Conclusions: Surgical ampullectomy and duodenal resection have between early group before the learning curve and late group after excellent morbidity and mortality in high-volume pancreatic the learning curve. centers and they should be considered a valid option for the Summary Background Data: Pancreaticoduodenectomy has been treatment of benign, borderline or early stage malignant duodenal a technically demanding and challenging procedure carrying a high and ampullary lesions. morbidity. Methods: Data for RDP and RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum O-250 (CUSUM). Based on CUSUM analyses, patients were was divided into early group before learning curve and late group after learning WHY HPB SURGEON HAS TO KNOW ABOUT THE ANASTOMOSES curve. BETWEEN MAIN HEPATIC ARTERIES? EXPERIENCE OF 9 CASES Results: There were 70 RDP and 61 RPD cases. It took 37 cases to Egorov V.I., Petrov R.V., Starostina N.S., Chernaya NR overcome the learning curve for RDP and 20 cases for RPD. The Bakhrushins Brothers Moscow City Hospital, Moscow Clinical median console time was also significantly shorter in the late group Scientific Centre, Sklifosovsky Emergency Institute, Russia, 107076. for both RDP (112 min. vs. 225 min., P < 0.001) and RPD (360 min. vs. 520 min., P < 0.001). The median blood loss was significantly Background: The resources of anastomoses between major less in the late group for both RDP (30 c.c. vs. 100 c.c., P = 0.003) hepatic arteries are underestimated and do not used by HPB and RPD (100 c.c. vs. 200 c.c., P < 0.001). No surgical mortality in surgeons. It is supposed that this is only theoretical knowledge. both groups. Clinical relevant pancreatic fistula (CRPF) was 22.9% Aim: To show the importance of this knowledge to practical for RDP (32.4% in early group vs. 12.1% in late group, P = 0.043), purposes. and 11.5% for RPD (0 in early group vs. 17.1% in late group, P = Method: Analysis of 9 cases of liver survival due to communicating 0.084). interlobar artery after major pancreatic and gastric resections and Conclusions: Robotic approach is feasible for both RDP and RPD hepatic artery embolization, accompanied by dearterialization of with less blood loss. Early experience of RDP contributes to one of the liver lobes. Monitoring of liver arterial supply intra- developing of complicated RPD. operatively was carried out by US Doppler of liver parenchima, and after surgery - by CT angiography(CTA) and angiography. O-249 Results: Distal pancreatectomy with celiac (CA) and gastroduodenal artery resection (Michels IV), total duodenopancreatectomy with CA CONSERVATIVE SURGERY FOR DUODENAL AND AMPULLARY resection (Michels III), pancreaticoduodenectomy with common LESIONS: A RETROSPECTIVE ANALYSIS OF A SINGLE CENTER hepatic artery resection (Michels IX), total gastrectomy with EXPERIENCE. resection of right hepatic artery originated from the CA (Michels I), total duodenopancreatectomy with resection of the left hepatic Nappo G., Capretti G., Gavazzi F., Ridolfi C., Uccelli F., Cereda M., and embolization of the right hepatic artery and embolysatio- Zerbi A. embolization of the right hepatic arteries for multiple gunshot Pancreatic Surgery Unit, Humanitas University. injuries (Michels I) and for huge hepatocellular carcinoma (Michels Humanitas Research Hospital, Rozzano (MI) – Italy. I) were performed without vascular reconstructions and ischemic Introduction: Pancreaticoduodenectomy is the treatment of sequelae within short- and long- term postoperative period. choice for the treatment of periampullary neoplasms. However, Postsurgical CTAs have shown that arterial supply to the liver lobes benign, premalignant and early stage malignant duodenal and lacking their main arteries is provided through the anastomoses ampullary lesions can undergo to a more conservative surgical between major hepatic arteries. approach (duodenal resection or ampullectomy). The aim of the Conclusion: The knowledge about the capability of anastomoses study was to review our experience of pancreas-preserving between major hepatic arteries allows to resect the main feeding procedures for the treatment of duodenal and ampullary lesions. lobar hepatic artery without reconstruction. In so doing intra- Material and methods: We retrospectively reviewed by a prospec- operative monitoring of blood supply must be used, which depend- tive collected database all patients underwent conservative ing on circumstances can be ultrasound Doppler or angiography. surgery for duodenal and ampullary lesions in our center. Surgical

198 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-251 N. Q Mahgoob. Mosul Medical College. Mosul. Iraq. HOW TO START LIVER TRANSPLANTATION IN A DEVELOPPING COUNTRY Objective: To determine factors that increases the effectiveness and safety of laparoscopic surgery for the management of hepatic Abdo Abdelmounem Eltayeib hydatid cyst. Design: A prospective study. O-252 Setting: Department of surgery at Aljamhori Teaching Hospital in Mosul, during the period from June - 1- 2009, to June – 1- 2012. A NEW SURGICAL STRATEGY IN THE TREATMENT OF ADVANCED Participants: Forty-eight patients who met our criteria for laparo- ALVEOLAR ECHINOCOCCOSIS OF THE LIVER scopic surgery were selected from 80 patients complained of liver hydatid cyst. Voskanyan S.E., Artemiev A.I., Naydenov E.V., Zabezhinsky D.A., Main Outcome Measures: The diagnosis was settled by ultrasonic Rudakov V.S., Shabalin M.V., Shcherbin V.V., Svetlakova D.S., evaluation and CT scan, the exclusion criteria was as follows: Deep Maltseva A.P. intra-parenchimal , posteriorly situated cyst (segment 7), State Research Center Burnazyan FMBC of the FMBA of Russia, More than 2 cysts, cysts with calcified wall, other intra abdominal Moscow, Russia. organ involvement by hydatid cyst, recurrent hydatid cyst in the Aim: Show the modern methods, technical possibilities and results liver, previous upper abdominal surgery and patient refusal. of the radical surgical treatment of the Alveolar Echinococcosis of Exposure of the cyst done by a 30° telescope inserted through the the liver. umbilical trocar, a 10-mm trocar was inserted from a point as close Material and methods: 112 patients with Alveolar Echinococcosis of as possible to the cyst where a high negative pressure suction tube the liver were operated from December 2011 to June 2017. 23 living introduced. The cyst was punctured with a 14-gauge 6F aspiration donor liver transplantations have been performed. 2 liver transplan- needle surmounted by second suction device inserted through 5 tations from the cadaveric donor have been performed. 23 mm trocar. 100mg Hydrocortisone was given to the patient at time extended liver resections with autotransplantations of unaffected of aspiration, the 10mm canulla introduced inside the cavity were liver segments have been performed (22 - «ante situm», 1 - «ex the germinal layers sucked completely. At time of penetration and situ»). 6 Associated Liver Partition and Portal vein ligation for Staged during suction, the flow rate of CO2 increased to maximum L /M hepatectomy have been performed. 39 extended liver resections and the intra abdominal pressure decreased to 12 mmgh. with resection and plasty of the main vessels have been performed Intracystic visualization was performed by the camera, the cavity (20 – Portal Vein, 5 – Inferior Vena Cava, 3 Hepatic Artery, 2 – washed by isotonic saline, omentoplaty done after deroofing of the Hepatic Veins, 9 – Multivisceral Resections). 19 standard liver cyst, tube drain at the vicinity of the cyst was put. resections have been performed. Inferior Vena Cava resections and Results: There were 29 male and 19 female patients, their age linear prosthesis of the Inferior Vena Cava by the PTFE-conduits varied from 14 to 58 years. The study included 42 patients with have been performed. Resections of the right atrium with atrium- solitary cyst and 6 patients with 2 cysts in their liver. The size of the caval prosthesis by the PTFE-conduits have been performed in 8 cyst according to ultrasonic measures were varied from 6 to 12cm, patients. All patients were treated by Albendazole for 6-12 months 34 cysts were in the right lobe and 20 cysts were in left lobe. The after surgery. mean operative time was 52 minutes. There was no intra operative Results: Resectability was 100%. The morbidity after liver trans- complication. All patients had uneventful recovery from anesthe- plantations was 36.0%. The morbidity after liver autotransplanta- sia. Cavity infection occurred in 1 patient, bile leakage was tions was 39.1%. The morbidity after extended liver resections was observed in 2 patients. The mean length of hospital stay was 2 28.2%. The morbidity after standard liver resections was 21.1%. days. No reported recurrences in any patients during 12 months The morbidity after ALPPS was 50.0%. The morbidity among all follow up period. No conversion was needed, no mortality was patients was 31.2%. Biliary complications (grade A, B (ISGLS, 2011)) recorded. and fluid accumulations in the abdominal cavity were the main Conclusion: Laparoscopic surgery for hepatic hydatid cyst is a safe complications. Frequency of the biliary complications (grade A, B and effective method when there is selection, with the use of (ISGLS, 2011)) was 27.7%. Frequency of the postoperative liver special maneuvers to decrease spillage and recurrence. Further failure (Grade A,В (ISGLS, 2011)) was 15,2%. Hospital mortality was studies should be encouraged in this field because there is no 2.7%. The mortality is 0% in the long term period after surgery. The universally accepted standard technique. maximum followup was 70 months. Отдаленная выживаемость Key words: Hepatic hydatid cyst. Laparoscopic treatment for составила 100%. Median of survival is 26 months. Disease-free hydatid cyst. period is 97,2%. Median of disease-free survival is 24 months. Conclusion: The concept of inoperability of Alveolar Echinococcosis O-254 of the liver is currently absent. Only transplantological technologies enable radically resected of the locally advanced alveolar disease of THE LIVER TUNNEL – INTENTION-TO-TREAT VALIDATION OF A liver with the total defeat of the portal gates and/or hepatic NEW TYPE OF HEPATECTOMY confluence, provide satisfactory immediate and longterm results of F. Procopio, L. Viganò, M. Cimino, M. Donadon, D. Del Fabbro, the surgical treatment. These operations must be carry out in the A. Palmisano, G. Torzilli. specialized centers. Division of Hepatobiliary & General Surgery, Department of Surgery, Humanitas Research Hospital, Humanitas University, O-253 Rozzano (MI), Italy Objective: We prospectively validate the liver tunnel (LT) on an LAPAROSCOPIC MANAGEMENT OF HEPATIC HYDATID DISEASE, intention–to-treat basis for patients with one or more tumors WHAT MAKES IT SAFE AND EFFECTIVE? occupying segments 1, 8, and eventually 4 superior (4s), with or

Surgery, Gastroenterology and Oncology, 22 (3), 2017 199 ABSTRACTS

without invasion of the middle hepatic vein (MHV). Given that Wen-Lung Su1, Hui-Gin Chiu2, Po-Hsuan Wu2, Ling-An Chen3, major hepatectomies have no negligible morbidity and mortality Jian-Wei Huang3, Shen-Nien Wang3, King-Teh Lee3. and that intrahepatic tumor-vessel detachment is oncologically 1Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, suitable, LT was proposed. Kaohsiung, 80145, Taiwan. Methods: Eligible patients were prospectively enrolled to undergo 2Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, LT. A minimum postoperative follow-up of 6-months was demanded. Kaohsiung, 807, Taiwan.

Sparing of segments 4 inferior (4i) and 5 and whether the MHV was 3 resected were established based on preoperative imaging and Division of General and Digestive Surgery, Department of intraoperative ultrasound. Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Results: Among 729 consecutive hepatectomies, 20 (3%) met the 807, Taiwan. inclusion criteria: all but one received the LT. MHV was resected in Objectives: Laparoscopic cholecystectomy (LC) has been the 6 patients, always sparing segments 4i and 5. Overall, 180 lesions golden standard procedure for the treatment of gallbladder were removed (median 7; range 1–37): 79 lesions were included in diseases. It's a safe and efficient surgery. However, as the improve- the LT specimen (median 3; range 1–13). In-hospital 90-day ment of the instruments and surgical technique, single incision mortality was nil. Overall morbidity occurred in 10 (50%) patients: laparoscopic cholecystectomy (SILC) becomes popular. major in 2 (10%). All complications were managed conservatively. Materials and Methods: During January 2014 to April 2017, 171 After a median follow-up of 15 months (range 6–48), 2 cut-edge patients received SILC. Lagiport, a commercial platform made in local recurrences occurred. Taiwan, was used for the single incision laparoscopic surgery. The Conclusions: This procedure is a safe, oncologically suitable surgery port was composed by three items. A transverse skin incision was in patients who are unsuitable for resection or large hepatec- made at subumbilical region, and then longitudinal fascial dissec- tomies. tion was done to approach into the peritoneal cavity. The wound retractor was applied into the peritoneal cavity, and through the above dissection method, the wound defect will be in a circle O-255 fashion. A removable cap was then locked onto the wound retrac- tor. Multiple ports of two 5mm seal and two 12mm seal enabled ALTERNATIVE LAPAROSCOPIC INTRACORPOREAL PRINGLE use of a wide range of instrumentation. Camera system with 5mm MANEUVER BY HUANG’S LOOP elongate scope was introduced for vision of the peritoneal cavity. Jian-Wei Huang, Wen-Lung Su, Ling-An Chen, Chieh-Han The manipulation of the cholecystectomy is via Endograb retrac- Chuang, King-Teh Lee, Shen-Nien Wang. tion system, 5mm straight grasp and dissector. Division of General Surgery, Kaohsiung Medical University Results: Male-to-female ratio was 2:3. Mean age was 50.98 years, Hospital, Kaohsiung, 807, Taiwan. body mass index 24.59 kg/m2, operation time was 67.07 minutes, mean blood 14.31 ml and mean length of stay 4.18 days. Objectives: This paper aims to describe an intracorporeal Percentages of acute cholecystitis and intraoperative bile leakage tourniquet (IT) method for laparoscopic Pringle maneuver (PM). were 34 % and 18 %, respectively. Three patients (1.75%) were Methods: The IT method was prepared according to the following converted to multiports. Two patients (1.17%) suffered from post steps: one shortened Foley tube with side-hole on the tip was put operative bile leakage. The mean length of the wound was 1.5cm. into the abdomen. We pulled out the tail through the side-hole to The groups for non-cholecystitis and acute cholecystitis were also make a loop to encircle porta hepatis for inflow control. It is easy to compared, and the data will be showed in oral presentation. keep the tension by a metallic clip and when released, the clip can Conclusion: Single incision laparoscopic cholecystectomy with the be removed and the loop loosened; therefore, PM is performed assistance of Lagiport and Endograb retraction system is a safe and inside the abdomen without special instrument. fast method for benign gallbladder disease. Results: From August to October 2016, we performed this method on 13 patients. The techniques included 3 laparoscopic right hemi- hepatectomy, 2 laparoscopic right posterior sectionectomy, O-257 1 laparoscopic left lateral hepatectomy, 1 robotic left lateral hepatectomy, 1 laparoscopic left hemi-hepatectomy, 2 laparoscopic PREDICTIVE FACTORS OF EXTERNAL BILIARY FISTULAS AFTER partial hepatecotmy, 1 laparoscopic S7 segmentectomy, 1 laparo- SURGICAL TREATMENT OF HYDATID CYST OF THE LIVER scopic S8 segmentectomy and 1 laparoscopic S4+S6 sectionecto- Baraket O., Ayed K., Triki W., Baccar A., Lahmidi A., Itami A., my. In every patient undergoing laparoscopic PM, no unsuccessful Bouchucha S. attempts were made. The median time to perform this procedure Department of general surgery. Hospital Habib BougatfA de was less than 5 mins. The average time of performing IT in every Bizerte. 7000 Bizerte, Faculty of Medicine of Tunis, University patient was one. The ischemic duration were 20.1 mins per time. Tunis El Manar, Tunisia No injury of porta hepatis was noted when performing laparoscopic PM by Huang’s loop. Objectives: Hydatid cyst in the liver is a major health problem in Conclusions: The intracorporeal Pringle maneuver with Huang’s endemic areas. Surgical management is still the best choice for loop could be routinely used during laparoscopic liver resection treatment of the hydatid cyst of the liver. This treatment expose to even for a laparoscopic beginner because it is so easily learnt, safe high morbidity especially biliary fistula. The aim of this study is to and effective. evaluate the predictive factors for specific morbidity after conser- vative surgical treatment of the hydatid cyst of the liver. O-256 Methods: A retrospective study including 220 patients who under- went a surgical treatment for a hydatid cyst of the liver SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY WITH Results: The median age was 33 years. The cysts were located in LAGIPORT the hepatic dome in 96 cases (41.5% of cases), the anterior part of

200 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

right lobe of the liver in 66 Cases and the left lobe in 18.1%.The carried out by isolated implantation of the right hepatic vein to the diameter of the cysts ranged from 4 to 20 cm. Conservative treat- inferior vena cava. Reconstruction and formation common ment was achieved in 165 cases and radical treatment in 55 cases. embouchment of the portal vein via using autovenous Y-shaped Directly suture of biliary fistula was done in 25 cases, included portal graft at «back table» was performed at trifurcation of the internal fistula drainage through the sphincter of Oddi (37.3%), The portal vein. Anastomosis between the portal vein of the recipient overall morbidity rate was 26.6%.The major specific complications and autovenous portal graft was formed for a short stump of the were infection of the residual cavity in 10 cases and an external right portal vein of the transplant. Reconstruction of the portal vein biliary fistula in eight cases. In univariate analysis. The predictive at it complete fibrous obliteration was performed by autovenous factors of morbidity were bilious cyst content, location of the cyst grafts. in the hepatic dome, and size >10 cm. After multivariate analysis, Results: Mortality among recipients was 4.0% at all transplantations. only the size of the cyst was an independent predictive factor of Mortality after LDLT was 2.6%. Morbidity was 38.4% at all transplan- morbidity. tations. Frequency of the vascular complications was1.5%. Conclusion: Hydatid cyst of the hepatic dome and cyst over 10 cm Frequency of the biliary complications (grade A, B (ISGLS, 2011) diameter are the major predictive factor of post operative biliary was 14.8%. Mortality among living donors was not. The morbidity fistulas. Management of hydatid cyst with these characteristics among living donors was 12.8% and was mainly represented of the rigorous surgical techniques biliary communication must be exam- bile leakage (grade A, B (ISGLS)). Postoperative hospital stay for ined systematically. recipients was 27 (23-32) days. Median of survival is 30 months. Conclusion: Presented technologies allow achieving a good venous inflow and outflowing from the liver transplantat and thereby O-258 ensure satisfactory early and long-term results of the liver trans- VARIANTS OF RECONSTRUCTION OF AFFERENT AND EFFERENT plantations, even in difficult cases. BLOOD FLOW FOR LIVING DONOR LIVER TRANSPLANTATION O-259 Voskanyan S.E., Artemiev A.I., Zabezhinsky D.A., Naydenov E.V., Rudakov V.S., Shabalin M.V., Shcherbin V.V., Svetlakova D.S., WELEDJI’S CLINICOPATHOLOGICAL CLASSIFICATION OF PERIANAL Maltseva A.P. PAGET’S DISEASE. State Research Center Burnazyan FMBC of the FMBA of Russia, Moscow, Russia. E.P. Weledji, B. Hummel, L. Marti, J. Gruenert, W. Brunner. University of Buea, Buea, POBox 63, Cameroon. Aim: The immediate and long-term results of the liver transplanta- tions at its terminal lesions have been studied. Objectives: Perianal disease is exceedingly rare. First discovered by Material and methods: 250 liver transplantations were performed Paget in 1874 as a breast lesion, similar findings in the perianal area in the Center for Surgery and Transplantology of the State Research were reported 20 years later by Darier. As perianal Paget’s disease Center Burnazyan FMBC of the FMBA of Russia between June 2010 is a heterogenous entity, the author proposed a clinicopathological and June 2017. 196 living donor liver transplantations (LDLT) in the classification system. form «adult-to-adult» have been performed. Liver cirrhosis in the Methods: The clinicopathological classification has been outcome of autoimmune hepatitis, primary sclerosing cholangitis, developed from the cases reported in the literature and texts on viral hepatitis, Wilson's disease, Budd-Chiari syndrome, primary perianal Paget’s disease. and secondary biliary cirrhosis, unresectable hepatic Echinococcus Results: The presenting author classifies perianal Paget’s disease Multilocularis, alimentary cirrhosis and cryptogenic cirrhosis have into four clinicopathological groups. In the first group (Type1), been indications for surgical treatment. 168 (85.7%) difficult liver there is a high frequency of an associated distant malignancy with transplantations have been performed because of the features of similar immunoprofile requiring an aggressive search for the donors liver vascular anatomy or defeat portal gates and/or primary. This is akin to a paraneoplastic syndrome and has the hepatic confluence and/or inferior vena cava by Echinococcus worse prognosis. In the second group (Type 2) which is the Multiloccularis. Complex reconstructions of the portal venous commonest presentation, perianal Paget’s disease represents a inflow or outflow from the cava vein from liver graft have been cutaneous manifestation through the intraepithelial spread of an required. Resections and reconstructions of the inferior vena cava underlying anorectal or vulvar adenocarcinoma (i.e. secondary). and/or the right atrium by PTFE-grafts due to the parasitic lesions The third group (Type 3) represents true primary intraepithelial of the inferior vena cava near the hepatic confluence have been cutaneous apocrine adenocarcinoma. The fourth group (Type 4) performed. Saving the middle hepatic vein in the living donor’s liver represents a primary perianal Paget’s disease with an associated was a prerequesite. Isolated venous outflow from the 8 segment of malignancy but with discordant immunoprofile. the liver to middle hepatic vein according computed tomography Conclusions: Clinicians and pathologists should carefully examine and its diameter was more than 5 mm were an indication for the perianal epidermis in anorectal carcinoma and vice versa if the vascular reconstruction, which was carried out by implantation in anorectal tumour shows intraepithelioid pagetoid (signet ring) the embouchment hepatic veins, right or middle hepatic vein and cells. Preoperative staging of perianal Paget’s diseaseshould the inferior vena cava. In addition, its implantation was performed include the Weledji’s clinicopathological classification before in the inferior vena cava with the right hepatic vein after the forma- deciding treatment. Long-term follow-up after definitive treatment tion of the common fistulas at "back table". Isolated venous out- is required as local recurrence may occur many years later with the flow from the 6 segment of the liver according computed tomogra- risk of metastatic spread. phy was an indication for vascular reconstruction, which was

Surgery, Gastroenterology and Oncology, 22 (3), 2017 201 ABSTRACTS

O-260 the colon were surgically treated during the study period. Of 62 patients, there were 51 (82.3%) males and 11 (17.7%) females with OUTCOMES OF NONSURGICAL MANAGEMENT IN PATIENTS median age 55 years, range (31- 72 years). The complications WITH HISTORY OF HINCHEY I AND II DIVERTICULITIS occurred and indicated for surgery included recurrent attacks of N. D. Machado, C.C. Pereira, C. M. Insua, S. Costa, J.C. Pereira. diverticulitis in 8 (12.9%) patients, pericolic abscess (15 – 24.2%), Centro Hospitalar do Tâmega e Sousa, Penafiel, 4564-007, diffuse peritonitis (3-4.8%), bleeding (16 -25.8%), stricture (1- Portugal. 1.6%), and colovesical fistula in 18 (29%) patients. As regard the extention of the disease, the sigmoid colon was the most common Objectives: The objective of this study was to evaluate recurrence site affected by diverticulosis (48.4%). Surgical resection was done rates and severity of disease after nonsurgical management of by open approach in 55 (88.7%) patients, laparoscopically in 6 nonperfurated diverticulitis. (9.7%) patients, and one patient converted to open approach. In 18 Methods: All patients admitted to our hospital with the diagnosis (29%) cases, faecal diversion was done including 12 (19.4%) cases of diverticulitis between January 2009 and December 2014 were with covering colostomy and 6 (9.7%) cases with covering loop included. Patients with Hinchey III and IV were operated and then ileostomy. Faecal leakage was the most common post-operative excluded from the study. One patient operated for sigmoid adeno- complications (9.7%). carcinoma discovered on follow-up colonoscopy was also excluded. Conclusion: he elective surgical treatment of colonic diverticular History of previous episodes and recurrence of disease until May disease is an effective and safe option. Laparoscopic approach is 2017 were recorded. feasible and satisfactory. Covering stoma should be limited for high Results: A total of 47 patients met the inclusion criteria. Patients risk patients. age was 26 to 93 years old (mean 62). Seven patients had diverticulitis complicated with an abscess (Hinchey Ib or II). Three patients died on the index admission and other three patients were O-262 lost to follow-up. All the 3 patients that died were 90 years or older, one of them had complicated diverticulitis (Hinchey II) and none HOW CHANGED PATTERN OF MESH IMPLANT FIXATION LEAD TO had previous records of diverticulitis. Recurrence occurred in 9 out RESULTS IMPROVEMENT OF PELVIC BOTTOM REPAIR AFTER of the 41 patients that were followed (22%). The total number of EXTENDED PELVIC SURGERY episodes per patient ranged from 1 to 5 (mean 1.3). Only one K. Zarkov, Chr. Petkov. patient recurred with complicated diverticulitis (Hinchey Ib). Time First Surgical Department, Fifth General Hospital, Sofia, Bulgaria. until first recurrence episode was approximately 4 months and a half to three and a half years (mean 2 years). Minimum follow up Background: A huge cavity is formed after extended pelvic surgery time was 2 years and eight months and maximum follow up since (extended rectal resections; exenterations). The remaining peri- first recorded episode was 12 years (mean 5 years). None of these toneum is not sufficient to close the pelvic entry. Reconstruction of patients died from the disease. pelvic floor is necessary to preclude small bowel from entering the Conclusions: Although the recurrence rate was 22%, all the new pelvis and to prevent bowel obstructions. episodes were successfully treated with medical therapy alone. A Aims: We present and compare two patterns of pelvic bottom nonsurgical management of nonperfurated diverticulitis seems to mesh repair – advantages, disadvantages and complications of be feasible and safe. Elective resection of the sigmoid colon might these patterns. be only necessary in the highly symptomatic patient that is fit for Materials and methods: We reconstruct pelvic floor with mesh surgical intervention. Follow-up colonoscopy should be undertaken implant at the pelvic entry. We used Bulgarian Antibacterial to exclude malignancy. Polycapronamid Mesh (BAPP) or Prolene mesh. For 2001-2015 mesh pelvic reconstruction was done in the course of 38 total, 37 anterior and 16 posterior pelvic exenterations (females–86; O-261 males–5; aged from 28 to 75) and 65 abdomino-perineal resections SURGERY FOR DIVERTICULAR DISEASE OF THE COLON: SINGLE (females– 29; males–36; aged from 56 to 78). Two patterns of CENTER EXPERIENCE mesh fixation (2 groups): 1) Mesh fixed highly at the pelvic entry (2001-2009), preventing bowels from entering the pelvis; fixed Ahmed ElGeidie, Ahmed Abdelrafee. with tension; forms amputation cavity, that is easily infected; 2) Mesh without tension lays in pelvis covering pelvic walls – no Introduction/background: Diverticulosis of the colon is a wide- amputation cavity (2010-2015). spread disease, and its incidence is increasing especially in the Results: • Pelvic cavity discharge exists for 25-65 days or more (1st developing world. Many complications of the colonic diverticulosis group); 25-35 days (2nd group). • Pelvic cavity infection–in 1st may occur during the course of the disease. The aim of this study group (63%); 2nd group (29%). • Ileus-3 patients from 1st group was to evaluate the role of the surgical treatment of diverticular due to mesh suture leakage and bowel incarceration, resulting in disease of the colon in high-volume referral center. reoperation; 0 patients in 2nd group. • Perineal fistula-in 9% from Methods: This was a retrospective study included all consecutive 1st group and 3% in 2nd group. patients with colonic diverticulosis who were treated with surgical Discussion: The implanted mesh increases pelvic floor stability and intervention in the period from January 2006 to June 2016 in separates visceral organs from the formed pelvic cavity. It is a Gastroeneterology surgical center,Mansoura university. Patients simple, reliable, and not time-consuming technique. demographics, preoperative data and surgical details were Conclusions: The change in the pattern of mesh fixation to analysed. Short-term outcome including early post-operative the pelvic walls results in significant decrease of pelvic bottom complications were detected. complications Results: A total 62 patients with complicated diverticular disease of

202 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-263 cases. A deviating colostomy was performed in 9 patients and a colonic resection was performed in 42 patients. A primary anasto- CECOPEXY, A REEMERGING TREATMENT FOR CECAL VOLVULUS: mosis was performed in 3 patients. The morbidity and mortality CASE REPORT AND REVIEW OF THE LITERATURE were 39% and 10% respectively. The predictive factors of mortality were; duration of operation greater than 240 minutes, the F.J.R. Pencle, T. Kathsichtis, J. Schneider, P. Strombom, Hartman intervention, resection of adjacent organs, the tumor S. Kigongo effraction, the bleeding and per operative transfusions, the Department of Surgery, Lincoln Medical and Mental Health occurring of post operative complications. The predictive factors of Center, Bronx, NY 10451, USA morbidity were: the cardiovascular co morbidity, the segmental Objectives: Cecal volvulus accounts for 25-40% of volvulus of the resection, the tumor effraction, the tumor perforation, bleeding large bowel causing obstruction with varying degrees of presenta- and per operative transfusions, the existence of peritonitis and a tion from obstructive symptoms to bowel necrosis and perforation. surgery time exceed three hours. The derivation colostomy was In the presence of viable bowel, cecopexy has previously been associated with a lower postoperative morbidity. The five years demonstrated as a treatment method of surgery. The authors aim overall survival was 70%. The factors affecting overall survival were; to demonstrate the reemergence of cecopexy as a laparoscopic Time between admission and surgery greater than ten hours, the and open technique. presence of distant metastasis, the invasion of adjacent organs, the Methods: We hereby present a case of open cecopexy in a patient presence of vascular emboli and the R2 resection. These factors with severe hyponatremia with cecal volvulus and a review of the decreased in a statistically significant way the global survival. The literature. A systematic search (January 2017) of PubMed, Scopus, derivation Colostomy was associated with better overall survival. Cochrane and EMBASE databases was conducted according to the Conclusion: Colonic obstruction is still associated with a high Preferred Reporting Items for Systematic Reviews and Meta- morbidity and mortality rate. A bridging strategy with derivation Analyses (PRISMA) guidelines for literature regarding cecal Volvulus colostomy may be valid alternative because it was associated with and cecopexy. Papers without cecopexy, non-English language, and a lower morbidity rate and a better overall survival rate. non-adult cases were excluded. Final papers meeting criteria were secondarily screened for analysis. Results: Total of 1080 articles were identified from all four databases. O-265 44 articles were then evaluated for surgical procedure performed; only 20 articles described Cecopexy. A total of 316 cases were OUTCOME OF COMPRESSION ANASTOMOSIS IN COLORECTAL documented for cecal volvulus with a mean age of 51.6+/-13 years. SURGERY: A COMPARATIVE CASE SERIES Further analysis demonstrated 83 cases of resection and 114 cases M. Alyami, P. Jannot, P. Lundberg, D. Vaudoyer , Y. François, for cecopexy. Overall cecopexy recurrence rate of 8.8%. O. Glehen, G. Passot, E. Cotte. Conclusion: Operative intervention is the preferred management of The Department of Surgical Oncology, CHU Lyon Sud, cecal volvulus. Cecopexy can be performed in patients who have Hospices civils de Lyon, University of Lyon, 69495, viable bowel and require further resuscitation. This can be Pierre Bénite, France. performed either via open or laparoscopic approach. Patient with non-viable bowel require resection with either primary anastomosis Objective: To compare the ColonRing™ device (CRD) and stapled or colostomy. anastomoses in left colectomies and low anterior resections. Methods: A study evaluating consecutive patients undergoing left colectomy or low anterior resection with anastomosis performed via O-264 CRD to a group of patients undergoing the same procedures via end-to-end (EEA) stapled anastomosis. Intraoperative and ELECTIVE COLOSTOMY IMPROVES OUTCOMES OF LEFT SIDE immediate postoperative outcomes were recorded. MALIGNANT COLONIC OBSTRUCTION Results: A total of 80 patients were enrolled for the analysis; CRD group N=17 and control group N=63. We initially planned to include Baraket O., Ayed K., Triki W., Abbassi I., Itami A., Baccar A., 40 patients in CRD group but terminated the study prematurely Lahmidi MA., Ganzoui I., Ben Hmida S., Bouchoucha S. because of a higher complication rate. There were no significant Department of general surgery. Hospital Habib BougatfA de differences in preoperative clinical demographics including age, sex, Bizerte. 7000 Bizerte, Faculty of Medicine of Tunis, University BMI, ASA score, or comorbidities. There was no 30 day mortality in Tunis El Manar, Tunisia. both groups. Anastomotic leaks (AL) occurred in 4 (23.5%) patients in Objective: Acute left sided colonic obstruction is most often caused the CRD group and 2 (3.2%) in the control group (p=0.0168). Overall by malignancy. Management of colonic obstruction remains postoperative complications arose in 8 (47.1%) patients in the CRD controversial. The treatment may involve either an acute resection group and 13 (20.6%) in the control group (p=0.0584). Major or a colostomy followed by a resection .The purpose of the study is complications (Clavien-Dindo Grade ≥ III) were observed in 4 to identify the predictive factors of morbi-mortality and to evaluate (23.5%) patients in the CRD group and 4 (6.3%) in the control group the long-term prognosis. (p=0.0583). Methods: All patients with malignant left sided colonic obstruction Conclusion: With a significantly increased rate of anastomotic leak treated between 2008 and 2015 in department of surgery in compared to the conventional stapled technique, CRD should not Bizerte University hospital-Tunisia were retrospectively identified. be recommended in routine for colorectal anastomoses. Results: In total, 51 patients were included. The mean age was 68 years with a male predominance. Treatment was surgical in all

Surgery, Gastroenterology and Oncology, 22 (3), 2017 203 ABSTRACTS

O-266 while negligible in other groups. Regenerated muscle bundles were significantly higher in the MDC group (p<0.001). Histology showed LAPAROSCOPIC PARTIAL SPLENECTOMY higher inflammation, cell infilteration and neovascularization in the MDC group (p<0.05). P. Bernard, A. Gilbert, M. Papillard, P. Marx, E. Odet, Conclusion: There were significantly fewer intra-peritoneal L. Demagistris. adhesions and significant muscle regeneration with better Centre Hospitalier des Chanaux Unité 33, Macon, 71018 France. cellularization and vascularity of the neo-abdominal wall when stem Objectives: Laparoscopic partial splenectomy is a delicate surgical cells were used to treat ventral hernia. This study establishes procedure that can be proposed in select cases to decrease post- feasibity of a live tissue engineered abdominal wall in rat model. operative complications related to total splenectomy. Methods: The authors present the video of the case of a O-268 suspected inflammatory pseudotumor of the spleen discovered by ultrasound in a 56-year-old woman. After a spleen CT-scan biopsy, TO STUDY THE EFFECT OF OCTREOTIDE ON MAGNITUDE the diagnosis of inflammatory pseudotumor was done, and a AND DURATION OF LYMPHORRHEA IN PATIENTS UNDERGOING simple clinical and radiological overseeing was proposed. The MODIFIED RADICAL MASTECTOMY patient accepted it, but she developed psychiatric complications S. Prajapati, A. Goel, S.K. Tudu, S. Neogi, S. Ramasamy, A. Jain. and was hospitalized some weeks later in a psychiatric unit for Maulana Azad Medical College, New Delhi, 110002, India. nervous breakdown and suicidal risk. The patient didn't support the idea to have a spleen tumor, and the psychiatric team asked for Objectives: To study the effect of octreotide in decreasing the removal of the tumor. lymphorrhea after axillary node dissection in Modified Radical Results: The surgery was done by laparoscopy. The harmonic Mastectomy. scalpel was used to dissect the splenic hilum and to cut the spleen. Methods: We evaluated 30 patients who underwent Modified The lower quarter of the spleen was not removed. The postopera- Radical Mastectomy between September 2015 and March 2017. tive course was uneventful, and the patient recovered all physical Lymphorrhea volume from 24 hours to 5 days and number of and mental functions. days until axillary drain removal (duration of lymphorrhea) were Conclusions: Laparoscopic partial splenectomy must be proposed evaluated along with incidence of seroma formation and duration in select cases, such as benign tumor, to decrease early and late of hospital stay. postoperative complications related to total splenectomy. Results: The amount of lymphorrhea was almost half in the octreotide group (mean 194+240.6 ml) as compared to the control group (mean 354.6+346.2 ml) but was not statistically significant O-267 (p value 0.081). The duration of lymphorrhea was lesser in the octreotide group (3.133±1.356 days) than the control group TISSUE ENGINEERED ABDOMINAL WALL USING MUSCLE (4.933±2.491 days) and was statistically significant (p value 0.029). DERIVED STEM CELLS IN THE TREATMENT OF VENTRAL HERNIA The duration of hospital stay was lesser in the octreotide group IN AN ANIMAL MODEL (5.13±1.060 days) than the control group (7.066±2.404 days) and was found to be statistically significant (p value 0.010). Post- Joshua Franklyn, Sowmya R., Bimal Patel, Dhivya A., operative complications like wound infection and flap necrosis Prabha Nair, Geeta Chacko, Inian Samarasam, Vrisha Madhuri. were similar in both the groups. The incidence of seroma formation Christian Medical College Vellore. in the octreotide group was significantly lower (p value 0.010) than Background: Upto 23% of mesh ventral hernioplasty operations the control group. will recur. The aim of the study was to use muscle derived cells to Conclusions: We concluded that the injection octreotide can be tissue engineer anterior abdominal wall in an animal model. This used safely and effectively to decrease the amount and duration of can enhance hernia repair by providing a living musclular layer lymphorrhea in patients undergoing modified radical mastectomy which will better incorporate with normal abdominal wall muscu- with axillary dissection with minimal or no complications and lature and reduce intra-peritoneal adhesions. adverse reaction. In addition, it reduces the duration of hospital Methods: Three experimental groups consisted of Sprague Dawley stay and seroma formation and its related morbidity. rats (n=12 each). A defect (2x1cm) created in the anterior abdomi- nal wall was either closed with polypropelene (PP) mesh, PP+ poly- O-269 caprolactone (PCL) scaffold or PP + PCL + autologous muscle derived cells (MDC). Culture expanded muscle derived cells were FEASIBILITY OF CATHETER PLACEMENT UNDER ULTRASOUND characterized for CD34 and Sca-1. 100,000 cells/cm2 was seeded on GUIDANCE FOR PROGRESSIVE PREOPERATIVE PCL and attached for 48 hours before transplant. Outcome at six PNEUMOPERITONEUM FOR LARGE INCISIONAL HERNIA WITH and ten weeks (n=6) was assessed for grade of adhesions, tensile LOSS OF DOMAIN strength, histology (haematoxylin & eosin and Masson’s trichrome) and immuno-histochemistry(PAX7, MyoD and CD 31). M. Alyami, G. Passot, E. Voiglio, P. W. Lundberg, P. J. Valette, Results: All animals in the MDC group survived with no hernia A. Muller. J. L. Caillot. recurrence. The mean adhesion score among MDC (3.5), PCL (6.5), The Department of Surgical Oncology, CHU Lyon Sud, PP (7) group was significantly lower (p<0.05). The tensile strength Hospices civils de Lyon, University of Lyon, 69495, (N/m2) was similar across all three groups MDC (72), PCL (60) and Pierre Bénite, France. PP (80) respectively (p=0.18). Evidence of muscle regeneration was Introduction: Large incisional hernias with loss of domain (LIHLD) observed in 9/12, 1/12 and 0/12 animals in the MDC, PCL+ PP and of the abdominal wall remain a therapeutic challenge due to the PP group respectively (p<0.01). This was corroborated by 3.5% of difficulty of replacing the contents of the hernia sac into the the regenerated fibres showing PAX7 staining in the MDC group peritoneal cavity. Preoperative progressive pneumoperitoneum

204 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

(PPP) is a valuable option. The purpose of this study was to number of preoperative cycles in patients with resectable liver evaluate the feasibility of peritoneal catheter insertion under metastases should be limited to four regardless of the chemo- ultrasound guidance for PPP and to compare the morbidity and regimen. Two to four additional preoperative cycles may be mortality of this new technique to previously used techniques in beneficial if further tumor shrinkage would significantly reduce the our department. complexity of liver resection. In Conclusion, patients undergoing Methods: Medical records were reviewed retrospectively from liver resection live longer. Our aim should be to increase the February 1989 to April 2013 in a single institution. Three different resectability rates of colorectal cancer patients by administering techniques of PPP were evaluated: surgical subcutaneous the best systemic therapy based on the characteristics of the implantable port (SIP), surgical peritoneal dialysis catheter (PDC), and patients and the tumors. radiologic multipurpose drainage catheter (MDC). Collected data included patients’ age, sex, body mass index, medical and surgical O-271 history, hernia location, PPP technique, length of hospitalization, volume of air injected, morbidity and mortality linked to PPP, and the OUTCOMES OF SIMULTANEOUS LIVER RESECTION procedure of hernia repair. AND COLORECTAL SURGERY FOR COLORECTAL LIVER METASTASES Results: Thirty-seven patients with a mean age of 63.1 years were evaluated. Progressive preoperative pneumoperitoneum was Dulundu Ender performed using SIP, PDC, and MDC for 14, 11, and 12 patients, respectively. Overall morbidity related to the technique was seen in O-272 36 % of SIP, 27 % of PDC, and 0 % of MDC. One patient from the SIP group died on the 3rd postoperative day due to septic shock SURGICAL TREATMENT OF SYNCHRONOUS LIVER METASTASES following aspiration pneumonia. No postoperative mortality in the OF COLORECTAL ORIGIN other groups was observed. Conclusion: The MDC is an interesting modification of the original Popescu Irinel technique and is a safe procedure. It is a minimally invasive technique with a very low risk of perforation of the viscera. O-273 Therefore, the use of a nonabsorbable prosthesis with MDC technique can be offered for all patients undergoing PPP without TISSUE ENGINEERING FOR HPB DISEASES increasing the risk of infection. Susumu Eguchi, Yu Huang, Yusuke Sakai. Department of Surgery, Nagasaki University Graduate School of O-270 Biomedical Sciences, Nagasaki, Japan. CONVERSION CHEMOTHERAPY IN COLORECTAL LIVER Tissue engineering has blossomed great success in developing METASTASES, WHICH REGIMEN TO WHOM? therapeutic strategies aimed at the replacement, repair, mainte- F. Dane. nance, or enhancement of tissue function. Tissue engineering is a relatively new field that uses living cells, biocompatible materials, Marmara University Hospital, Department of Internal and suitable bio-physilogical factors, as well as combinations Medicine, Division of Medical Oncology. Istanbul, Turkey. thereof, to create tissue-like structures. Most frequently, the It has been reported that only %10 to %30 percent of the patients ultimate goal is implantation of these tissue constructs into the with unresectable liver metastases have a sufficient objective body to repair an injury or replace the function of a failing organ. response to allow a subsequent complete resection. Patients who Our library has fulfilled some items using cell sheet engineering. In have undergone metastasectomy have significantly higher survival 2013, we reported a rapid and efficient technique for generating rates than the patients who do not. However, the definition of multi-layered human hepatic cell (HepaRGH cell) sheets using pre- unresectability in the literature is a bit subjective and mainly based cultured fibroblast monolayers derived from human skin (TIG-118 on the aggressiveness of the liver surgeon. We know that the cells) as a feeder layer on a temperatureresponsive culture majority of radiographic completely responding lesions contain dish (PLoS ONE 2013;8: e70970). This technique is considered a viable tumor. Thus, even in the case of a complete clinical response, promising modality for rapidly fabricating multi-layered human resection is still required. The optimal regimen for conversion hepatocyte sheets from cells with limited proliferation potential, therapy is not established yet, but since there is a correlation and the engineered cell sheet could be used for cell transplantation between response rate and a subsequent resection rate, a chemo with highly specific functions. In 2015, we describe a subcutaneous regimen with a high response rate is generally chosen. Although, human liver construction allowing for rapidly vascularized grafts for young healthy patients FOLFOXIRI may be chosen as (VSLT) by transplanting engineered cellular sheets consisting of chemotherapy regimen, for others FOLFOX or FOLFIRI with or with- human primary hepatocytes adhered onto a fibroblast layer out biologics may be preferred. Doublets regimes containing (Biomaterials 2015;65:66e75 ). Study describes this new approach irinotecan or oxaliplatin plus a fluoropyrimidine are considered to for vascularized human liver organogenesis under mouse subcuta- be equivalent colorectal cancer; therefore the choice is typically neously. At the same time, it was demonstrated that viable dermal preferred according to side effects profile. The benefit of the fibroblast sheets induce the migration of hepatic progenitor cells and addition of a biologic agent such as cetuximab or panitumumab for cause their differentiation into hepatic structures in the incised host RAS wild tumors or bevacizumab to a chemotherapy backbone liver in allogeneic rat model (J Tissue Eng Regen Med 2015; containing oxaliplatin or irinotecan may increase the resectability 9:E108–5). Data showed that the proliferation and differentiation of rates and improve outcomes. On the other hand, in patients with liver progenitor cells were not influenced by hepatectomy, and potentially resectable liver metastases, a phase III trial showed that clarified that the origin of BD-like structures and hepatocyte-like the addition of cetuximab was associated with a significantly worse cells was the recipient liver. Those items help to get many valuable progression-free survival. Due to the potential liver toxicity, the experience about the cell sheet engineering technology. Except for

Surgery, Gastroenterology and Oncology, 22 (3), 2017 205 ABSTRACTS

the liver diseases, we also have experienced on the islet and ADSC Department of General Surgery, Istanbul 34668 Turkey. cell sheet engineering (Tissue Eng Part C Methods. 2015;21:1205- Objective: Local ablation-assisted liver resection is one of the 15, Cell Transplant. 2016;25:1525-37). Moreover, we have several methods to enable unresectable colorectal liver metastases ongoing projects using those technologies, such as the observation (CRLM) to be operated. Oncological consequences of this method of healing process of porcine biliary duct anastomosis using ADSC are controversial due to a lack of comparative prospective studies. and obtaining the functional bile duct using co-culture with biliary Tha aim of this study is to evaluate survival data of patients with epithelial cells and fibroblasts method. CRLM who received resection only or in combination with local ablation. O-274 Methods: Prospective data obtained from patients treated in the Haydarpasa Numune Education and Research Hospital between LIVER-FIRST APPROACH FOR SYNCHRONOUS COLORECTAL LIVER 2004-2016 were retrospectively evaluated. Local ablation was METASTASES IS A FEASIBLE AND ONCOLOGICALLY SAFE STRATEGY: performed with radiofrequency until 2012, after which microwave LONGTERM FOLLOW UP AND PREDICTIVE FACTORS OF SURVIVAL. ablation was preferred. Results: 141 patients were operated for CRLM. 36 patients received Giammauro Berardi, Marc De Man, Stéphanie Laurent, resection assisted with local ablation (25.5%). Perioperative Peter Smeets, Federico Tomassini, Riccardo Ariotti, mortality was 1.4% (2 patients) and morbidity 26% (Clavien-Dindo Anne Hoorens, Jo van Dorpe, Oswald Varin, Karen Geboes, classification). Mean follow-up period was 42.8 months, during Roberto I. Troisi. which 102 (72%) patients demonstrated recurrence and 31 Background: Three different approaches have been implemented patients received remetastasectomy. Overall 5-year survival was for patients presenting with colorectal cancer and synchronous identified as 58.5% and disease-free survival as 35.5%. In the local liver metastases (CRLM): the conventional approach addressing ablation assisted group, 5-year survival and disease-free survival surgery of the primary tumor first, the combined approach and the were found to be 41.8% and 19.6%, respectively. liver-first approach (LFA). This study investigates the outcomes of Conclusion: Liver resection assisted with local ablation is a may LFA in patients with synchronous CRLM, evaluating short- and long- render unresectable patients eligible for a potential cure. In our term outcomes and evaluating predictive factors of survival. study group, the rate of remetastasectomy after recurrence were Methods: Sixty-two patients who underwent a LFA with a higher compared to the literature (30%), which may be attributed minimum follow-up of 2 years were selected for the study. All to local ablation assisted for hepatectomy. patients underwent neoadjuvant chemotherapy. Re-evaluation after neoadjuvant therapy was performed to classify patients according to the RECIST criteria. Liver resection was performed O-276 4-6 weeks after chemotherapy. Primary tumor resection was scheduled 4-8 weeks following liver resection, or after completion THE CHANGING FACE OF TWO-STAGE HEPATECTOMY: HOW of chemotherapy. The 90-days mortality and morbidity as well as THE INTERVAL BETWEEN THE TWO STAGES MAY NOT BE AS survival parameters and predictive factors of survival were PEJORATIVE AS IT LOOKS ? analyzed. F. Faitot, P. Addeo, E. Monsch, E. Felli, M. Narita, M. Greget, Results: Five patients (8.1%) were categorized as “Progressive P. Bachellier. Disease”, 22 (35.5%) as “Stable Disease” and 35 (56.5%) as “Partial CHRU de Strasbourg, Hepatobiliary, Pancreatic and General Response” at re-evaluation after neoadjuvant chemotherapy. After surgery Department, 67000 Strasbourg, France. liver resection, 14 patients (22.6%) experienced complications mainly classified as minor according to Clavien-dindo classification. Background: Two-stage hepatectomy with portal vein embolization An R0 liver resection was recorded in 46 patients (74.2%). Thirty- (TSH) has evolved with the advent of parenchymal sparing seven patients had a liver recurrence. The 5 year survival rate was techniques and alternatives such as ALPPS. Interstage time is a 55% while 5 year disease free survival (DFS) rate was 16%. matter of concern in TSH given the risk of progression. The goal of Multivariate analysis showed that RECIST criteria after neoadjuvant this study was to evaluate the changes in the practice of TSH and the treatment, T-stage and N-stage were independently associated impact of interstage management on long-term results especially in with overall survival (OS). Bilobar presentation of disease, RECIST case of tumor progression. criteria after neoadjuvant treatment and R1 margin were Study design: 1st. A retrospective monocentric study including independently associated with DFS. patients undergoing PVE after a hepatectomy was conducted. The Conclusions: LFA is a feasible and oncologically safe strategy with pre-PVE risk factors for tumor progression were evaluated in uni- good short-term and long-term outcomes. Patient selection is a and multivariate analysis. The impact of interval chemotherapy critical point and therefore all patients should be discussed in a and tumor progression on long-term survival was evaluated. A multidisciplinary board at different time points from diagnosis, review of the literature was conducted to evaluate the correlation including all possible predictors of outcomes. This should eventually between R0 rate and survival in the setting of initially unresectable lead to improved survival. colorectal liver metastases focusing on TSH and ALPPS. Results: A total of 107 patients were included and 85 patients O-275 (79%) underwent the 2nd stage. There was a significant increase in the tumor load treated during the first stage with increased use of LOCAL ABLATION-ASSISTED LIVER RESECTION FOR COLORECTAL RFA. An increased proportion of patients with tumor progression LIVER METASTASES underwent the second stage. Whereas tumor progression signifi- cantly impacted overall survival (p=0.003), this was not the case M. Tilki, M.A. Uzun, E. Dulundu, A. Kocman, A. Surmelioglu, when considering only patients completing the TSH (p=0.533). G.Kilicoglu, S. Ozkara. Tumor progression after PVE was predicted by an increase in Haydarpaæa Numune Education and Research Hospital, portal pressure during PVE greater than 4 (p=0.018). Preemptive

206 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

interval chemotherapy increased overall survival (p=0.053) Methods: Fifty three sessions of endovascular treatment was whereas curative interval chemotherapy did not (p=0.889). The performed for 38 patients between December 2005 and May 2017. review of the literature showed that ALPPS significantly altered the Pancreaticoduodenectomy (PD), major hepatectomy (resection of correlation between R0/R1 feasibility and survival. more than 4 Couinaud’ segments), minor hepatectomy, and other Conclusion: TSH is still a good option for advanced bilobar CRLM. procedures were performed for 23, 6, 5 and 4 patients, respectively, Interstage time should not be looked at as a pejorative factor as it mainly for HPB malignancies. Technical success rate, clinical success can be used to enhance oncological control. Portal pressure rate, mortality rate, and the cause of death were evaluated. increase during PVE may be an objective tool to select patients for Results: Isolation of the parent artery and stent graft deployment the interstage management. was primarily performed for bleeding from the gastroduodenal artery stump or the proper/ common hepatic artery (PHA/CHA) in O-277 34 sessions and one session, respectively. Packing of the pseudo- aneurysm were performed in 3 sessions; however, recurrent PREOPERATIVE TARGETING OF LIVER TUMORS USING bleeding required subsequent isolation of the parent artery in one REAL-TIME FUSED US WITH CT/MRI session. Selective embolization was performed for bleeding from branch vessels in 14 sessions. Technical success was achieved in all Villard N.1, Muller A.1, Gay F.1, Kepenekian V.2, Valette PJ.1 cases. Rebleeding occurred in 10 cases (26.3%), and additional TAE 1Department of radiology, Hôpital Édouard-Herriot, Hospices was performed. Haemostasis was finally achieved in 8 cases, while civils de Lyon, 69437 Lyon, France. control of bleeding was not possible in 2 cases. Extensive biloma 2Department of Surgery, Centre Hospitalier Lyon-Sud, Hospices and pancreatic fistula was observed in these two cases, and insult Civils de Lyon, Pierre-Bénite, France. to multiple vessels was revealed by angiography. In-hospital Objectives: Liver tumor removal may need local resection or mortality was observed in 12 patients (31.6%). Four patients died thermoablation through preoperative or percutaneous approaches. of liver failure after isolation of the PHA/ CHA following major To do so, US guidance is in most cases used to target the treatment. hepatectomy, while liver ischemia was not observed after the However, some lesions may be not clearly visible due to very small procedure following PD and minor hepatectomy. Two patients died size, isoechogenicity to the liver, deep location, disappearance after of refractory bleeding as stated earlier, three of multiple organ neoadjuvant therapy, and also heterogeneous liver echo failure, one of acute respiratory distress syndrome, one of sepsis, pattern in cirrhosis. MRI and CT are the reference techniques to and the other of massive pulmonary thrombosis. detect and to localize most of liver tumor masses, but at the same Conclusions: Endovascular treatment is effective for post-operative time may not be used as a guidance method during operative bleeding after HPB surgery. Liver ischemia is a drawback to or interventional procedures. Therefore, an option is to place a isolation of the parent artery after major hepatectomy. metallic marker clip before treatment as near as possible to the tumor, using fused MRI/CT for tumor detection and real time US for O-279 puncturing. We conducted a study to assess the precision of such clip placement for optimal spotting when tumors are expected to be INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIO- difficult or impossible to localize by US alone at the time of the PANCREATOGRAPHY: A USEFUL TOOL IN THE HANDS OF THE treatment. HEPATOBILIARY SURGEON Methods: 21 lesions, difficult (16) or impossible (5) to detect by ultrasound alone, were included. A marker clip was placed using El Nakeeb A., Sultan AM., Hamdy E., El Hanafy E., Atef E., fusion with MRI (16) or CT (5). The performance of the clip place- Salah T., El Geidie AA., Kandil T., El Shobari M., El Ebidy G. ment was evaluated by measuring the distance between the target lesion and the clip on a control imaging (CT/MRI). Aim: To evaluate the efficacy of intraoperative endoscopic Results: The average distance between the clip and the lesion was retrograde cholangio-pancreatography (ERCP) combined with 3.8 mm on control imaging. All lesions were easily found during laparoscopic cholecystectomy (LC) for patients with gall bladder treatment or follow-up imaging controls. stones (GS) and common bile duct stones (CBDS). Conclusion: This study confirms the precision of marker clip Methods: Patients treated for GS with CBDS were included. LC and targeting of hepatic lesions with the help of fused images even in intraoperative transcystic cholangiogram (TCC) were performed in case of invisible or ill-defined lesions at US. This technique is most of the cases. Intraoperative ERCP was done for cases with now available with most US equipments and should probably be proven CBDS. generalized as a preoperative procedure in such cases. Results: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 O-278 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed ENDOVASCULAR TREATMENT FOR POST-OPERATIVE BLEEDING stones in 6 cases (7.9%); short lower end stricture with small stones AFTER HEPATO-PANCREATO-BILIARY SURGERY present in two cases (2.6%) which were treated by removal of D. Yasui, S. Murata, T. Ueda, F. Sugihara, H. Saitou, N. Taniai, stones with stent insertion; long stricture lower 1/3 CBD in one case E. Uchida, S. Kumita. (1.3%) which was treated by open hepaticojejunostomy; and one Nippon medical school, Tokyo, 1138603, Japan. case (1.3%) was proved to be ampullary carcinoma and whipple's operation was scheduled. Objectives: To evaluate the efficacy of endovascular treatment Conclusion: The hepatobiliary surgeon should be trained on ERCP for post-operative bleeding after hepato-pancreato-biliary as the third hand to expand his field of therapeutic options. (HPB) surgery.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 207 ABSTRACTS

O-280 length of stay and overall costs. Surgery remains the only curative treatment for tumors of pancreaticobitiary area, but for the LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY EXTENDED outcomes and prolongation of survives of the patients crucially WITH IVB SEGMENT ON 74-YEAR OLD WOMAN WITH JUVENILE important is choosing of the correct before and after pancreatico- LIVER HEMANGIOMA duodenectomy nutritional support. Methods: Early enteral and total parenteral nutritions must Belev N., Atanasov B.,Petleshkov I., Moshekov E., Dgarov G. be choosing individually for each patient according to the UMHAT-Eurohospital, Plovdiv-4000, Bulgaria. malnourished status, involving of adjacent organs and comorbidities. Objectives: Infantile hepatic haemagioendothelioma/haeman- Early enteral nutrition could be performed by temporally nasal tube gioma (IHE) is a rare benign tumor. Most cases are diagnosed in (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or patient younger than 6 months. It is the third most common liver surgically placed tube (gastrostomy, jejunostomy, gastrojejunostomy tumor in childhood (12%), but the most common with manifested tubes). Parenteral nutrition typically performed intravenously. symptoms. In 45-50% of the patients skin hemangiomas are Results: Oral before operative nutrition (when it is possible present, more often in girls 2:1. Liver leasions can be single or mul- according to the symptoms of the patients) is most effective among tiple with calcifications in 50% of the patients. Most tumors grow a wide variety of nutritional modalities for the malnourished until the end of the first year followed by spontaneous regression, patients. According to the ERAS recommendation fast-track oral probably because of thrombosis. Cases of malignant sarcoma are feeding strategies results less delayed gastric emptying than normal reported to arise in existing hemangioendo-thelioma. IHE presents oral feeding strategies. Parenteral nutrition is crucial for the patients as mesenchymal tumor composed of a connecting network of in whom oral or enteral nutrition is not possible. small diameter vascular channels lined by endothelial cells. Unlike Conclusions: For the better outcomes, prolongation of surviving cavernous hemangiomas, which contain larger blood filled spaces and less morbidity and mortality rates must be individual multi- lined with endothelial cells, IHE are not obviously vascular tumors disciplinary approach for evaluation and choosing the best before at gross examination of the cut surface. and postoperative nutritional support for the patients undergoing Material and Method: Here we present a case of a vascular tumor, pancreatic surgery in malnourished state. morphologically corresponding to infantile hemangioendothe- lioma in 76 year old female. Identified liver tumor – hemangioma spreading all over the left liver lobe, hemangioma on a pedicle O-283 attached to IVB segment and a smaller one in VII segment. The patient suffered from severe abdominal pain with nausea and BICENTRIC EXPERIENCE AND COMPARISON BETWEEN vomiting. We didn’t find weight loss, anemia, thrombocytopenia, PARENCHYMA-SPARING AND STANDARD PANCREATECTOMIES coagulation disorders. No heart involvement symptoms are present. FOR PRESUMED NON INVASIVE IPMNS Performed procedure – laparoscopic left lateral sectionectomy T. Marchese, G. Perri, G. Marchegiani, M. Collard, R. Salvia, extended with IVb segment. Pathology report show infantile C. Bassi, S. Dokmak, S. Gaujoux, P. Levy, A. Sauvanet. haemangioma of the liver. Introduction: Studies comparing standard resections (SR) and O-281 parenchyma-sparing pancreatectomies (PSP) for presumed non- invasive IPMNs are scarce and included few patients. We aimed to IPMN - WHEN SURGERY IS INDICATED? compare PSPs versus SRs in two high volume centers regarding early complications and distant functional results. Radenkovic Dejan Methods: From 2000 to 2016, 240 consecutive patients were operated in these institutions with a preoperative diagnosis of IPMN O-282 without high risk stigmata. In Group 1 (n=110), enucleations and uncinate resections (EN/UR,=59) were compared to pancreatico- NUTRITIONAL SUPPORTS BEFORE AND AFTER PANCREATICO- duodenectomies (PD=51); in Group2 (n=130), central pancreatec- DUONEDECTOMY tomies (CP=62) were compared to distal pancreatectomies (DP=68). Results: In Group 1, EN/UR had an overall morbidity rate equivalent M. Marino. to observed with PD (60% versus 57%) and POPF was in total more “Ospedali Riuniti Villa Sofia-Cervello”of Palermo, Piazza frequent (55% versus 17%, p<0.05). In Group2, CP had a significant Salerno, 1, 90146 Palermo PA, Italy higher overall morbidity rate (75% versus 40%, , p-value<0.05; one Objectives: Pancreatic cancer still have very high frequency in the death occured after CP) and a higher incidence of POPF (grade world, and is the fifth most common cause of death from cancer in A+B+C, 64% versus 17%, p-value<0.05). Hospital stay was longer for the United Kingdom and fourth most common in United States. PSPs (EN/UR=20 ± 9 versus PD=13 ± 6 days, CP=29 ± 14 versus Those patients typically present in a different severity malnourished DP=10 ± 8 days). PSP showed better long-term results, with an state. Malnutrition is a medical condition, what caused by improper inferior rate of new onset of both exocrine and endocrine or insufficient diet, especially together with cancer cachexia, pancreatic insufficiency (Group 1: EN/UR=6% versus PD=43%, considered as independent risk factor for morbidity and mortality in p-value<0.05; Group 2: CP=35% vs DP=50%, p-value<0.05). patients undergoing surgical procedures. This is could include Conclusion: PSPs represent a valid alternative to SRs to preserve increased incidence of superficial and deep infections, sepsis, pancreatic function in selected patients, at the price of a higher impaired wound healing, failure of ventilator weaning, pneumonia, early morbidity and a longer hospital stay. renal insufficiency, cardiac and neurogenic events, re-admission,

208 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

O-284 Results: Postoperative lactate levels were significantly lower in patients who received preoperative BCAA supplementation than in FATE OF THE REMNANT PANCREAS AFTER RESECTION OF PDAC patients who did not (2.6 mmol/L vs. 3.1 mmol/L, P = .005), CONCOMITANT WITH IPMN although preoperative blood lactate levels were statistically equivalent between the two groups. In the univariate analysis, pre- Y. Miyasaka, Y. Mori, K. Nakata, T. Ohtsuka, M. Nakamura. operative BCAA supplementation, preoperative lactate levels, Department of Surgery and Oncology, Kyshu University 3-1-1 operation time, and postoperative glucose levels were associated Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582, Japan. with postoperative lactate levels. A multiple regression analysis Objectives: While intraductal papillary mucinous neoplasm (IPMN) is was performed between the four factors, and the preoperative use known as a precursor lesion of pancreatic ductal adenocarcinoma of BCAA supplementation was independently correlated with post- (PDAC), it has been recognized that pancreas harboring IPMN operative lactate levels (P = .046). occasionally develop PDAC distinct from IPMN, namely PDAC Conclusions: Preoperative BCAA supplementation decreased concomitant with IPMN. It is considered that PDAC concomitant with postoperative blood lactate levels. These results suggest that pre- IPMN reflects cancer susceptibility of pancreas harboring IPMN. operative BCAA supplementation may help patients recover after Therefore, it is expected that remnant pancreas after resection of surgery. PDAC concomitant with IPMN is also susceptible to PDAC. The purpose of this study was to analyze long-term outcomes after resection of PDAC concomitant with IPMN and clarify incidence of O-287 PDAC in the remnant pancreas. Methods: Thirty patients who underwent partial panceatectomy IMPACT OF DIABETES MELLITUS ON THE OUTCOMES AFTER for PDAC concomitant with IPMN were retrospectively reviewed. PANCREATICODUODENECTOMY FOR PANCREATIC DUCTAL Results: Initial operations were pancreatoduodenectomy in12 ADENOCARCINOMA patients and distal pancreatectomy in 18 patients. Stages of the A. Shehta, A. Elnakeeb, W. Askar, A. Monier, R. Said, initial PDAC according to UICC classification were 0 in 7 patients, IA M. Eldesoky, M. Elrefai, T. Abdallah, M. Abdel-Wahab. in 3 patients, IIA in 3 patients and IIB in 17 patients. Median follow- Gastrointestinal Surgery Center, Mansoura University, up period was 26 months (1-166). Recurrences of the initial PDAC Mansoura, Egypt 35516 Mansoura. were observed in 15 patients, of whom 11 patients died of the disease. 5-and 10-year overall survivals were 48.2% and 40.2%, Objectives: Pancreatic ductal adenocarcinoma (PDAC) is a life- respectively. Secondary PDAC in the remnant pancreas developed threatening health problem. Surgical excision is the principal step in 5 patients. Median duration between the initial operation and of multimodal treatment, but it is associated with poor outcomes. the diagnose of the secondary PDAC was 55 months (33-160). Several risk factors have been identified to be associated with the 5-and 10-year cumulative incidences were 32.7% and 49.5%, development of post-operative morbidity and poor long term out- respectively. Total remnant pancreatectomy was performed in 3 comes, but the role of pre-operative diabetic status in this setting patients, while the remaining 2 patients had unresectable disease. is still unclear. Few studies have evaluated the impact of preopera- 3 patients died of the disease, and the remaining 2 patients are still tive Diabetes Mellitus (DM) on perioperative and long term out- alive without recurrence. comes after pancreatic resection for PDAC. The results of these Conclusions: PDAC frequently developed in the remnant pancreas studies are very controversial. after resection of PDAC concomitant with IPMN. Long-term surveil- Methods: We reviewed the data of patients who underwent PD for lance of the remnant pancreas is necessary for the patients who PDAC during the period between 1993 and 2016. Patients underwent resection of PDAC concomitant with IPMN. were divided into 2 groups according to presence or absence of preoperative DM. Results: Our study included 451 patients. DM group included 113 O-286 patients (25.1%), and Non-DM group included 338 patients EFFECT OF ORAL BCAA SUPPLEMENTATION ON POSTOPERATIVE (74.9%). Firmer pancreas was found in DM group, and more BLOOD LACTATE LEVELS IN PATIENTS UNDERGOING PANCREATO- clinically relevant postoperative pancreatic fistula was found in DUODENECTOMY Non-DM group. There was more delayed gastric emptying, especially grade C, in DM group which required longer nasogastric Y. Nanno, H. Toyama, S. Terai, H. Mukubo, S. Shirakawa, tube decompression. Also, there was more wound infection rate in H. Yamashita, T. Mizumoto, Y. Ueda, T. Lee, H. Kinoshita, DM group. The median follow up period was 24 month (4 – 120 D. Tsugawa, S. Komatsu, M. Tanaka, M. Kido, T. Ajiki, month). Recurrence occurred in 53 patients (11.8%), 10 patients T. Fukumoto, Y. Ku. (8.8%) in DM group and 43 patients (12.7%) in Non-DM group, (p = Kobe University Graduate of Medicine, Kobe, 650-0017, Japan 0.269). Mortality occurred in 306 patients (67.8%), 56 patients (49.6%) in DM group and 250 patients (74%) in Non-DM group, (p Background: Elevations in blood lactate levels have been associated ˂ 0.001). The long-term oncological outcomes were comparable with poor postoperative outcome. The aim of the present study was between groups regarding the overall (p=0.55) and disease-free to determine if preoperative supplementation with branched-chain (p=0.972) survival rates. amino acids (BCAA) decreases postoperative blood lactate levels in Conclusion: Preoperative DM did not affect the perioperative patients undergoing pancreatoduodenectomy. outcomes after PD for PDAC. Preoperative DM is not associated Methods: A total of 223 consecutive patients who underwent with postoperative pancreatic fistula; however, it is significantly pancreatoduodenectomy were retrospectively reviewed. Post- associated with delayed gastric emptying and wound infection. operative blood lactate levels in patients who were treated with BCAA supplementation before pancreatoduodenectomy (December 2011 to December 2014) were compared to levels in patients who were not pretreated (January 2008 to November 2011).

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O-288 Conclusions: Operation note proforma’s significantly enhanced compliance with the RCS guidelines, however there is still room for FEASIBILITY OF ENHANCED POSTOPERATIVE RECOVERY PATHWAY improvement with the operation notes. The optimal solution IN EMERGENCY MINIMAL ACCESS SURGERY perhaps would be prompted electronic operation notes. PremKumar Anandan. Bangalore medical college and research institute, Bangalore- O-290 560002, India. Objectives: Minimal access surgery is an imperative element of POSTOPERATIVE ADVANTAGE OF PROXIMAL PARENCHYMAL Enhanced Recovery after surgery (ERAS) and has significantly PANCREATECTOMY (; PPP) AS AN ORGAN FUNCTION PRESERVING improved the outcomes. Largely described for colorectal surgery SURGERY and reported to be feasible. Most of the patients who present for K. Umemoto, T. Tsuchikawa, T. Kawamura, Y. Nakanishi, emergency surgery are not adequately prepared and many have T. Asano, T. Noji, T. Nakamura, K. Okamura, S. Hirano. abnormal parameters. The feasibility of ERAS protocol in such Department of Gastroenterological Surgery II, Hokkaido emergency minimal access surgery remains indistinct. The University Graduate School of Medicine. N-15, W-7, Kita-ku, objective of this study was to validate an ERAS program in such Sapporo 060-8638, Japan. scenarios. Methods: The subjects were patients who underwent emergency Objectives: Proximal Parenchymal Pancreatectomy (PPP) has minimal access surgery between Feb 2016 and March 2017 at the been established for resecting low-malignant lesion arisen in the Victoria hospital, Bangalore. They received perioperative care pancreatic head. With this procedure, the duodenum and the entire according to ERAS protocol. All data were collected and analyzed. biliary tract is able to be preserved anatomically. The aim of this The end points were the incidence of hospital stay, pain and post- study was to evaluate postoperative advantages of PPP regarding operative complications. operative outcomes and postoperative clinical course in comparison Results: A total of 135 patients were studied. Majority were hollow with those of standard pancreaticoduodenectomy (PD). viscus perforation (37.7%) these included gastric, duodenal and ileal Methods: PD and PPP were performed from January 2009 to perforations. Second most common condition was appendicitis March 2017 in 15 and 14 patients respectively, who had been diag- (26.5%) others were liver abscess, cholecystitis etc. Postoperative nosed as IPMN, NET or SPN. Postoperative cholangitis, operative complications were assessed using Clavien-Dindo classification. Only blood loss, time of operation, postoperative complications, and 3.5 % were ≥ grade 3. The average postoperative hospital stay was 6 length of hospital stay were evaluated in each procedure. In days. There was 8.5 % (11 cases) mortality. addition, the body weight loss rate, serum-Alb, AST, and ALT values Conclusions: Our results suggest that our ERAS program is feasible at postoperative 3, 6, and 12 months in patients who undergo emergency minimal access surgery. were evaluated, respectively. Results: There was no postoperative mortality in all 29 patients during median follow-up period of 35 (2 -97) months. Regarding O-289 the perioperative factors, operative blood loss was significantly lower (p=0.0346) and in-hospital stay was shorter (p=0.0383) in COMPLIANCE OF OPERATION NOTE CONTENTS WITH THE ROYAL PPP patients than those in PD. Also, in terms of postoperative COLLEGE OF SURGEONS GENERAL SURGICAL PRACTICE 2014 clinical course, rate of body weight loss was significantly lower in GUIDELINES PPP patients at 3 months after the operation (p=0.0253). Serum- Alb levels were significantly higher in PPP patients at 3 and 6 M. Kedrzycki, O. Adebayo, J.Tognarelli, W. Hayhurst. months after the operation. Furthermore, AST and ALT levels were Queen Elizabeth Hospital, London, SE18 4QH, United significantly lower in PPP at every time of observation. Kingdom. Postoperative cholangitis had been observed in 3 patients with PD, Background & Aims: The Royal College of Surgeons Good Surgical whereas only 1 patients with PPP in whom choledocho-duodenos- Practice (RCS GSP) 2014 guidelines recommend including 18 tomy with bile duct resection was performed due to biliary particulars in an operation note. Our aim was to determine the ischemia. Otherwise, no postoperative cholangitis occurred in 13 effectiveness with which our operation notes comply with the RCS PPP patients whose biliary system were preserved. GSP guidelines. Conclusions: PPP for the pancreatic head low-malignant lesion was Methods: We retrospectively analysed medical records for 50 superior to PD in terms of postoperative nutrition status. Complete patients who underwent operations in November & December preservation of biliary tract in PPP could decrease the risk of post- 2017 in both Queen Elizabeth Hospital and Lewisham University operative cholangitis compared with PD. Hospital using a pro-forma based off of the RCS guidelines. We then presented our initial findings at a trust departmental meeting, O-291 and afterwards we repeated the audit on 20 patients operated on in March 2017. TRENDS AND OUTCOMES OF PANCREATICODUODENECTOMY Results: Generally the key elements to operative notes (date, FOR PERIAMPULLARY TUMORS: RESULTS OF A 25 YEARS SINGLE elective vs emergency, signature, surgeon, procedure, incision, CENTER STUDY ON 1000 CONSECUTIVE CASES findings closure, tissue removed/added) were completed in >95% cases. The poorest completion rate was with time, problems & Ayman El Nakeeb, Waleed askar, Talaat Abd Allah complications, extra procedures, prosthesis usage, and blood loss (<60% compliance). There was variation within the trust with Objectives: to evaluate the evolution, trends in surgical Queen Elizabeth Hospital performing better than Lewisham approaches and reconstruction techniques, and important University Hospital. lessons learned from performing 1000 consecutive

210 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Pancreaticoduodenectomy (PD) for periampullary tumors Conclusion: Central pancreatectomy is a feasible and safe option Backgrounds: PD is a complex abdominal procedure. The hospital for patients with benign tumors /trauma/ lesions of low malignant mortality rate has decreased to less than 5% however the rate of potential in the neck / body of the pancreas preventing the loss of postoperative morbidities remains high, from 40 to 50%. exocrine and endocrine functions. Pancreatic reconstruction following PD is still debatable. The long survival rate after PD is clearly improved with time but still poor. Methods: This is a retrospective review of the data of all patients O-294 who underwent PD for periampulary tumour during the period from January 1993 to April 2017. The data were categorized into PANCREATICODUODENECTOMY IN PATIENTS WITH CHRONIC three periods, early period (1993-2002), middle period (2003- LIVER DISEASE 2012) and late period (2013-2017). S. Shirakawa, H. Toyama, S. Terai, H. Mukubo, Y. Nannno, Results: The frequency of PD is increasingly performed after 2000. T. Mizumoto, Y. Ueda, D. Lee, M. Tanaka, M. Kido, T. Ajiki, With time, elderly, cirrhotic, obese patients, patients with uncinate T. Fukumoto. process carcinoma and borderline tumour are increasingly selected Division of Hepato-Biliary-Pancreatic Surgery, Department of for PD. The median operative time and posoperative hospital stay Surgery, Kobe University Graduate School of Medicine, Kobe, decreased significantly over the periods. The hospital mortality is 6500017, Japan. declined significantly from 6.6% to 3.1%. The postoperative compli- cations is significantly decreased from 40% to 27.9%. There was Objectives: There were few reports of pancreaticoduodenectomy significant decrease in POPF in the second ten years from 15% to in chronic liver disease (CLD) patients. We describes short-and 12.7%. There was a significant improvement of median survival and long-term outcomes after pancreaticoduodenectomy in CLD the overall survival among the periods. patients. Conclusion: Surgical results of PD were significantly improved with Methods: We reviewed consecutive 469 patients who had under- mortality rate nearly reach 3%. Pancreatic reconstruction following gone pancreaticoduodenectomy in our institution from 2003 until PD is still debatable. The survival rate was also improved but the 2016 and identified 26 patients (5.5%) with CLD, included 21 Child- rate of recurrence is still high 36.9% Turcotte-Pugh (CTP) class A, four B, and one C. Outcomes were assessed also in 26 age-, sex-, disease-and UICC-stage¬matched controls. O-292 Results: Preoperatively, significantly higher serum creatinine and lower serum albumin were noted in CLD group. There was no SURGICAL MANAGEMENT OF PANCREAS DIVISUM significant difference between the two groups in operative factors, Varshney Subodh although higher use of fresh frozen plasma (FFP) was found in CLD group. Postoperative morbidities were 92% in CLD group and 44% O-293 in non-CLD group whereas no inhospital mortality occurred. Some CLD patients experienced severe complications and required inten- CENTRAL PANCREATECTOMY – SAFE SURGERY FOR MIDDLE sive management: prolonged course of antibiotics; use of diuretics SEGMENT PANCREATIC PATHOLOGY and FFP. The 2-year disease free survivals for CLD and non-CLD group were 65% and 61%, and overall survivals were 54% and 71%, R. Dama1, R. Pradeep, G.V. Rao, D.N. Reddy. respectively. Four of CLD patients had liver-related death. Adjuvant Asian Institute of Gastroenterology, Hyderabad 500082, India. chemotherapy was indicated for 15 patients with CLD and 17 with- Objectives: Pancreatic pathologies in the neck and body when out CLD patients, whereas 7 (47%) and 14 (82%) were received. treated by pancreaticoduodenectomy or distal pancreatectomy Conclusion: In CLD patients, the decision for the surgery should be result in a significant loss of normal pancreatic parenchyma and made carefully with consideration of the risk of poor outcomes: impairment of exocrine and endocrine function. We assess the difficult early postoperative course associated with hepatic decom- safety and effectiveness of central pancreatectomy regards preser- pensation; and worsening liver dysfunction late after the surgery vation of the pancreatic function that makes adjuvant chemotherapy impossible, and may cause Methods: 27 patients underwent central pancreatectomy between liver-related death. 2004 to 2017. 11 patients had serous cystadenoma, 5 patients neuroendocrine tumor (NET), 4 -solid cystic pseudopapillary tumour of the pancreas. Two patient each of IPMN and focal chronic O-295 pancreatitis and 1 each of post trauma, inflammatory myofibroblas- tic tumour of the pancreas and . The MODIFIED BLUMGART METHOD FOR proximal end was transected with a linear stapler and edges PANCREATICODUODENECTOMY oversewn, and the distal stump was anastomosed to roux en y-jejunal loop (21) or pancreaticogastomy (6). All patients were Yi-Ming Shyr, Shin-E Wang. followed up for exocrine and endocrine insufficiency with fecal From Division of General Surgery, Department of Surgery, elastase and fasting blood sugar levels Taipei Veterans General Hospital, National Yang Ming Results: 18/27patients had uneventful recovery. Eight patients had University, Taiwan. post operative grade A pancreatic fistula and 1 patient had grade B Pancreatic reconstruction has been the Achilles tendon after fistula. Preoperative diabetes mellitus in 8 patients did not worsen pancreaticoduodenectomy (PD). Currently, there is no universally during follow up. None of the patients had denovo exocrine or accepted technique to reduce the pancreatic leakage. In our endocrine insufficiency on mean follow up of 80 months (10 -154 institute, two techniques have been adapted, Blumgart pancreatico- months). Mean operative time, blood loss, length of segment jejunostomy (PJ) and pancreaticogastrostomy (PG). A matched excised were, 128 mts, 100ml, & 4 cms respectively case-control study of modified Blumgart PJ and PG after PD was

Surgery, Gastroenterology and Oncology, 22 (3), 2017 211 ABSTRACTS

conducted, and the experience and outcome of open Blumgart PJ O-297 and PG are to be shared. Data of patients undergoing Blumgart PJ ACUTE PANCREATITIS IN PREGNANCY and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on F.R Mohideen, A.Shariff. the Callery risk scoring system for clinically relevant postoperative Aga Khan University Hospitals, Karachi Pakistan. pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters Acute pancreatitis in pregnancy is a rare entity with an incidence and risks were compared between these two groups. A total of 206 ranging from 1 in 1000 to 1 in 10000 pregnancies. Gallstones are the patients undergoing PD were included. Blumgart PJ was associated most common cause of pancreatitis in pregnancy. High triglyceride with shorter postoperative hospital stay (median (range) 25 levels are the second commonest cause followed by drugs, connec- (10 – 99) vs. 27 (10 – 97) days, P = 0.022). There was no surgical tive tissue disorder, alcohol abuse and trauma. It concerns two lives. mortality in the Blumgart PJ group, but a 4.9% perioperative Imaging controversies, limitation in the use of medication, nutrition mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is and fetal monitoring are aspects that need to be thought through significantly lower than that by PG for overall patients (7.8% when approaching these patients. A shift in the treatment paradigm vs. 19.4%, P = 0.024), as well as for those with soft pancreas -from a conservative approach to surgical ventures such as ERCP and parenchyma (10.2% vs. 26.2%, P = 0.033), ampullary, duodenal, cyst, laparoscopic cholecystectomy has significantly improved fetal and neuroendocrine tumor pathology (11.1% vs. 29.9%, P = 0.010), maternal outcomes. pancreatic duct diameter = 2 mm (7.3% vs. 31.3%, P = 0.012), inter- Objective: To analyze the maternal and fetal outcomes of acute mediate fistula risk zone (3 – 6 Callery risk scores) (6.0% vs. 20.7%, P pancreatitis in pregnancy. = 0.048) and high fistula risk zone (7 – 10 Callery risk scores) (14.3% Materials and Methods: A retrospective audit 12 years (2004- vs. 47.4%, P = 0.038). In conclusion, Blumgart PJ is superior to PG in 2015) was conducted. All pregnant patients diagnosed with acute terms of pancreatic leakage and surgical mortality. Blumgart PJ can pancreatitis were included in the study. Data was recorded on a be recommended for pancreatic reconstruction after PD for all designed performa and SPSS 19 was used for data analysis pancreatic remnant subtypes. Results: 22 patients were included in the study. Mean Age was 28 years. The mean gestational age was 27.7 weeks. Gallstones were the cause in 13/22 patients, while in the remaining patients no O-296 etiology was identified. All patients were managed conservatively. 6 patients underwent interval laparoscopic cholecystectomy following RESULTS OF 27 PANCREAS-PRESERVING DUODENECTOMIES NOT delivery. 15 patients delivered at our institution. Two patients ASSOSIATED WITH FAP delivered during the acute attack. There was one intra-uterine death and one patient delivered triplets; the total live births were 16. 7 Egorov V.I., Petrov R.V., Starostina N.S.. were term and 8 were pre-term deliveries while. There was no 1Bakhrushins Brothers Moscow City Hospital, significant association of pre-term delivery or birth weight with 2Moscow Clinical Scientific Centre, Russia, 107076. disease severity. The maternal mortality rate was zero. Background: Pancreas – preserving duodenectomies (PPD) are Conclusion: Acute Pancreatitis in Pregnancy is a rare disease, but uncommon procedures usually reserved for duodenal the maternal and fetal outcome in our institution is promising. The associated with familial adenomatous polyposis (FAP). PPDs sample size in our study is small, hence multi centre studies should performed for other entities are much more rare operations. be considered. Aim: To assess possibilitiy of PPD use for lesions not associated with FAP O-298 Method: Prospective analysis of 27 consecutive cases of PPD (2006 – 2016). with assessment of preoperative (US,CT,MRI,EUS) and SEVENTY FIVE CASES OF DUODENAL DYSTROPHY (GROOVE OR hystologiacal diagnosis, short-and long–term results, including QoL PARADUODENAL PANCREATITIS) TREATMENT. WHICH WAY AND for benign and survival for malignant diseases WHICH NAME IS BETTER? Results: Duodenal dystrophy in 14 cases, duodenal GIST in 10 cases, villous adenoma, gigantic leiomyosarcoma, paraganglioma and Egorov V.I., Petrov R.V., Vankovich A.N., Starostina N.S. solitary endometrial cancer metastasis in 1 case each were met. In 22 Bakhrushins Brothers Moscow City Hospital, Moscow Clinical cases the diagnosis was established before surgery. The most precise Scientific Centre, Moscow, Russia, 107076. diagnostic modalities were CT and EUS. The main symptoms were Background: The term “paraduodenal pancreatitis (PP)“ was pain (12), GI bleeding(11) and vomiting(4). Infrapapillary duodenec- proposed as an umbrella for cystic dystrophy in heterotopic tomy (ID) was performed in 12 cases, one with aorta and inferior pancreas (duodenal dystrophy,DD), paraduodenal cyst and groove vena cava resections, and in 50% of cases duodenal resection with pancreatitis, by reasoning that these conditions mimic pancreatic replantation of common bile and main pancreatic ducts in neoduo- head tumors and share certain histological evidences. The reasons denum was performed. Morbidity rate 29%. One patient with duo- for amalgamation of these terms are unclear. denal sarcoma had died on 100th day after ID due to complications Objective: To assess the results of different types of DD treatment. of pancreonecrosis. Other patients are alive demonstrating long- Method: 1) Prospective analysis of 75 cases of DD (2004-2015), term survival and good QoL. comparing 75 pretreatment and 57 histopathological findings; Conclusion: Well-timed PPD is an efficient method of treatment as 2) Assessment of clinical presentation and the results of DD for benign so as for some malignant duodenal lesions and can be treatment. an alternative for pancreaticoduodenectomy. Results: Preoperative diagnosis was correct in all the cases except one, when cystic tumor of the pancreatic head was suspected (1,9%). Patients were presented with abdominal pain (100%), weight loss (76%), vomiting (30%) and jaundice (18%). CT, MRI and

212 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

endoUS were the most useful diagnostic modalities. Nine patients (below 19 years) is 0.19 per million population. Given this rare were treated conservatively, 35 underwent pancreaticoduodenec- incidence in young adult population, the impact of young age on tomies (PD), pancreatico-and cystoenterostomies (8), Nakao the short-term and long-term outcomes after PD is not well procedures (4), duodenum-preserving pancreatic head (DPPH) studied. The aim of our work is to report the surgical outcomes resections (5), and 14 pancreas-preserving duodenal resections after PD in young adult population (< 35 years) and to compare it (PPDR). No mortality. Full pain control was achieved after PPRDs in to a cohort of adult patients who underwent PD at our institute at 93%, PDs in 83%, and after PPPH resections and draining the same study period. procedures in 18% of cases. Diabetes mellitus developed thrice Methods: After Institutional Review Board approval, we retrospec- after PD. In 3 PD cases only moderate pancreatitis was revealed in tively analyzed the data of all patients who underwent PD at specimen. Gastro-intestinal Surgery Center, Mansoura University in the period Conclusions: 1) The diagnosis of DD can be confidently determined between 2000 and 2016. Patients under 35 years were defined as by modern methods preoperatively; 2) Early diagnosis of DD saves young adults (YA) according to previous studies. The adult cohort pancreas; 3) Late diagnosis convert DD in PP and leaves patient represents adult patients who underwent PD in the same study only PD; 4) The efficacy of PPDR proves that DD is an entity of period at our institute. Patients data were collected in a web based duodenal, but not paraduodenal origin. hospital registry. All patients underwent a subtotal stomach preserving PD through a bilateral subcostal incision. The severity of post-operative complications was graded according to the O-299 Dindo–Clavien complication classification system. ISGPS definitions PANCREATICOGASTROSTOMY VS PANCREATICOJEJUNOSTOMY were followed. Patients were followed up 1 week after discharge (SIMPLE AND ISOLATED LOOP). PROSPECTIVE RANDOMIZED then at 1, 3, 6 months intervals. STUDY. Results: The most common pathological diagnosis in the YA cohort was adenocarcinoma (41.4%) followed by solid pseudopapillary El Sorogy M., El Nakeeb A., El Shahawy T., Salah T, ElEbidy G. tumor (SPT) (29.3 %). The mass was found to reach significantly larger sizes in the YA cohort reaching 15 cms in some patients (P = Introduction: Since the first description of PD, management of the 0.001). The overall incidence of post-operative complications in the pancreatic remnant has been considered the most important YA cohort was 36.3 % which was comparable to that in the adult determinant of post-operative outcome. Although the technique group (32.5 %). The most common post-operative complication of PD has been standardized over the past decades, the optimum was POPF (19 %), however, the majority of pancreatic fistulae were method of pancreatic reconstruction is still a controversy. Various grade A. The overall survival in the YA cohort was significantly surgical approaches have been described to manage the pancreatic higher than the adult group (P = 0.0001) where the 5 year survival remnant aiming to decrease the incidence of POPF. reached 58 %. The median overall survival for SPT was 280 months Methods: 60 patients admitted to Gastrointestinal Surgery Center, with 5 years survival of 94 %, while, the median survival for adeno- Mansoura University were randomized into three groups intra- carcinoma in the YA group was only 34 months with 5 years survival operatively after resection; pancreaticogastrostomy (PG), simple of 35 %. loop pancreaticojejunostomy (SPJ) and isolated loop PJ (IPJ). The Conclusion: This study concludes that PD in young adults when primary end point was the incidence and severity of post operative performed in tertiary centers with good surgical experience is pancreatic fistula (POPF). ISGPS definitions were followed. relatively safe. However, given the rarity of the procedure in this age Results: The three groups were comparable regarding the patients group, we suggest that further well designed studies involving demographics, DM and pre-operative biliary drainage. The rate of multiple centers to be carried out to draw more accurate overall post operative complications was similar among the groups. conclusions. POPF occurred in 11/60 cases (18.3%); 10 % for PG group, 20 % for SPJ group and 25 % for IPJ (p= 0.46). Grade C fistula was higher in O-301 IPJ group (10%) however the p value was non-significant. Reconstruction operative time was significantly higher in IPJ group LAPAROSCOPIC EXCISION OF ADENOMA OF LEFT LOBE OF LIVER (p <0.001). R. Dama, R.Pradeep, G.V. Rao, D.N. Reddy. Conclusion: The results of this study contribute evidence that there Asian Institute of Gastroenterology, Hyderabad-500082 India. is no difference between PG, simple loop PJ and isolated loop PJ regarding the rate and severity of POPF and other post-operative Objectives: Minimaly invasive surgery for liver tumours is truly complications. However, further RCTs are required to confirm our amazing for obese patients as it has no morbid incisions, post results. operative respiratory issues or any wound problems. We present a video of laparoscopic excision of adenoma in the segment 3 of the liver. O-300 Methods: 55year old morbidly obese patient underwent laparo- scopic excision of segment 3 liver lesion, of size 5x4 cms, which was PANCREATICODUODENECTOMY IN YOUNG PATIENTS. A SINGLE inconclusive on FNAC and imaging. 3 ports were used-one 5mm CENTER EXPERIENCE and two 10 mm. A percutaneous suture through the specimen was R. Dama, R.Pradeep, G.V. Rao, D.N. Reddy. used for retraction. Harmonic scalpel was the energy source and a single vascular stapler was used for transecting the pedicle of the Introduction: As pancreatic and periampullary pathologies are tumour. Specimen was removed in a glove bag by extending the 10 uncommon in young populations, pancreaticoduodenectomy (PD) mm port by a cm. is not a frequently performed procedure in pediatric and young Results: Total surgical time was 75 mts. Patient was extubated on adults. In a statistical review performed by the National Cancer table and had no post operative morbidity. No blood transfusion institute, the incidence of pancreatic tumors in young population required. Post o stay was for 3 days. No pain, wound infection or

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prolonged icu stay or any pulmonary issues. Final histopathology laboratory and instrumental examination. Source bleeding was suggestive of a liver adenoma. installed at esophagogastroduodenoscopy conducted. Patients Conclusion: Laparoscopic liver resection is feasible and safe, were divided into 3 groups. The first group of patients received only especially in a non cirrhotic liver and peripheral tumours. Patient conservative therapy, the second group of patients received has less pain and post o stay and can have early return to work conservative treatments and performed endoscopic ligation of bleeding gastroesophageal varices, the third group of patients received conservative therapy performed endoscopic ligation of O-302 varices and performed endovascular embolization of the splenic MINIINVASIVE SURGICAL TREATMENT OF PORTAL HYPERTENSION artery. COMPLICATED BY BLEEDING GASTROESOPHAGEAL VARICES Results: Mong the 195 patients treated with portal hypertension complicated by bleeding from gastroesophageal varices discharged Petrushenko V.V., Khytruk S.V. from the surgical department 152 patients (77.95%), 43 patients died (22.05%). All dead patients received only conservative Objectives: Variceal bleeding is a life-threatening complication of symptomatic therapy. In patients who underwent ligation of portal hypertension with a high probability of recurrence and gastroesophageal varices -made reliable hemostasis, after splenic mortality. Treatment to prevent first bleeding or rebleeding is artery embolization -a steady decrease in pressure in the portal mandatory. The goal of our research to improve outcomes of vein. Following the combined miniinvasive surgery all patients patients with portal hypertension complicated by bleeding from were discharged home, mortality was not. gastroesophageal varices and increase the survival of patients with Conclusions: Patients with portal hypertension complicated this disease. by bleeding from gastroesophageal varices should receive compre- Methods: During the period from 2014 to 2016 in the surgical hensive treatment: to stop the bleeding -endoscopic ligation of center of gastrointestinal bleeding Vinnytsa Regional Hospital varicose veins, to reduce the pressure in the portal vein and treated 195 patients with portal hypertension complicated by prevention of rebleeding -endovascular embolization of the splenic bleeding from gastroesophageal varices. In this cohort of patients artery and symptomatic supportive therapy on the every stage. there were 105 men (53,8%) and 90 women (46,2%). An average age of patients was 54,8±10,6 years. All patients were conducted

214 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

POSTERS (P)

P-001 with choledochotomy with T-tube and choledochoduodenostomy, and indication for CDD is dilated CBD more than 1.5 cm, stone CHOLEDOCHAL CYST IN ADULTS, ITS PRESENTATION AND forming patients and benign distal duct stricture. Data was MANAGEMENT: OUR EXPERIENCE analysed with statistical package of social sciences (SPSS) version 23. J.B. Stott, N. Lethbridge, A. Zholos, M. Ennis. Results: Seventy-eight patients were studied, the mean age was Mahim Koshariya, Surbhi Garg, Abhishek Shitole, Prashant 50.65 years (SD+15.1), female to male ratio was 2:1, of the them 58 Kharat Sheikh Behram, M.C.Songra. patients (74.4%) were treated with choledochoduodenostomy and Gandhi Medical College & hHamidia Hospital, Bhopal, 20 patients (25.6%) were treated with choledochotomy + T-tube. 462001, INDIA Main indication was dilated common bile duct diameter; in chole- Introduction: Choledochal cyst is a rare congenital dilatation of the dochoduodenostomy mean diameter 14.5 mm (SD+2.8) vs 10.6 bile ducts and majority of them presents during childhood. mm (SD+2.7) in T-tube group (P value 0.0001). there were three Choledochal cyst in adult is rare and is usually suspected or diag- patients out of 20 had retained stone after choledochotomy (15%). nosed by hepato biliary imaging studies often initiated for evaluation Wound infection was 3.4% in choledochoduodenostomy vs 5% in of upper abdominal complaints and obstructive biliary disease. choledochotomy. Bile leak occurred in 2 patients (3.4%) in choledo- Objectives: This paper aims to analyze and review the manage- choduodenostomy vs 2 patients (10%) among choledochotomy + T- ment of choledochal cyst in adults who presented to our hospital. tube group. Methods: Total number of 15 patients were managed from June Conclusion: Choledochoduodenostomy is safe and effective in 2008 to June 2016 in our unit and reviewed on their presentation treatment of common bile duct stones in those patient with dilat- clinical information and management. ed common bile duct, with good clinical outcome. Results: There were 12 female patients and 3 male patients out of Key words: Choledochotomy, T- tube, choledochoduodenostomy, 15 patients. Majority of them had upper abdominal. Only two common bile duct stones, Sudan. patient presented with the classical triad i.e abdominal pain, jaundice and mass. There were 11 type 1 (73.3%), type II-2 (13.3%), type III-1,(6.6%) and type IV-1(6.6%) patient. 3 patients had P-003 associated cystolithiasis. 11 patients were treated by total cyst excision and reconstruction by Roux-en-Y hepatico jejunostomy. COMPARISON OF EFFECTIVENESS OF CEFTRIAXONE WITH Rest 2 were treated with simple cyst excision.There was no signifi- CIPROFLOXACIN IN THE MANAGEMENT OF ACUTE CALCULUS cant intraoperative and postoperative morbidity or mortality. CHOLECYSTITIS Histopathological report revealed no evidence of malignancy. S. Ramasamy, S. Neogi, S.K. Tudu, A. Goel, S. Prajapati, A. Jain. Conclusions: Choledochal Cyst should be considered in the Maulana Azad Medical College, New Delhi, 110002, INDIA. differential diagnosis in all patients with a history of biliary colic, recurrent cholangitis or pancreatitis with associated dilatation of Objective: To compare the effectiveness of ceftriaxone with bile duct with jaundice, particularly if they are less than 40 years of ciprofloxacin in the initial management of patients with acute cal- age.Diagnosis is often delayed due to variable presentation and the culus cholecystitis. best surgical option is total cyst excision along with reconstruction Methods: We evaluated 40 patients with acute cholecystitis Roux-en-Y hepatico jejunostomy. between September 2015 to march 2017. Time for resolution of symptoms, response to treatment and duration of hospital stay were assessed between those receiving ciprofloxacin and ceftriax- P-002 one. Diabetic patients and Pregnant females were excluded from CHOLEDOCHOTOMY WITH T-TUBE VERSUS the study. CHOLEDOCHODUODENOSTOMY IN MANAGEMENT OF PATIENTS Results: The mean age of acute cholecystitis was 40.8 ± 10.9. Male: WITH COMMON BILE DUCT STONES WITH LOW FACILITIES female ratio was 1:7. Mean duration of hospital stay was 4.4 ± 1.39 days whereas in ceftriaxone group it was 4.8 ± 1.24 days which was Rami Yassin Mahmoud1, Nassir Alhaboob Arabi2*, Abdulmagid statistically insignificant with p value of 0.343. 95% of patients Mohammed Musaad3, Elsaggad Altayeb A4, Muataz Salaheldin4, responded to ciprofloxacin and 90 % patients responded to Sawsan Abulgasem5 and MA Ibn ouf3 ceftriaxone with a p value of 1.00 which was statistically insignificant. Department of GI Surgery, Ibn Sina hospital, Khartoum, Sudan Responses to the symptoms of cholecystitis were comparable with these two antibiotics. Background: In limited facilities to perform laparoscopic and/or Conclusion: We can conclude from the study that ciprofloxacin is endoscopic common bile duct exploration; open choledochotomy equally effective with ceftriaxone in the management of acute with T-tube and choledochoduodenostomy remain the valid calculus cholecystitis if not superior in terms of resolution of pain options for treatment of common bile duct stones. This study and fever, normalization of pulse and TLC and duration of hospital aimed to compare both procedures in term of indication, surgical stay. Ciprofloxacin can be used as an alternative in place of ceftriax- technique and outcome. one. So we recommend that ciprofloxacin as a first line antibiotic in Patients and Methods: It is prospective descriptive cross sectional the management of acute calculus cholecystitis. hospital based study, conducted at Ibn Sina Specialized Hospital, it included all patients with common bile duct stone who treated

Surgery, Gastroenterology and Oncology, 22 (3), 2017 215 ABSTRACTS

P-004 (GOP) in 14 (28%) patients. Preoperative appearance of residual cancer(RC) were present at the preoperative CT scan in 15 patients GALLBLADER TUBERCULOSIS MIMICKING TUMOR : A CASE (30,6%), 11 patients (22%) had T3 and/or poor differentiated REPORT. tumors and 13 resections were labelled as R1(26%). Operative A. O. Touré, M. Faye, O. Thiam, M.L. Gueye, M. Cissé, O. Kâ, mortality and morbidity were 2% and 22% respectively. Overall M. Dineg survival was 40 months with 80%-50%-41%-36% at 1-3-5-10 years. General Surgery Department, CHU A. Le Dantec, Avenue Independent preoperative risk factors for specific disease related Pasteur, BP 3001, Dakar (SENEGAL) survival were T3 tumors(HR:4.62;1.54-13.8), GOP (HR:1.84;1.10- 7.3) and RC (HR:3.23;1.30-7.9). Patients presenting with 0,1,2-3 risk Introduction: Tuberculous involvement of the gall bladder is factors had 3-years survival rates of 89%,33%,9%(p<0.0001). rare.The pseudo-tumor form poses a differential diagnosis problem Conclusions: The presence of RC, GOP and T3 tumors indicates with gallbladder cancer. Diagnosis is usually postoperative with the poor survival after resection for I-GBC following LC. The combina- histological analysis of the gallbladder. tion of these three easily available factors might be helpful to Observation: A 51-years-old male patient presenting episodes of identify a subgroup of patients in need of neoadjuvant treatment hepatic colic with nocturnal vespero fever. Abdominal examination before surgery. objectified an ovoid painfull mass of the right hypochondrium, evoking a dilated gallbladder. Biological exams showed no inflam- mation and hepatic tests were normal. Hepatobiliary MRI was in P-006 favor of multi-lobular cystic mass of the gallbladder evoking a cystic vesicular tumor or hydatid cyst. On sub-costal surgical explo- LIVER TRANSPLANTATION FOR PRIMARY SCLEROSING ration there was a tumor of the bottom of gall bladder measuring CHOLANGITIS about 4 cm, without extension on liver. Cholecystectomy was D. Nobuoka, T. Yagi, Y. Umeda, R. Yoshida, T. Kuise, K. Kumano, performed. After removal, we noticed a milky liquid issue from the T. Koujima, K. Takagi, T. Fushimi, T. Fujiwara gallblader, with many little stones. The post-operative course was Department of Gastroenterological Surgery, Okayama marked with skin infection treated by local care and antibiotic. University, Okayama, 700-8558, Japan Histological analysis showed a gallbladder tuberculosis. An anti- tuberculous treatment Rifampicin + Isoniazid + Ethambutol + Objectives: Primary sclerosing cholangitis (PSC) is an idiopathic and Pirazinamide) was instituted during 6 months. Two months later, intractable disease. Liver transplantation is the only proven the patient presented an incisional hernia treated with prothesis. long-term surviving treatment of PSC. However, data from There was no further complication after. Japanese registry of liver transplantation suggest that receiving a Conclusion: Pseudo-tumor tuberculosis of the gallbladder is excep- living donor liver transplantation (LDLT) from a first-degree relative tional, even in tuberculous endemic countries. Clinical, imaging and might lead to a higher risk of recurrence of PSC. Here, we biology are not specific. The diagnosis is made by pathological retrospectively reviewed the cases of liver transplantation in our analysis. A well-conducted antituberculosis treatment can lead to institution. healing. Methods: From 1996 to 2015, 371 consecutive patients underwent liver transplantation at the Okayama University Hospital, Japan. Among them, 12 patients with PSC were enrolled in this study, 11 P-005 LDLT and 1 DDLT. Results: Among 5 patients who received LDLT from first-degree INCIDENTAL GALLBLADDER AFTER LAPAROSCOPIC relatives, only 1 patient had a recurrence of PSC 6 years after LDLT. CHOLECYSTECTOMY: PREOPERATIVE FACTORS ASSOCIATED On the other hand, the patient who received DDLT had a WITH POOR OUTCOMES AFTER REOPERATION. recurrence of PSC 4 years after DDLT. No patients suffered graft loss Pietro Addeo, Leonardo Centonze, Emanuele Felli, François caused by a recurrence of PSC. Faitot, Philippe Bachellier. Conclusions: LDLT from a first-degree relative might not have a HepatoPancreatoBiliary Surgery and Liver Transplantation, higher risk of recurrence of PSC under the appropriate condition of University of Strasbourg, Starsbourg, France immunosuppression. Objective: Reoperation is generally recommended when an incidental (I) gallbladder carcinoma(GBC) is found after a laparos- P-007 copic cholecystectomy(LC). However, despite a radical reoperation early recurrence and a reduced overall survival are observed in up MIRIZZI SYNDROME: OPEN OR LAPAROSCOPIC? to 20% of patients. The present study attempted to identify pre- M.A. Perdomo, J. Rabellino, P. Valsangiácomo, G. Wagner, L. Ruso. operative factors associated with poor disease-specific survival Clínica Quirúrgica “3”, Hospital Maciel. Montevideo, after resection of an I-GBC. Uruguay. PC: 11300 Methods: A retrospective review of a prospectively maintained database of patients undergoing resection for GBC from January Background: Mirizzi Syndrome (MS) is an uncommon complication 1995 and March 2017 were retrospectively evaluated. Patients of cholelitiasis that consist of the extrinsic obstruction of the undergoing a radical reoperation for I-GBC were identified and common bile duct, and is related with obstructive jaundice as univariate and multivariate Cox analysis were performed in order clinical presentation. Surgical management of SM constitutes a to assess preoperative survival prognostic factors. challenge for surgeons and is associated with severe BD lesions. MS Results: There were 50 consecutive patients with I-GBC (median has been suggested as a contraindication for laparoscopy, but it is age-64 years; range,38-82) undergoing re-resection at a median of currently described as a viable option for selected patients (MS 36 days (range15-98) form a LC. LC was converted to open in type I in Csendes classification). 7(14%) and complicated by various form of gallbladder opening Objective: To review our initial experience in laparoscopic

216 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

management of MS, comparing outcomes with open approach in a P-009 low-volume centre. Methods: This is a retrospective review of patients with MS from OUR EXPERIENCE OF THE MANAGEMENT OF PATIENTS WITH January 2006 to December 2016. Electronic health records were OBSTRUCTIVE JAUNDICE OF DIFFERENT ETHIOLOGY analysed and clinical presentation, diagnostic modalities, surgical A. Baimakhanov, D. Toksanbayev, N. Sadykov, N. Sarmanov, approach, complications and Csendes classification of MS were M. Duisebekov, A. Bayzhanov. evaluated. Asphendiyarov’s Kazakh National Medical University Almaty, Results: During the evaluated period 10 patient were diagnosed A25P3A1, Kazakhstan with MS, all of them preoperative (incidence 3,3%). There were 2 males and 8 females with a mean age of 52 years (range: 19-76). Objectives: Mini-invasive interventions for patients with obstruc- Three patients had MS type I (30%); two were treated with laparo- tive jaundice implements wider within last several years, with scopic cholecystectomy (LC) with no conversions. In the remaining growth of the number of patients with tumors of hepatopancreato- one open cholecystectomy (OC) were performed. One patient had biliary zone. One of the principal components of surgical manage- type II MS (10%) and was successfully treated with open subtotal ment of these patients is the appropriate decompression of biliary cholecystectomy. No type III MS were found. Three patients had system. Today most of professionals considers that wide imple- MS type IV (30%). Laparoscopic subtotal cholecystectomy with mentation of antegrade and retrograde biliary interventions shall Pezzer tube cholecistostomy were performed in this cases. Finally significantly improve general results of the treatment of patients one type V MS were reported (10%), presenting a cholecystoduo- with obstructive jaundice, due to decreasing of complication and denal fistula and was treated with a laparotomic subtotal cholecys- mortality rate. tectomy, duodenorrhaphy, and Roux-en-Y hepaticojejunostomy. Methods: Current investigation includes 22 patients with obstructive Conclusions: Preoperative diagnosis of MS is essential in the proper jaundice, treated in the period between 2016, June and 2017, April. management of the disease. We believe that initial laparoscopic From treated patients, there were 14 men (63.6%) and 8 women approach for MS (including type IV) is feasible and safe, and conver- (36.4%); the age of patients ranged from 26 to 79. Patient’s sion would be subject to intraoperative findings. hospitalization day differed between 9th and 45th day after appearing of jaundice. The common bilirubin level ranged from 89 to 560 Umol/L. Causes of jaundice were: pancreatic cancer – 7 (31.9%); P-008 cancer of common bile duct – 2 (9.0%); cancer of gallbladder – 1 (4.5%); cancer of intrahepatic bile ducts – 1 (4.5%); cancer of major MULTIPLE GALLBALDDERS: ANALYSIS OF A HISTORICAL COHORT duodenal papilla – 2 (9.0%); liver tumor with invasion of bile ducts – OF 180 CASES 3 (13.7%); benign stricture of common bile duct – 3 (13.7%); chole- docholithiasis – 3 (13.7%). For 22 patients, we have provided 28 mini- B. Darnis, K Mohkam, F Cauchy, JB Cazauran, B Bancel, A Rode, invasive interventions: 13 – percutaneous transhepatic (antegrade) C Ducerf, M Lesurtel, JY Mabrut draining, 14 – endoscopic (retrograde) stenting, using plastic or metal Digestive surgery and liver transplantation unit. Croix-Rousse stents; 1 – combine external-internal draining (“rendezvous” University Hospital. 103, Grande rue de la Croix-Rousse 69317 technique). Lyon Cedex 4 Results: There were no any mortality associated with percuta- Objectives: Biliary malformations, such as pancreatobiliary malu- neous transhepatic or endobiliary interventions. In 2 cases (9%) nion or bile duct cysts are sometimes associated with an oncologic after percutaneous draining, there were migration of drain, which risk. Multiple gallbladders (MG) are a rare malformation with no forced us to provide re-draining. Patients after endoscopic stenting clear data about its risk, and management. has not had any complications. Methods: Retrospective analysis of 176 published cases of MG Conclusion: The use of minimally invasive decompression during the last 25 years literature and 4 cases from 2 french techniques in obstructive jaundice management is quite effective institutions. palliative action, which prevents the development of liver failure, Results: Eighty-two per cent of patients were diagnosed during the improves the quality and length of life of patients with biliary and treatment of a gallstone-related disease, of which 13% had a pancreatic malignancies. previous cholecystectomy. Ultrasound scan and MRCP showed a sensitivity of 66% and 99%, respectively. The cystic duct was P-010 common to both gallbladders (type1) in 43% and separated (type 2) in 50% of patients. In the latter case, there was no way to differen- RE-AROUSAL OF A VANISHING SURGICAL PROCEDURE: tiate preoperatively an accessory gallbladder from a Todani II bile APPLICATION OF SURGICAL CHOLECYSTOSTOMY IN CRITICALLY duct cyst. Cholecystectomy was performed in 129 patients by ILL OR NON-PERCUTANEOUS-CHOLECYSTOSTOMY FIT PATIENTS laparotomy (42%) or laparoscopy (58%), with a postoperative biliary OF ACUTE CHOLECYSTITIS leakage rate of 2.4%. Two cases of cancer were found (1%). Conclusion: MG have the same natural history than single Hui-Pu Liu, Yu-Chiuan Wu, Chin-Wen Hsu, Wen-Yen Chang, gallbladder without major oncologic risk. Surgical indications are Wen-Ching Kung, Chun-Min Su, Ping-Hung Liu usually similar except in case of type 2 MG because of the potential Department of General Surgery, Kaohsiung Armed Forces misdiagnosis with a Todani II bile duct cyst, which is associated with General Hospital, Kaohsiung, Taiwan a risk of cancer. Today, surgical cholecystostomy(SC) is nearly replaced by image- guide percutaneous techniques, and it’s been scarcely mentioned since 1980s after the introduction of percutaneous cholecystostomy (PC). However, SC may be needed in some situations. Cholecystostomy has been shown to be beneficial in high-risk patient groups to decompress the gallbladder, reducing patient’s symptoms

Surgery, Gastroenterology and Oncology, 22 (3), 2017 217 ABSTRACTS

and the systemic inflammatory response. It also has been proven the These up-regulated detoxification enzymes can increase the water most feasible bridging treatment prior to elective cholecystectomy. solubility of hepatotoxicity through hydroxylation (Cyp3a), sulfa- The majority of PC has often performed via transhepatic route, tion (Sult2a1), and glutathione conjugation (Gsta2-4). Rowachol transversing the liver for theoretically greater catheter stability and significantly reduced the expression of genes involved in inflamma- lower rate of bile leakage. The transperitoneal route is considered a tion (mRNA expression of IL-1β, MCP-1, and IL-6, and NF-κB /p65) more suitable option in patients with liver disease and uncorrected in BDL group. coagulopathy. To date, either route of PC is executed with the help of Conclusions: Six cyclic monoterpenes attenuates liver injury and sonography or computerized tomography by radiologist, and that are cholestasis in BDL rats, which may be associated with hepatic not always available in some developing districts. Herein, we detoxification and alteration of bile synthesis. introduce this forgotten surgery: SC to reach the goal of bile diversion similar to transperitoneal PC. We enrolled total 9 patients in a single P-012 institute with acute cholecystitis not suitable for transhepatic route, underwent SC since 1999 to 2016. The reasons for SC are as below: SURGICAL INTERVENTION FOR BENIGN BILIARY DISEASES IN THE 1. Liver cirrhosis with coagulopathy. 2. Sepsis with coagulopathy. ERA OF ERCP 3.Gallbladder empyema with rupture. 4. Unavailability of radiologist. And among these 9 patients, 6 have undergone following cholecys- A.Ganguly, R.Kale, C.P.Kothari tectomy. And all of the 9 patients were uneventful during 1-year CHL group of hospitals, Indore 452008 India follow-up. Objective: To assess the role and outcome of surgical procedures for various benign diseases of biliary tree, when the endoscopic P-011 retrograde cholangiopancreaticography (ERCP) has either failed or could not be done either due to anatomical or technical reasons. SIX CYCLIC MONOTERPENES (ROWACHOL®) ATTENUATES Method: Data collected for a period of 2 years (2014-2016) and LIVER INJURY, INFLAMMATION, AND CHOLESTASIS IN BILE analysed for all the patients who were seen for benign biliary dis- DUCT LIGATED (BDL) RATS. eases and undergone surgery in the institution.18 patients were found to be eligible for the study. Their clinical features, investiga- Min Young Kim1, Ho Soon Choi1*, Kyo-Sang Yoo1, Hye Young Lee1, tions, imaging, ERCP findings,operative findings and outcome were Eun Jin Kim1, Kang Nyeong Lee1, Dae Won Jun1, Hang Lak Lee1, Oh reviewed. Young Lee1, Byung Chul Yoon1, Ki Seok Jang2, Dong Ho Choi3. Results: The common indications for the surgery remain stone 1Department of Internal Medicine, 2Pathology, and 3General diseases including Mirrizi‘s syndrome (10/18), choledochal cyst Surgery, Hanyang University College of Medicine, Seoul (3/18) and biliary tract injuries (3/18). Uncommon indication Objectives: Six cyclic monoterpenes has choleretic properties and include chronic pancreatitis and choledochoduodenal fistula with inhibits the formation of cholesterol crystals in bile. Choleretic cholangitis. • 50 % (9/18) patients were directly taken up for effects of Rowachol increase the volume of biliary secretion; candi- surgery. (5/18) patients had undergone ERCP before reaching to us. date of possible cholelitholytic agent. However, whether Rowachol In (4/18) patients ERCP was attempted but could not be done. has a protective role in obstructive cholestasis remains unclear. The • Patients underwent Roux-en-Y Hepatico-jejunostomy (13/18) and aim of this study is to investigate the protective effect of Rowachol CBD exploration (5/18 -2*). Cholecystectomy was the most on liver injury induced by BDL, as well as the potential mechanism. common previous surgery (3/18) and one patient has undergone Methods: We divided male Sprague-Dawley rats into 5 groups T-tube drainage for Choledochal cyst perforation in the past. In (n=7/group): Group 1 : sham operated group with saline (n=7), (5/18) patients congenital anomaly of ductal system and normal Group 2 : BDL group with saline_3 Days (n=7), Group 3 : BDL group vascular variant was noted. CBD stent was removed from 4 with Rowachol (provided from Pharmbio Korea Co. Seoul, Korea)_3 patients,one had stent left in situ for 3 years. • Wound infection Days (n=7), Group 4 : BDL group with saline_7 Days (n=7), Group 5 and ascites remained most common complications, while one : BDL group with Rowachol_7 Days (n=7). Twenty-four hours after patient developed bile leak.One patient required additional proce- surgery, each group followed by saline or Rowachol treatment daily dure for retained stone following Laparoscopic CBD exploration. for 3, 7 days. We perform biochemical, western, RT-PCR, IHC and There was no mortality. On long term follow up (12/18) patients histologic evaluation. were clinically and biochemically normal. Results: Liver index in the BDL group increased highly compared to Conclusion: Even with wide availability of endoscopic procedures, control group. Compared to the BDL group, rats treated with the surgical intervention is still required. A good patient and procedure dose 0.31mmol/kg of Rowachol slightly decreased the liver index selection and understanding of biliary anatomy is essential to have and cholestasis. Rowachol does not cause liver injury in SD rat for good outcome. 7days and 14 days. Serum aspartate aminotransferase (ALT), alanine aminotransferase (AST), and alkaline phosphatase (ALP), total bilirubin, direct bilirubin, and gamma GGT increased signifi- P-013 cantly in BDL group for 7days were reduced in BDL group with Rowachol for 7days. In the BDL group, there was tissue disorgani- LIVER REMNANT FUNCTION IN METASTATIC COLORECTAL CANCER zation with loss of hepatocyte cords and inflammatory infiltration. PATIENTS However, liver histology was improved in the BDL group with A.A. Burlaka, V.I. Dorozhynskyi, O.O. Kolesnik Rowachol. BDL group for 7days showed significant increases in liver National Cancer Institute, Kyiv, Ukraine mHAI and bile duct proliferation. BDL group with Rowachol revealed lower scores for mHAI. The mRNA expression levels of bile Introduction: In case of colorectal cancer patients with liver metas- acid synthesis (Cyp7a1, Cyp7b1, and Cyp27a1) were decreased in tases (mCRC), liver surgery increases the threat of postoperative the 7days BDL group with Rowachol. Also, Hepatic detoxification acute liver failure (ALF). The aim of our study is the functional state enzymes were increased in the 7days BDL group with Rowachol. of hepatocytes of liver remnant investigation.

218 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Material and methods: Patients with resectable forms of colo- adverse prognostic factor in ICC cohort, possibly through KRAS rectal cancer and liver metastases (n=25). Lactate in the liver tissue signaling with auto- regulation, and through TUBB3 interplayed was determined spectrophotometrically. Defining the detoxifying with HuR. Expression of miR-200 family, TUBB3 and cytoplasmic function of biological oxidation coupling of phosphorylation in HuR helps differentiate primary liver cancers, as well to predict hepatocytes was performed by electron paramagnetic resonance long-term outcome. at a temperature of liquid nitrogen. Results: In the cult the liver tissue revealed a functional exhaustion detoxification capacity of hepatocytes (levels of oxidized and lowspin P-015 form of cytochrome P-450 system in the catalytic cycle of detoxifica- tion were 0,33 ± 0,08 RU and 1,11 ± 0,13 RU respectively). A RESECTED CASE OF METACHRONOUS CHOLANGIOCARCINOMA Mitochondria of this cells operate in violation of phosphorylation OCCURRED AFTER PANCREATICODUODENECTOMY FOR CANCER coupling oxidation in NAD•H-ubiquinone oxidoreductase. Levels OF THE EXTRAHEPATIC BILE DUCT FeS-protein N-2 in eleсtron-transport complex was 0,32 ± 0,06 RU. M.Oba, Y.Nakanishi, K.Okamura, T.Tsuchikawa, T.Nakamura, Also it was noted increasing levels of NO-FeS-proteins to the values S.Murakami, Y.Ebihara, Y.Kurashima, T.Noji, T.Asano, of 0,33 ± 0,08 RU. (normal levels are 0,14 ± 0,07), which is the cause T.Kawamura, D.Miyasaka, T.Shichinohe, S.Hirano of mitochondrial energy function and formation of cellular hypoxia, Department of Gastroenterological Surgery II, Division of which correlates with increased levels of lactate in the liver tissue (> Surgery, Faculty of Medicine, Hokkaido University, Sapporo, 2.00 mkM/g•tissue at a rate of 1,80 ± 0.26 mkM/g•tissu)e and 060-8638, Japan. demonstrates the functioning of hepatocytes in hypoxic conditions. Conclusions: We found that ALF can diagnose by the level of Objectives: We present a case of metachronous cholangiocarcinoma lactate in the liver tissue. In future research it should explore in the intrahepatic duct occurred 23 months after Pancreato- the sensitivity of this marker for complications and mortality duodenectomy (PD). prognosing. For the prevention of intestinal barrier function and Methods (Case presentation): A 78-year-old man who underwent intestinal microbial balance, leading to systemic inflammation and PD with extended bile duct resection including hilar plate for a infectious complications considers it appropriate to monitor the cancer of the extrahepatic bile duct. The histopathological diagnosis activity of NADPH-oxidase in neutrophils and iNOX. was well-differentiated adenocarcinoma with superficial spread. All the margins of the specimen were proved pathologically to be free of the tumor. Twenty-three months after the surgery, a tumor in P-014 segment 4 of the liver and a small nodule in the hepatic duct near the previous anastomotic site was detected by image findings. Under a OPPOSITE PROGNOSTIC ROLE OF MICRORNA- 200 FAMILY UPON diagnosis of recurrence at the hepaticojejunostomy with liver metas- PRIMARY LIVER CANCERS tasis, chemotherapy with GEM and TS-1 were administered. After 12 months of chemotherapy, the hepatic lesion had been disappeared, Yu-Tung Wu, Pei-Jung Katy Chung, Yu-Xun Chang, Tse-Ching then left hepatectomy combined with the resection of hepatico- Chen, Ta-Sen Yeh jejunostomy was performed. Department of Surgery, Chang Gung Memorial Hospital, Results: The histopathological specimen revealed that carcinoma in Chang Gung Memorial University situ expanded along large bile duct of the segment 2, 3, and 4. The 5 Fu-Hsing Street, Kwei-Shan Taoyuan 33305, Taiwan lesion was accompanied by extremely localized invasive mucinous Background: MicroRNA (miR)-200 family, long recognized as a carcinoma. The final diagnosis was intraductal papillary neoplasm of tumor suppressor, plays an important role upon hepatocellular the bile duct (IPNB) associated with invasive carcinoma. No metasta- carcinoma (HCC) undergoing epithelial-to-mesenchymal transition sis lesion was shown in liver parenchyma. Since the lesion was far (EMT); whereas the expression of miR-200 family in intrahepatic from the anastomotic site of previous surgery, it was diagnosed as cholangiocarcinoma (ICC) and combined ICC and HCC (cHCC-ICC) not a recurrence but a “de novo” metachronous cholangiocarcino- remain unexplored. ma. The postoperative course was uneventful and radiological Methods: Sixty-five ICC, 27 cHCC-ICC and 60 HCC were enrolled for examinations has shown no evidence of recurrence, during the measurement of miR-200 family and its targeted molecule, TUBB3, follow up periods of 60 months after the second surgery. and HuR (a RNA binding protein), respectively. In vitro gain- and Discussion: Multicentric adenocarcinoma of the biliary tract is very loss-of functional studies were conducted using the cholangiocarci- rare. Some reports state that repeated resection for metachronous noma cell lines. adenocarcinoma might improve survival of these patients. Results: Expression of miR-200 family was up-regulated in ICC and Conclusions: We present a case of metachronous cholangio- was down-regulated in HCC, with cHCC-ICC as the intermediate. In carcinoma treated successfully by hepatectomy following PD. situ hybridization confirmed that the expression of miR-200c was derived from the neoplastic cells. TUBB3 and cytoplasmic but not P-016 nuclear HuR were highly expressed in ICCs, compared to those of cHCC-ICCs and HCCs (p<0.01, p<0.01). Over-expression of miR-200c DIGITAL GENE EXPRESSION ANALYSIS REVEALS PREDICTIVE was correlated with KRAS mutation in ICC cohort, and represented GENES FOR RECURRENCE IN BILIARY TRACT CANCER an adverse prognostic factor. Functional studies demonstrated an 1 1 1 auto-regulation loop existing between miR-200c and KRAS. Cellular Hironori Ryota , Hiroaki Yanagimoto , Sohei Satoi , Tomohisa 1 1 1 1 invasion of high miR-200c-expressing HuCCT1was attenuated by Yamamoto , Hisashi Kosaka , Satoshi Hirooka , So Yamaki , 1 1 2 1 depleting HuR and enhanced by anti-miR-200c, respectively; while Masaya Kotsuka , Yoichi Matsui , Koji Tsuta , Masanori Kon 1 their effects were neutralized by the simultaneous administration. Department of surgery, Kansai Medical University 2 Conclusion: Unlike miR-200 family acting as a tumor suppressor on Department of laboratory medicine, Kansai Medical University HCC through EMT, miR-200 family works phenotypically as an Objectives: Biliary tract cancer(BTC) with recurrence is poor

Surgery, Gastroenterology and Oncology, 22 (3), 2017 219 ABSTRACTS

prognosis. There is little evidence to improve the prognosis in these Objectives: Type IV peri-hilar cholangiocarcinoma often have major groups with several treatments. The aim of the current study is to vascular invasion due to anatomical proximity. To obtain negative determine the recurrence prediction genes in BTC with digital gene resection margins, it may need major hepatectomy with vascular expression analysis with nCounter analysis system. resection. This procedure is technically demanding. Several authors Methods: We examined 69 patients with BTC who underwent reported negative results especially for combined hepatic artery surgery. RNA was extracted from surgical specimen and examined in resection. We report case of left trisectionectomy combined with a molecular counting assay, which counts RNA molecules by simulta- simultaneous portal vein and hepatic artery resection for type IV neous hybridization of several probes. The molecule counting assay tumor. was done with custom code set of 45 genes which selected from 770 Methods: Patient with type IV peri-hilar cholangiocarcinoma cancer related genes. Patients were devided into recurrence group involving portal vein and hepatic artery. Preoperatively, patient (28patients) and no recurrence group (41patients). We researched underwent percutaneous biliary drainage via right posterior duct RNAs with significant differences in expression between the two and embolization of left & right anterior portal vein. Post-emboliza- groups. tion CT volumetry showed 38% future remnant liver volume. At Results: We identified the high and low expression of genes in operation, after careful exploration for extrahepatic metastases, recurrence group. Interleukin-8(p=0.000258), Oncostatin M dissection around Rouviere's sulcus was performed to assess (p=0.00264) and Leukemia inhibitory factor(p=0.00492) were high resectability. Skeletonization of hepatoduodenal ligament and expression. These genes were expressed regardless of R1 and distal bile duct transection were performed. Distal right posterior lymph node metastasis. portal vein and hepatic artery were encircled. Left portal vein and Conclusions: High expression of Interleukin-8, Oncostatin M, left hepatic artery were divided. After complete parenchymal Leukemia inhibitory factor genes can be a predictive marker of transection and caudate lobe resection, right posterior duct was recurrence. People in these groups are necessary to introduce divided. Then, right posterior hepatic artery and portal vein were adjuvant therapy with or without lymph node metastasis and to transected. Surgical specimen was removed. Right posterior portal shorten the follow interval. vein was re-anastomosed to main portal vein. Right posterior hepatic artery was reconstructed using rotating gastroduodenal artery under microvascular technique. Intraoperative ultra- P-017 sonography was performed to ensure good intrahepatic vascular flow. Then, Roux-en Y hepaticojejunostomy was performed. COMBINED VASCULAR RESECTION BENEFITS OF PERIHILAR Results: Left trisectionectomy combined with vascular resection CHOLANGIOCARCINOMA PATIENTS IS CONTROVERSIAL. was performed successfully without intraoperative complications. THIS STUDY WAS UNDERTAKEN TO COMPARE MORBIDITY AND Operative time was 540 minutes and estimated blood loss 500 ml. MORTALITY IN PATIENTS WITH PERIHILAR CHOLANGIOCARCINOMA Pathology showed cholangiocarcinoma with portal vein and WITH OR WITHOUT VASCULAR RESECTION AND THE EFFECT hepatic artery invasion. Uninvolved all resection margins but posi- OF COMBINED VASCULAR RESECTION TO RESECTABILITY. tive 3/12 lymph nodes. Patient was discharged on postoperative Alikhanov R.B., Efanov M.G., Kazakov I.V., Akhaladze D.G., day 12 without peri-operative complications. Kim P.P., Vankovich A.N., Tscirkun V.V. Conclusions: Left trisectionectomy combined with simultaneous portal vein and hepatic artery resection for type IV peri-hilar Methods: Clinical data of 62 perihilar cholangiocarcinoma patients cholangiocarcinoma is feasible procedure and provide chance for who had been treated in Moscow Clinical Scientific Center from achieving negative resection margins. December 2013 to April 2017 were retrospectively analyzed. The patients were divided into two groups based on vascular resection: P-019 those without vascular resection; those with portal vein resection alone and/or those with hepatic artery resection. The complication PAPILLARY CARCINOMA OF THE GALLBLADDER: A DISTINCT rates, mortality and the number of R0 resection were compared VARIANT among the two groups. Results: No significant differences were found in complication Mahim Koshariya, Surbhi Garg, Prashant Kharat, Sameer rates, mortality among the two groups (P>0.05). The number of R0 Ahmed, Abhishek Shitole, Sheikh Behram, M.C. Songara. resections were significantly increased in patients with vascular Gandhi Medical College and Hamidia Hospital, Bhopal, resection. 462001 India Conclusions: Vascular resection improved resectability rate of Introduction: Papillary are the rare variants patients with perihilar cholangiocarcinoma and do not increase accounts for only 5 % of gall bladder malignancy and have much their morbidity and mortality. better prognosis as compared to the adenocarcinoma gallbladder and this favourable outcome is due to its delayed invasion in tissue, exophytic growth and possibly early clinical presentation obstruc- P-018 tive symptoms. LEFT TRISECTIONECTOMY COMBINED WITH SIMULTANEOUS Objectives: This paper intends to analyze the clinicopathological PORTAL VEIN AND HEPATIC ARTERY RESECTION FOR TYPE IV features of papillary adenocarcinoma of gallbladder and its surgical PERIHILAR CHOLANGIOCARCINOMA: A CASE REPORT outcome. Methods: Between the period of Janaury 2006 to December W Taesombat, M Sutherasan, B Nonthasoot, S Nivatvongs, 2016 there was total 5 cases of papillary adenocarcinoma of the B Sirichindakul gallbladder which were pathologically diagnosed post operatively. All Department of Surgery, Faculty of Medicine, King the patient underwent properative evaluation by ultrasound and Chulalongkorn Memorial Hospital, Chulalongkorn University, CECT of abdomen and underwent surgical resection. Bangkok, 10330 Thailand. Results: The 5 patients with papillary carcinomas included 4

220 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

women and 1 men, aged 50-72 years, 2 patient had gall stone Objectives: To assess the role of a pre-operative chemotherapy on disease. 3 patients underwent Laparoscopic Cholecystectomy, liver regeneration following formal right hepatectomy for CRLM. Extended laparoscopic cholecystectomy in 1 patient and 1 patient Background: Neo-adjuvant systemic chemotherapy is frequently underwent open cholecystectomy. The pathological lesion was well used prior to surgical resection of CRLM. While chemotherapy has to moderately differentiated. Patients were followed up for a been shown to induce histopathological changes in liver parenchyma, period of 10 years. its impact on liver regeneration remains poorly assessed. Conclusions: Though adenocarcinoma of the gallbladder has Patients and methods: This retrospective study included 40 dismal prognosis, the rare variety of papillary adenocarcinoma has patients undergoing right hepatectomy for CRLM. Patients were got the better prognosis in terms of surgical outcome and survival, allocated to two groups according to the number of chemotherapy irrespective of tumour size and degree of differentiation. And cycles delivered pre-operatively: 0 to 6 cycles (n = 34), 7 or more simple cholecystectomy can be a complete curative procedure. cycles (n = 6). Liver hypertrophy rate was assessed using liver volumetry on pre and post-operative imaging. Results: Patients receiving a sustained pre-operative chemotherapy P-020 (> 6 cycles) exhibited a reduced liver hypertrophy of the left remnant HOW TO TREAT SYNCHRONOUS LIVER METASTASES FROM liver compared to patients receiving 6 cycles or less (471 ml versus COLORECTAL CANCER? 706 ml; P = 0,015). Liver hypertrophy was comparable in patients receiving 6 cycles or less and those without any pre-operative A. Takahashi, K. Amikura, D. Ito, M. Kajiwara, H. Sakamoto. chemotherapy. Preoperative chemotherapy had no influence on Saitama Cancer Center, Saitama, 3620806, Japan. overall post-operative morbidity. Objectives: Recent development of chemotherapy has Conclusion: Pre-operative chemotherapy impairs liver regenera- tremendous impact on patients with advanced colorectal liver tion following right hepatectomy for CRLM. This should be taken metastases (CRLM). The purpose of this study is to clarify the account when planning multi-steps procedures. appropriate strategy for advanced synchronous CRLM. Methods: We retrospectively reviewed 317 patients who under- P-022 went hepatectomy for synchronous CRLM with curative intent. Upfront resection was performed for 245 patients (resectable group). Pre-operative chemotherapy was performed for 72 LAPAROSCOPIC COMBINED COLORECTAL AND LIVER RESECTION patients as initially unresectable CRLM (conversion group, n = 48) FOR METASTATIC COLORECTAL CANCER or marginally resectable CRLM (NAC group, n = 24). Unresectable I. Takorov, Ts. Lukanova, I. Vasilevski, V. Mihaylov, M. Iakova, CRLM means post-operative liver function or volume is not Ts. Trichkov, R. Kostadinov, E. Odisseeva, N.Vladov. acceptable. Marginally resectable CRLM (n=24) presented invasion Department of Hepato-Pancreato-Biliary and Transplant to IVC, metastases to other organs, massive multiple bilobular Surgery – Military Medical Academy, 1606 Sofia, Bulgaria. metastases, and so on. Results: The 3, 5 and 10-year overall survival rate (OS) was 64.0%, Objectives: Nowadays, regarding a personalized multimodal 46.2% and 33.1% respectively. In terms of classification defined by approach, laparoscopic liver and colorectal resections, separately tumor number and size, 5-year OS of H1 (tumor number =<4 and distinguished, are accepted as feasible, safe and oncologically size <5cm), H2 (except for H1 and H3) and H3 (tumor number =>5 equivalent to open resections surgical methods of treatment for and size =>5cm) were 53.2%, 43.0% and 28.4% respectively. colorectal carcinoma. However, there is still no consensus, regarding Univariate analysis revealed that tumor size =>5cm, tumor number the applicability of combined laparoscopic colon and liver resection. =>5 and elevation of CEA or CA19-9 were significant prognostic The aim of the present study is to determine the feasibility of factor. As for the treatment strategy, 5-year OS of NAC group was combined different volume laparoscopic colon and liver resection in significantly superior to conversion group (p=0.0034) but not selected patients with primary colorectal cancer and synchronous significantly better than resectable group (p=0.092). Limiting for H3 liver metastases. patients, 5-year survival rate of the resectable group (n=21, 11.0%) Methods: From April 2014 to April 2017 thirteen patients with was inferior to conversion group (n=25, 27.9%) and NAC group primary CRC and a synchronous liver metastases underwent (n=5, 100%) significantly. combined totally laparoscopic or “hybrid” liver and colorectal Conclusions: Surgical outcome of advanced CRLM such as H3 group surgery. Patient and tumor (primary and metastatic) characteristics, is seriously dismal. Curative hepatectomy followed by preoperative operative variables, and postoperative outcomes were evaluated chemotherapy for advanced CRLM can improve both marginally- prospectively. resectable cases and initially unresectable cases. Both curative Results: The primary tumor was located in the colon in 9 patients resection and adequate chemotherapy are demanding to achieve and in the rectum - in 4 patients. Seven patients had a solitary better outcome, we should emphasize to succeed a series of synchronous liver metastasis and 6 patients - multiple. Surgical proper treatment. approach was totally laparoscopic in 10 patients and the “hybrid” technique was applied in 3 patients. The major hepatic resections were 5. Median operative time was 270 min, with a mean blood P-021 loss of 120 ml for the combined major liver resections and 70 ml for INFLUENCE OF PRE-OPERATIVE CHEMOTHERAPY ON LIVER the group with minor liver resections. The average postoperative REGENERATION AFTER RIGHT HEPATECTOMY FOR COLORECTAL hospital stay was 7,5 days. Postoperative complications were LIVER METASTASES (CRLM) observed in two patients (grade IIIa and IIIb, respectively), mortality rate was zero. R0 resection was achieved in 12 patients, S. Derieux, S. El Mouhadi, T. Hor, P. Balladur and F. Paye. and in one patient laparoscopic combined procedure was the first Department of Digestive surgery .Hôpital Saint Antoine, 184 stage of a two-stage liver resection. Recurrent disease was found in rue du Faubourg Saint Antoine, 75012 Paris France two patients on the 3rd and on the 14th month respectively.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 221 ABSTRACTS

Conclusions: Simultaneous laparoscopic colorectal and liver resec- diuretic that selectively promotes the excretion of water. We tion appears to be feasible in selected patients with CRC and SLM recently introduced tolvaptan for postoperative fluid management on providing an adequate preoperative selection and combined after living-donor liver transplantation (LDLT). surgical expertise. Methods: We compared clinical outcomes of LDLT recipients who were treated with tolvaptan, furosemide, and human atrial natriuretic peptide (hANP) (tolvaptan group, n=16) and those who P-023 were treated with furosemide and hANP only (control group, n=10). Results: There were no significant differences in preoperative and SIGNIFICANCE OF MULTIDISCIPLINARY APPROACH FOR intraoperative demographic data between the tolvaptan and ADVANCED COLORECTAL LIVER METASTASES: A SINGLE control groups except for the follow-up period after surgery. Urine INSTITUTIONAL EXPERIENCE volume was 1242 ± 692, 2240 ± 1307, and 2268 ± 1262 mL on post- operative day 1, 3, and 7, respectively, in the tolvaptan group. J. Shindoh, Y. Kiya, T. Sugawara, Y. Kobayashi, M. Hashimoto. These volumes did not significantly differ from those in control Department of Gastroenterological Surgery, Toranomon Hospital group (1027 ± 462, 1788 ± 909, and 2057 ± 1216 mL on post- Tokyo, 105-8470 Japan. operative day 1, 3, and 7, respectively). There were no significant Objectives: Multidisciplinary team (MDT) approach has reportedly between-groups differences in postoperative body weight gain or been a keyword for the treatment of Stage IV cancers in the era of drainage volume from abdominal drain tubes. Times to hANP modern chemotherapy. However, actual impact of MDT approach discontinuation and central venous catheter removal were signifi- on the treatment outcomes of colorectal liver metastases has not cantly reduced in the tolvaptan group. No severe side effects yet been discussed so well. The objective of this study was to directly related to tolvaptan were observed. Six-month survival was clarify the significance of MDT approach in clinical decision making 90.0% and 93.8% in the control and tolvaptan groups, respectively. process for advanced colorectal liver metastases. Conclusions: The results of this study suggest that addition of Methods: Based on the retrospective review of a prospectively tolvaptan to furosemide and hANP is a safe and effective option for collected clinical database in a single high-volume hepatobiliary postoperative fluid management after LDLT. center, impact of MDT approach including hepatobiliary surgeon on the treatment outcomes of synchronous liver metastases was investigated by comparing the estimated clinical results based on P-025 the initial treatment plans offered by colorectal surgeons and the actual clinical results based on the treatment plans modified by RANDOMISED STUDY COMPARING EFFECT OF RESTRICTED VS hepatobiliary surgeons. LIBERAL FLUID ADMINISTRATION ON POST-OPERATIVE CLINICAL Results: Among 689 patients who underwent curative resections OUTCOME AFTER LAPAROSCOPIC CHOLECYSTECTOMY for primary colorectal lesions between April 2014 and October A. Goel, S.K. Tudu, S. Neogi, S. Ramasamy, A. Jain, S. Prajapati. 2015, 42 (6.1%) patients presented synchronous liver metastases Maulana Azad Medical College, New Delhi, 110002, India. with (n=14) or without (n=28) extrahepatic disease. Proportion of patients who were diagnosed with resectable or potentially Objectives: To find out the effects of restricted vs liberal fluid resectable disease at initial assessment was 40.5% (17/42) by administration on post-operative clinical outcome after laparo- colorectal surgeons and 61.9% (26/42) by hepatobiliary surgeons scopic cholecystectomy. (P=0.049). With adequate combination of preoperative chemo- Methods: We evaluated 50 patients who underwent laparoscopic therapy and advanced hepatobiliary surgical approach, 54.7% cholecystectomy between September 2015 and April 2017. (23/42) patients eventually underwent curative surgical resection Subjective parameters, analgesic and antiemetic requirements and including 4 conversion cases. Based on the outcome-based duration of hospital stay were compared between the two fluid estimation, approximately 20% of patients would have benefit groups. from curative surgical options with 10% of conversion rate among Results: Post-operative subjective parameters like vomiting, initially unresectable population by including hepatobiliary dizziness, fatigue and pain as well as analgesic (p value 0.002) and surgeons in MDT. antiemetic requirement (p value 0.001) were significantly more in Conclusion: MDT approach including hepatobiliary surgeons the restricted group than liberal group. However, the duration of significantly improves resection rate and may offer potential survival hospital stay was similar in both restricted group with mean of benefit even for patients with initially unresectable disease. 19.68 hours and liberal group with mean of 21.36 hours (p value 0.2664). Conclusions: Restricted fluid administration is equally effective if P-024 not superior to liberal fluid administration given intra and post opera- POSTOPERATIVE FLUID MANAGEMNET USING TOLVAPTAN tively in terms of resolution of pain, fatigue, vomiting and dizziness, if AFTER LIVING DONOR LIVER TRANSPLANTATION adequate analgesia and antiemetic are given post operatively on a regular basis. Also, there is no difference in hospital stay with M. Shinoda, H. Obara, M. Kitago, T. Hibi, Y. Abe, H. Yagi, discharge on the same day if early ambulation and early adequate K. Matsubara, G. Oshima, S. Imai, T. Mizota, H. Higashi, oral intake is promoted without any need for excessive fluid O. Itano, and Y. Kitagawa. administration making it a day care procedure without adding on to Department of Surgery, Keio University School of Medicine significant complications. 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan Aim: The vasopressin V2 receptor antagonist tolvaptan is a new

222 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

P-026 urgently needed. Recently, we identified the combination of the death ligand TRAIL and CDK9 inhibition as an exceptional potent WHEN AND HOW TO REMOVE DRAINS AFTER HEPATECTOMY: strategy to selectively kill tumor cells. Here, we evaluated the AN EVALUATION OF DRAIN REMOVAL ON THE THIRD AND FIRST combination of the clinical tested CDK9-inhibitor Dinaciclib and POSTOPERATIVE DAY TRAIL for HCC and investigated underlying molecular mechanism. The combination of Dinaciclib and TRAIL synergistically and Akihiko Ichida, Kiyoshi Hasegawa, Yoshiharu Kono, Nobuhisa effectively reduced cell viability in HCC cells and, importantly, Akamatsu, Junichi Arita, Junichi Kaneko, Yoshihiro Sakamoto, almost completely abolished clonogenic survival of these cells. The Norihiro Kokudo. combination induced cell cycle arrest and caspase-8-dependent Hepato-Biliary-Pancreatic Surgery Division, Department of apoptosis in these cells. Moreover, this combination displayed a Surgery, Graduate School of Medicine, The University of Tokyo, superior cytotoxic effect in HCC cells compared to Sorafenib treat- Tokyo, Japan ment alone. Interestingly, this combination overcame acquired Background: There is no standard way of drain management after Sorafenib-resistance in HCC cells by the shift of the ratio of pro- and hepatectomy. We introduced early removal of drains in a step-by- anti-apoptotic proteins on the transcriptional level. In conclusion, step manner. Outcomes of drain removal on postoperative day due to its potency, CDK9-inhibition in combination with TRAIL (POD) 3 and POD 1 were evaluated. provides a novel and promising therapeutic approach for Methods: Conventionally, drains were pulled out gradually from Sorafenib-resistant HCC. POD 7 and removed within 14 PODs in our institute (control group). Recently, we defined the criteria for early removal of drains: (i) P-028 drain-fluid bilirubin level below 3 mg/dl; (ii) drain discharge volume less than 500ml/day; (iii) macroscopic findings of the drain COMPARATIVE CLINICAL OUTCOMES OF LIVER RESECTION FOR discharge neither bloody nor infected. In patients meeting the HEPATOCELLULAR CARCINOMA WITH AND WITHOUT BILE DUCT criteria, drains were removed on POD 3 between January 2012 and TUMOR THROMBUS February 2013 (POD 3 group), and on POD 1 between February and December 2013 (POD 1 group). Outcomes were compared L. Worakitti, L. Akkaphod, J. Sunhawit, K. Wasana, S. Trichak between groups. and C. Anon. Results: Median duration of postoperative hospital stay was shorter HBP surgery unit, Department of Surgery, Faculty of Medicine, in POD 3 group (11 days, range 7-60) than in the control group (14 Chiang Mai University, Chiang Mai, Thailand 50200 days, range 7-41) (P < 0.0001). The incidence of drain infection was Background: Hepatocullular carcinoma (HCC) presenting with lower in POD 3 group (1.2%) than in the control group (5.7%). The obstructive juandice caused by bile duct tumor thrombus(BDTT) is incidence of grade B bile leakage and complications ≥ grade III did not an uncommon event. The role of hepatectomy and clinical increase in POD 3 group (1.2% and 2.4%) compared with those in the outcomes are remaining controversy. The aim of this study was to control group (2.3% and 3.5%). Meanwhile, in POD 1 group, median evaluate short and long-term outcomes of hepatectomy for HCC duration of postoperative hospital stay was 11 days (range 6-37), with BDTT comparing to non-BDTT. which was comparable to POD 3 group. However, the incidence of Methods: Total twenty-two HCC patients with BDTT who under- grade B bile leakage and complications ≥ grade III was higher (5.7% went hepatectomy in author’s institute were retrospective and 4.6%) than other groups. When limited to patients whose drains reviewed of shot and long-term outcomes comparing with 111 HCC were actually removed, the incidence of bile leakage and complica- patients without BDTT. An impacted of BDTT to clinical outcome tions in POD 1 group was almost the same as other groups. and survival benefit after surgical resection was analyzed. Intraoperative findings were also taken into account when removing Results: HCC with BDTT group presenting with higher level of drains. serum total bilirubin, alpha-fetoprotein and CA 19-9. Six HCC Conclusions: Drain removal on POD 3 reduces the length of post- patients with BDTT (26.1%) received preoperative percutaneous operative hospital stay and the incidence of drain infection without transhepatic biliary drainage (PTBD). All HCC with BDTT cases impairing safety. However, we should take into account the intra- received major hepatectomy VS 32.4% in non-BDTT group. The operative findings to remove drains safely on POD 1. HCC patients with BDTT who underwent hepatectomy have longer operative time (420 VS 217 minute), more blood loss (1,200 VS 500 P-027 ml) and higher morbidity (53.5% VS 16.7%). Two patients in BDTT group death within 30 days from peri-operative sepsis and post- CDK9-INHIBITION AND TRAIL OVERCOMES hepatectomy liver failure. The 1-, 3- and 5-year survival rates of SORAFENIB-RESISTANCE OF HEPATOCELLULAR CARCINOMA BDTT group were 85.7%, 71.4%, and 71.4%, respectively. These were slightly lower than non-BDTT group (97.3%, 82.9%, and J. Lemke, E. Kitzig, A.L. Kretz, U. Knippschild, D. Henne-Bruns. 81.1%, respectively) but no statistical significant (P-value = 0.208). Clinic of General and Visceral Surgery, University of Ulm, BDTT was not showed impact to survival and recurrence (P-value = Albert-Einstein-Allee 23, 89081 Ulm, Germany 0.608, 0.807). Only tumor size more than five centimeters dose Sorafenib remains the standard therapy for patients with advanced impact to both survival and recurrence (P-value = 0.015, 0.001). HCC despite considerable side-effects and the fact that systemic Conclusion: Bile duct obstruction from tumor thrombus does not treatment only prolongs survival by a few months. One major imply as an advanced disease. HCC with BDTT patients can achieve reason for its limited efficiency is the fact that that HCC cells favorable surgical outcomes and long term survival after liver commonly exhibit or acquire resistance to Sorafenib. Therefore, resection when appropriate operation is carefully selected. novel effective and cancer-selective therapeutic strategies are

Surgery, Gastroenterology and Oncology, 22 (3), 2017 223 ABSTRACTS

P-029 Results: In the segmental group (n = 20), H/L ratio and enhance- ment volume of HCC and liver parenchyma were significantly lower EXPRESSION OF LYSYL OXIDASE LIKE-2 IN HEPATOCELLULAR with balloon occlusion than without balloon occlusion. However, in CARCINOMA AND ITS CLINICAL SIGNIFICANCE the subsegmental group (n = 18), H/L ratio was significantly higher Go Ninomiya1, Suguru Yamada2, Kazuomi Takeda2, Hideki Takami2, and liver parenchyma enhancement volume was significantly lower Masaya Suenaga2, Masamichi Hayashi2, Yukiko Niwa2, Tsutomu with balloon occlusion; HCC enhancement volume was similar with Fujii2, Hiroyuki Sugimoto2, Yasuhiro Kodera2. and without balloon occlusion. Rate of change in H/L ratio and 1Toyohashi Medical center,Toyohashi, 440-8510, Japan enhancement volume of HCC and liver parenchyma were lower in 2Nagoya University Graduate School of Medicine, Nagoya, the segmental group than in the subsegmental group. There were 466-8550 significantly more perfusion defects in the segmental group. Conclusions: Hepatic artery occlusion causes hemodynamic Objective: In this study, we investigated the role of LOXL2, the changes in HCC and liver parenchyma, especially with segmental correlation between LOXL2 and epithelial to mesenchymal transition occlusion. (EMT), and the effects of using beta-aminopropionitrile (BAPN) to inhibit LOXL2 with the goal of reducing tumour progression in hepatocellular carcinoma (HCC). P-031 Methods: The expression level of LOXL2 was evaluated in HCC and adjacent noncancerous tissues using quantitative reverse transcrip- INCORPORATION OF DNMT1 AND HLA-DRΑ WITH TNM STAGING tion polymerase chain reaction and clinicopathological analyses. IN HCC The effects of BAPN on cell proliferation, migration, and invasion Haowen Tang, Wenping Lu, Zhanyu Yang, Yongliang Chen, were investigated in vitro. Additionally, LOXL2 expression was Jing Wang, Shichun Lu, Kai Jiang. measured in the culture supernatants of HCC cell lines. Hospital and Institute of Hepatobiliary Surgery, Chinese PLA Results: Our results show that LOXL2 expression was higher in HCC General Hospital, Beijing100853, China cell lines and tissues. There was a significant correlation between EMT status and LOXL2 levels (p=0.004). BAPN reduced migration Background: Hepatocellular carcinoma (HCC) is the most common and invasion in HCC cells. HCC patients with high levels of LOXL2 type of hepatic cancer and is particularly a problem in China. Bio- expression had relatively shorter disease-free survival (p=0.009) molecular markers have been demonstrated to be of prognostic and overall survival (p=0.035) times. The expression level of LOXL2 significance and might help predict tumor behavior. Methods: In was similar between cell supernatants and HCC cell lines. A multi- our study, we aimed to assess the prognostic values of DNA methyl- variate analysis demonstrated that portal vein invasion (p=0.015), transferase 1 (DNMT1), HLA-DRα, and β-catenin, as well as the venous invasion (p=0.026), serum AFP (α-fetoprotein) levels combined use of molecular biomarkers, clinicopathological (p=0.019), and LOXL2 expression (p=0.009) were independent parameters and the TNM staging system to find a method for prognostic factors. superior prognostic performance for HCC by analyzing a Chinese Conclusions: Our results suggest that a higher level of LOXL2 may HCC cohort. contribute to tumour progression, indicating that LOXL2 has clinical Results: We revealed the significant prognostic roles of DNMT1 value as a therapeutic target in HCC. (OR: 2.570; 95% CI: 1.401-4.715; P = 0.002) and HLA-DRα (0.350; 0.189-0.616; 0.001), and further developed an estimation formula to predict prognosis in HCC patients after curative resection, based P-030 on TNM staging, operative blood loss, abnormal total bilirubin, HEMODYNAMICS IN HCC AND LIVER PARENCHYMA UNDER DNMT1 and HLA-DRα. The receiver operating characteristic curve HEPATIC ARTERY BALLOON OCCLUSION AND ITS THERAPEUTIC analysis showed that prediction from the multivariate logistic APPLICATION regression had an area of 0.847 and performed better than the conventional TNM staging system, as well as other current HCC F. Sugihara, S. Murata, T. Ueda, D. Yasui, H. Saito, C. Kawamoto, staging systems. E. Uchida, S. Kumita. Conclusion: Our study demonstrated the prognostic values of Nippon Medical school, Tokyo, 113-8603, Japan DNMT1 and HLA-DRα in HCC patients after curative resection. Additionally, we developed a prognostic estimation formula Objectives: Balloon-occluded transarterial chemoembolization featured better stratification ability than the conventional TNM (B-TACE) method has recently gained attention again as a useful staging and provided a practicable stratification method for HCC treatment for hepatocellular carcinoma (HCC). However, hemo- patients after curative resection. dynamics of the liver and tumor under balloon occlusion of the hepatic artery has not been evaluated, and the effectiveness of B-TACE remains controversial. Therefore, the aim of this study was P-032 to investigate hemodynamic changes in HCC and liver parenchyma under hepatic artery occlusion. INSULIN TREATMENT CAN ACCELERATE THE RECURRENCE Methods: Thirty-eight HCC nodules in 25 patients were included. OF HEPATOCELLULAR CARCINOMA AFTER SURGERY Computed tomography (CT) hepatic arteriography (CTHA) with and H. Baba, K. Shibuya, I. Yoshioka, H. Kojima, M. Moriyama, without balloon occlusion of the hepatic artery was performed. CT S. Sekine, I. Hashimoto, S. Hojo, T. Okumura, T. Nagata, attenuation and enhancement volume of HCC and liver parenchyma S. Hirokawa, T. Fujii. with and without balloon occlusion were measured on CTHA. Department of Surgery and Science Influence of balloon position (segmental or subsegmental branch) Graduate School of Medicine and Pharmaceutical Sciences was evaluated based on differences in HCC-to-liver parenchyma University of Toyama, 2630, Sugitani, Toyama 930-0194 Japan attenuation ratio (H/L ratio) and enhancement volume of HCC and liver parenchyma. Aim: Insulin treatment is a possible risk factor for hepatocellular

224 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

carcinoma (HCC) in patients with diabetes mellitus (DM). However, was 14 months and the actual 1 and 3-year overall survival rates the effect of insulin treatment on the prognosis after the surgical were 64 and 18 %, respectively. treatment of HCC is unclear. In the present study, we examined the Conclusions: Dual treatment could offer mild-term survival in a effect of insulin treatment on the prognosis of HCC patients after subset of patients with major portal invasion who were previously hepatectomy. deemed to have dismal prognosis. However, our strategy yielded Methods: We examined 124 HCC patients who underwent hepa- much longer survival term than any other previous reports. Dual tectomy from 2004 to 2014 at our hospital and met the following treatment should be considered as a first line treatment. criteria: 1) hepatectomy was the initial treatment for HCC and 2) surgery was curable. We focused on the treatment for DM after surgery, which was reviewed retrospectively from the medical P-034 records. Results: Out of 124 patients, 54 (44%) were diagnosed with DM. PREDICTION OF POSTHEPATECTOMY LIVER FAILURE IN PATIENTS Relapse-free survival (RFS) and overall survival (OS) were not WITH HEPATOCELLULAR CARCINOMA significantly different between the DM and non-DM groups. Out of H. Nishida, S. Hai, E. Hatano, T. Okada, Y. Asano, N. Uyama, 54 patients with DM, 15 (28%) were treated with insulin. RFS was K. Suzumura, I. Nakamura, M. Tada, Y. Kondo, K. Iida, H. Sueoka, significantly shorter in patients who received insulin treatment A. Kurimoto, R. Ito and J. Fujimoto. than in those who did not (median RFS 468 days vs. 1376 days, Department of Surgery, Hyogo College of Medicine respectively; log-rank p = 0.0121), but OS was not different Nishinomiya, Hyogo, 663-8501, Japan between both groups. RFS remained significantly different even after adjustment for other factors such as sex, age, liver disease, Objectives: Posthepatectomy liver failure (PHLF) is a fatal complica- Child–Pugh class, histopathology of background liver, and clinical tion in patients with hepatocellular carcinoma (HCC). Recently, pre- stage (hazard ratio 4.30, p = 0.0016). On the other hand, RFS and operative 3D-CT simulation has enabled us to estimate the future OS were not significantly different between groups with low HbA1c remnant liver volume (FRLV) properly. This study aimed at clarifying (<7.5%) and high HbA1c (≥7.5%). what predicts PHLF. Conclusion: Insulin treatment can be a prognostic factor for recur- Methods: The retrospective study was performed on 112 patients, rence after surgery in HCC patients. who underwent hepatectomy for HCC with preoperative simula- tion using Synapse Vincent between January 2013 and June 2016. P-033 The plasma disappearance rate of indocyanine green of the future remnant liver (ICGKrem) was calculated as ICGK multiplied by MULTIDISCIPLINARY TREATMENT FOR STAGE B, C %FRLV. PHLF was defined according to the International Study HEPATOCELLULAR CARCINOMA Group of Liver Surgery. Results: Estimated resection liver volume with tumor showed a Y.Yasuhara, M.Kido, M.Tanaka, H.Kinoshita, S.Komatsu, strong correlation with weight of resected liver specimen (r=0.969, D.Tsugawa, M.Awazu, H.Gon, M.Tyuma, K.Arai, K.Tai, p<0.001). PHLF occurred in 26 patients (23.2%); grade A in 19 H.Mukubou, S.Terai, H.Toyama, K.Ueno, Y.Ku, T.Fukumoto. patients (17.0%), grade B in 6 patients (5.4%), and grade C in 1 Department of Surgery, Division of Hepato-Biliary-Pancreatic patient (0.9%). Patients with PHLF required significantly longer Surgery, Kobe University Graduate School of Medicine, Chuo-ku, postoperative hospital care than the patients without PHLF Kobe, Hyogo, Japan. (median: 22.5 vs. 18 days). There were significantly differences in Department of Surgery, Kohnan Hospital, Kobe, Hyogo, Japan. ICGK (AUROC; 0.693), ICGKrem (0.672), platelet count (0.649) and Background: According to Barcelona Clinic Liver Cancer (BCLC) intraoperative blood loss (0.630) between PHLF and non-PHLF staging system, TACE for Stage B hepatocellular carcinoma (HCC) groups. By multivariate analysis using a logistic regression model and sorafenib for Stage C HCC are standard treatment. However, determined by univariate analysis, ICGKrem and platelet count the results are not satisfactory at all in spite of a ratio to become a were independent predictive factors of PHLF (p<0.05). target patient accounting for 60%. Prothrombin time and intraoperative blood loss were risks for Aim: This retrospective trial was to determine the prognosis of grade B/C PHLF by multivariate analysis. multidisciplinary treatment using percutaneous isolated hepatic Conclusions: ICGKrem might predict PHLF in patients with HCC. perfusion (PIHP) for Stage B, C HCC. Control of intraoperative bleeding is important to prevent grade Materials and Methods: Between January 1989 and December B/C PHLF. 2015, 224 consecutive patients with Stage B, C HCC were enrolled in prospective clinical trials of PIHP. 104 patients who had good P-035 liver function received sequential reductive hepatectomy. Out of 104 patients, 10 did not complete PIHP because of hepatic dysfunc- SHORT AND LONG-TERM OUTCOME OF LIVER RESECTION tion or other reasons. 14 patients received preoperative PIHP. 4 FOR ELDERLY PATIENTS WITH HEPATOCELLULAR CARCINOMA patients received the combination of particle radiotherapy and PIHP. H. Nakayama, T. Takayama, Y Midorikawa Results: The median overall survival (MST) of all 104 patients in the Department of Digestive Surgery, dual treatment group was 19 months and the actual 1, 3, and Nihon University School of Medicine, Tokyo, 173-8610, Japan 5-year overall survival rates were 70, 28, and 21 %, respectively. A Background: Number of elderly patients who underwent resection total of 94 patients completed the dual treatment and its local of hepatocellular carcinoma (HCC) are increasing in recent years. control rate was 67%. And 75 patients in the group of the dual Objectives: The postoperative outcome for these patients were treatment categorized Stage C. But the MST of 75 patients catego- evaluated. rized Stage C who completed the dual treatment is 19 months. And Methods: 1267 patients (mean age: 66 years) between 1990 and more, the MST of all 14 patients in the group of preoperative PIHP 2015 who underwent resection of HCC were enrolled in this study.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 225 ABSTRACTS

The patients background factors, operative factors, tumor factors (5.4% versus 1.8% at 1 year, 8.7% versus 4.1%, p=0.115). and prognosis were evaluated in 239 elderly patients aged 75 years Conclusions: MRFA represents a safe and effective alternative to and more (19%) and 1028 younger patients aged less than 75 years SR for non-subcapsular HCC of 20 to 50mm, both in the setting of (81%). a bridge to LT, or for patients with severe underlying liver-disease. Results: Although the percentage of the elderly patients in 1990s was 6%, it in 2010s was 35%. In elderly group, 182 patients were under 80 years old (76%) and 57 patients were 80 years and more P-037 (23%). The ratio of patients who had hepatitis B virus was significantly lower (p=0.000) than that of younger patients. As CLINICAL ADVANTAGES OF SINGLE PORT LAPAROSCOPIC LIVER hepatitis C virus, no differences were found between the two SURGERY groups. Examinations revealed lower values of haemoglobin JH Han, YK You, HJ Choi, TH Hong, DG Kim. (p=0.000), serum albumin (p=0.001) and total bilirubin (p=0.001), Division of HBP Surgery and Liver Transplantation higher values of platelets (p=0.004), prothrombin (p=0.000) and Department of Surgery, Seoul St. Mary's Hospital, The Catholic creatinine (p=0.043) in elderly patients. Although no differences in University of Korea, 06591, Seoul, Korea duration of operation, amount of intraoperative blood loos and blood transfusion were lower in elderly patients. There were no Objectives: Single-port laparoscopic liver surgery has been differences in all postoperative complications. Five-year survival performed sporadically. The aim of this study is to assess our was 53.6% in elderly patients and 59.0% in younger patients with experience with single-port laparoscopic liver surgery as one of the no statistical differences (p=0.166). In regards to cause of death, in usual treatment modality for various kinds of hepatic diseases. 77% of the younger group, in 60% of the elderly group died with Methods: We retrospectively review the medical records of 246 HCC, respectively. patients who performed a laparoscopic liver surgery between Dec Conclusions: Liver resection for the elderly was performed safely 2008 and Dec 2015 at our hospital. We divided it into two groups, and might extend the patient's life expectancy. single incision laparoscopic hepatectomy (SILH) and multiport laparoscopic hepatectomy (MPLH). P-036 Results: Of the 246 patients, 155 patients were underwent SILH and 91 were underwent MPLH. Conversion rate was 22.6% in SILH TREATMENT OF SOLITARY 2 TO 5-CM LARGE. HEPATOCELLULAR and 19.8% in MPLH (p = 0.358). We adopted SILH in major hepate- CARCINOMA: SURGICAL RESECTION VS MULTI-BI-POLAR ctomy resected more than 2 sections for 39 patients (25.2%) and RADIOFREQUENCY ABLATION. A COMPARATIVE RETROSPECTIVE 29.7% in MPLH group (p = 0.459). Operative time was 124.6 ± 73.5 MONOCENTRIC STUDY OF 141 CONSECUTIVE PATIENTS. minutes in SILH group and 335.9 ± 131.7 minutes in MPLH group (p < 0.001). Blood loss was 352.5 ± 408.3 ml in SILH group and 866.7 P.-N. Dumont, J.-Y. Mabrut, P. Merle, M. Lesurtel, C. Ducerf, ± 709.7 ml in MPLH group (p < 0.001). The safety resection margin A. Rode, K. Mohkam. was not showed significant difference (0.9 ± 0.86 cm vs 1.1 ± 1.6 Service de chirurgie générale, digestive et de transplantation cm, p = 0.553). The enteral feeding was started earlier in SILH group hépatique (1.01 ± 0.103 days after operation) than MPLH group (2.18 ± 1.57 Service de radiologie, Hôpital de la Croix-Rousse, Hospices days) (p < 0.001). The mean hospital stay after operation was Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69317 shorter in SILH group (7.3 ± 2.7 days vs 9.9 ± 3.1 days, p < 0.001). Lyon cedex04, France There was no major perioperative complication or mortality case in Objectives: Multi-bi-polar radiofrequency ablation (MRFA) is a this study. new procedure to treat hepatocellular carcinoma (HCC). Better Conclusions: Single-port laparoscopic liver surgery seems to be a local recurrence rates were recently demonstrated when feasible approach for various kinds of liver diseases. compared to mono-polar radiofrequency ablation. The aim of this study was to compare the oncological results and morbi-mortality P-038 between surgical resection (SR) and MRFA. Methods: We performed a comparative retrospective monocentric GETTING STARTED WITH ROBOTIC IN HPB SURGERY study of consecutive patients treated for a solitary 20-50 mm HCC by A. Vanlander, L.F. Abreu de Carvalho, F. Berrevoet, R.I. Troisi. either SR or MRFA. The curative-treatment option was chosen during Department of general, HPB surgery and liver transplantation multidisciplinary staff meeting. Patients who were already treated Ghent University Hospital, 9000 Ghent, Belgium for HCC were excluded. Results: Between 2011 and 2016, 79 and 62 patients were treated Objectives: The Robotic-assisted surgery is used with an increasing by MRFA and SR, respectively. Tumors in the SR-group were larger frequency in HpB surgery. This robotic interface is different to open (35mm [30 ; 45] versus 30mm [25 ; 34] p<0.001), and more and even to laparoscopic surgery. A learning curve to get familiar frequently subcapsular (81% versus 40%, p<0.001, respectively). with this interface, setup and different material is indicated for the MRFA patients had more advanced MELD score and clinical surgeon, but also for the anaesthesiologist and the OR-nurses. evidence of portal hypertension. Ninety days morbi-mortality was Methods: Before starting with advanced HpB procedures two not different, but hospital stay was longer for SR patients (11 days surgeons completed the Intuitive Surgical da Vinci training and [4;36] versus 7 days [3;67], p<0.001). A liver transplantation (LT) performed Robotic cholecystectomies together. We evaluated the was further undertaken in 8.1% of SR patients and 7.6% of MRFA learning curve by means of the total duration of the procedure. patients (p=1.000). Overall survival was not different (63% after SR, Results: We noticed a reduction of 50 % of the total OR time 78% after MRFA at 5 years, p=0.870) but disease-free survival (DFS) already after 4 cases. This significant gain of time was due especially was better after SR group (49% versus 42% at 5 years, p=0.02) with to the reduction in docking and dedocking time combined with a a median follow-up of 26 (IQR: 13-44) months. Patients in the swifter placement of the trocars. After those 4 cases we obtained a MRFA showed a trend toward more local recurrence than in the SR steady state. No complications were noticed in this group of

226 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

robotic-assisted cholecystectomies. in Asian countries than in Western countries, and is more commonly Conclusion: The robotic cholecystectomy is a safe procedure to diagnosed in young woman. Since patients with CBD have a high rate perform and enables the HpB surgeon to increase his confidence of biliary tract cancers, surgery should be performed. Laparoscopic level and knowledge of the robotic interface to evolve towards resection of the extrahepatic bile duct (LREBD) for CBD is good more advanced procedures. Enrolling for the training program indication in terms of minimal invasive. We introduced LREBD for facilitated the transition towards robotic procedures. CBD in 2011. Methods: We investigated usefulness of LREBD for CBD. The indi- cation of LREBD for CBD in our institution is Todani’s classification P-039 Type Ia and Ic. We compared laparoscopic resection with open resection of the extrahepatic bile duct for patient’s characteristics, LAPARO-ENDOSCOPIC LITHOTRIPSY-ASSISTED BILE DUCT surgical and postoperative factors. EXPLORATION – IMPROVING OUTCOMES Results: Eighteen cases that performed resection of the extra- N. Thiruchelvam, R. Paul, Y. Feng, LS Lee, SS Tan, AKH Chiow. hepatic bile duct from 2011 to 2016 were investigated. The Changi General Hospital, Singapore – 529889 Singapore number of cases was 11 cases in the laparoscopic group and 7 cases in the open group. The open group was significantly younger than Introduction/Objectives: A one-stage laparoscopic cholecystectomy the laparoscopic group (p=0.037). Body Mass Index was lower in and bile duct exploration is the preferred technique for the manage- the open group than in the laparoscopic group (p=0.005). Todani’s ment of choledocholithiasis as it has been shown to have lesser classification was different between 2 groups (p=0.001) because morbidity, a shorter hospital stay and lower cost. Impacted open group included type IV. Blood loss was less in the laparoscopic common bile duct stones and stone size are common reasons for group than in the open group (p<0.001). Operation time and compli- technical failure, which can be addressed with the introduction of cations were not different significantly. Postoperative hospital stay laparo-endoscopic lithotripsy assisted bile duct exploration. was more likely to shorter in the laparoscopic group than in the Methods: At Changi General Hospital in Singapore, we performed open group. our first laparo-endoscopic laser lithotripsy-assisted bile duct Conclusion: LREBD for CBD can be performed safely and may be exploration in July 2015. To date, we have performed 6 such cases useful. whereby laser lithotripsy is utilized after experiencing failure with standard retrieval methods such as Dormia baskets. We performed a retrospective review of these patients’ clinical presentations and P-041 their outcomes post-procedure. Results: All 6 patients had their CBD stones extracted successfully, MY FIRST TWENTY ROBOTIC RIGHT HEPATECTOMY: OUR INITIAL 5 of whom were performed via a transcystic duct approach. 4 of EXPERIENCE these patients had presented with acute cholangitis secondary to M.V. Marino, G. Shabat, G. Gulotta. choledocholithiasis of whom 2 had Mirizzi’s syndrome, whilst P. Giaccone Hospital, Palermo, 90127, Italy. another 2 patients had acute cholecystitis with concurrent chole- docholithiasis. All operations were completed laparoscopically, Objective: Firstly described in 2002, the robotic liver surgery with a median operative duration of 405 minutes (250 – 470 didn’t gain a wide acceptance due to its high cost and the lack of a minutes). They stayed a median of 3 post-operative days (2-11 standardized training program. Still considered a "development days). There was only 1 Clavien-Dindo Grade IIIb complication in an in progress" technique, we decided to evaluate the potential elderly patient who had initially presented with acute cholangitis advantages of the robotic over laparoscopic approach for a and was found to have a concurrent choledocho-duodenal fistula complex liver procedure also in hands of a young surgeon during intra-operatively. She subsequently developed post-operative his initial experience. intra-abdominal collections requiring a laparotomy and wash-out. Methods: We analyzed the postoperative outcomes of 20 patients There were no mortalities and no episodes of recurrent CBD stones undergoing to robotic right hepatectomy since March 2015 to requiring repeat intervention. September 2016. Conclusion: Laparo-endoscopic lithotripsy-assisted bile duct explo- Results: The overall mean operative time was 430 min (range ration is a useful technique that can increase technical success of 290,550) and the estimated blood loss was 325 ml (range CBD stone extraction via a one-stage laparoscopic procedure. With 120,720), no blood transfusion was required. Only 2 patients more widespread utilization of this technique, operative times will (10%) underwent to conversion to open surgery both for likely reduce as surgical personnel become increasingly more oncologic reason; the overall morbidity was 3/20 (15%) and all familiar with the unique set-up and technicalities involved. complications occurred (two biliary fistula and one transient liver failure) were classified like minor according to Clavien- Dindo score. The histological characteristics showed a mean P-040 surgical margin of 25 mm and we achieved a R0 resection rate of LAPAROSCOPIC RESECTION OF THE EXTRAHEPATIC BILE DUCT FOR 95% (19/20). The reoperation and 90-days mortality rate were CONGENITAL BILIARY DILATATION : RETROSPECTIVE ANALYSIS both null. The 1-year overall and disease free-survival rate were 92.3% and 84.6% respectively. T. Takadate, T. Morikawa, M. Ishida, T. Hata, M. Iseki, S. Maeda, Conclusions: Nevertheless some concerns regarding the cost- K. Ariake, K. Masuda, T. Aoki, K. Fukase, H. Ohtsuka, M. Mizuma, effectiveness and the absence of liver-specific robotic tools, the N. Sakata, K. Nakagawa, H. Hayashi, F. Motoi, T. Naitoh, T. Kamei, robotic right hepatectomy is a safe and feasible technique, M. Unno. providing interesting short-term outcomes and oncological results Department of Surgery, Tohoku University Graduate School of also in the initial phase of learning curve. Medicine, Sendai, Miyagi, 980-8574 Japan. Introduction: Congenital biliary dilatation (CBD) is more prevalent

Surgery, Gastroenterology and Oncology, 22 (3), 2017 227 ABSTRACTS

P-042 is recommended that SPNs should be resected. Case presentation: This 23 years old female denied any systemic THE EFFICACY OF RADIOFREQUENCY ABLATION IN THE disease. According to her statement, she suffered from traffic MANAGEMENT OF LIVER TUMOURS accident on 1/7. At ER, a series of image examination was arranged. Ahmed Najjar1, Saied Froghi1,2 And Abdominal CT revealed suspect solid pseudopapillary tumor of King’s College London, SE1 1UL, England the pancreas in the pancreatic tail was noted. Due to above 1MRC Centre for Transplantation, King’s College London, problems, she went to our OPD for help, pseudopapillary tumor of King’s Health Partners, Guy’s Hospital, St Thomas Street, the pancreas was diagnosed. She was admitted for HBS ward for London SE1 9RT, UK further treatment. • 2Renal & Transplant Surgery, Hammersmith Hospital, Discussion: Laparoscopic benefit: short hospital stay, mild wound • Imperial College NHS Trust, Du Cane Rd, London W12 0HS pain, cosmetic effect, economic issue. About warshaw technique: prevent post splenectomy overwhelming infection, preserve Objectives: Hepatocellular carcinoma (HCC) is currently the 2nd immunosystem function. • About splenectomy: SPEN is a potential most prevalent cause of death from cancer worldwide, with malignant change tumor, therefore intraoperative frozen section prognosis for HCC generally remaining very poor. In addition, the maybe needed to make sure if splenectomy should be done or not. efficaciousness of Radiofrequency ablation (RFA) versus resection We will close follow up ultrasound for this patient in case of any for HCC are relatively unclear. Primary objectives of this review recurrence. were to assess 1-, 3- and 5-year overall and recurrence free survival Conclusion: Solid pseudopapillary neoplasms (SPNs) of the in studies looking at the efficacy of RFA versus other accepted pancreas are rare neoplasms that typically occur in young women therapeutic modalities for the treatment of HCC. New evidence has less than 35 years of age. laparoscopic subtotal pancreatectomy also emerged regarding the efficacy of RFA in comparison with with spleen preservation is a good way for the treatment of SPNs. Percutaneous cryoablation (PCA), Laser Ablation (LA) and However, frozen section maybe needed to make sure if splenectomy Percutaneous ethanol injection (PEI), which are explored in this should be done or not. review. Methods: A review was assembled in accord with the guidelines presented by the Cochrane handbook for systematic reviews of P-044 interventions and the PRISMA statement. Included in this review are 16 trials, with 2602 participants included. Comparative studies LIVER RESECTION FOR NEUROENDOCRINE TUMORS LIVER assessing RFA with Surgical resection, Microwave ablation (MWA), METASTASES IN PATIENTS WITHIN THE MILAN CRITERIA FOR PEI and PCA that fulfilled the inclusion criteria were selected. TRANSPLANTATION Results: A total of 16 studies matched the inclusion criteria, with F. Bertuzzo, F. Bagante, A. Ruzzenente, S. Conci, L. Aldrighetti, 2602 participants. 4 Randomised Control Trials (RCT’s) were F. Ratti, G. Ercolani, A. Ferrero, N. Russolillo,F. Giuliante, A. M. identified comparing resection and RFA, generally study outcome De Rose, G. Torzilli, M. Cimino,G L. Grazi, P. Perri, A. Guglielmi, homogeneity was observed in stating that RFA is similar to C. Lacono. standard surgical resection in terms of efficacy and long-term Department of Surgery, Univesity of Verona, Hepatobiliary surgery survival, however resection remains the most preferable option. 6 Policlinico GB Rossi, 37124, Verona, Italy RCT’s were found comparing RFA and PEI (and Percutaneous Acetic Acid Injection (PAI)), all 6 trials presented evidence supporting the Background: Liver transplantation (LT) has been prosed as a superiority of RFA, with improved overall survival. curative treatment for metastatic gastro-entero-pancreatic neuro- Conclusion: Currently EASL and EORTC guidelines indicate that the endocrine tumors (GEP-NETs) but there is a lack of consensus on its therapeutic of choice in patients unsuitable for resection is RFA, real benefit when compared with hepatectomy. We sought to and if RFA is not feasible than PEI is the next most preferred thera- analyze survival outcomes of patients undergoing liver resection peutic. No evidence found in this review poses any serious for GEP-NETs liver metastasis (NELM) according to the Milan challenges to the current guidelines, however evidence supporting Criteria proposed to select patients with GEP-NET candidate to LT. PEI as a great alternative for RFA has developed. Methods: A multicentric national database including seven tertiary referral Hepato-biliary-pancreatic centers was used to identify patients who underwent hepatectomy for NELM between January P-043 1990 and December 2014. We identify patients fulfilling Milan Criteria: well-differentiated NET (Ki-67<10%), age <60 years, no THE VIDEO SHARING OF LAPAROSCOPIC SUBTOTAL extrahepatic disease, primary NET resected, stable disease for >6 PANCREATECTOMY WITH SPLEEN PRESERVATION IN months, and <50% liver involvement (Group 1). Extended Milan KAOHSIUNG MEDICAL UNIVERSITY HOSPITAL Criteria included patients up to 70 years age old (Group 2). Recurrence after liver surgery was treated per standard protocols Po-Hsuan Wu, Ling-An Chen, Jian-Wei Huang, Wen-Lung Su, according to international guidelines. No patients underwent liver Wen-Tsan Chang, Shen-Nien Wang, Shih-Chang Chuang, transplantation during the follow-up Kung-Kai Kuo, Jong-Shyong Chen, King-Teh Lee Results: A total of 238 patients were included in our study. Among Division of General Surgery, Kaohsiung Medical University them, 23 (10%) patients were in Group 1 while 35 (15%) in Group Hospital, Kaohsiung, Taiwan 2. In Group 1 and Group 2, 12 (52%) and 20 (57%) patients had a Introduction: Solid pseudopapillary neoplasms (SPNs) of the pancreatic NET, respectively. Median Ki-67 was 5% (IQR,1-7) in both pancreas are rare neoplasms that typically occur in young women Group 1 and Group 2. In Group 1, 4 (17%) and 17 (74%) patients less than 35 years of age. SPNs are most commonly found in the had NELM of type I and II according to Frilling classification body or tail of the pancreas and may contain both solid and cystic compared with 8 (23%) and 22 (63%) patients in Group 2. While components and occasional calcifications. Due to malignant risk, it 5-year OS for the whole cohort was 67%, 5-year OS for Group 1 and

228 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Group 2 was 80% and 77%, respectively. RAS by a vertical plane represented by the S8 branch of the median Conclusions: In our series, only 10% of patients fulfilled Milan hepatic vein (MHV). S8 dorsal or ventral sub-segmentectomy allows criteria. The 5-year OS after hepatectomy of this small selected significant parenchymal preservation while keeping oncological goals group was comparable with that reported in the literature for in patients for which liver function is already impaired. We reviewed patients undergoing LT for NELM within Milan criteria. the segmental anatomy of the RAS in order to facilitate the develop- ment of this technically demanding surgery. Results: Depending on the studies, the ventro-dorsal portal variation P-045 was present in 47% to 50.3% of patients, including bifurcation, trifurcation and quadrifurcation types. Ventral and dorsal part of the RECURRENT PRIMARY LIVER NEUROENDOCRINE TUMOR: RAS represented respectively 15.7% and 20.9% of the whole liver on LITERATURE REVIEW AND SINGLE CASE REPORT average (11.4% and 12.2% respectively for S8 alone). The S8 hepatic vein was present in 85.1% to 100% of the patients. Surgery, as G Pirozzolo, C Cona, M Rizzo, F Shala, S Berisha, A Recordare reported by Ogiso et al and Kishi et al., was conducted along the S8 Ospedale dell’Angelo,30121, Venice, Italy hepatic vein, guided by the ischemic demarcation line arising from Objectives: tumors are a rare disease which mainly occlusion, ligation or external compression of the branch of the occurs in the gastrointestinal system. The liver is the most common portal vein that irrigate the sub-segment including tumor and site of metastasis, but its involvement as primary tumor site is provided evidence of its feasibility. Along this review, it appeared to extremely rare. We report a case of surgically treated Primary Liver us that despite a preferential right-sidedness of hepatic parenchymal Neuroendocrine Tumors (PLNT) and the treatment of its recur- volumes, both portal and hepatic venous branches showed rence. A literature review was carried out with the aim to collect symmetrical configuration in the right and left liver on both side of and analyse all reported data about PLNT, focusing on incidence the MHV. and treatment of recurrent PLNT. Conclusion: Subsegmentectomy, instead of segmentectomy or Methods: A 52 years old woman presenting with jaundice and anterior sectoriectomy propose the option of curative, less invasive single nodule on segment IV and V was operated of extended right and safe liver resection in selected patients with impaired hepatic hepatectomy in 2008. The histology revealed a T2N0 G2 PLNT. functions. After 9 years she developed a new 8 cm mass in the remnant liver. It was surgically removed with atypical resection histology confirmed recurrent NET. We conducted a comprehensive search P-047 of all reported cases or series of PLNT. Considering the last update about grading, we limited the search period to 2010. We used the HISTOPATHOLOGICAL REVIEW OF CHOLECYSTECTOMY Kaplan Meier method and Log-Rank test for survival analysis. SPECIMENS IN A TERTIARY HOSPITAL IN GHANA Results: After combined search of 3 databases we found 6 studies BM Duduyemi, E Aboakye, Y Ashie, NA Titiloye, MY Afihene, reporting recurrent PLNTs, with 12 cases of recurrence overall. AC Yifieyeh Median Overall Survival (OS) was 33 months, median Disease Free Kwame Nkrumah University of Science and Technology, survival was 5 months. The preferred treatment modality, in Kumasi, 2331, Ghana included studies, was chemoembolization (TACE). Our analysis showed that OS and DFS are related with tumor grade (p:0,002 and Introduction: Diseases of the gall bladder are relatively common 0.05 respectively) but not with clinical presentation and tumor size. ranging from inflammation to neoplastic conditions. While the Conclusions: Reported data showed that PLNTs are uncommon inflammatory conditions are rife in our environment, the neoplas- andheterogeneous; few data about recurrence are reported. Our tic ones are generally rare. Our study aims to analyse the pattern of survival analysis showed no correlation with clinical presentation, gall bladder lesions from cholecystectomy specimens submitted to size and location; moreover tumor grade has great relevance in the pathology department of our hospital. This is because not predicting DFS and OS. Our case shows a e good prognosis with G2 much has been done in this regard. histology if no nodal involvement, and, at our knowledge, is the Methodology: A retrospective study was undertaken to review all second case of recurrent PLNET treated by surgery. the cholecystectomy specimens submitted to the Department of pathology of Komfo Anokye Teaching Hospital, Kumasi, Ghana from January 2009 to December 2014. Data regarding age, sex, P-046 clinical diagnosis and histological diagnosis were retrieved from the surgical daybook. This was analysed with SPSS version 21 and ANATOMICAL DECRIPTION OF THE RIGHT ANTERIOR SECTOR OF observation drawn were put in tables and figures. THE LIVER – INTRODUCTION TO HEPATIC SIMMETRY Results: Our patients were in the age range of 1-88 years with J.B. Cazauran, L. Paris, A. Viste, P. Rousset, G. Passot mean age of 46.04 years. There were 34 males and 148 females Lyon Sud Hospital, Dept of Surgical oncology, Hospices Civils with M:F ratio 1:4.4. Cholecystectomy specimens were reviewed de Lyon, Université Lyon 1, 69310 Pierre-Bénite, France over a 6 year period. Cholecystitis 129 cases, cholelithiasis 46 cases, 7 cases (0.04%) were malignant, male 1, female 6 with age range Background: Anatomical segmentectomy based on the Couinaud 49-75 years, mean 64 years. All were adenocarcinomas with 5 well segmentation remains the gold standard practice. Volumetric differentiated (Grade 1) and 2 poorly differentiated (Grade 3) studies reported the right anterior sector (RAS) as the largest, tumours and all were associated with gall stones. representing 37+/-5% of the liver volume on average, mostly Conclusion: This study showed that the indication for cholecystec- represented by segment-8 (S8). Recent 3D-imaging studies tomy in our centre is inflammatory gall bladder lesions and that confirmed the anatomical variations of the portal vascularization cancer of the gall bladder is very rare in our environment. described by Horstjo and Mikami, which divides in some patients the

Surgery, Gastroenterology and Oncology, 22 (3), 2017 229 ABSTRACTS

P-048 P-050

HYDATID CYST OF LIVER PERFORATED INTO TRANSVERSE SEMPRE FIDELIS. A PAIN THE NECK AND ABDOMEN COLON: A CASE REPORT HJ Tan, LHT Tay, CY Chan S. Ramasamy, S. Neogi, A. Goel, S. Prajapati, A. Jain. Singapore General Hospital, Singapore, 169608 Maulana Azad Medical College, New Delhi, 110002, India. Objectives: Hemangiopericytoma is a rare tumour with Echinococcosis is endemic in Mediterranean countries, the Middle low metastatic potential. Metastases can occur anywhere in the and Far East, SouthAmerica, Australia, and East Africa. The most body with the most common sites of distant spread is being the frequent complications of liver hydatid cysts include those related lungs and liver. We describe a case of metastatic hemangiopericy- to the compression of adjacent organs or to perforation into the toma to the liver more than 25 years after primary resection. biliary tree, pleural, or pericardial cavity, or even to cyst infection. Methods: A gentleman was admitted for right hypochondriac pain. Direct perforation of the cyst into hollow abdominal organs is very Physical examination showed hepatomegaly. An ultrasound unusual. The communication usually not found till surgery. We abdomen revealed a heterogenous liver mass which was further report a case of hydatid cyst perforated into transverse colon which characterized with a computed tomography (CT) scan of the was found intra operatively. Managed by cyst excision with trans- thorax, abdomen and pelvis which showed a highly vascular verse colostomy. dominant hepatic mass in the right lobe. Results: He underwent right hepatectomy and was discharged well and stable. Histology returned as returned metastatic, multifocal P-049 solitary fibrous tumours. NEW VIEWS ON TREATMENT OF HEPATIC ECHINOCOCCAL CYSTS Conclusions: Hemangiopericytoma can recur many years after WITH USING OF ARGON PLASMA COAGULATION primary resection. Long term follow up is essential. V.V. Petrushenko, V.I. Stoika, D.I. Grebeniuk, I.V Radoha, Stukan P-051 S.S. Chair of Endoscopic and Cardiovascular Surgery, Vinnytsya SHORT COURSE ANTIBIOTIC PROPHYLAXIS TO PREVENT National Medical University n.a. Pirogov, Vinnytsya, 21018, SURGICAL SITE INFECTIONS IN HPB AND GI SURGERIES. Ukraine ARE WE GIVING TOO MUCH?? A PROSPECTIVE STUDY. Objectives: The aim of study was to improve the results of treat- Bhavin Vasavada, Hardik Patel ment of patients with hepatic echinococcal cysts by using of argon Department of hepatobiliary surgery and liver transplantation, plasma coagulation. Shalby Hospitals, Ahmedabad, India 380015 Methods: The analysis of treatment results of 66 patients during 2010–2016 years was put into the basis of this study. It was 12 Background: Use of antibiotics in perioperative period is common (18.2%) men and 54 (81.8%) women in total. An average age of practice to prevent septic complications and surgical site infections. them was 47.7 ± 15.9 years. The main difference between groups Now a days more and more evidences are emerging that short was a way of liver parenchyma coagulation in order to make period of prophylactic antibiotics is equally effective for prophylaxis. reliable hemostasis. In main group the final stage of surgical inter- Material and Methods: We prospectively evaluated protocol of vention on liver was APC. It was performed to 45 (68.2%) patients. single dose preoperative antibiotic for laproscopic surgeries and 48- Alternatively, monopolar coagulation was performed to 21 (31.8%) hour prophylactic antibiotic for open hepato-pancreatico-biliary patients (comparison group). surgeries and colorectal surgeries. We evaluated 37 patient prospec- Results: In main group in the 86.6% cases pericystectomy was tively in our department, 2 patient were excluded as they were conducted. The resecting surgeries was performed to 13.4% cases. operated for grade 4 peritonitis and died within 24 hours due to In comparison group was conducted in 28.6% cases. In early post- sepsis. Surgical Site infections were defined as any culture positive operative period in main group the complications were observed in discharge from the main surgical wound or complications like bile 4.4% of cases. The same parameter was 4.8% in comparison group. leaks through the wound or drain. Categories of surgeries were It led to relaparomies. The forming of external biliary fistulas was decided according to CDC protocol (clean, clean contaminated, observed in 2 (4.4%) patients in main group and in 3 (14.3%) contaminated and dirty). Statistical analysis were done using SPSS patients in comparison group. However, all the fistulas have closed version 21. spontaneously on 7th–10th day in both groups. Hernias of abdomi- Results: Out of 35 patients 1 patient had undergone grade 1 (clean) nal wall and peritoneal adhesions that manifested by intestinal surgery, 15 patients grade 2 surgery (clean contaminated), 15 obstruction of different degree were considered as complications patients grade 3 (contaminated) surgery, and 4 patient had grade 4 of late postoperative period. These values were 0% and 4.4% in (dirty) surgery. Total 6 patient developed surgical site infections main group versus 19% and 14.3% in comparison group, respec- giving over all SSI rates of 17 percent. No Patients in grade 1 or tively. grade 2 surgeries developed surgical site infections. 5 patients in Conclusions: The resection of hepatic echinococcal cysts with grade 3 (33 percent) surgeries and 1 patient in grade 4 (25 percent) further application of argon plasma coagulation on the cyst bed surgeries developed surgical site infections. No patient in lapros- was accompanied by complications quantity decrease in patients copic surgery group developed surgical site infections, which is that underwent surgery in early as well as in late postoperative comparable to international data. Contaminated and dirty (grade 3 period. In this case more positive dynamics of functional liver and grade 4) surgeries were significantly associated with surgical values improvements was observed. site infections. (p=0.038). Conclusion: Short course prophylactic antibiotics protocol has similar SSI rates and can reduce hospitalization and cost. Short

230 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

course prophylactic antibiotic protocol also helps in reducing extracted deaths occurred with Ps>0.5 as unexpected non-survivors antimicrobial resistance. and extracted survivals occurred with Ps<0.5 as unexpected survivors. This study examined the outcomes of trauma and relation- ship to Ps with underlying variables such as morbidity and mortality P-052 rates, and considered the details of unexpected survivors/non- survivors. SPECTRUM OF GASTROINTESTINAL AND Results: About 40% of the patients had the severe liver injury. They HEPATOPANCREATICOBILIARY DISEASES had the lower Ps, and the higher mortality. Survival had a certain SEEN AT THE KOMFO ANOKYE TEACHING HOSPITAL IN GHANA correlation between Ps. On the cases of laparotomy, the mortality was 31.2%, and the almost all of those Ps was less than 0.5. The MY Afihene, FNA Sackey, BM Duduyemi surgical treatment of liver injuries included definitive procedure Kwame Nkrumah University of Science and Technology, (hepatorrhaphy, hepatotomy with selective vascular ligation, Kumasi, 2331, Ghana debridement, selective hepatic artery ligation, liver resection) and Introduction: Even though there have been concerns regarding damage control surgery with liver packing. The survival rate of global expansion of gastrointestinal (GI) and Hepatopancreatico- laparotomy whose Ps< 0.5 was 0%, but the lowest Ps of survived biliary (HPB) disorders, greater increases are observed in surgical case was 0.51. Unexpected survivors contained the cases developing countries. The characterization of a spectrum of these that the vital status got stable due to the success of the interven- disorders, however, is not well-defined in developing countries. tion for hemorrhage. On the other hand, unexpected non-survivors This study sought to profile the frequency of GI and HPD disorders contained the cases that the initial vital status was stable, but it got and their fundamental demographic characteristics. worse soon before performing a certain intervention. Methods: A 12-year retrospective study was conducted between Conclusions: Ps shows a certain clinical benefit to predict July 2005 and June 2017 at the GI-Hepatology outpatient clinics of prognosis of traumatic liver injury. We should observe the patients the Komfo Anokye Teaching Hospital, Kumasi, Ghana. All of the carefully due to acute deterioration of traumatic liver injury. patients who visited the clinic within the indicated period were included in the study population. Patients’ records were retrieved P-054 and reviewed by gastroenterologists from the clinic. The doctors classified the respective diagnoses according to ICD-10. EVALUATION OF PROGNOSIS AFTER MAJOR Results: The following disease percentages were obtained among HEPATECTOMY-INDUCED SEPSIS the 2629 patients who visited the GI- Hepatology clinic: HPB: Hepatitis B (47%) > cirrhosis (32.5%) > Hepatitis C (3.9%). Misc (2%) Y. Katayose, I. Ise, H. Hayashi, M. Mutoh, K. Nakagawa, GI: Gastritis (24.6%) > H. pylori (16.5%) > Hiatal hernia (13.7%) > T. Morikawa, F. Motoi, T. Naitoh, M. Unno GERD (8.4%) Misc (24%) Mean age (41.5 yrs); Male (47.5%); 1Surgery, Tohoku Rosai Hospital, Sendai, 981-8563, JAPAN Female (52.5%); Patients in > 2 disease categories (49%) 2Department of Surgery, Tohoku Medical and Pharmaceutical Conclusions: Our HPB and GI broad spectrum characterization University, Sendai, JAPAN revealed viral hepatitis B to be the most prevalent diagnosed 3Department of Surgery, Tohoku University Graduate School of disease, followed by cirrhosis, and hepatitis C among the liver Medicine, Sendai, 980-8574, JAPAN diseases; gastritis was the most common among the GI disorders, Background: Postoperative sepsis is a major factor of surgical followed by hiatal hernias and GERD. Since all of these diseases are morbidity and mortality. However, the rate and epidemiology of preventable, our findings call for a community education by postoperative sepsis after major hepatectomy has not been specialists to impact public awareness regarding preventive clarified yet. measures and immunization procedures for hepatitis B. Objectives: We analyzed postoperative sepsis after elective major hepatectomy in Tohoku University hospital. P-053 Methods: Samples of major hepatectomy were queried between 2011-2015, and patients who experienced sepsis after elective TREATMENT OUTCOME AND EFFECTIVE UTILITY OF PROBABILITY surgeries were identified retrospectively. In this study, two OF SURVIVAL FOR THE PATIENTS WITH TRAUMATIC LIVER sectionectomy and more were defined as a major hepatectomy. INJURY Result: 160 elective surgical cases were analyzed. Males were 112 cases (66%) and Females were 58 cases (34%). Median age was 67 Keiso Matsubara, Akihiko Oshita, Yasuhiro Matsugu, year old (40 - 85 y.o.). Disease were below. Cholangiocarcinoma Hideki Nakahara, Toshiyuki Itamoto were 90 cases (56%), metastatic liver cancer were 26 cases (16%), Department of Gastroenterological Surgery, Hiroshima intrahepatic cholangiocarcinoma were 12 cases (13%), hepato- Prefectural Hospital cellular carcinoma were 12 cases (8%), and other were 12 cases. In 1-5-54 Ujina-kanda, Minami-ku, Hiroshima 734-8530, Japan all cases, the incidence sepsis was 14% (26 cases). Sepsis rate of left Objective: The purpose was to evaluate the options for manage- tri-segmentectomy was the highest, 29%, right hepatectomy with ment of severe liver trauma with multiple accompanying injuries as bile duct resection was 25% and left hepatectomy with bile duct well as the treatment outcome. resection was 16%. Simple hepatectomy is 6 - 9 %. Multivariate Material and Method: 74 patients with traumatic liver injury, trans- analysis, operative time is a risk factor of sepsis. Analysis for ported to our hospital from January 2009-September 2015. overall survival (OS), we compared 90 days sepsis recovered cases Diagnosed and classified according to the hepatic injury classification (SRC) after sepsis and no sepsis cases. OS of SRC was significant low of the Japanese Association for the Surgery of Trauma (JAST) with than no sepsis cases. the use of contrast enhanced CT. We calculated Probability of Conclusions: Sepsis rate of major hepatectomy was 14%. survival (Ps) with Trauma Injury Severity Score (TRISS) and examined Preoperative data could not predict sepsis. Sepsis is a prognosis the relationships of classification, prognosis, and treatment. We factor in oncology.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 231 ABSTRACTS

P-055 P-057

WHAT IS THE OPTIMAL TIMING FOR PERFORMING BILE DUCT RECONSTRUCTION USING A JEJUNAL CONDUIT CHOLECYSTECTOMY AFTER ERCP CLEARANCE OF INTERPOSITION OF VARIABLE DIAMETER IN CASE OF HIGH CBD STONES? A PROSPECTIVE RANDOMIZED STUDY STRICTURE Atef E., El Nakeeb A, Ezzet H., Askar W, El Hanafy E., Hamdy E., P. Markov Youssef M., Talaat H., Hamed H., Abdallah T. Kuban State Medical University, Krasnodar, 350063, Russia Introduction: The time interval between endoscopic retrograde Background: The "gold standard" surgical procedure for major bile cholangiopancreatography (ERCP) and laparoscopic cholecystectomy duct injury and biliary stricture is Roux-en-Y hepaticojejunostomy. (LC) is a matter of debate. This study was planned to compare early LC But this method is not anatomical and physiological. The ideal versus late LC. interposition for restoring the continuity between the biliary tract Patients and methods: This is a prospective randomized study on and duodenum is a pedicle graft of jejunum reduced in caliber to patients who are presented with concomitant gallbladder and approximately that of the ductal system. But in case of high common bile duct stone. The study population was divided into stricture this method cannot be used. two groups; group (A) managed by early LC within three days after Methods: We present new method of reconstruction extrahepatic ERCP; and group (B) managed by late LC one month after ERCP. bile duct using an isolated intestinal segment of a variable diameter: Results: No significant difference between both groups as regards the proximal part remains of original intestine segment during 3-5 the conversion rate, the degree of adhesion, cystic duct diameter, cm (to create hepaticojejunal anastomosis in the hepatic hilum or and intraoperative common bile duct injury or bleeding. Recurrent with separate anastomoses for isolated ducts) and then the biliary symptoms were significantly more in delayed LC group in 7 diameter is reduced to 1 cm, proportional to the biliary tract. For this (12.71%) patient versus 1 patient in early LC (P=0.03). the antimesenteric part of the intestinal wall of the distal part of Conclusions: No significant difference between both groups as intestinal segment was resected, and the free edges of the intestinal regards the conversion rate. Recurrent biliary symptoms were wall were sewn together so that the diameter of the graft 1 cm significantly more in delayed LC while waiting LC. Morbidity was throughout several cm was obtained. The distal anastomosis was significantly more in delayed LC. formed with the end of the common bile duct. In case the end of the common bile duct cannot be used, the distal anastomosis was performed with duodenum. P-056 Results: This method was applied in 10 patients with benign biliary FIBROBLASTIC CELL SUBPOPULATIONS ROLE DURING HEPATIC strictures. 4 patients were Bismuth III and 6 - Bismuth IV. There DAMEGE were no intraoperative or postoperative deaths (30-day or in- hospital deaths). There were two postoperative complications. Tophuria Davit1, Matoshvili Maia2 Long-term results were obtained in all patients up to 11 years. The Tbilisi State Medical University mean follow-up was 5.5 years. There were no recurrence of 1Departments: Human Normal Anatomy, 2Dermatology and stricture, cholangitis and normal biochemical parameters were Venereology observed. Accumulation of extracellular matrix observed in fibrosis and Conclusions: This new technique is reliable and might be recom- cirrhosis is due to the activation of fibroblasts, which acquire a mended as an alternative method for reconstruction extrahepatic myofibroblastic phenotype. Myofibroblasts are absent from bile duct in cause of major bile duct injury and biliary stricture. normal liver. They are produced by the activation of precursor cells, such as hepatic stellate cells and portal fibroblasts. These fibro- genic cells are distributed differently in the hepatic lobule: the P-058 hepatic stellate cells resemble pericytes and are located along the sinusoids, in the Disse space between the endothelium and the DEVELOPMENT OF A NEW BIODEGRADABLE OPERATIVE CLIP hepatocytes, whereas the portal fibroblasts are embedded in the MADE OF A MAGNESIUM ALLOY: EVALUATION OF ITS SAFETY portal tract around portal structures (vessels and AND TOLERABILITY. biliary structures). Differences have been reported between these K.Tai1, M.Kido1, M.Tanaka1, H.Kinoshita1, S.Komatsu1, two fibrogenic cell populations, in the mechanisms leading to D.Tsugawa1, M. Awazu1, H.Gon1, M.Tyuma1, K.Arai1, Y.Yasuhara1, myofibroblastic differentiation, activation and "deactivation", but H.Mukubou1, S.Terai1, H.Toyama1, K.Ueno1, Y Ku2, T.Fukumoto1 confirmation is required. Second-layer cells surrounding centro- 1Department of Surgery, Division of Hepato-Biliary-Pancreatic lobular veins, fibroblasts present in the Glisson capsule surround- Surgery, Kobe University Graduate School of Medicine, Kobe, ing the liver, and vascular smooth muscle cells may also express a Hyogo, 650-0017, Japan myofibroblastic phenotype and may be involved in fibrogenesis. It 2Department of Surgery, Kohnan Hospital, Kobe, Hyogo, is now widely accepted that the various types of lesion (e.g., lesions 658-0064, Japan caused by alcohol abuse and viral hepatitis) leading to liver fibrosis involve specific fibrogenic cell subpopulations. The biological and Background: Operative clips used to ligate vessels in abdominal biochemical characterisation of these cells is thus essential if we operation usually are made of titanium. They remain in the are to understand the mechanisms underlying the progressive body permanently and form metallic artifacts in computed development of excessive scarring in the liver. These cells also tomography images, which impair accurate diagnosis. Although differ in proliferative and apoptotic capacity, at least in vitro. All this biodegradable magnesium instruments have been developed in information is required for the development of treatments other fields, the physical properties necessary for operative clips specifically and efficiently targeting the cells responsible for the differ from those of other instruments. We developed a development of fibrosis/cirrhosis. biodegradable magnesium-zinc-calcium alloy clip with good

232 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

biologic compatibility and enough clamping capability as an thin caudate branches. Recently, we have established contrast- operative clip. In this study, we verified the safety and tolerability enhanced intraoperative ultrasonic cholangiography (CE-IOUSC) as of this clip for use in canine cholecystectomy. a tool for biliary navigation instead of IOC. Here, we demonstrate Methods: Nine female beagles were used. We performed the feasibility and usefulness of CE-IOUSC in hepatobiliary surgery. cholecystectomy and ligated the cystic duct by magnesium alloy or Methods: CE-IOUSC was performed using an ultrasound imaging titanium clips. The chronologic change of clips and artifact forma- system with a 4D probe, a T-shaped linear probe and a micro- tion were compared at 1, 4, 12, 18, and 24 weeks postoperative by convex probe in various hepatobiliary operations including open computed tomography. The animals were killed at the end of the hepatectomy for hepatoma, hepatobiliary resections for hilar observation period, and the clips were removed to evaluate their cholangiocarcinoma, and living donor hepatectomy. After perfluo- biodegradability. We also evaluated their effect on the living body robutane (Sonazoid) solution was injected via an intra-biliary by blood biochemistry data. catheter, ultrasound scanning on the liver surface, the hepatic Results: The magnesium alloy clip formed much fewer artifacts hilum, or the cut surface was performed in contrast imaging mode. than the titanium clip, and it was almost absorbed at 6 months Results: CE-IOUSC could provide 3D mapping and 2D regional postoperative. There were no postoperative complications and no anatomy of the biliary tree for biliary navigation in hepatobiliary elevation of constituent elements such as magnesium, calcium, surgery. CE-IOUSC could visualize the biliary drainage area of each and zinc during the observation period in both groups. bile duct as pseudostaining of the liver parenchyma and the Conclusion: The novel magnesium alloy clip demonstrated enhanced bile ducts in the remnant liver after hepatobiliary sufficient sealing capability for the cystic duct and proper resection for perihilar cholangiocarcinoma. CE-IOUSC was applied biodegradability in canine models. The magnesium alloy clip safely and successfully as a tool for identification of the biliary revealed much fewer metallic artifacts in CT than the conventional configurations, guidance for bile duct division, and confirmation of titanium clip. the remnant biliary system in living donor hepatectomy. Conclusions: CE-IOUSC is a novel IOC technique that provides excellent visualization of the biliary tree and the biliary drainage P-059 areas. CE-IOUSC can facilitate the surgeon’s understanding the spatial relationships between bile ducts and liver parenchyma to HEPATIC FALCIFORM LIGAMENT FLAP FOR REPAIRING BILE DUCT reduce the potential risk of biliary complications. DEFECT

M.Hyodo, Y.Yasuda. P-061 Department of Surgery, Haga Red Cross Hospital, Tochigi, 329-4306 Japan IMPACT FOR PROGNOSIS AFTER NON-ANATOMICAL RESECTION Objectives: To clarify the usefulness of hepatic falciform ligament FOR HEPATOCELLULAR CARCINOMA WITH MICRO PORTAL VEIN flap for repairing bile duct defect. TUMOR THROMBUS Methods: We performed hepatic falciform ligament flap for K.Arai1, M.Kido1, M.Tanaka1, H.Kinoshita1, S.Komatsu1, patients with bile duct defect or with bile leakage after surgical D.Tsugawa1, M.Awazu1, H.Gon1, M.Tyuma1, K.Tai1, Y.Yasuhara1, procedures. For bile duct defect, we plugged the ligament into the H.Mukubou1, S.Terai1, H.Toyama1, K.Ueno1, Y Ku2, T.Fukumoto1, defect. For bile leakage, we covered the leakage point wrapping the 1Department of Surgery, Division of Hepato-Biliary-Pancreatic ligament. We put an intraperitoneal drain all the patients. We Surgery, Kobe University Graduate School of Medicine, Kobe, evaluated drainage day by intraperitoneal drain, hospital stay after Hyogo, 650-0017, Japan surgery and postoperative complications. 2Department of Surgery, Kohnan Hospital, Kobe, Hyogo, Results: We performed plugging the ligament for 3 patients in 658-0064, Japan Mirizzi syndrome, and wrapping the bile duct by the ligament for 9 patients with small bile leakage in 3 biliary cancer, 3 acute Objectives: The purpose of this study was to evaluate the intra- cholecystitis, 2 bile duct stones, and cystic duct leakage after chole- hepatic recurrence pattern of patients undergoing hepatectomy, and cystectomy. All the12 patients had no persistent bile leakage and. to assess its influence to the prognosis according to the operative The median drainage day was 5(3-9) days, and the hospital stay after procedure (anatomical resection (AR) and non-anatomical resection surgery was 7(5-35) days. (NAR)). Conclusions: Hepatic falciform ligament flap is useful for repairing Methods: Between 2006 and 2012, a total of 52 patients who had no bile duct defect. macroscopic vascular invasion in the pretreatment imaging, and his- torically proven portal vein tumor thrombus in distal to second-order P-060 portal branches were analyzed with regard to overall survival rates, disease-free survival rates, and intrahepatic recurrence patterns. HEPATOBILIARY NAVIGATION SURGERY USING CONTRAST- Results: There was no significant difference with regard to the ENHANCED INTRAOPERATIVE ULTRASONIC CHOLANGIOGRAPHY overall survival rates at 5 years according to the operative procedure. The disease-free survival rates at 3 years according to the operative T. Urade, T. Fukumoto procedure were 59.2% (AR group) and 30.1% (NAR group), respec- Department of Surgery, Division of Hepato-Biliary-Pancreatic tively, which was significantly different between the 2 groups Surgery, Kobe University Graduate School of Medicine, 7-5-2 (P=0.0420). Intrahepatic recurrence in the remnant same segment Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan was recognized in 5 patients undergoing NAR. These 5 cases Objectives: Radiographic intraoperative cholangiography (IOC) has developed multiple bilobar recurrences including the same segment, been widely used to confirm the biliary anatomy in hepatobiliary and there was no case that the recurrences developed only in the surgery. However, it has radiation exposure and difficulty with remnant same segment, whether the recurrence type was solitary or handling a C-arm machine, generating 3D images and delineating multiple.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 233 ABSTRACTS

Conclusions: None of the intrahepatic recurrences in the remnant transplantation in all the cases. Descriptive and analytical statistics same segment influence the disease-free survival rate for patients were applied to summarize the findings and Kaplan-Meier survival after NAR. Although AR would be an ideal treatment for HCC if analysis was performed to investigate the survival rates in LDLT allowed, the current study suggests its validity to NAR for patients recipients. A p- value <0.05 was considered statistical significant. inappropriate for AR. Results: Of 53 LDLT recipients, 50 (94.3%) were male, mean age of 52±7.64 years and a majority (86.8%) of the patients were HCV positive. However, nearly three-forth (73.6%) of the patients have P-062 comorbidities at the time of transplantation and the mean model for end-stage liver disease (MELD) score was 17.3± 6.1 (range: 8 – SPELENIC PSUEDOCYST MIMICKING AS A CYSTIC LESION 35). Nineteen (35.8%) patients developed recurrent HCV after OF LIVER – MAKING A DIAGNOSTIC DILEMMA transplantation and nine (17%) had faced transplant rejection. After one year of LDLT, 64.1% of recipients survived, 58.49% for Mahim Koshariya, Surbhi Garg, Abhishek Shitole, Anshul Siroliya, three years, and 39.6% for five years. One year mortality was 35.8% Jai Prakash Burman, Rameshwar More, Anuradha Chaudhary, M.C. (19 cases), 41.5% (22 cases) in three years and on five years it Songra reached to 60.3% (32 cases). Gandhi Medical College and Hamidia Hospital, Bhopal, Conclusion: This studies identified that the success of LDLT in HCC 462001 India patients rely on a stepwise approach that incorporates morphologi- Pseudocysts of the spleen are uncommon entities. They are found in cal and biological criteria of the tumor. Major vascular invasion, <1% of the splenectomies done and usually develop secondary to massive infiltrative type, ruptured HCC and distant metastasis are to trauma. Pseudocysts of spleen seldom grow to large size and most of be considered as absolute contraindications for transplant. these remain asymptomatic, they require exploration only in Key words: Hepatocellular carcinoma, liver transplantation, living symptomatic cases and chances for spleen preservation in these donor liver transplantation, survival, mortality, Egypt. cases are usually less. Here, we present a case of this rare entity who presented to us with complaints of pain and lump in the abdomen. Clinically and radiologically, the lump appeared to be a cystic lesion P-064 of the liver and patient underwent diagnostic lap and exploration. On exploratory laparotomy patient had gastric perforation and massively LONG-TERM CHANGES IN THE SPLEEN VOLUME AFTER LIVING enlarge spleen compressing left lobe and stomach with emptiness in DONOR LIVER TRANSPLANTATION left hypochondrium.patient underwent spleenectomy along with Y. Mitsuhashi, T. Wakiya, K. Ishido, D. Kudo, N. Kimura, K. Sato, perforation repair. On histopathological examination, diagnosis J. Amagasa, T. Shibazuka, K. Hakamada of splenic pseudocyst was confirmed by the absence of lining Department of Gastroenterological Surgery, Hirosaki University . We would like to report this case because of its rarity and Graduate School of Medicine, Hirosaki, 036-8562, Japan diagnostic dilemma with unusual presentation. Objectives: The aim of this study was to clarify the long-term changes in the spleen volume after pediatric living donor liver P-063 transplantation (LDLT). Methods: A total of 19 pediatric patients underwent LDLT at our CLINICAL OUTCOMES OF LIVING DONOR LIVER TRANSPLANTATION facility between 1994 and 2011. Among these patients, the 13 FOR HEPATOCELLULAR CARCINOMA IN EGYPT pediatric patients who survived for more than 5 years after LDLT and who did not meet the exclusion criteria were retrospectively Mohamed Heneish1, Abduh Elbanna1, Magdy Salah1, analyzed in this study. The exclusion criteria were as follows: emer- Akshaya Srikanth Bhagavathul2, Abd Elrazek Abd Elrazek3 gency transplantation, graft failure and no data for post-operative and Khaled Amer4 computed tomography (CT) our institution. We calculated the 1Department of General, Hepatic and Laparoscopic Surgery, Al spleen volume to standard spleen volume (SV/SSV) ratio by Azhar Faculty of Medicine, Al Azhar University, Cairo, Egypt. automated CT volumetry. We assessed the liver and spleen 2College of Medicine and Health Sciences, School of Pharmacy, volumes using CT before LDLT, at roughly postoperative week University of Gondar- Gondar, Ethiopia. (POW) 4, at postoperative year (POY) 1, at POY 5, and at POY 10. 3Department of Tropical, Hepatology, Aswan Faculty of Medicine, Results: Regarding the SV as evaluated by CT volumetry, there were Aswan, Egypt. no consistent trends, with median values as follows: before LDLT, 4Department of General, Hepatic and, laparoscopic Surgery, 282.5 (71-641) cm3; POW 4, 252 (109-798) cm3; POY 1, 222.5 (97- IMC, Egypt 948) cm3; POY 5, 263.5 (123-564) cm3; and POY 10, 377 (201-1080) Background: Over the last decade, there has been considerable cm3. In contrast, the SV/SSV ratio decreased chronologically, as improvement in the outcome of liver transplantation in patients follows: before LDLT, 5.0 (0.7-6.0); POW 4, 3.7 (2.3-4.3); POY 1, 2.2 with Hepatocellular carcinoma (HCC). (1.7-6.3); POY 5, 1.7 (1.1-5.4); and POY 10, 1.4 (1.1-6.9). In the Aim: To evaluation the prognosis of living donor liver transplantation remote phase after LDLT, many cases showed a trend toward an (LDLT) as a definitive treatment of HCC in patients who met criteria improved SV/SSV ratio, but splenomegaly was prolonged without of transplantation including the recurrence of HCC in Egypt. improvement in 3 cases (23.1%) with portal vein complications and Methods: We retrospective analysed preoperative, operative, advanced fibrosis. Furthermore, all three cases showed a post-operative and follow-up records of liver transplanted patients’ decreased platelet count due to hypersplenism. attending hepato-pancreato-biliary (HPB) surgery department at Conclusion: Splenomegaly requires a long time to achieve an International Medical Center (IMC), Egypt from April 1, 2013 to the improvement. In cases without an improvement of splenomegaly, December 31, 2016. During this period, 53 patients underwent we should suspect abnormalities in the graft liver and portal LDLT and hepatic focal lesions (FLs) were the indication of liver hemodynamics.

234 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

P-065 combined method of liver isolated hepahocytes and with performing hemosorbtion methods died – 20%. MANSOURA EXPERIENCE OF LIVING DONOR LIVER Conclusion: The main reason of death was acute liver insufficiency TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA which was caused by liver damage by toxic agent. Fafhy O., Abd-wahab M., EI-Shobari M. Aim of the study: To evaluate the result of LDLT in HCC PTS P-067 regarding the safety of the donor & the outcome of the recipient assessing the factor affecting prognosis mainly survival & CASE OF PATIENT OPERATED FOR RECTAL CANCER, DIAGNOSED recurrence. YEARS AFTER SURGERY WITH IBD (ULCERATIVE COLITIS) RESISTANT Patient & method: This study include 146 pts with HCC transplanted TO THERAPY in our center Mansoura university hospital period 2005 to 2017 (137 S. Bekir1, K. Zarkov1, Chr. Petkov1, G. Stoyanova2, A. Vlahova1. Male & 9 Female), most of the~ were child B&C & 85% within Milan 1First Surgical Department, 2Gastroenterology Department & uscf criteria, 61 pts were subjected to preoperative loco regional Fifth General Hospital, Sofia, Bulgaria therapy either for down staging or abridge to transplantation Results: 10 year survival was 92 pts (63%). 52 pts past sound. post Background: Ulcerative colitis usually involves rectum; other operative. without complication. 3 months mortality (13.6%) late affected colon parts vary in every patient. Incidence 160/100 000 mortality (16.4%) mostly due to tumor recurrence. Morbidity population. occurred 50 Pt (34.2 %). Biliary complication in form of bile leak or Material: This is a case report of a male at 37 in 2007 – for rectal structure in 16 Pt (19.9%) & responsible for 2 mortality. In this study bleeding and pain he received colonoscopy and endoscopic the multi variate analysis for factor affecting. Tumor recurrences & polypectomy. Histopathology revealed polypus with adenocarcinoma. survival are vascular invasion, multiple. Tumor & FP > 200 ng. Multidisciplinary team decided for surgery - patient underwent low Regarding donor" no mortality & only 21 pt (14.4 %) develop minor rectal resection – no cancer found in the specimen. After surgery the complication that respond to conservative management. patient complained with anorectal and pelvic pain, thenesmas, Conclusion: Liver transplantation is best option for treatment of diarrhea, bowel obstruction, rectal bleeding. Colonoscopy and CT HCC in cirrhotic patient provided no extra hepatic metastasis & no scans found nothing significant. In 2010 another surgery – vascular vision. performed adhesions debridement. Postoperatively the same complains continued. In 2014 Colonoscopy with biopsy revealed - Ulcerative colitis involving recto-sigmoid and cecum. The P-066 treatment with Salofalk - orally and enemas; Imuran; methylpred- nisolone reduced defecations to 2-3 with quality of life improve- TRANSPLANTATION OF ISOLATED HEPATOCYTES AND THEIR ment. Later disease course shows often symptoms relapses, ROLE DURING ACUTE HEPATIC INSUFFICIENCY spastic ring of splenic flexure at X-ray – not proved on colonoscopy; histopathology-crypto-abscesses and fibrosis. In 2017 patient D. Tophuria, M. Matoshvili, I. Kakhniashvili, L. Benashvili. started anti-TNF-therapy. Human Normal Anatomy, Topography anatomy, Clinical Skills, Results: Patient has 5-7 annual symptoms relapses with the Dermato-Venerology Departments standard ulcerative colitis therapy. Three months after start of anti- Tbilisi State Medical University TNF-therapy patient is symptoms-free. Backrounds/Aims: According to current experimental and clinical Discussion: This case best illustrates the controversies in the data the principles of treatment of liver toxic illness : liquidation of management of IBD with cancer. In 2007 we didn’t perform intra- etiological factor; retention of the organism metabolism on such operative colonoscopy; the patient was verified to have cancer necessary level which provides the organ function recovery and after endoscopic polypectomy but not IBD and received anterior stimulation of reparative regeneration processes in the toxically resection; specimen showed neither cancer nor IBD. The 7-years damaged liver. Complex method of treatment which unites delay in IBD diagnosis resulted in disease advance and resistance to hemosorbtion and cellular transplantation on one side will provide standard management. This case is still opened. For the moment metabolism and hemodinamics timely recovery, and on the other patient isn’t candidate for surgery. hand stimulation of the reparation regeneration of the damaged Conclusions: To improve quality of life of ulcerative colitis patient organ. physician should regard the start of biologic treatment after precise Methodology: In the experiment studies was conducted with usage indications and no effect of standard therapy. Surveillance of 120 Wister Line white lab. rats. The animals were divided in four including colonoscopy with biopsy and blood assays is mandatory. groups. The first group after creation of the model of acute liver damage was under examination without treatment. The II group in the conditions of ethylene-ester mask narcosis after three days of P-068 modeling was made one-time hemosorbtion. In III group animals the conditions of ethylene-ester mask narcosis after three days of HISTOPATHOLOGICAL REVIEW OF CHOLECYSTECTOMY modeling occurred transplantation of allogenic hepatocytes, IV SPECIMENS IN A TERTIARY HOSPITAL IN GHANA group animals the conditions of ethylene-ester mask narcosis as well BM Duduyemi, E Aboakye, Y Ashie, NA Titiloye, MY Afihene, as II group animals were made one time hemosorbtion, furthermore AC Yifieyeh. as well as in III group animals were conducted transplantation of Kwame Nkrumah University of Science and Technology, allogenic liver isolated hepatocytes. Kumasi, 2331, Ghana Results: After modeling liver acute insuficincy on 3-7 day all animals of the control group died, with transplantation method died Introduction: Diseases of the gall bladder are relatively common - 70 %; with detoxication treatment method died – 26%. And ranging from inflammation to neoplastic conditions. While the

Surgery, Gastroenterology and Oncology, 22 (3), 2017 235 ABSTRACTS

inflammatory conditions are rife in our environment, the neoplas- laparoscopic and open approaches in case of radical D3 tic ones are generally rare. Our study aims to analyse the pattern of lymphadenectomy in stage II and III transverse colon cancer. gall bladder lesions from cholecystectomy specimens submitted to the pathology department of our hospital. This is because not much has been done in this regard. P-070 Methodology: A retrospective study was undertaken to review all the cholecystectomy specimens submitted to the Department of SHORT-TERM OUTCOMES OF NEOADJUVANT CHEMORADIOTHERAPY pathology of Komfo Anokye Teaching Hospital, Kumasi, Ghana FOLLOWED BY TOTAL MESORECTAL EXCISION IN RECTAL CANCER from January 2009 to December 2014. Data regarding age, sex, T.C. Chang1, K. Inada2, K. Nasu2, M. Hiyoshi2 clinical diagnosis and histological diagnosis were retrieved from the 1Division of Radiation Oncology, surgical daybook. This was analysed with SPSS version 21 and 2Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, observation drawn were put in tables and figures. Tokyo, 130-8575, Japan Results: Our patients were in the age range of 1-88 years with mean age of 46.04 years. There were 34 males and 148 females Objectives: The aim was to examine the effects of neoadjuvant with M:F ratio 1:4.4. Cholecystectomy specimens were reviewed chemoradiation (nCRT) followed by total mesorectal excision (TME) over a 6 year period. Cholecystitis 129 cases, cholelithiasis 46 cases, in rectal cancer. 7 cases (0.04%) were malignant, male 1, female 6 with age range Methods: From April 2013 to May 2017, a total of 22 patients with 49-75 years, mean 64 years. All were adenocarcinomas with 5 well rectal cancer were retrospectively studied. Neoadjuvant treatment differentiated (Grade 1) and 2 poorly differentiated (Grade 3) comprised external beam radiation (50.4 Gy/28 fractions) with tumours and all were associated with gall stones. concurrent oral capecitabine or tegafur-uracil. Four to 6 weeks Conclusion: This study showed that the indication for cholecystec- after the nCRT, the patients with rectal cancer underwent surgical tomy in our centre is inflammatory gall bladder lesions and that resection. cancer of the gall bladder is very rare in our environment. Results: Distribution of median age, median follow up months, pts by male/female, clinical TMN stage and adjuvant chemotherapy after TME was 72 y/o (range 44~86); 22.9 mons (range 4.4~47.1); 19 (86%)/ P-069 3 (14%); cI/IIA/IIB/IIIA/IIIB/IIIC:2(9%)/4(18%)/3(14%)/2(9%)/4(18%)/ 7(41%); yp0/I/IIa/IIb/IIIa/IIIb/IIIc: 5(23%)/3(14%)/5(23%)/2(9%)/2(9%) ONCOLOGIC OUTCOMES IN STAGE II AND III TRANSVERSE COLON /4(18%)/1(4%), 7(32%). Pathological tumor downstaging rate, patho- CANCER: A COMPARATIVE STUDY FOR LAPAROSCOPIC VERSUS logical complete response rate and sphincter preservation rate were OPEN APPROACH WITH RADICAL D3 LYMPHADENECTOMY 77% (17/22), 23% (5/22) and 32% (7/22). The local recurrence rate and Han Deok Kwak, Jae Kyun Ju distant metastasis rate was 4.5% (1/22), 18% (4/22). Chonnam National University Hospital, Gwanju, 61469, Conclusions: The results showed that nCRT followed by TME South Korea in rectal cancer was feasible to tumor downstaging, increase sphincter preservation rates and reduce local recurrence rates. Background: Surgical type or approach varies for transverse colon cancer largely depending on the location of the tumors or surgeons’ preference. However, it has an evidence that extensive P-071 lymphadenectomy is favorable for long-term outcomes in locally advanced colon cancers. This study was designed to compare the THE EFFECTIVENESS OF SELF-EXPANDABLE METALLIC STENT AS A short- and long-term outcomes following laparoscopic or open BRIDGE TO SURGERY FOR LEFT-SIDED MALIGNANT COLORECTAL approach with radical D3 lymph node dissection for stage II and III OBSTRUCTION. transverse colon cancer patients. Methods: Between May 2006 and December 2014, patients were S. Uegami, A. Nakamitsu, Y. Imamura, M. Sasaki, M. Kouyama, treated for stage II and III transverse colon cancer. This is a retro- Y. Sugiyama, T. Tatsuya, R. Shintakuya, Y. Kameda, S. Tazuma, spective study of prospectively collected data in a tertiary teaching K. Shinbara, K. Miyashita hospital. Radical D3 lymphadenectomy includes the principal Hiroshima General Hospital, Hiroshima, 738-8503, JAPAN nodes of middle colic artery, which is numbered as 223 defined by the Japanese Classification of Colorectal Carcinoma. Objectives: In Japan, self-expandable metallic stents (SEMS) were Results: A total of 144 patients were included, of whom 118 approved for insurance coverage for treatment colorectal obstruc- (81.9%) performed laparoscopically. The patients’ characteristics tion in 2012. This study aimed to evaluate the effectiveness of between laparoscopic and open group had no differences. Most SEMS as a bridge to surgery (BTS) compared with emergency patients in laparoscopic group were performed extended right surgery for left-sided malignant colorectal obstruction. hemicolectomy (90.7%), while open group underwent in 65.4% Methods: From January 2012 to March 2017, we retrospectively (p=0.005). Operative time was longer in laparoscopic group identified patients received emergency surgery or received elective (laparoscopic vs. open, 151.3 vs. 131.2 min, p=0.021), and open surgery after SEMS placement due to left-sided malignant colo- group had more estimated blood loss (160.8 vs. 289.3 ml, p=0.011). rectal obstruction. Bowel obstruction was defined as having gastro- Pathologic outcomes including proximal and distal margin, intestinal symptoms and having oral bowel expansion obviously by retrieved lymph nodes, T and N stages had no differences except image findings (abdominal x-ray examination and/or computed tumor size (5.8 vs 7.9 cm, p=0.007). Both groups also had not tomography). Patients, received any surgery without primary different in postoperative parameters such as first flatus, initial tumor resection, or diagnosed as perforation, bleeding, abscess diet, hospital stay, and complications. There was not statistic formation and rectal cancer (excluding rectosigmoid), were difference on disease-free, overall, and cancer-specific survivals. excluded. Clinical and pathological findings and surgical outcomes Conclusion: There was no long-term difference, except for the were compared between Emergency surgery group (ES) and BTS methods of surgery and the associated differences between group (BTS).

236 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Results: In 488 consecutive colorectal cancer patients, twenty- eight patients were included in this study. There were 11 patients P-073 in the ES group and 17 patients in BTS group. Age, gender, BMI, Charlson comorbidity index, ASA score, tumor location and TNM WHAT TO DO IN FRONT OF A COLORECTAL CANCER IN OCCLUSION? staging were similar between these two groups. Also tumor (T), lymph nodes (N), lymph vascular invasion (ly and v) and tumor A.Bereksi-Reguig, S.Loudjedi, M.Bendimerad, B.Fandi, grading weren’t different. The rate of laparoscopic surgery was M.Kherbouche. significantly higher (82.4% versus 0%, p<0.01) and operative time Surgery B Unit, Teaching Hospital of Tlemcen, 13000 Algeria was longer in BTS group (333 min versus 230 min, p<0.01). No Introduction: Intestinal occlusion due to CRC has always raised difference was verified in blood loss, primary anastomosis rate and problems regarding surgical treatment. Due to the fact that most of stoma creation rate. Intensive care unit (ICU) treatment rate (ES these patients are operated as an emergency, their metabolic state 36.4%, BTS 5.9%) and postoperative complication rate (ES 63.6%, is insufficiently assessed and mechanically, the colon is not ready BTS 23.5%) were higher in ES group (p<0.05). However mortality for surgical intervention. Surgical teams must make an ongoing case wasn’t detected in both groups. choice between surgical treatments in one operative session and Conclusions: SEMS placement as BTS for left-sided malignant serialized surgical interventions. colorectal obstruction could allow the laparoscopic surgery after Objectives: Our objectif is to adopt a standard therapeutic attitude decompression and reduce the postoperative ICU treatment and Methods: Through a retrospective study made in the surgery B unit complications. of the TEACHING HOSPITAL of TLEMCEN we report all emergency operated patients for acute intestinal occlusion due to colorectal P-072 cancer between January 2007 and December 2016. Results: 34 patients were operated including 25 males and 9 TREATMENT OF COLORECTAL CANCER REQUIRING females with an average age of 61 years .The cancer localization PREOPERATIVE DECOMPRESSION. was left colon in 31 cases. First group;an upstream stoma without resection was made in 9 cases (6 colostomies and 3 ileostomies), 25 H. Hachiya, Y. Iwasaki, K. Takagi, H. Nagata, M. Ishizuka, T. Aoki, resections were performed in the second group, all the patients K. Kubota were operated at a second time. Second Department of Surgery, Dokkyo Medical University, Discussion: We did not observe any difference in the operative Tochigi, 321-0293, Japan. follow-up for the two groups: stoma of bypass / resection but the Objectives: Colorectal cancer requiring preoperative intestinal operative time is markedly reduced in the first group which reduces decompression has been increasing. Although it has been reported the operative risks for these fragilized patients. that good short-term outcome can be obtained by performing Conclusion: Occlusive colorectal cancers are severe forms of intestinal decompression, long-term outcome depending on the disease which represent a serious problem of therapeutic strategy presence or absence of intestinal decompression remains unclear. that is still intensely debated at present. The objective of this study was to examine the relationship between intestinal decompression and long-term prognosis in P-074 colorectal cancer patients. Methods: The subjects were colorectal cancer patients who under- DESPITE CLEAR ADVANTAGES OF LAPAROSCOPY, COLON CANCER went surgery in our hospital from November 2005 to May 2017. RESECTIONS ARE MOSTLY PERFORMED OPEN; LITERATURE Preoperative decompression was required in 65 patients (6%). OVERVIEW AND OUR DATA Intestinal decompression was performed with nasal or transanal ileus tube, colonic stent, and colostomy. Patients were divided into B Krebs, A Ivanecz, S Potrč two groups: decompression group and non-decompression group. Department for abdominal surgery, UCC Maribor, 2000 Results: Between the decompression group and the non- Maribor, Slovenia decompression group, there was no significant difference in age, sex, Objectives: In some advanced centers laparoscopic colorectal and location of the lesion while there was a significant difference in surgery represents standard procedure and vast majority of stage (0/Ⅰ/Ⅱ/:0/1/25/19/20 vs 36/192/261/267/185, p=0.002). In patients are operated on laparoscopically. But the fact is that surgery-related factors, the proportion of patients who underwent majority of colonic cancer operations in the world is still performed open surgery (84％ vs 56%, p=0.001) was higher in the decompres- open, even in the most surgically developed countries. sion group. Although there was no significant difference in operation Methods: We searched Pubmed and Medline for data about the time (232min vs 217min, p=0.213), intraoperative bleeding amount ratio of laparoscopic colonic cancer operations. We performed a (481ml vs 272ml, p=0.001) was larger in the decompression group. retrospective cohort study of all patients operated on for colon While there was no significant difference in the incidence of post- cancer (but not rectum) at our department between 2006 and operative complications (52% vs 46%, p=0.377) and the incidence of 2015. Inclusion criteria were: patients with primary, solitary colon suture failure (7% vs 6%, p=0.783), the incidence of surgical site infec- carcinoma above 15 cm from anal verge, where we managed to tion (50% vs 34%, p=0.007) was higher and the length of postopera- perform R0 resection. tive hospital stay (16days vs 14days, p=0.005) was longer in the Results: The exact proportion of laparoscopic colon operations is decompression group. In terms of survival prognosis, the 5-year hard to define. At our literature review the rate was rarely over 50 %. survival rate (44% vs 73%, p=0.001) after surgery was significantly After inclusion criteria we studied 1007 patient with colon cancer. lower in the decompression group. There were 146 or 16 % laparoscopic procedures. The percent of Conclusions: Since colorectal cancers requiring decompression laparoscopic resections is constantly rising. From only few cases in were more likely to be advanced cancers, open surgery was more year 2006 to 31 percent in year 2015. There are mostly sigmoid and frequently selected and the prognosis was poorer. right colon resections.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 237 ABSTRACTS

Conclusions: Although surgeons are familiar with advantages of be achieved through only the antegrade or retrograde DBE laparoscopic surgery most of them still prefer open procedures for procedures. As treatment for small bowel bleeding, especially colonic cancer. The reasons are numerous: home department spout bleeding, localization of the lesion for the decision of DBE recommendations, too much opposition from colleagues, anesthe- insertion facilitates early treatment, such as endoscopic hemostatic siologists and staff, personal discomfort with long and in the clipping, allowing patients to avoid useless transfusion and the beginning demanding operation or perhaps even not believing in worsening of their disease into life-threatening status. Also, advantages of laparoscopy for cancer surgery. applying endoscopic India ink marking prior to laparoscopic surgi- cal resection is a particularly useful technique for more minimally P-075 invasive treatment. We report two cases of small bowel heman- gioma found in examinations for OGIB that were treated with com- NEW TECHNIQUE FOR SUTURED LAPAROSCOPIC ILEOCOLIC bination of laparoscopic and endoscopic modalities. The preceding ANASTOMOSIS ENTEROTOMY CLOSURE implementation of VCE made the selective decision of DBE inser- tion easy, and the endoscopic process facilitated early treatment, C.C. Pereira, C.M. Insua, S. Costa, I. Romero, J.C. Pereira. resulting in avoidance of progression to life-threatening status. Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal Furthermore, preceding contrast-enhanced computed tomography Introduction/Objective: Intracorporeal anastomosis after right with a characteristic of rapid and minimally invasive technique may laparoscopic hemicolectomy is associated with lower complications omit VCE, making it a useful algorithm for further early treatment. and shorter length of stay. However, the closure of the enterotomy These findings imply that various preoperative endoscopic con- made for the stapling device requires advanced laparoscopic skills trivances may result in safer, more minimally invasive treatment. and is time consuming. We report a new technique of sutured enterotomy closure Methods: We use a slowly absorbing surgical suture cut to roughly P-077 25 cm. On the free end, we create a loop by first placing a double knot and then looping the thread 4 times. We begin the suture on NEUROENDOCRINE RECTAL TUMOR AS A RARE ETIOLOGY OF ADULT the posterior edge of the defect, and after the first stich is passed the RECTO-SIGMOIDAL INTUSSUSCEPTION: CASE PRESENTATION needle is passed through the loop made previously making a Matei R., Bratu, Bogdan Diaconescu, Sebastian Valcea, self-locking knot. We make a full thickness running suture and on the Mircea Beuran. other end of the defect we tie a Cushieri knot, we continue back using the same thread to make a running seromuscular suture. Intestinal intussusception is a frequent pediatric pathology, but Finally, we tie a knot using the needle edge and the free edge left in adult cases are rare and don’t have a specific presentation. In most the beginning of the suture. cases, adult intestinal intussusception , regardless of its localization, Results: Using the standard technique of double layer suture the is caused by an endoluminal tumor which can be of multiple patho- surgeon must tie four knots. This technique requires the surgeon to logical types. We report a sigmoido-rectal intussusception in an tie only one standard knot intracorporeally and to throw one adult in whom an adenoneuroendocrine tumor was identified as Cushieri knot. the lead point. This case is unique for several reasons: (1) the tumor Conclusion: By using self-locking knots and a single suture this is a rare subtype of adenoneuroendocrine variant, (2) neuro- technique has the potential to decrease the complexity and time endocrine tumors rarely involve the distal segment of the gut, (3) spent on enterotomy closure in intracorporeal ileocolic anastomosis. the clinical presentation with a recto-sigmoidal intussusception presented a diagnostic challenge. P-076 P-078 PREOPERATIVE ENDOSCOPIC CONTRIVANCES FOR GASTROINTESTINAL BLEEDING EXPAND A RARE CAUSE OF CHRONIC CONSTIPATION IN A MIDDLE AGE THE POSSIBILITIES OF MINIMALLY INVASIVE SURGERY FEMALE: ANTERIOR SACRAL MENINGOCELE. Taiichiro Miyake, Nobuhisa Takase, Kouji Hisano, Eri Maeda, A.H.Widatalla, G.M.Mohamed, A.M.Abelhai, M.Y.Alnkhly. Keisuke Fukui, Tohru Nishimura, Kouichiro Abe, Akihito Kouzuki, Ibrahim Malik University Hospital, University of Khartoum Tomohiro Tanaka, Naoki Harada, Manabu Takamatsu, Kunihiko 11111. Kaneda Introduction: Anterior sacral Meningiocele (ASM) is a rare clinical Department of Surgery, Kakogawa Central City Hospital presentation. 439, Honmachi, Kakogawa-cho, Kakogawa, Hyogo prefecture, Case Report: A 40 years old female presented with 10 years history 675-8611, Japan of right iliac fossa pain. She described lower limb numbness but no Small bowel hemangioma is a relatively rare small bowel tumor weakness or sphincter disturbances. Five years before her current and can cause gastrointestinal bleeding, which often results in a presentation she was diagnosed as a case of ovarian mass based on diagnostic dilemma. Among the various diagnostic modalities for abdomino-pelvic ultrasonography. She undewent surgery but no small bowel hemangioma, video capsule endoscopy (VCE) and gynaecological abnormality was found. She presented to us because double-balloon enteroscopy (DBE) can be recommended as part of of new onset constipation. Digital rectal examination revealed the work-up in patients with obscure gastrointestinal bleeding bulging of the posterior rectum wall because of an extra luminal (OGIB). VCE and DBE are both useful modalities for the diagnosis mass effect. Colonoscopy was normal apart from bulging in the of small bowel disease with OGIB including hemangioma, and posterior wall. Lumbosacral spine and pelvis MRI showed preceding observation by VCE can result in a synergistic treatment partial sacral agenesis and a large presacral meningocele. Surgical effect. DBE is superior to VCE in the accuracy of diagnosis and treatment was discussed with the patient and the neurosurgeon. therapeutic potential, while in most cases total enteroscopy cannot Through lower midline abdominal incision dissection in the

238 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

retro-rectal space was done. The meningocele was released from cause of neonatal intestinal obstruction. In our centre, it is the surrounding tissues down to the pelvic floor. Then patient on Jack- second most frequent indication for operating on a neonate after Knife position, dissection was done till the pedicle of the sac was anorectal malformation. While prognosis is excellent in the identified and ligated. The sac was excised. Her post- operative developed world, morbidity and mortality figures of resource- course was uneventful. challenged countries are only just improving. Our goal was to Discussion: ASM can present with a wide range of symptoms. identify the peculiarities of the presentation and management Compression on sacral nerve roots presents with a variety of neuro- outcomes of intestinal atresîa at our hospital. We present our logical symptoms. Compression on the rectum causes worsening preliminary findings. constipation. MRI is superior in diagnosing ASM. It gives details Methods: The clinical notes and operative records of neonates about size, shape, and relation to surrounding structures. The managed for intestinal atresia at Komfo Anokye Teaching Hospital abdominal approach is used for high retro-rectal extra-spinal Kumasi from January 2013 to December 2016 were retrospectively lesions. The posterior (trans-sacral) approach is used for low lesions retrieved. Data regarding patient characteristics, diagnosis, co- and infected cysts. morbidities, surgery, surgical outcome and duration of admission Conclusion: MRI is important to assess pelvic masses; gives details were extracted. Data analysis was done with SPSS 23.0 version. about size, shape, and relation to surrounding structures. The Results: Seventy-one neonates underwent surgical repair for abdomino-sacral approach is being recommended for large high intestinal atresia. The age range was 4 – 12 days with median age presacral masses because it offers good exposure and allows for of 7 days and male to female ratio of 1.5:1. Atresias were most excellent haemostasis. common in the jejunum (50.7%, n=36/71) and least so in the ileum (16.9%, n=12/71). The most common types of atresias by category P-079 were Type 2 (40%, n=10/25), Type 2 (40%, n=4/10) and Type 1 (41.7%, n=15/36) for duodenal, ileal and jejunal atresias respectively. ACUTE INTUSSUSCEPTION SECONDARY TO A LIPOMA OF THE The most frequently performed procedures were duodeno- SMALL BOWEL duodenostomy, ileal resection and anastomosis and jejunoplasty. From the nineteen clinical notes that had been accessed at the Abbassi I, Baraket O, Triki W, Baccar A, Ayed K, Ayari H, time of this write-up, the mean maternal age and gestational age Lahmidi A, Ganzoui I, Bouchoucha S. at delivery were 27.6 years and 34.1 weeks respectively. Averagely, Department of surgery Bizerte hospital, feeds were commenced 3.5 days post-operatively. Mean duration Faculty of medicine of Tunis, University of Tunis El Manar of admission was 17.56 days. Additional clinical problems included Objective: Intussusception as a cause of intestinal obstruction in poor glycaemic control, neonatal sepsis and cholestatic jaundice. adults is rare.There is various pathology which leads to intussuscep- Mortality was 10.5% (n=2/19) tion in adults. Ultrasound and abdominal CT scan may help in a Conclusion: Late presentation and the challenges associated with preoperative diagnosis. However early surgical intervention is the neonatal intensive care in our environment have contributed to the mainstay of treatment in order to confirm the diagnosis. We report morbidity identified in this study. a case of ileoileal intussusception in an adult caused by an ileal lipoma. P-081 Case: A 45 year old male, was admitted with abdominal pain and vomiting for two days. The patient had no past history of alteration COLORECTAL ANASTOMOTIC DEHISCENCE: RISK FACTORS AND in bowel habits, melena or weight loss. All the vital parameters IMPACT ON SURVIVAL were within normal limits. His abdomen was distended and there is no palpable abdominal mass; bowel sounds were hyper audible. L. Carvalho, M.L. Matos, A.M. Correia, I. Bessa, J. Costa, Laboratory blood tests were normal. Abdominal radiography A.C. Soares, M.R. Sousa, J. Costa Pereira, G. Gonçalves, M. Nora. revealed prominent dilatation of the small bowel with air fluid Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da levels. Computed tomography (CT) scan was done which was Feira, 4520-211, Portugal showed dilatation of small intestine because of ileo-ileal invagina- Objectives: The goal of this study was to evaluate the importance tion. The decision was made to undertake an urgent exploratory of several risk factors on colorectal anastomotic leakage in patients laparotomy: ileo-ileal intussusception was present. Resection and submitted to rectal cancer surgery: previous radiotherapy, gender, ileo-ileal anastomosis was done. A histopathological diagnosis was age, disease stage and derivative stoma. We also aimed to evaluate reported as intussusception as a complication of intestinal lipoma. the impact of anastomotic leakage in survival and disease-free There was no evidence of dysplasia or malignancy. The postopera- survival. tive period was uneventful and the patient was discharged on the Methods: We analysed a retrospective cohort of patients submitted sixth postoperative day. to low anterior rectal resection with curative intent from January Conclusions: Lipoma of the small bowel is a rare etiology 2012 to December 2014. Exclusion criteria were: non-curative Intussusceptions in adults. Preoperative diagnosis is possible resection and benign pathology. We used the Χ2 test for proportions through abdominal CT scan. Emergent surgery is the only curative and log rank test for comparison of the Kaplan-Meier curves. treatment P values < 0.05 were considered statistically significant. Results: We identified 61 patients who underwent anterior rectal P-080 resection: 39.3% were women (n=24) and 60.7% were men (n=37); 26.2% of the patients had neoadjuvant radiotherapy (n=16). Thirty- INTESTINAL ATRESIA: THE GHANAIAN EXPERIENCE one patients were older than 70 years old. According to the disease stage, 25 patients were in stage I and II, 26 in stage III and 10 in A.C. Yifieyeh, B.M. Duduyemi, E. Kumahor, B. Nimako, M. Amoah stage IV (41%, 43% and 16%, respectively). Six patients had an Komfo Anokye Teaching Hospital, Kumasi anastomotic dehiscence (9.8%). We did not identifiy a statistical Objective: Intestinal Atresias are the most common congenital significance between colorectal anastomotic leakage and neither

Surgery, Gastroenterology and Oncology, 22 (3), 2017 239 ABSTRACTS

previous radiotherapy, gender, age, disease stage or derivative emergency and accounted for half of all emergency laparotomies stoma. There was no significant statistical impact of anastomotic in the UK in 2014-15. According to the British Medical Journal, leakage on overall survival and disease-free survival. patients with partial small bowel obstruction may benefit from Conclusion: The results of this study do not support the routine use conservative rather than operative management. Although the of derivative stoma. The occurrence of anastomotic leakage is not diagnostic purposes of gastrograffin are acknowledged, the influenced by any of the several risk factors analysed. The overall therapeutic usage of gastrograffin remains debated and is not survival and disease-free survival were not affected by the clearly documented. Our aim was to determine the effectiveness presence of anastomotic dehiscence. with which gastrograffin can be used to aid in conservative management of small bowel obstruction. P-082 Methods: We retrospectively analysed medical records for 23 patients who were admitted with small bowel obstruction in SHORT BOWEL SYNDROME: ADJUVANT THERAPY WITH VITAMIN C January & February 2017. We looked at data pertaining to the AND ERYTHROPOIETIN IN TREATMENT OF ANEMIA IN PATIENTS aetiology of their small bowel obstruction, how many of those patients were given gastrograffin, how many days it took for them Sundov Z, Sundov A. to resume enteral intake afterwards, and how many of them 1 Department of Gastroenterology, University Hospital Split, required surgery. 2 Split, Croatia; Community Health Center Split, Split, Croatia Results: 8/23 patients admitted with small bowel obstruction in Background: Adjuvant therapy may allow patients being treated January & February 2017 were given gastrograffin. 4 of these with epoetin to derive greater clinical benefit. Due to inadequate patients had become obstructed due to post-operative adhesions, mobilization and incomplete utilization of iron, some patients and the remainder had adhesions due to fibroids, an internal treated with erythropoietin can have weakened clinical response hernia, disseminated intraabdominal malignancy, and a stenotic than expected. However, the quality of treatment could be small bowel anastomosis. 6 of these patients had resolution of improved by additional administration of vitamins C. their obstruction in an average of 1.83 days after being given Methods: Twenty patients with short bowel syndrome (SBS, or gastrograffin. The other 2 patients required surgery for their small short gut) divided into the intravenous vitamin C (IVC) (n=10) and bowel obstruction. control (n=10) groups. Their have had hemoglobin value below 100 Conclusions: The therapeutic usage of gastrograffin is a debatable g/l and serum ferritin level in range of 100-500 ng/ml. Both issue; however it has the potential to augment recovery time of were given erythropoietin (3x75-100 ij/kg weekly). Besides that, small bowel obstruction. This topic should be further researched, experimental group was treated with vitamin C (3x500 mg weekly using larger numbers and in a multi-centre trial as the potential intravenously) (n=10), and control group was administered placebo benefits both clinical and financial of avoiding surgery in these (n=l0). The hemoglobin level, hematocrytes and hypochromic patients would be substantial. erythrocytes value was estimated, as well as hemoglobin concen- trations in reticulocytes, transferin saturation index and serum P-084 ferritin level. The research lasted for 90 days. Indexes were set at the beginning, 30-th, 60-th and 90-th days after start. THE AIM OF THIS STUDY IS THE PRESENTATION AND ANALYSIS Results: Both groups had a increase in their hemoglobin (19,2 % vs OF COMPLICATIONS OF THE COLON AND RECTUM SURGERY 15,7 %) and hematocryte (19,3 % vs 15,2 %) and comparison groups ESPECIALLY DURING OF FINANCIAL IS CRISIS. do not have significant differences . But the value of transferrin saturation index increased considerably in vitamin C treated group Piperos Th.1,2, Nikou Ef.2, Flessas I.2, Papapanagiotou I.2, after the 30-th day of research (20,6%) in comparison with control Zoulamoglou M.2, Kakaviatos D.2, Zarokosta M1, Papavasileiou G.4, group increase (4,8%), with statistical significance (p=0,023). Also, it Mariolis-Sapsakos Th.2,3 was compared ferritin value periodically, with steep decrease of feritin level in experimental group (119,6%) in comparison with Meterial-method: The study is retrospective and refers the period control (66,4%), and statistically significant differences (p=0,023) on 2011 to 2016.It includes 430 patients with colon and rectal cancer. 90-th day. These data implicated fastened iron storage mobilization 60% of them were males. The age ranged from 24 to 92 years. All in experimental group. It wasn’t significant rise neither of patients had preoperative diagnosis by colonoscopy, while the hypochromic erythrocyte value (p=0,57), nor has the increase of staging of disease determined with CT (Computed Tomography) hemoglobin concentration in reticulocytes (p=1,16). scan of upper and lower abdomen. All patients with rectal cancer Conclusion: The research has shown that vitamin C, applying with underwent to pelvic MRI (Magnetic Resonance Imaging). 35% of human recombinant erythropoietin, have place in treatment of the patients had sigmoid cancer,17% cecum cancer, 5% cancer of anemic patients with short bowel syndrome. The results have ascending colon 5% cancer of descending colon and 3% transverse implicated to fastened iron mobilization from tissue storage, better colon cancer. transferrin saturation, and more dynamic erythropoiesis. Results: At this time of period were performed (73-16.97%) right colectomies, (34-7.9%)extensive right colectomies, (172-40%) left P-083 colectomies, (140-32.5%) low anterior resections and (11-2.55%) abdominoperineal resections. At low anterior resections was used SMALL BOWEL OBSTRUCTION: EVIDENCE FOR SUCCESSFUL NON the TME technique (total mesorectal excision) and to the right and OPERATIVE MANAGEMENT left colectomies the CME (Complete Mesocolic Excision) technique. All anastomoses at the low anterior resections were done using M. Kedrzycki, J.Watt, P. Ng Cheng Hin. circular stapler and additional sutures at the suture line. The Queen Elizabeth Hospital, Woolwich, anastomoses to the remaining operations by 90% was done London SE18 4QH, United Kingdom handmade with suture of the bowel into 2 layers due to restiction Objectives: Small bowel obstruction is a common medical of (to lack of) staplers for economic reasons. Concerning the

240 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

complications, we had the following results: anastomotic leakage: P-086 3%, bleeding: 2%, intrabdominal abscess: 5.5%%, ileus: 5% wound infections: 18%, atelectasis: 9.5%, pulmonary embolism: 0,5%. WIDE LOCAL EXCISION FOR ANAL GIST: A CASE REPORT AND There were two deaths. Of the patients who experienced compli- REVIEW OF LITERATURE cations, 92%were treated conservatively. In 5% of the patients A. Chhaidar, M. Azzaza, M.A.Said, F. Harrabi, M. Ben Mabrouk, performed drainage of abscess under CT. Reoperation needed in A.Ben Ali. 15 patients.42 patients needed treatment in the ICU. The average SAHLOUL hospital, Sousse4022, Tunisia. period of hospitalization was seven days. Conclusions: Colon and rectum surgery requires an accurate Objectives: Describe an anal GIST successfully treated with wide preoperative diagnosis and thorough preorerative screening for local excision. staging. The performance of the operation by a constant, Presentation of case: We describe a case of a 70-year-old lady pre- experienced team reduces significantly the complications with the senting with a 2 cm mass in the anal canal. Endoanal ultrasound standardization of the procedure. The management of complications revealed a well-circumscribed solid nodule in the intersphincteric should be direct to the benefit of patients, while an important space. The patient was successfully treated by wide local excision objective remains the reduction of the cost in a country with and adjuvant therapy with imatinib mesylate. financial crisis and of cource the reduction of stay in Hospital. Conclusions: Small lesions (< 2 cm) with low mitotic rate may be Respect for the principles of CME and TME technique is crucial to successfully managed by local excision. Radical surgery should be achieve correct oncological preparations and improve surgical reserved for large, aggressive tumors. technique in the surgery of the colon and rectum. P-087 P-085 EXTRAGONADAL OMENTAL TERATOMA IN A MALE WITH NORMAL PERINEAL RECTOSIGMOIDECTOMY FOR GANGRENOUS RECTAL TESTIS: A RARE CASE REPORT PROLAPSE. A. Goel, R. Jain, S. Neogi, T. Chand, S. Ramasamy, S. Prajapati, A.H.Widatalla, A.S.Elawad, S.M.Mohamed, A.S.Alasha, A. Jain. H.D.Elsiddig, W.B.Balla, S.H.Suliman. Maulana Azad Medical College, New Delhi, 110002, India. Ibrahim Malik University Hospital, University of Khartoum Introduction: Mature cystic teratomas are among the most Rectal prolapse with incarceration and strangulation needs common ovarian tumors; however, teratomas of extragonadal emergency intervention either by medical reduction or surgical origin are extremely rare, most common site being the omentum. procedures. Most cases reported were frequently found in female with only a Case report: A 28-years old male presented with strangulated couple of cases reported in male. rectal prolapse for 5 days prior to admission. He had recurrent Case report: A 15 year old boy was admitted for upper abdominal rectal prolapse after defecation for one month. He is a young lump since 6 months. There was no history suggestive of intestinal healthy man with full thickness rectal prolapse which was edema- obstruction. Abdominal examination revealed 17x10 cm lump tous, ulcerated, with signs of gangrene. There was a rectal polyp. occupying epigastrium and umbilical region. Genitalia examination Blood, urine tests, abdominal ultrasound and plain X-ray were was normal. Ultrasonography and CECT abdomen showed well normal. Osmotic reduction by hypertonic solution had failed. The defined, cystic, multiseptated 17x11x10 cm lesion in central decision of surgery was made. The patient on Lloyd Davies position abdomen with dense ossification and calcification along with fat under general anesthesia; using the perineal approach procto- attenuation, fluid and enhancing soft tissue. Laparotomy revealed sigmoidectomy was done at the demarcation between the healthy a cyst within the greater omentum with rupture at one site and and the gangrenous rectum. Distal stump was closed and reduced. protrusion of hair follicles through it. Histopathological sections Defunctioning left iliac fossa end colostomy was performed showed mature cartilage, gastric , adipose tissue, glial tissue, through a laparotomy incision. The patient was discharged after 12 bone, smooth and skeletal muscle, respiratory epithelium and days. Histopathology revealed gangrenous mucosa and the polyp stratified squamous epithelium with skin appendages with no was a juvenile. Colonoscopy was done after twelve weeks of immature components. discharge and revealed normal mucosa. After six months the Discussion: Teratomas originate in pluripotent cells, and are colostomy was reversed and the two ends of bowel were joined composed of wide diversity of tissue foreign to the organ or with a circular stapler. Post-operative course was uneventful. anatomic site in which they arise. Approximately thirty-one interna- Discussion: When prolapse can’t be reduced, sedation and tional reports on the omental teratoma have been published which Trendelenburg position with osmotic reduction may decrease included only a couple of male cases. The causes are poorly bowel oedema and help reduction. When the prolapsed bowel is understood, but three main theories have been proposed to explain incarcerated, strangulated or ulcerated this becomes a surgical their location: 1. Primary teratomas of the omentum may originate emergency. The operation of choice is perineal proctosigmoidectomy from displaced germ cells. 2. Teratomas may develop in a with or without colostomy. Our patient underwent perineal supernumerary ovary of the omentum. 3 Teratomas may result from proctosigmoidectomy with a defunctioning left iliac fossa end auto-amputation of an ovarian dermoid cyst with secondary colostomy. Primary anastomosis was not done because the rectum implantation into the greater omentum. Definitive diagnosis is was oedematous, ischaemic, with deep mucosal ulceration. possible following histopathological examination. Teratomas of the Conclusion: Emergency perineal proctosigmoidectomy with greater omentum are benign lesions, but malignant transformation closure of distal stump combined with end colostomy is a good is known. Surgical excision is all that is necessary. Immature option in gangrenous difficult sewn bowel. Reversal of colostomy teratomas are potentially malignant, so the patient may require can be done as a second stage of the procedure. chemotherapy and radiotherapy.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 241 ABSTRACTS

P-088 appropriate. The P value was considered significant if < 0.05. Result: The mean age was 50.5 years (SD+/- 10.5), male to female EXVIVO RESECTION AND INTESTINAL AUTOTRANSPLANTATION FOR ratio was 1.3:1, there were 28% (n=97) live in Khartoum and 22.8% THE TREATMENT OF TUMORS AT THE ROOT OF THE MESENTRY (n=77) were come from centre and west of Sudan, about 12.8 % A.A.Ahmed1, Saman NikIgbalian2, Alireza Shamsaeefar3, (n=43) from east Sudan, and 11% (n=37) from north Sudan while Amin Bahraini4 1.8 % (n=6) were live in South Sudan. The commonest GI 1HPB &organ transplantation fellow, Shiraz center of organ malignancy in our study was pancreatic cancer followed by colonic transplantation, Shiraz,Iran then gastric malignancies in 36.5%, 26.7% and 16% respectively, the 2Associate professor of Surgery, Shiraz University of Medical majority of pancreatic cancer (58%) from west Sudan and 31% from Science, Shiraz, Iran north Sudan. 3HPB & organ transplant surgeon.Shiraz Center of Organ Conclusion: The commonest GI malignancy in our study was transplantation, Shiraz, Iran pancreatic cancer, followed by colonic & gastric malignancies. 4HPB & organ transplant surgeon. Ahwaz University of Medical Khartoum and west of Sudan were common states for pancreatic Science, Ahwaz, Iran. and colonic cancer. Colonic cancer tends to occur in young age group. Background: Pancreatic tumors involving the root of the mesentry Keywords: GI malignancies, pancreatic cancer, gastric malignancies, continue to be a management problem in hepatopancreaticbiliary Sudan. field, these tumors constitute a wide spectrum of pathology NET, PDAC, GIST. Previously these tumors were labeled as irresectable tumors, late stage and untouchable. P-090 Material and Method: Between the period January 2015-June MANAGEMENT OF CA APPENDIX – AN INSTITUTIONAL 2016, Twenty one patient underwent exvivo resection and auto- EXPERIENCE transplantation of the small bowel for tumors of the pancreatic head, neck involving the root of the mesentry, in Shiraz Center for Osama Shakeel, Awais Amjad Malik, Sadaf Batool, Umer Farooq, Organ Transplantation, Namazi hospital, Islamic Republic of Iran. Shehryar Riaz, Irfan-ul-Islam Nasir, Aamir Ali Syed, Shahid Tumors and mesentricvessels were evaluated using triphasic CT Khattak. and MRV. Internal jugular, great saphenous veins and Deep venous system of the lower limbs were assessed preoperative by duplex Introduction: To study the surgical and oncological outcome of all examinationfor venous graft of the resected portal vein the patients presenting with a diagnosis of Ca Appendix at Results: Mean operative time 780+_46 min, mean blood loss 1900 SKMCH&RC. ml, short term mortality 14%, three patients. Main cause of death Methodology: From 2006 to 2015 all patients with a diagnosis of Ca is respiratory complications (pneumonia, ARDS). Mean cold Appendix were included in the study. Demographic variables were ischemic time 110+_25 min. Exploration rate 42%, nine patients collected. Surgical outcomes in terms of operation performed and its were explored for different causes. R0 resection could be achieved complications were recorded. Short and long term oncological in most of the cases, and symptoms relief was pleasantly accepted outcomes were recorded. All data was entered and analyzed in SPSS by the patients. ver 21. Conclusion: Exvivo resection and autotransplantation of small Results: A total of 19 patients were included in the study. Median bowel is good and justifiable option for pancreatic tumors involving age was 58 years. There were 7 male and 12 female patients. Most the root of the mesentry. It provides good relief of symptoms, long common presentation was pain RIF in 16 patients followed by disease free survival and potential cure. altered bowel habits in 3 patients. 17 patients had an adenoca and 2 had Neuroendocrine Ca. 13 patients had a standard right hemi- P-089 colectomy performed. 5 only had an appendectomy performed. One patient had a TAH BSO + appendectomy. 12 patients received GASTROINTESTINAL MALIGNANCIES IN SUDANESE PATIENTS; adjuvant chemotherapy. 8 patients had a disease recurrence. All WHERE WE ARE? patients had a median survival of 24 months. Conclusion: Cancer of the appendix is rare and needs to be Muhaned Mohammed Ahmed1, Nassir Alhaboob Arabi2*, managed aggressively. All patients are best treated with a formal Abdulmagid Mohammed Musaad3, Elsaggad Altayeb A4, right hemicolectomy with adjuvant chemotherapy. Muataz Salaheldin4, Sawsan Abulgasem5

Background: Gastrointestinal cancers are a leading cause of cancer P-091 related death worldwide (after lung cancer). There is significant RECURRENT MALIGNANT OF THE BREAST geographic variation in gastrointestinal cancers. The aim of this IN A TWO ADOLESCENT FEMALE study is to identify variety, pattern of presentation, management and hospital mortality of gastrointestinal malignancy in Sudanese Mahim Koshariya, Surbhi Garg, Prashant Kharat, Sudhanshu patients. Agarwal, Rameshwar More, Sameer Ahmed, Abhishek Methods: Data from 337 patients with GI malignancies were Shitole,Sheikh Behram, Anuradha Chaudhary. collected prospectively and retrospectively, it is cross section hospital based study. It included all patient with GI malignancy Phyllodes tumors (PT) are characterized except those with thoracic oesophageal cancer and it was conducted by a combination of hypercellular stroma and cleft-like or cystic in two years’ period, data collected, and analysed using Statistical spaces lined by epithelium, into which the stroma classically package of social science (v 19.0), frequencies, descriptive statistic project in a leaf-like fashion and have a potential to recur and and test of significant Chi squire, t test were used when metastasize. These tumors are more common in 3rd to 4th decade.

242 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Here we present our experience of two cases seen in a young age was 86. Tumor location: 12-gastric, 5-the small bowel, 4-the adolescents female of recurrent malignant Phylloides Tumor of the large bowel, 5-non digestive tube location. Preoperative diagnosis breast. has been established for 22 cases. 4 cases required emergency Keywords: Malignant, adolescent, phyllodes tumor, recurrence procedure (intraoperative diagnosis). Certainty of diagnosis associated Histopathological Examination with Immunohisto- chemistry (CD117+). Imatinib (Glivec) therapy was set for 8 P-092 patients. Immunotherapy was associated for 7 patients. STANDARDIZATION OF DIET FOLLOW-UP FOR PATIENTS WITH Conclusions: Emergency surgical procedure may occur for GIST’s DIGESTIVE CANCER. due to important digestive bleding. Compression on proximity viscera may lead to emergency surgery. Surgical procedure guided H. Tete, F. Subtil, M.C. Le Goff, B. Delwarde, C. Roux, L. Bonnet, from oncological limits is main treatment. Surgical procedure may be M. Roldan, M.P. Souteyrat, F. VEYRI, Y. Bouffard, T. Rimmele. performed as single treatment. Imatinib (Glivec) induces a decrease Edouard Herriot Hospital, Lyon, 69003, France of tumor and may prevent tumor relapse. Immunotherapy is to be considered. Objectives: In oncology, weight loss is an independent factor of morbi-mortality. The aim of this study was to evaluate the impact of standardizing diet practices in patients with digestive cancer on P-094 weight evolution (weight loss, stabilization or gain) six months after the first diet consultation (DC). CHALLENGES OF SETTING UP DEDICATED PERITONEAL SURFACE Methods: This retrospective analysis of a monocentric “before- MALIGNANCY CENTRE IN RESOURCE LIMITED SETTINGS after” clinical study included all consecutive patients with digestive Raza Sayyed1, Samiullah Khan Niazi2 cancer with a DC. We compared outcomes from two periods 1Surgical Oncologist, Patel Hospital, Karachi Pakistan of time. In the first period, DC was performed on request and 2Assitant Professor, Liver Transplant and Hepatopancreatobiliary follow-up depended of nutritionist. In the second period of time, Unit, Dow University of Health Sciences, Karachi Pakistan DC was performed early after consultation where cancer was announced and follow-up was standardized with a systematic DC at A newly established surgical oncology service in Pakistan has month 1, 3 and 6. Primary outcome was favorable weight evolution started management of peritoneal surface malignancies (PSM) (FWE) (stabilization or gain) at 6 months of first DC. A multivariate almost a year ago. Looking back at the process of development, the analysis was performed to estimate diet standardization effect, problems and challenges faced were identified. The challenges of adjusted on type of treatment and type of digestive cancer. dealing with management of PSM were multifaceted. These include Results: 65 patients were followed up at six months, divided into 30 lack of awareness of physicians and patients, lack of organized multi- before standardization and 35 after, with no significant differences disciplinary teams for PSM management, appropriate perioperative in baseline characteristics (etiology of cancer, type of treatment). management including anaesthesia, theatre staff and intensivists, After standardization, first DC occurred significantly earlier after and availability of equipment for delivery of HIPEC. These challenges cancer announcement (3.7 vs 1,6 months); and number of DC for are looked at from the standpoint of resource-limited settings. We each patient increased (4.9 vs 3.5 DC). In univariate analysis, FWE describe how each of these challenges were dealt by our team. at six months was significantly higher after standardization (51.4% Possible solutions in view of our experience in setting up a vs 20%, p = 0.018). In the first group, mean weight loss was 5.7 Kg peritoneal surface oncology service in a developing country are put at 6 months, and only 2.3 Kg after standardization. The adjusted forward. This will serve as a guide to centres interested in odds ratio was 4.12 (CI 95% 1.18-14.45, p = 0.027), confirming the developing programs especially in resource limited settings. results of the univariate analysis. Severe malnutrition increased from 33% to 47% before standardization while it decreased from P-095 23% to 11% after. Conclusion: Diet standardization is an independent factor of FWE HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY (HIPEC): at 6 months of first diet assessment in digestive cancer patients. THE TUNISIAN EXPERIENCE H. Slama1, M. A. Makni2, M. Jouini2, M. J. Kacem2, Z. Ben Safta2. P-093 1Surgery Department, Mohamed Taher Maamouri Hospital, Nabeul, 8000, Tunisia STROMAL TUMORS – CONSIDERATIONS ON 26 PATIENTS SERIES 2Surgery Department, La Rabta Hospital, Tunis, 1007, Tunisia M. Panescu, Octavia Rusu, R. Costea, C. Balan1, Maria Sajin2, Objectives: The interest of Hyperthermic intraperitoneal Carmen Ardelean3, St. Neagu. chemotherapy (HIPEC) led us to propose the development of this 1Second Surgery Department, SUUB, UMF “Carol Davila” technique in the surgery department ‘A’ at La Rabta Hospital, Tunis. 2Endoscopic Laboratory, SUUB The aim of the study was to describe the technique, discuss its 3Anatomopathologic Department, SUUB indications and analyze its results. 4Morphopathology Institute “V.Babes”, Bucharest, Romania Methods: We did a retrospective, descriptive, consecutive, mono- Introduction: Stromal tumors present clinical and histopathological centric study including all patients who have underwent HIPEC, diversity. Surgeons encounter many challenges from this pathology. between january 2009 and december 2014. We analyzed clinical, New diagnosis methods and treatement approaches have emerged biological and technical data in the pre, intra and post operative. during the past years. Results: Forty cases were included. The average age was 50 years, Material and method: Retrospective analysis over 26 cases from the sex ratio was 0.73. The indication was peritoneal pseudo- 1998 to 2017. in 21 cases (53%), peritoneal carcinomatosis of colorectal Results: Gender distribution: female dominance (15/11). Maximum origin in 12 (30%), peritoneal mesothelioma in two cases.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 243 ABSTRACTS

Preventive HIPEC for gastric tumors was performed in 5 patients. Objectives: Determinate incidence and study the management of Carcinomatosis was diffuse in 26 patients (65%), located in eight intra-operative laparoscopic incidents and absent in six. The mean peritoneal cancer index of Sugarbaker Methods: This was a retrospective descriptive study carried out was 9. The average operative time was 284 minutes [150-600]. from 842 laparoscopic procedures over a period from January 1st HIPEC technique chosen was the open technique. The duration of of 2006 to 31 December 31st of 2015 within the Department of the HIPEC was 30 minutes in 39 patients and 45 minutes in a single General Surgery of the Aristide Le Dantec Hospital in Dakar. We patient. The chemotherapy agents used were oxaliplatin in 31 pro- Included all cases of intraoperative incidents (59 cases). We cedures (77.5%), cisplatin in 8 (20%), two of which in combination studied: the epidemiological data, the interventions concerned, with mitomycin C, and in one case camptomycine. The postopera- their nature, and their management. tive stay was 11 days [5-35]. One death within thirty postoperative Results: Incidence of intra-operative accidents was 7%. The female days was observed. The overall morbidity rate was 37.5%. In uni- predominated with a sex ratio of 0.9 (28 men/31 women). The variate and multivariate analysis, splenectomy was independent mean age was 35 years (extremes of 12 and 85 years). The morbidity factor. The relapse rate was 30%. The one-year survival incidents mostly occured in daily surgery (50 cases). They occurred was 80%. Overall survival was 28.2 months. mainly during hepatobiliary surgery, including cholecystectomy Conclusions: Our operative times were lower than those of with 45 cases (76.2% of incidents). Gastrointestinal accidents literature, splenectomy was an independent factor of morbidity. dominated with 39 cases (66.1%). The biliary tract injury was the Better patient selection, standardization of protocols and the most common (n=24 or 40.6%). Controlled surgical incidents (n = creation of a national register of peritoneal malignancies are 50 or 84.7%) were dominated by biliary complications with 19 necessary conditions for improving the management of peritoneal cases of vesicular breccia (32.2%) and 8 liver wounds (14.1%). carcinomatosis. There were 9 cases (15.3%) of urgent intraoperative incidents (5 ileal wounds (8.9%), 1 cecal wound (1.6%), 2 appendicular arterial bleeding (3, 2%), 1 case (1.6%) of pneumoperitoneum intolerance). P-096 The laparoscopic conversion rate was 40.7% (n = 24): uncontrolled A NOVEL MODIFIED TRANS-ORAL APPROACH FOR ENDOSCOPIC bleeding in 10 cases; Intestinal injury in 8 cases; Wound of the THYROIDECTOMY main biliary tract in 3 cases and 3 cases of intolerance to pneumo- peritoneum. The sequences were simple in 37 cases (62.7%). An Dharini A., PremKumar P.R.T. Naik. operative morbidity of 37.3% was noted (n = 22). In Table V, we Bangalore Medical College and Research Institute have detailed the nature of these complications, their origin and Bengaluru, Karnataka 560078 India their management. Two deaths were observed following post- operative peritonitis (3.4%): The mean hospital stay of our patients Objectives: Modification of the total trans-oral approach for was 11 days with extremes of 3 and 29 days. endoscopic thyroidectomy by placing high cervical ports for better Conclusions: The per-coelisocopic incidents are not negligible and triangulation to overcome the obstacle of swording. it is necessary to take appropriate care in order to avoid dramatic Methods: From April 2016 to May 2017 a total of 9 cases were consequences. operated. Three port technique- one 10mm port through the vestibule near lower incisors for a standard 30 degree scope was placed. Subplatysmal plane created using CO2 insufflation with P-098 pressure set at 6 mm of Hg. Two 5mm ports were placed at the junction of upper 1/3rd and lower 2/3rd along the anterior border MINIINVASIVE SURGICAL TREATMENT OF PORTAL HYPERTENSION of sternocleidomastoid for working instruments. Thyroidectomy COMPLICATED BY BLEEDING GASTROESOPHAGEAL VARICES performed using standard ultrasonic harmonic scalpel. Specimen Petrushenko V.V., Khytruk S.V. retrieved through one of the neck ports. Vinnytsa national medical university named after M.I. Pyrogov, Results: Of the 9 cases, 7 were females and 2 males. One case was Vinnytsa, 21000, Ukraine. converted to open thyroidectomy, rest all were successfully completed. 7 were hemithyroidectomies and 2 were total Objectives: Variceal bleeding is a life-threatening complication of thyroidectomies. Average size of the nodule 4.5 cm. On histo- portal hypertension with a high probability of recurrence and pathology, 8 cases were colloid goitres and one was papillary mortality. Treatment to prevent first bleeding or rebleeding is carcinoma. None of the patients had hypocalcemia or recurrent mandatory. The goal of our research to improve outcomes of laryngeal nerve palsy. No patient had surgical emphysema or patients with portal hypertension complicated by bleeding from pneumomediastinum. One patient suffered from surgical site gastroesophageal varices and increase the survival of patients with infection in the form of abscess over the neck, which was drained. this disease. Conclusion: The novel modified trans-oral technique for thyroidec- Methods: During the period from 2014 to 2016 in the surgical tomy is a feasible procedure with excellent cosmetic results. center of gastrointestinal bleeding Vinnytsa Regional Hospital treated 195 patients with portal hypertension complicated by bleeding from gastroesophageal varices. In this cohort of patients P-097 there were 105 men (53,8%) and 90 women (46,2%). An average INTRA-OPERATIVE INCIDENTS OF LAPAROSCOPY: A 10-YEARS age of patients was 54,8±10,6 years. All patients were conducted STUDY AT SURGICAL DEPARTEMENT OF LE DANTEC HOSPITAL laboratory and instrumental examination. Source bleeding IN DAKAR. installed at esophagogastroduodenoscopy conducted. Patients were divided into 3 groups. The first group of patients received only A. O. Touré, A. Niasse, M. Cissé, O. Thiam, M. L. Gueye, M Seck, conservative therapy, the second group of patients received O. Ka, C.T. Touré, M. Dieng. conservative treatments and performed endoscopic ligation of General Surgery Department, CHU A. Le Dantec, Avenue bleeding gastroesophageal varices, the third group of patients Pasteur, BP 3001, Dakar (Senegal). received conservative therapy performed endoscopic ligation of

244 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

varices and performed endovascular embolization of the splenic Conclusions: Although the preoperative diagnosis of splenic SANT artery. is difficult, it might be considered even in patients with decreased Results: Among the 195 patients treated with portal hypertension splenic tumor size and/or increased accumulation of FDG. complicated by bleeding from gastroesophageal varices discharged from the surgical department 152 patients (77.95%), 43 patients died (22.05%). All dead patients received only conservative symp- P-100 tomatic therapy. In patients who underwent ligation of gastro- esophageal varices - made reliable hemostasis, after splenic artery CASE REPORT OF ANGIOMYXOMA OF THE EPIGLOTTIS WITH embolization - a steady decrease in pressure in the portal vein. REVIEW OF LITERATURE Following the combined miniinvasive surgery all patients were T. Venkataram, A. Razack, H.R. Harindranath, B.D. Manjunath. discharged home, mortality was not. Bangalore Medical College and Research Institute, angalore, Conclusions: Patients with portal hypertension complicated by Karnataka, 560078, India. bleeding from gastroesophageal varices should receive compre- hensive treatment: to stop the bleeding - endoscopic ligation of Objectives: In this case report, we present only the second case varicose veins, to reduce the pressure in the portal vein and ever, to our knowledge, of an angiomyxoma of the epiglottis. We prevention of rebleeding - endovascular embolization of the have also presented a review of literature of angiomyxomas of the splenic artery and symptomatic supportive therapy on the every head and neck. stage. Methods: A clinical case report of a 50 year old female, moderately built and nourished, with complaints of Grade 2 dysphagia for 1 year. She suffered one episode of retching. Not associated with vomitus P-099 or blood. Complains of an irregular, large, pink coloured mass A CASE OF SCLEROSING ANGIOMATOID NODULAR protruding from the mouth following the episode of retching. On TRANSFORMATION OF THE SPLEEN WITH INCREASED examination, a 15cm long, tubular swelling, and a 6x6cm globular ACCUMULATION OF FLUORODEOXYGLUCOSE AFTER swelling seen protruding from the mouth (Image 1). Both swellings 5-YEAR FOLLOW-UP attached to one another and separately palpable from the tongue and the origin not visible. On endoscopy, an irregular, pink coloured Keiso Matsubara, Akihiko Oshita, Takashi Nishisaka, growth seen arising from the epiglottis and progressing into the Tamito Sasaki, Yasuhiro Matsugu, Hideki Nakahara, oral cavity and out of the mouth. On Computed Tomography, a Takashi Urushihara, Toshiyuki Itamoto growth seen arising from the supraglottic region. The patient was Department of Gastroenterological Surgery, Hiroshima taken into surgery. Under awake fibreoptic nasal intubation, the Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, growth was visualised at the base under direct laryngoscopic Hiroshima 734-8530, Japan guidance. Seen to be arising from the epiglottis. Using a harmonic Background: Sclerosing angiomatoid nodular transformation (SANT) scalpel, the growth was excised in toto (Image 2), leaving the of the spleen is a new entity defined as a benign pathologic lesion. epiglottis intact. Patient tolerated the surgery and has recovered Ruling out the malignancy in preoperative imaging studies is difficult. well, and has no complaints of difficulty in swallowing or breathing. PET/CT shows weak accumulation, thereby making the preoperative diagnosis difficult. Herein, we reported a case of shrinking SANT 1 2 of the spleen with increased FDG accumulation during a 5-year follow-up period, which was treated by laparoscopic splenectomy. Case presentation: A 64-year-old female had been first referred to our hospital for the evaluation of a splenic tumor. Initial contrast- enhanced CT showed a well-defined, and ovoid hypoattenuating lesion, measuring 52 mm in diameter in the spleen on the portal phase and "filling-in" of contrast and increasing homogeneity of the splenic parenchyma on the delayed phase. Initial MRI revealed a low-intensity mass on T1-/T2-weighted images with heteroge- nous contrast effect. Initial PET/CT had revealed accumulation of FDG in the tumor (maximum standardized uptake value [SUVmax]: 2.8). The mass had been diagnosed as SANT, and the patient was followed-up every 6 to 12 months for 5 years. A follow-up CT scan revealed an enhanced mass that was similar to those observed in the initial CT scan, although this one demonstrated a mild-interval- size decrease, measuring 44 mm in diameter. Follow-up MRI Results: A 15cm long, irregular, pink, oedematous tumour was revealed a central low-signal, non-enhancing focus on T1-/T2- excised in toto from the epiglottis. On histopathological examina- weighted images, while follow-up PET/CT revealed increased accu- tion, the growth was confirmed to be Angiomyxoma. mulation of FDG (SUVmax: 3.5). As it was suspicious considering Conclusion: This is only the second case ever reported to date, of the differential diagnosis, including malignant lymphoma and Angiomyxoma of the Epiglottis, and the very first one of this size. It inflammatory pseudotumor, she underwent reduced-port laparo- is interesting to note that, with such a large tumour, the patient had scopic splenectomy. The pathological results showed three types of just Grade 2 dysphagia and no respiratory symptoms. There have vessels including CD34+/CD8-/CD31+ capillaries, CD34-/CD8- been only 44 cases of Angiomyxoma of the head and neck reported, /CD31+ ectatic small veins, and CD34-/CD8+/CD31+ dilated making this case rare, especially considering it’s site and size. sinusoids-like vessels, consistent with the features of splenic SANT.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 245 ABSTRACTS

P-101 General Hospital, Kaohsiung, Taiwan No.2, Zhongzheng 1st Rd., Lingya Dist., Kaohsiung City 802, EMERGENCY TPN – ARE WE USING IT CORRECTLY? Taiwan (R.O.C.) W. Evans, F. Salimi, S. Rai, C. Doyle. Background: Adrenal is an uncommon, benign, and Stepping Hill Hospital, Stockport NHS Foundation Trust, hormonally non-functioning tumor that is composed of mature Manchester, SK2 7JE, UK. adipose tissue and normal hematopoietic tissue. Most cases to Total Parenteral Nutrition (TPN) provides nutrition in a non- date are asymptomatic or have epigastric pain. Acute hemorrhage functioning GI tract. TPN is implemented according to the decision is the most dramatic manifestation of adrenal myelolipoma; made through MDT. though, it is a rare entity. Hemorrhagic shock due to adrenal Objectives: As a 2nd re-audit, this is to establish whether TPN is myelolipoma, to our knowledge, was much less mentioned so far. being used correctly in accordance with local and national guide- Persistent bleeding and uncontrollable hypotension are considered lines and what the rate of ‘Emergency’ TPN prescribing is. to be absolute indications for immediate surgical operation. Methods: Data was collected according to a) indication and Case presentation: Herein we presented a 32-year-old male patient documentation, b) if other feeding methods are excluded, c) if with initial symptoms of nausea, vomiting, and epigastric pain BMI/weight at start and end are recorded, d) the TPN agent used, progressing to altered consciousness and hypotension during ER e) duration of TPN, f) if TPN was prescribed correctly, g) TPN course. Hemorrhagic shock due to a giant adrenal myelolipoma, R’t delivery route, and h) if need for TPN is reviewed. Aseptics was diagnosed. Emergent exploratory laparotomy was executed, and provided patients list and ICU/HDU patients were excluded. en bloc excision of tumor was done. Results: Dietician review was done for all the cases in three audits. Conclusion: Adrenal myelolipoma might be diagnosed as a The rate of TPNs initiated by dieticians rather than OOH Dr had adjunction to other main causes of illness; furthermore, adrenal positively progressed during the audits. After an enhancement in the myelolipoma could be asymptomatic in lifetime. In our case, indications documented from 80% to 88%, a slight drop to 80% was however, manifesting as hemorrhage shock was challenging to recorded. One case was not reviewed for need to TPN in the 2nd re- diagnose step by step; instead, maintaining vital organs perfusion audit where all the cases were reviewed in the previous audits. and identifying bleeding sources were to be done. Management of Inaccurate TPN prescription was found in 38% of the cases in the 2nd myelolipoma should be done on a case-to-case basis. re-audit while all prescriptions were correct in previous audits. A better rate of checking BMI/weight at start and end of TPN was P-104 observed in the initial audit (70%); however, the rate decreased significantly to 30% and 38% in the 1st and 2nd re-audit respectively. INTRA-HILARE APPROACH IN THE LAPAROSCOPIC TREATMENT Conclusions: Majority of the patients had their indications docu- OF HAEMATOLOGICAL SPLEEN mented. All patients were reviewed by dieticians and majority of TPN used was dietician led. Continued need for TPN was reviewed A. Simerabet, M. Boubekeur. regularly. However, poor documentation of BMI/weight at start Service de chirurgie générale EHU 1er novembre 1954 – Oran and end of TPN still presents and a high rate (38%) of inaccurate Algérie. prescribing in latest audit was noted. The use of surgery is necessary in the treatment of several splenic disorders such as benign and malignant haematological diseases. P-102 The safe feasibility and reproducibility of laparoscopic splenectomy (SL) is proven. Indeed, laparoscopic splenectomy helps to avoid a HEMOPERITONEUM OF GREAT ABUNDANCE REVEALING long incision, inevitable in traditional surgery because of the rela- SPONTANEOUS UTERINE RUPTURE ON HEALTHY UTERUS 7 DAYS tive inaccessibility of the spleen. SL is a technique that requires POSTPARTUM: CASE REPORT AND REVIEW OF THE LITERATURE proven skill and rigour. Laparoscopic splenectomy is a now well codified intervention that becomes a "gold standard" (reference Walid Barka technique). The intra-Hilar approach has proven itself in our EPH Miliana service de chirurgie general, W Ain Defla, Algérie service. It allows to consider the splenectomy safely, especially in We report a case of spontaneous uterine rupture occurring in a 30- the large child or the diameter of the pedicle is small and reduced year-old female patient with no history of uterine surgery. The The main difficulties are the exposure and the vascular control. In diagnosis of uterine rupture, evoked in late post-partum in the order to carry out a safe operation, it is indeed essential not to presence of acute abdominal pain, collapsus and haemoperi- cause any bleeding or seepage in the operative field. After using toneum of great abundance on ultrasonography and CT scan, was different techniques during the first laparoscopic splenectomies, confirmed laparotomy. The treatment consisted of a hysterrhaphy we have for several years privileged a first intra Hilaire strictly to the and the operative follow-ups were simple. The etiopathogenesis of Ligasure ® clamp. spontaneous ruptures of the non-cicatricial uterus, the clinical and therapeutic aspects are discussed through a literature review. P-105

P-103 MULTIPLE SHARP FOREIGN BODY INGESTION MANAGED CONSERVATIVELY- A CASE REPORT INTRA-ABDOMINAL BLEEDING WITH HEMORRHAGIC SHOCK: A S. Ramasamy, M. Vats, S. Neogi, A. Goel, S. Prajapati, A. Jain. CASE OF ADRENAL MYELOLIPOMA AND REVIEW OF LITERATURE Maulana Azad Medical College, New Delhi, 110002, India. Hui-Pu Liu, Wen-Yen Chang, Shan-Tao Chien, Yu-Chiuan Wu, Introduction: It is not uncommon for a surgeon in the Emergency Chin-Wen Hsu, Wen-Ching Kung, Chun-Min Su, Ping-Hung Liu. Department to be presented with patients of ingestion of foreign Department of General Surgery, Kaohsiung Armed Forces body. Although, patients come from all ages; children who have

246 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

swallowed coins, toys, safety pins or small batteries accidently. Conclusion: A strong positive relationship exists between number of Adults usually have a rather different set of ingested foreign bodies neonatal surgeries and total number of surgeries. There is therefore which include food boluses, meat and fish bones, denture parts, a need for specific training of personnel to cater for the growing nails, pins. demand. The outcome could be better, particularly for gastroschisis, Case Report: We report a case of 20 years lady who was brought to through strengthening of neonatal intensive care and surgical the Emergency with the complaints of epigastric pain following facilities. ingestion of multiple sharp pins along with a cup full of toilet cleaner with the suicidal intentions. On examination, patient was mildly dehydrated, vitals within normal limits. Abdomen showed P-107 no signs of peritonitis. X-Ray abdomen showed multiple ‘needle’ like radio opaque shadows in the abdominal cavity, with no OSSIFYING FIBROMYXOID TUMOR OF THE TRUNK MIMICKING evidence of free gas under the diaphragm. Since no signs of HYDATID CYST: A CASE REPORT. perforation were present and the patient was tolerating oral diet; a A. Chhaidar, M.A. Said, F. Harrabi, M. Ben Mabrouk, A. Ben Ali. non-operative expectant management was followed. Under close SAHLOUL hospital, Sousse 4022, Tunisia. monitoring, by periodic examination and serial abdominal roentgenograms the patient was managed non operatively. After Introduction: Ossifying fibromyxoid tumor (OFMT) is a rare lesion 11 days of admission, the patient had passed all the sharps without that generally occurs in the soft tissues of proximal limbs, or head any complication. However, after 3 weeks she came with and neck presenting as slowly growing mass. Abdominal or trunk symptoms of gastric outlet obstruction for which she required a location is extremely rare. gastrojejunostomy. Presentation of case: We report a case of 50-year-old man who Discussion: The initiation of management of a suspected case of presented with a painless, slow growing epigastric mass for 5 years. foreign body should not be delayed due to unnecessary investiga- Radiologic assessment revealed a well circumscribed median tions. The management of a patient with suspected FB ingestion subcutaneous parietal mass lesion present in front of the xiphoid depends on multiple factors; namely, patient’s age and clinical con- process suspicious of a calcified hydatid cyst. Diagnosis of OFMT dition; characteristics of the FB; anatomical location of ingested FB; was made on histopathological examination of resected specimen expertise of the endoscopist. Conclusion: OFMT is a rare soft tissue tumor with malignant Conclusion: Wait and watch policy for an ingested foreign body, potential often misdiagnosed as a benign lesion. Complete surgical even for sharp objects, is a well justified approach, provided close excision should be performed to prevent local recurrence. monitoring and a periodic assessment of the patient, along with serial abdominal radiographs are done stringently. P-108

P-106 PRIMARY IDIOPATHIC TUMORAL CALCINOSIS M.E. Azoz, A.M.M.Makawi NEONATAL SURGERY IN A TERTIARY HOSPITAL IN GHANA: Faculty of Medicine and health sciences, University of Elemam A 3 YEAR REVIEW. Elmahadi, Kosti, 209, Sudan. A.C. Yifieyeh, B.M. Duduyemi, E. Kumahor, B. Nimako, Introduction: Tumoral calcinosis is a rare disorder which usually M. Amoah. presents as painless solitary swelling or multiple painless swellings Komfo Anokye Teaching Hospital, Kumasi of large joints, particularly the hips, elbows, shoulders and knees. P.O. box 1934, Kumasi – Ghana The condition has been reported in all age groups. It affects black Objective: Middle and low income countries have challenges Africans more than Caucasians. resulting in comparably less desirable outcomes for neonatal Objectives: To highlight its rarity, index of suspicion for this disease, surgical conditions. A shortage of the required manpower for the its types and options of treatment of the tumoral calcinosis. surgical care of neonate has been highlighted. Documentation of Method: These three cases presented to outpatient clinic at Kosti the burden of neonatal surgical diseases in Africa is rare. This retro- Teaching Hospital (Sudan) from 2009 to 2016 by subcutaneous spective 3 year study was undertaken to document this burden and swellings around the hip joints. Preoperatively, plain X ray, fine advocate for specialized training in neonatal surgical services. needle aspiration cytology and blood chemistry done to all Method: The operation records of the main theatre at the Komfo patients. All the patients underwent surgical excision of the tumor. Anokye Teaching Hospital, Kumasi, Ghana between June 2013 and Results: Three females their ages were 17, 60 and 70 years. Two of November 2016 were retrospectively reviewed. The biodata, them presented with bilateral stony hard masses around the hips diagnosis, intraoperative findings and surgical procedure on joints and the third one (70 yrs) presented with unilateral Lt hip joint patients aged 30 days or less was extracted. The total number of mass. The patients experienced pin prick sensation on the site of paediatric surgeries over the same period was correlated with swelling which was increased during walking and the movement of neonatal surgeries. the joints not affected. Patients could not recall episodes of Results: With 3 paediatric surgeons in attendance, there were 334 trauma or injection over the affected area, excessive milk or antacid neonatal surgeries during the study period constituting 12.56% of intake, or any local or systemic illness prior to the development all paediatric surgical procedures recorded. There has been a of the lesion. Plain X R for hip joints showed calcified lobulated sub- progressive increase in neonatal surgery in our centre. The male to cutaneous mass around the hip joints. Renal profile, serum calcium female ratio was equal. The modal and mean ages were 1 and 10 and phosphate were normal. The FNAC showed tumoral calcinsis. All days respectively. There were 110, 71, 31 and 22 operations for the patients underwent surgical excision of the tumor. Anorectal malformations, Intestinal atresias, Gastroschisis and Conclusion: Primary idiopathic Tumoural Calcinosis is still a disease Omphalocele respectively with corresponding success rates of of unknown cause but complete surgical resection is an effective 90%, 90%, 10% and 50%. method of management of this disease and it prevents recurrence.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 247 ABSTRACTS

P-109 meticulous patients selection and the multidisciplinary and multi- team approaches application. REAL-TIME INTRAOPERATIVE FLUORESCENT LYMPHOGRAPHY – A NEW TECHNIQUE FOR LYMPHATIC SPARING SURGERY. P-111 Giuseppe Letto, Francesco Amico, Gabriele Soldini, Domenico Iovino, Marco Calussi, Cristiano Parise, RETRO PERITONEAL PARAGANGLIOMA MIMINCK PERIPANCREATIC Elia Zani, Veronica Raveglia, Matteo Tozzi, Giulio Carcano. TUMOR General and Transplant Surgery, University of Insubria, Varese, 21100, Italy. Abbassi I, Baraket O, Triki W, Baccar A, Ayed K, Ayari H, Lahmidi A, Ganzoui I, Bouchoucha S. Background: Many surgical procedures can produce persistent Department of general surgery. Hospital Habib BougatfA de lymphorrea, lymphoceles and lymphedema after lymph nodes and Bizerte. 7000 Bizerte, Faculty of Medicine of Tunis, University lymph vessels damages. Appropriate visualization of the lymphatic Tunis El Manar, Tunisia system is challenging. Indocyanine green (ICG) is a well-known non- toxic dye for lymphatic flow evaluation. ICG fluorescent guided Introduction: Para gangliomas are extra-adrenal chromaffin lymphography has emerged as a promising technique for intra- tumours develop at the expense of neuroectodermal cells of the operative lymphatic mapping. autonomous nervous system. Retroperitoneal and nonfunctioning Objective: We aimed to develop a high spatial resolution real-time forms are very rare. They are often asymptomatic and can reach a intraoperative imaging technique to avoid or early recognize deep substantial size. Treatment usually involves surgery with the goal of lymphatic vessels damage. total excision.We report the case of a patient who presented with Methods: We intraoperatively performed ICG fluorescence-guided indistinct abdominal pain. We analyzed the presentation, diagnosis lymphography during a kidney transplant. ICG was injected in the and treatment of retroperitoneal paraganglioma subcutaneous tissue of the patient's groin in the Scarpa's triangle Case Presentation: A 40-year-old male, ASA status 1, was admitted (A). A dedicated laparoscopic high definition camera system was to explore epigastria abdominal pain. There was no family history used. of illness. The physical examination was unremarkable with no Results: Soon after ICG injection, lymphatic vessels were identified palpable abdominal mass present. Laboratory blood tests were in the abdominal retroperitoneal compartment as fluorescent normal. Abdominal ultrasonography showed an abnormal soft linear structures running side by side to the iliac vessels (B-C). tissue mass in retrogastric. Computed tomography demonstrated Surgical dissection was therefore conducted avoiding iatrogenic an homogeneous 10 cm diameter retrogastric tumor that have a damages to major lymphatic structures. Another ICG injection at cystic apperance at its center and seems depending in the caudal the end of the procedure confirmed that the lymphatic vessels portion of pancreas. During surgery with a median approach, we were intact without lymph spread. found a retroperitoneal tumour of about 10 cm diameter that was Conclusions: Intraoperative lymphatic mapping with ICG fluores- encapsulated and soft. It was adhered to the aorta. We conducted cence-sensitive camera system it's a safe and feasible procedure. a complete excision of the tumour. On macroscopic examination ICG real-time fluorescent lymphography can be used to avoid or the mass measured 8.5 × 6 × 3cm and was encapsulated with a cut early recognize deep lymphatic vessels damage and reduce post- surface. Histological examination identified a highly cellular, operative complications related to lymphatic system. multinodular encapsulated tumor with a vascular framework led to a diagnosis of retroperitoneal paraganglioma. The postoperative period was uneventful and the patient was discharged on the fifth P-110 postoperative day. RESECTION AND SIMULTANEOUS RECONSTRUCTION Conclusions: The paraganglioma is a rare tumor associated with OF THE INFRARENAL AORTA AND INFERIOR VENA CAVA. high morbidity and mortality when the diagnosis is made intra- operatively. Surgical excision remains the mainstay of treatment, A.A. Burlaka, V.I. Dorozhynskiy, O.V. Vasiliev, O.O. Kolesnik. although advanced disease and prominent vascularity can at times National Cancer Institute, Kyiv, Ukraine. make excision difficult or impossible. Background: The simultaneous circular resection of inferior vena cava (IVC) and abdominal aorta is very rare surgical approach. P-112 Methods: We report the case of a 36-year-old man with retro- peritoneal tumor cT4cN0cM0 IIIB (AJCC, 7th ed. 2010) with tumor TARGET IDENTIFICATION OF AUTOPHAGY KEY KINASE ULK1 AND invasion to abdominal aorta and inferior vena cava (IVC) between RESEARCH OF LEAD COMPOUND ACTS ON ULK1 renal vessels and bifurcation. S.T Xue, Z.R Li. Results: R0-resection of retroperitoneal tumor with resection and Institute of Medicinal Biotechnology, Chinese Academy of prosthesis of IVC and abdominal aorta, total resection of retro- Medical Sciences and Peking Union Medical College, Beijing, peritoneal fat was performed. On the 4-th postoperative day (POD) 100050, China. the external fistula was drained from the doubled right ureter which was stented. On the 6-th POD the separated liquid in the Autophagy is related with many diseases such as cancer. The retroperitoneal space was drained. Patient was discharged from combination of chemotherapy drugs and autophagy inhibitors will hospital on 24 POD. increase patients’ susceptibility to chemotherapy and thus reduce Conclusion: We have successfully used a non-standard approach drug resistance. Key kinases in autophagy signal pathway may act in malignant retroperitoneal tumor treatment, which includes as potential drug targets. ULK1 (UNC-51-like kinase 1) is the only simultaneous resection and reconstruction of the infrarenal serine/threonine kinase activity protein in autophagy pathway and segment of aorta and IVC in order to achieve the R0-resection. We also is a promising drug target. Our results show that interference believe that such a tactic can be safe and effective in case of of ULK1 gene expression inhibits proliferation and metastasis of

248 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

liver cancer cells significantly.Start from our probe found earlier, we F ratio of 7:3. Average time of symptoms prior to presentation was are systematically studying the effects of our probe in autophagy 6.4+/-1.7days. Correlation analysis performed between variables pathway through the binding of ULK1 now, including its influence of symptom days prior to presentation and WBC, demonstrated on tumor cell death. At the same time, we are trying to answer R2=0.970, p<0.001. Correlation analysis performed between whether ULK1 can act as a new drug target for cancer, explore its variables of symptom days prior to presentation and days prior to therapeutic spectrum and get more structure information of probe surgery, demonstrated R2=0.286, p=0.466. Resection and/or binding site. After that, we will adopt fragment-based drug ligation of affected internal jugular vein was the most commonly discovery and structure-based drug design to looking for lead com- performed surgical management pounds. We plan to cultivate the co-crystal of the lead compound Conclusion: Early consultation with establishment of a conclusive with ULK1, to support our structure-based drug design. In all, this diagnosis with the aid of CT imaging yields optimal clinical outcome research will change the landscape in the path of target identifica- in Lemierre’s syndrome. The authors conclude this rare syndrome tion of ULK1, as well as provide scientific evidences for relevant presentation needs a multidisciplinary approach with vascular disease treatment. surgery intervention after failed medical management.

P-113 P-115

UNE CAUSE RARE D’OCCLUSION INTESTINALE AIGÜE: TORSION VERY RARE LOCALIZATION OF A RETROPERITONEAL D’UN VOLUMINEUX FIBROME UTÉRIN. À PROPOS D’UN CAS. HEMANGIOPERICYTOMA: A CASE REPORT. Walid Barka A. Chhaidar, M.A. Said, A. Rguez, M. Ben Mabrouk, A. Ben Ali. EPH Miliana W Aindefla Algérie SAHLOUL hospital, Sousse4022, Tunisia. Nous rapportons le cas d’une patiente âgée de 40 ans nullipare Objective: We report a rare case of retroperitoneal hemangio- porteuse d’un volumineux fibrome (> 10 cm) compressif, com- pericytoma. pliqué d’une nécrobiose avec multiples adhérences inflammatoires Case Presentation: A 31 years old patient presented with right- d’anse jéjunal responsables d’une occlusion intestinale aigüe (iléus sided L5 radiculopathic pain of three months duration. There was paralytique et compression). Il s’agit à notre connaissance du pre- no family history or features of neurofibromatosis. The patient did mier cas rapporté traité de manière conservatrice par adhésiolyse not have other symptoms including nausea, vomiting, bowel habit et myomectomie. Ce cas illustre la morbidité des fibromes de plus changes, fever, or weight loss. Physical examination showed no de 10 cm en dehors de grossesse. positive finding. In double contrast abdominopelvic CT scan, a well- defined retro peritoneal mass with measuring about 105 × 73 × 83 mm at right lower quadrant of the abdomen anterior to right psoas P-114 muscle was seen. After contrast injection, tumoral mass was enhanced intensely. Magnetic Resonance Imaging showed an VASCULAR SURGERY INTERVENTION IN LEMIERRE’S SYNDROME: encapsulated and well limited retro peritoneal masse occurring in CASE REPORT AND SYSTEMATIC REVIEW. hypo signal T1 and hyper signal T2 with intense enhancement after injection of Gadolinium. It is flush with the right intervertebral Fabio J.R. Pencle, Polina L. Litvin, Vashti A. Wagner, foramen L5-S1. On exploratory laparatomy, a solitary large Diana J. McPhee, Yilmaz Gunduz, Alexander Gart retroperitoneal multiloculated mass with hemorrhagic fluid was Department of Surgery, Lincoln Medical and Mental Health excised. Further evaluation by immune histochemistry revealed Center, Bronx, NY 10451, USA that tumoral cells were positive for desmin, CD34, smooth muscu- Objective: Lemierre’s syndrome classically presents with initial lar antigen, and negative for cytokeratin and CD31, confirming the pharyngotonsillitis or peritonsillar abscess in young, previously diagnosis of hemangiopericytoma. The patient is under follow up healthy persons, manifesting with septic thrombophlebitis of the with regular CT scans and after one year, is currently well without ipsilateral internal jugular vein. It has been described as a rare and any evidence of recurrence. pre-antibiotic era syndrome with an incidence rate of one in one million. There has, however, been a reported increase over the past P-116 two decades. The disease and syndrome presentation can easily be missed and thus a multidisciplinary approach is required for CHEMOPORT INSERTION BY THE RESIDENT OF GENERAL diagnosis and treatment. The purpose of this study is to review SURGERY IN A TEACHING-HOSPITAL: CAN THEY SHOW available literature to determine vascular surgery intervention in SURGERY OF GOOD QUALITY? Lemierre’s syndrome. Methods: A systematic search (August 2016) of PubMed, Scopus, J.H. Baek, S.W. Park, W.S. Lee. Cochrane and EMBASE databases was conducted according to the Department of Surgery, Gachon University Gil medical Center, Preferred Reporting Items for Systematic Reviews and Meta- Incheon, 21565, South Korea. Analyses (PRISMA) guidelines for literature presenting Lemierre’s Objectives: This study designed to evaluate the safety and syndrome and vascular surgery intervention. Included studies were competitiveness as complications and operating time for peer-reviewed articles or academic society publications. Papers implantable catheter insertion by residents. And to analyze the with non-vascular surgery, non-English language, and non-adult factors affected operating time for time-saving. cases were excluded. Final papers meeting criteria were secondarily Methods: This study enrolled 383 consecutive patients with screened for analysis. malignancy who underwent chemoport implantation. The Results: The search yielded 1,242 unique articles with 7 studies patients’ age, gender, body mass index (BMI), number of operation meeting final selection criteria. 10 of31 cases required vascular on the same side, inserting route, postoperative complications, surgery intervention. Average age was 29.7+/-4.4 years, with a M: lead time for implantation were evaluated, retrospectively.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 249 ABSTRACTS

Chemoport insertions were done by 6 trainee-residents in history of upper abdominal pain, distension and coffee grown Department of Surgery. They divided two groups to senior resident vomitus. Abdominal examination showed signs of generalised (SR) and junior resident (JR). The study period embraced two years; peritonitis. He had history of marked weight loss, recurrent upper third to fourth year of senior resident and second and third year of abdominal pain and dyspepsia for eight months. On admission, he junior resident. was dehydrated with acute renal impairment. The nasogastric tube Results: SR reduce about 4.6 minutes than JR in total operation time output in the ER was four litres, dark fluid. While resuscitating the (31.1 vs. 35.7 minutes, P < 0.001) Although SR showed slightly down patient and preparing him for an emergency laparotomy, CT slope and JR showed up slope for operation time during the study abdomen (without contrast because of impaired renal function) period, there were no definite change in ANOVA regression analysis was done which showed pancreatic neck and body mass, fat (P = 0.460 vs. 0.606). If the operator was not use USG, there were stranding, free fluid and distended bowel loops. Laparotomy not showed significant difference on total lead time and complica- showed big pancreatic mass arising from the neck and body of the tion between two groups. But, if the operator was not use C-arm, SR pancreas. The coeliac trunk was completely infiltrated by the were performed surgery shorter than JR (29.9 vs. 32.4 minute, P = tumour. The stomach and lower oesophagus were gangrenous 0.035). Considering results of the multivariate analysis, without with gastric perforation. He also had extensive splenic infarction USG [hazard ratio (HR) 5.415, 95% confidence interval (CI) 2.773- and liver was normal. He was unstable during surgery and nothing 10.576, P<0.001], without C-arm (HR 2.918, 95% CI 1.812-4.700, could be done. He did not recover from anaesthesia and died in the P<0.001), and JR (HR 1.634, 95% CI 1.001-2.667, P=0.049) were ICU in day two. also identified as independent factor affecting to operation time in Discussion: Stenosis of the celiac artery is present in up to 10% of this study. patients undergoing pancreaticoduodenectomy, as reported in Conclusion: Chemoport insertion by the trainee-resident of general series where arteriography was routinely performed before surgery in a teaching-hospital is competitive because of low post- surgery. However, this has no clinical significance, owing to operative complication rates and reduced operation time. The collateral pathways that develop from the SMA via the inferior factors affecting to total operating time were grade of resident, use pancreaticoduodenal artery to provide retrograde flow through the of the USG or C-arm. gastroduodenal artery. Coeliac artery thrombosis with gastric ischemia and splenic infarction was reported in the literature, mostly due myloproliferative and thrombotic disorders. This this P-117 probably the first case report of acute coeliac artery occlusion due to advanced pancreatic cancer presenting with upper gut ischemia. VALUE OF PREOPERATIVE BILIARY DRAINAGE ON POSTOPERATIVE His pancreatic cancer was not diagnosed before. OUTCOME AFTER PANCREATICODUODENECTOMY. Conclusion: High index of suspicion and CT abdomen with intra- A CASE-CONTROL STUDY venous contrast is needed in patient with advanced pancreatic Gamal El Ebidy, Ayman El Nakeeb, Talaat Abd Alah. cancer presenting with acute upper abdominal pain to rule out coeliac artery occlusion. The potential benefit of preoperative biliary drainage (PBD) on postoperative outcomes remains controversial. The aim of this study was to elucidate surgical outcomes of pancreaticoduodenec- P-119 tomy (PD) in patients PBD and to show the impact of bilirubin level. Patient and methods: We retrospectively studied all patients who HEPATOID CARCINOMA OF THE PANCREAS underwent PD in our center between January 2003 and June 2015. S.E. Wang, Y.M. Shyr. Group A (patients with PBD) and Group B (patients with non-PBD). From Division of General Surgery, Department of Surgery, The primary outcome was the rate of postoperative complication. Taipei Veterans General Hospital, National Yang Ming University Results: A total number of 588 cases underwent PD. Group A Taipei, Taiwan included 314 (53.4%) patients while group B included 274 (46.6%) patients. The overall incidence of complications and its severity Objectives: Hepatoid carcinoma of the pancreas is extremely rare. were higher in PBD group (P= 0.03 and 0.02). There was significant This study summarized the clinical features and outcomes of difference in the incidence of postoperative pancreatic fistula pancreatic hepatoid carcinoma. (P =0.002), delayed gastric emptying (P=0.005), biliary leakage Methods: Data pool for analysis includes the case we encountered (P=0.04), abdominal collection (P=0.04) and wound infection with hepatoid carcinoma of the pancreas and reported cases in the (P= 0.04) in PBD group. The mean length of hospital stay was literature. significantly longer in PBD group than in non PBD group (12.86 Results: Twenty-three cases of hepatoid carcinoma of the pancreas ±7.65 days vs 11.05±7.98 days, P= 0.01). No significant impact of were recruited. Nausea/vomiting (62.5%) is more common for the preoperative bilirubin level on surgical outcome. tumors at pancreatic head, followed by jaundice and epigastric pain Conclusion: PBD before PD was associated with major postoperative (50.0%). For those at pancreatic body-tail, 42.9% of the patients complications and stent related complications. presented no symptom. Alpha-fetoprotein (AFP) was abnormally elevated in 60% cases. This tumor could be either pure or mixed form with other malignancy (40.9%), with the most common co-existed P-118 pathology of malignant neuroendocrine tumor (22.7%). Metastasis AN UNUSUAL PRESENTATION OF ADVANCED PANCREATIC CANCER: occurred in 36.4% cases at the diagnosis, including liver metastasis in COELIAC AXIS OCCLUSION AND ACUTE UPPER GUT ISCHEMIA 31.8% and lymph node metastasis in 21.1%. The overall 1-year survival was 71.1% and 5-year 40.4%, with a median of 13.0 months. H.D. Elsiddig, I.O.Jabra, S.Z.Ibrahim. Irresectability, hepatic and lymph node metastasis were associated Royal Care International Hospital. Khartoum, 10445 Sudan. with negative impact on survival. Case Report: A 50-year-old male was admitted with four days Conclusions: Elevation of serum AFP may be a clue leading to the

250 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

diagnosis of pancreatic hepatoid carcinoma. This tumor could be "74 non-resected PDAC cases” from 2000 to 2015 in our institute mixed form with other malignancy. Surgical resection should be the were enrolled. treatment of choice whenever possible. Results: 31 cases (9.2%) received resection despite CY1 at laparotomy. Out of other 305 cases of CY0, Stage 2A, 2B, 4 were 86, 180, 39 cases, respectively. Three cases underwent resection after CY become P-120 negative after the “new generation anticancer drug” treatment (ND) HHV-8 ASSOCIATED LYMPHADENOPATHIC KAPOSI’S SARCOMA such as FOLFRINOX and/or GEM+nab-PTX. The MST of CY1 case was MIMICKING PTLD AFTER PANCREAS TRANSPLANT 14.7 months, and was significantly shorter than that of Stage 2A (30.6 months, P=0.0007), 2B (25.6 months, P=0.0034) cases, and was S.E. Wang, Y.M. Shyr. equivalent to Stage 4 (13.2 months, P=0.5419), and was significantly From Division of General Surgery, Department of Surgery, longer than the non-resected case (11.0 months, P=0.0324). Among Taipei Veterans General Hospital, National Yang Ming University non-resected cases, the MST of the patients who received ND (MST Taipei, Taiwan 19.3 months) was significantly better than the patients who received Objectives: Kaposi's sarcoma currently comprises more than 5% of only “conventional anticancer drugs”, such as GEM and/or S-1, (MST all de novo neoplasms in this group. The average time to develop- 9.1 months; P=0.0052), and was equivalent to the patients with CY1 ment of Kaposi sarcoma following transplantation is 15-30 months. resected case. Human herpesvirus 8 (HHV-8) genomic sequences have been Conclusions: After the recent availability of ND, the MST of non- identified by polymerase chain reaction in more than 90% Kaposi resected cases was prolonged and became equivalent to that of . CY1 resected cases. Because there are some cases in which CY Materials: From 2003 to 2016, Kaposi's sarcoma was identified for becomes negative, macroscopically M0 but CY1 cases at laparotomy study from 128 patients with 133 pancreas transplants performed should not receive resection and wait to become CY0 with adminis- at Taipei Veterans General Hospital. Literature review was also tration of ND. done. Results: Only one case of Kaposi's sarcoma was identified, with an P-122 incidence of 1.5%. The patient suffered from varicellar zoster Infection (chicken pox) 11 months after pancreas transplant alone METASTATIC POLYP OF THE GALLBLADDER FROM RENAL CELL (PTA). Four months later (15 months after PTA), lymphadenopathy CARCINOMA with enlargement of multiple lymph nodes in neck, around celiac S.E. Wang, Y.M. Shyr. trunk, along the superior mesenteric artery and abdominal aorta, From Division of General Surgery, Department of Surgery, which mimicked posttransplant lymphoproliferative disorder (PTLD). Taipei Veterans General Hospital, National Yang Ming University The biopsy for pathology turned out to be Kaposi's sarcoma. HHV-8 Taipei, Taiwan viral gene was detected by the molecular (PCR) assay. The lymphadenopathic Kaposi's sarcoma regressed 3 months after Objectives: Background Gallbladder metastasis from renal cell treatment by adding sirolimus, reducing the dose of tacrolumus and carcinoma (RCC) is extremely rare. The purpose of this study is to discontinuing mycophenolate mofetil. There has been no evidence clarify the characteristics of metastatic RCC to gallbladder. of tumor recurrence for more than 2 years, and he has been Methods: The pooled data for analysis were collected from gall- enjoying an insulin-free life with euglycemia for more than 3 years. bladder metastasis from RCC cases encountered by our institution Conclusion: This is an unusual HHV-8 associated Kaposi's sarcoma along with sporadic cases reported in 35 English articles from 1991 mimicking PTLD presenting as lymphadenopathic form, instead of to 2015. usual cutaneous form. Sirolimus is recommended for the Results: A total of 50 cases of metastatic RCC to the gallbladder treatment of Kaposi's sarcoma, in addition to reduction, cessation were recruited for study, including 49 from literature and 1 from or modification of immunosuppressive regimen. our institution. 57% of the primary RCC was from the right kidney and 43% of the left. The median interval between diagnoses of P-121 primary and metastatic RCC to gallbladder was 36 months, with the longest duration up to 324 months. Most 70% were asymptomatic. MACROSCOPICALLY M0 BUT PERITONEAL CYTOLOGY POSITIVE (CY1) The size of metastatic RCC to gallbladder ranged from 0.8 cm to 9 PANCREATIC CANCER PATIENTS: SHOULD WE RESECT OR NOT? cm, with median of 2.6 cm. Majority (91%) of the metastatic RCCs presented as a polypoid mass with narrow stalk, and 82% were H. Hayashi, M. Iseki, M. Ishida, T. Takadate, T. Hata, S. Maeda, hypervascular lesion. The overall 1 year, 3 year and 5 year survival K. Ariake, K. Masuda, T. Aoki, K. Fukase, H. Ohtsuka, M. Mizuma, rate was 91.5%, 76.2% and 59.3% respectively, with a median of N. Sakata, K. Nakagawa, T. Morikawa, F. Motoi, T. Naitoh, 26.5 months. Number of the metastatic site, timing of metastasis T. Kamei, M. Unno. gallstone, symptom, tumor size and operation type of cholecystec- Department of Surgery, Tohoku University Graduate School of tomy seemed to have no impact on survival. Medicine, Sendai, Miyagi, 980-8574 Japan. Conclusions: Metastatic RCC to the gallbladder should be taken Introduction: The significance of resection of pancreatic duct into account for a gallbladder polypoid mass with narrow hyper- adenocarcinoma (PDAC) with macroscopically M0 but peritoneal vascular stalk during the diagnosis and/or follow-up of primary lavage cytology positive (CY1) is still unknown. RCC. Gallbladder metastasis from RCC is not necessarily to be an Objective: To clarify the prognosis of CY1 resected PDAC patients advanced stage with poor outcome, and cholecystectomy is recom- and elucidate whether those patients should be resected or not. mended whenever possible. Methods: “336 resected PDAC patients (stage II and above)” and

Surgery, Gastroenterology and Oncology, 22 (3), 2017 251 ABSTRACTS

P-123 cant difference in surgical morbidity and pancreatic leakage. As for the initial presentations, young group patients are often asympto- PANCREATIC GROOVE CANCER matic (4.7%) when compared to the old (1.5%, P=0.026) but less Y.M. Shyr, S.E. Wang. jaundice and GI upset (P=0.004, P=0.012). Division of General Surgery, Department of Surgery, Conclusions: PD in the young did not carry more surgical morbidity Taipei Veterans General Hospital, National Yang Ming University or pancreatic leakage, but had less surgical mortality, as compared to Taipei, Taiwan the old. Young group patients after PD had better 5 year survival in periampullary malignancy and pancreatic head adenocarcinoma. Objectives: Pancreatic groove cancer is very rare and can be indistinguishable from groove pancreatitis. This study is to clarify the characteristics, clinical features, managements and survival P-125 outcomes of this rare tumor. Methods: Brief description were made for each case of pancreatic SEPSIS ASSOCIATED WITH LONG-TERM PROGNOSIS AFTER groove cancer encountered at our institute. Individualized data of PANCREATICODUODENECTOMY FOR PANCREATIC CANCER pancreatic groove cancer cases described in the literature were I. Ise1, H. Hayashi1, M. Iseki1, T. Takadate1, T. Hata1, S. Maeda1, extracted and added to our database to expand the study sample K. Ariake1, K. Masuda1, T. Aoki1, M. Ishida1, K. Fukase1, size for a more complete analysis. H. Ohtsuka1, M. Mizuma1, N. Sakata1, K. Nakagawa1, T. Morikawa1, Results: A total of 33 patients with pancreatic groove cancer were F. Motoi1, T. Naitoh1, Y. Katayose2, T. Kamei1), M. Unno1. included for analysis, including 4 cases from our institute. The 1Department of Surgery, Tohoku University Graduate School of median tumor size was 2.7 cm. The most common symptom was Medicine, Sendai, Miyagi, 980-8574 Japan. nausea or vomiting (89%), followed by jaundice (67%). Duodenal 2Department of Surgery, Tohoku Medical and Pharmaceutical stenosis was noted by endoscopy in 96% of patients. The University Graduate School of Medicine, Sendai, Miyagi, 981-8558 histopathological examination revealed well differentiated tumor Japan. in 43%. Perineural invasion was noted in 90%, and lymphovascular invasion and lymph node involvement in 83%. Overall 1-year Background: There is no data whether sepsis after pancreatico- survival rate was 93.3%, and 3-year or 5-year survival rate was duodenectomy (PD) influences the long-term outcome of pancreatic 62.2%, with a median survival of 11.0 months. Survival outcome for cancer patients. the well-differentiated tumors was better than those of the Objective: The aim of this study is to elucidate whether sepsis moderate/poorly differentiated ones. after PD had the impact on long- term outcome of pancreatic can- Conclusions: Early involvement of duodenum causing vomiting is cer patients. often the initial presentation, but obstructive jaundice does not Methods: The medical records and data base of 111 pancreatic always happen until the disease progresses. Tumor differentiation cancer patients who underwent PD at Tohoku University Hospital is a prognostic factor for survival outcome. The possibility of pan- between 2011 and 2015 were reviewed and prognostic factors creatic groove cancer should be carefully excluded before making were extracted using univariate and multivariate analysis. the diagnosis of groove pancreatitis for any questionable case. Results: Nine of 111 patients suffered from sepsis and its incidence was 8.1%. The causes of sepsis were grade C (44.4%) postoperative pancreatic fistula (POPF), perforation of the colon (44.4%), cholangi- P-124 tis (11.1%), pneumonia (11.1%). There were 2 mortality cases (1.8%). One suffered from sepsis and required reoperation for the PANCREATICODUODENECTOMY FOR PANCREATIC perforation of colon and died 46 days after PD. The other died due to AND PERIAMPULLARY LESIONS IN THE YOUNG bleeding caused by POPF after 52 days after PD. Multivariable Cox regression analysis showed that sepsis after PD was the risk factor for Y.M. Shyr, S.E. Wang. long-term prognosis [HR=3.05; 95% CI 1.15-6.83; p=0.028]. The ratio From Division of General Surgery, Department of Surgery, of adjuvant chemotherapy was significantly less in patients with Taipei Veterans General Hospital, National Yang Ming University sepsis after PD (p=0.033). The period to start adjuvant chemo- Taipei, Taiwan therapy was significantly longer in patients with sepsis after PD Objectives: The purpose of this study was to clarify surgical out- (p=0.0497) comes and to assess the biological behavior of periampullary Conclusion: Sepsis after PD leads to the disadvantage of the malignancy after pancreaticoduodenectomy (PD) in the young. PD pancreatic cancer patients and is associated with the poor long- remains a formidable challenge to many pancreatic surgeons. term outcome. There is no literature report regarding PD in the young. Materials and Methods: Data on patients undergoing PD were P-126 retrieved for study between January, 1997, and December, 2010. Demographics, disease patterns, clinical presentations, operative SPONTANEOUS SPLENIC RUPTURE: UNUSUAL FIRST PRESENTATION findings, surgical risks, tumor pathologic characteristics, and OF PANCREATIC CANCER. survival outcomes were evaluated in the young patients less than 60 years old and compared with those in the older population. Á. Cuadrado, I. Ortega, R. Fernández-Sánchez, S. Nuñez- O’Sullivan, Results: There were 585 patients in our study. Of there, 172 were M. A. Vaquero, E. Esteban, S. Moreno, A.L. Picardo. patients 60 years or younger. Higher proportions of female patients Hospital Infanta Sofía San Sebastián de los Reyes, 28770, Spain were found in the young age group compared to old in regards to Objective: Describing an infrequent pancreatic cancer clinical sex distribution. Young group had more benign tumor compared to debut with spontaneus spleen rupture due to tumor infiltration. the old, ex. neuroendocrine tumor. The surgical mortality rates are Clinical case report: Presentation of a spontaneous spleen rupture significant less in the Young group. However, there was no signifi- due to unknown neoplasic infiltration by pancreatic cancer. Male,

252 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

41y. Diarrhea and LUQ occasional pain. He arrived in shock to ER only 15.2 months and 12.5 months respectively. dept with acute abdominal pain without any abdominal trauma. Conclusion: Surgical resection for single-metachronous liver Abdominal CT: 14cm splenomegaly, with complete parenchyma metastasis with ACC improve survival. In the selected cases, the laceration and splenic hillium damage, ischemia signs and hemo- aggressive repetitive surgery may be useful. peritoneum (spleen rupture grade IV). Results: Emergency Surgery: Hemoperitoneum. Splenomegaly with congestive spleen, color changes suggestives of ischemia and P-128 parenchymal rupture. Inflammatory mass affecting to spleen, gastric wall, colonic splenic flexure and omentum. Difficult movilization with INVERSE PROBABILITY OF TREATMENT WEIGHTING ANALYSIS Mattox manouver. Splenic artery massive bleeding with very difficult OF UPFRONT SURGERY VERSUS NEOADJUVANT control due to fibrosis. Ligation of splenic artery at celiac trunk origin. CHEMORADIOTHERAPY FOLLOWED BY SURGERY FOR PANCREATIC Anatomopathological report: Splenic hilium infiltration by ADENOCARCINOMA WITH ARTERIAL ABUTMENT pancreatic adenocarcinoma. Tumoral markers: CA 19.9 = 2668, K. Shibuva1, T. Fujii1, S. Yamada2, K. Murotani3, H. Takami2, CEA = 2.4. Body CT and Pancreatic IRM ruled out vascular infiltra- M. Hayashi2, Y. Niwa2, I. Hashimoto1, S. Hojo1, I. Yoshioka1, tion or distant metastases. 2nd Programmed Surgical Procedure: T. Okumura1, H. Sugimoto2, Y. Kodera2. Left pancreatectomy with near total gastrectomy and left colec- 1University of Toyama, Japan tomy. 2nd Anatomopathological results of surgical specimen: 2Nagoya University Graduate School of Medicine, Japan Ductal Adenocarcinoma well differenciated 4.5 cm, infiltration of 3AichiMedical University. Japan peripancreatic tissues, gastric wall and left colon: T3N1(3/28). Deparment of Surgery and Science, Graduate School of Free surgical margins. Postoperative course: Low debit pancreatic Medicine and Pharmaceutical Sciences, University of Toyama fistula with good evolution until discharge. He began Chemo but Toyama, 930-0194 after 6,5 month he presented a local relapse, liver metastases and exitus. Background: Combined arterial resection during pancreatectomy Conclusions: Splenic rupture is an infrequent complication due to can be a challenging treatment, and outcome would be more progression of pancreatic tumours and venous splenic congestion. favorable if the tumor becomes technically removable from the In unknown neoplasms, diagnosis is incidental after histological artery. Neoadjuvant chemoradiotherapy (NACRT) is expected to exams. It must be mandatory a meticulous histological exam in all achieve locoregional control and enable margin-negative resection. spontaneous splenic ruptures excluding pancreatic neoplasms. Aim: To investigate the effects of NACRT in patients with pancreatic adenocarcinoma (PDAC) which were deemed borderline resectable through preoperative imaging due to abutment of the major artery, P-127 including the superior mesenteric artery (SMA) or common hepatic artery (CHA), but were still considered to be technically removable. THE SURGICAL RESECTION OF LIVER METASTASIS FROM Patients & methods: Comparisons were make between 71 patients PANCREATIC ACINAR CELL CARCINOMA – IS IT USEFUL OR NOT? who underwent upfront surgery and 21 patients who undenvent NACRT followed by surgery in the strategy to preserve the artery, S. Nakada, H. Yoshitomi, K. Furukawa, T. Takayashiki, S. Kuboki, using unmatched and inverse probability of treatment weighting S. Takano, D. Suzuki, N. Sakai, S. Kagawa, H. Nojima, analysis (UMIN000017115). T. Mishima, M. Miyazaki and M. Ohtsuka. Results: Fifty patients in the upfront surgery group and 18 in the Department of General Surgery, Graduate School of medicine, NACRT group underwent curative resection (70% vs 86%, respectively; Chiba University, Chiba City, 260-8670, Chiba, Japan P = 0.1609). The results of the propensity score weighted logistic Objection: Acinar cell carcinoma (ACC) of the pancreas is rare regressions indicated that the incidences of pathological lymph node malignant neoplasm and its prognosis remains poor. One of the metastasis and a pathological positive resection margin were reason of poor prognosis is high metastatic potential and most significantly lower in the NACRT group (odds ratio, 0.006; P < 0.0001 frequently site of metastasis is liver. However, the treatment and odds ratio, 0.007; P = 0.0005, respectively). Among the strategy for liver metastasis remains unclear. The aim of this study propensity-score matched patients, the estimated 1- and 2-year is to investigate the optimal treatments for liver metastasis of ACC. survival rates in the upfront surgery group were 66.7% and 16.0%, Methods: From January 2000 to December 2013 a total of 4 cases respectively, and those in the NACRT group were 80.0% and 65.2%, were diagnosed as ACC with liver metastasis at the Department of respectively. General Surgery, Chiba University Hospital. We investigated the Conclusion: It was suggested that chemoradiotherapy followed by clinical characteristics, treatment course and therapeutic out- surgery provided clinical benefits in patients with PDACs in contact comes. with the SMA or CHA. Results: All cases were men. The mean age was 63.5 (range 57-71). Pancreatectomy was performed in all patients, with two cases of dis- tal pancreatectomy, a case of pancreaticoduodenectomy and a case P-129 of total pancreatectomy. The median tumor size was 65 mm (range, 45-134 mm) and all cases have no lymph metastasis. One case has TYPE OF SURGICAL PROCEDURE IN PATIENTS WITH CHRONIC synchronous liver metastasis and pancreatectomy with liver resec- PANCREATITIS DEPENDING ON STAGES OF FIBROSIS tion was performed. Median disease free survival was 10 (4-20) O.E. Kanikovsky, I.V. Pavlyk. months and median survival time was 41.4 (12.5-68.5) months. Two National Pirogov Memorial Medical University, Vinnytsya cases of single-metachronal liver metastasis were treated with plural repeat surgery. Both cases resulted in long term survival for 68.5 Objectives: The aim of our investigation were to define stage and months and 43.2 months. On the other hand, a case of synchronous zone of pancreatic fibrosis as criteria to choose a type of surgical metastasis and a case of multiple recurrence cases were survived treatment of patient with CP.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 253 ABSTRACTS

Methods: The results of surgical treatment of 181 patients with CP techniques, it was difficult to diagnose epidermoid cyst in a complicated with pancreatic hypertension were submitted. In 37 of pancreas. We make a comprehensive review of the literature. patients with calcification and multiple strictures, we check a tissue resistant pressure (TRP) with Stryker tissue pressure monitor and pressure inside the main pancreatic duct. In 37 patients Frey P-131 procedure were done in 6, Frey-Izbicki in 26, pancreatoduodenal resection in 5. A CASE OF SOLID PSEUDOPAPILLARY NEOPLASM OF Results: In all cases TRP was highest it the place of pancreatic duct THE PANCREAS (SPN) IN A MALE PREOPERATIVELY stricture (>200 mm.Hg), as in other parts of the pancreas it DIAGNOSED BY USE OF EUS-FNA decrease till 120 mm.Hg and lower. Ductal pressure was increased Yudai Takehara, Yoshifumi Fujimoto, Hironori Tokumo. only in 22 (59,5%) patients. All patients histologically had severe Department of gastroenterology and hepatology fibrosis in the stricture place. TRP was >200 mm. Hg in the head of JA Hiroshima General Hospital, Hatsukaichi-City, 738-8503, Japan the pancreas only in 30 (81,1%) patients. In 7 patients location of the stricture were in the place between the pancreatic head and Case: A 37-year-old man was referred to our hospital with chief neck and TRP in that place proved zone of severe fibrosis. Patient complain of epigastric pain. The finding of Computed Tomography with calcification (head – 6, total – 8) and obstructive CP (increased (CT) scan showed duodenal ulcer perforation and then he under- main pancreatic duct with multiple strictures – 8 patients) had TRP went an emergency surgery against it. The CT scan also showed a as high as >200 mm.Hg in all part of the pancreas indicating the low density pancreatic body tumor which was 16mm in diameter. total pancreatic fibrosis. No capsules or cysts were identified in the tumor. The finding of Conclusions: The pacemaker of CP should be considered as zone of magnetic resonance imaging (MRI) on the tumor showed low maximal fibrosis that not always located in the pancreatic head. signal on T1-weighted, a mildly elevated signal on T2-weighted and Surgical procedure should not only decreas ductal pressure and a highly elevated signal on diffusion weighted. FDG-PET imaging involve local resection of the head of the pancreas but wide showed increasing uptake in the pancreatic body. Endoscopic excision of the pancreatic strictures with the opening of the retrograde cholangiopancreatography (ERCP) showed stenosis of secondary and tertiary ducts (Frey-Izbicki procedure). Moreover, the main pancreatic duct. There was no dilatation of the main excision should perfomed in zone of maximal TRP (>200 mm.Hg), pancreatic duct in the pancreatic tail. In endoscopic ultrasonography but in place TRP lower 120 mm.Hg it is enough to do simple (EUS), the tumor was visualized as a hypoechoic lesion in which has drainage procedure. hyperechoic mass lesion that suggested calcification. We performed endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to obtain a definitive diagnosis. The pathological P-130 findings showed fibrovascular pseudopapillary structure and solid hyperplasia of small tumor cells. Immunostaining revealed that the A CASE OF EPIDERMOID CYST IN AN INTRAPANCREATIC tumor was positive for Synaptophysin and CD10 and negative for ACCESSORY SPLEEN Chromogranin A and CD7. SPN was strongly suspected based on Y oshifumi Fujimoto, Y.Takehara, H.Tokumo, Y. Sugiyama. this pathology and Immunostaining pattern. We performed middle Department of gastroenterology & hepatology, pancreatectomy and finally diagnosed this tumor as SPN at the JA Hiroshima General Hospital, Hatsukaichi-City, Hiroshima, histopathological examination of the resected specimen. 738-8503, Japan Conclusion: SPN is a rare tumor which occurs primarily in young woman and preoperative diagnosis is very difficult. In our case, Case presentation: A case is a 40-year-old woman. She was EUS-FNA was useful for differential of pancreatic tumor and admitted to our hospital for further examination of the tumor near contribute to select appropriate surgery. Here we present this case the left kidney, which was incidentally detected by abdominal ultra- along with a review of the literature. sonography of medical examination. Enhanced-contrast abdominal computed tomography (CT) demonstrated a 45 mm-sized unilocular cyst in the tail of the tail of the pancreas. CT showed P-132 calcification in the wall of the cyst. Magnetic resonance imaging (MRI) revealed the cystic component was hypointense on SURGICAL MANAGEMENT FOR PANCREATIC CYSTIC NEOPLASMS T1-weighted images and hyperintense on T2-weighted images. On (PCNS): A SINGLE-INSTITUTION EXPERIENCE MRI, no connection was revealed between the cyst and D.Z. Li, X. Lu, C.Z. Zhang, Yu. Zhou, M. YU, Y. Lin, Z.X. Jian, main pancreatic duct. Physical examination was essentially B.H. Hou. unremarkable and laboratory data showed almost normal values. Department of General Surgery, Guangdong General Hospital, As concerns serum tumor markers, carbohydrate antigen (CA) 19-9 Guangdong Academy of Medical Sciences, Guangzhou, 510080, levels had increased to 145.1 U/ml. Because a malignant tumor of China. the pancreas was suspected, the patient underwent a distal pancreatectomy and splenectomy. The cyst measured 45 mm at its Objective: To summarize our experience in the surgical treatment greatest diameter, and contained a serous composition fluid. of pancreatic cystic neoplasms (PCNs). Microscopic analysis revealed that a unilocular cyst lined by Methods: A retrospective analysis was conducted on the clinical stratified squamous epithelium and surrounded by normal splenic data of 110 consecutive patients with PCNs who were treated tissue. The final histological diagnosis revealed the presence of an between Jan 2004 and Mar 2017in Guangdong General Hospital, epidermoid cyst of an accessory intrapancreatic spleen. China. Clinical characteristics, pathology, morbidity and oncology Postoperatively, serum CA 19-9 decreased to normal levels after outcome were analyzed. one month. Results: The average age of male patients was significantly higher Conclusions: We report a rare case of epidermoid cyst in an than that of females (54.7 ± 12.3 vs. 44.0 ± 15.1, P< 0.001), while intrapancreatic accessory spleen. Despite advances in radiologic the tumor’s diameter was less than that of females (3.0 ± 1.8vs. 6.0

254 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

± 3.3 P< 0.001).The overall postoperative morbidity rate was 19%, Objective: The incidence of postoperative pancreatic fistula (POPF) the rate of pancreatic fistula was 4.5%. Results of univariate analysis remains high after laparoscopic distal pancreatectomy (Lap-DP). To showed that age, preoperative hemoglobin, albumin, levels of serum find the most appropriate stapling technique for the pancreatic CAl9-9 and CEA were associated with malignant PCNs. Multivariate stump, we standardized the stapling procedure using a newly analysis results showed that serum CEA was independent risk developed electric stapler. The electric-powered tip movement factor for the preoperative prediction of malignant PCNs may reduce hand tremor, reducing trauma to surrounding tissue (OR=85.539, P<0.05). The overall survival rate for PCNs patients during cutting and stapling. The black cartridge used has the was 93.6%. The five-year survival rates of benign and borderline longest staples (Open/Closed staple height; 4.2/2.3mm) and could PCNs were 98.6%, for malignant PCNs was 56.3% after radical be optimal for Lap-DP. surgery. Methods: From March 2016 to January 2017, eight consecutive Conclusions: The surgical operation for PCNs was safe and feasible, patients (two males and six females) underwent Lap-DP for benign with acceptable complications. Aggressive surgical management pancreatic tumors. Four patients had a mucinous cyst neoplasm, one for PCNs may receive better oncology outcome. serous cyst neoplasm, one solid pseudopapillary, one intraductal papillary mucinous neoplasm, and one pancreatic neuroendocrine P-133 tumor. The standardized procedure using the electric stapler includes 5 minutes compression, 5 minutes fitting (pre-compression), 5 POST-ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY minutes cutting, 5 minutes fitting (post-compression), and release. PANCREATITIS: RISK FACTORS AND PREDICTORS OF SEVERITY This is a total of 20 minutes to cut the pancreas using the electric stapler. We measure drain amylase on postoperative day (POD) 1, 3, EhabEl Hanafy, Ayman El nakeeb, Ehab Atef 5, 7 to evaluate POPF according to the International Study Group on Gastrointestinal surgical center, Mansoura University, 35516, Pancreatic Fistula definitions. Postoperative complications were Egypt. graded using the Clavien-Dindo classification. Pancreatic thickness Objectives: Endoscopic retrograde cholangiopancreatography was measured at the resection line on preoperative computed (ERCP) is increasingly used for therapeutic management of various tomography scan. biliary and pancreatic diseases. However, ERCP is not a procedure Results: All eight patients were POPF grade A. There were no without morbidities. Post-ERCP pancreatitis (PEP) remains the serious complications greater than Clavien-Dindo Classification most common and serious complication after ERCP. Our aim is to grade III. Mean pancreatic stump thickness was 16.3mm (range: detect risk factors for post-endoscopic retrograde cholangio- 11.6-22.1mm). All patients were discharged by POD 10. pancreatography (ERCP) pancreatitis (PEP) and investigate the Conclusions: In Lap-DP, a novel 20 minute compression procedure predictors of its severity using an electric stapler may reduce the incidence of POPF for a Methods: This is a prospective cohort study of all patients who pancreas 22mm thick or less. underwent ERCP. Pre-ERCP data, intraoperative data, and post- ERCP data were collected P-135 Results: The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there CLINICAL OUTCOMES OF EVEROLIMUS IN PATIENTS WITH were 454 male and 442 female patients. Overall, PEP occurred in ADVANCED PANCREATIC NEUROENDOCRINE TUMORS: A 102 (10.2%) patients of the study population; eighty (78.4%) cases MULTICENTER STUDY IN KOREA were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was HM Kim1, KJ Lee1, JH Cho2, SH Lee3, SY Song4, KH Lee5, reported for any of PEP patients during the study duration. Age less S Jeong6, JK Ryu3, SM Woo7, SM Bang4, JK Lee5, TH Lee8, than 35 years (P = 0.001, OR = 0.035), narrower common bile duct WH Paik3, YT Kim3, WJ Le71 (CBD) diameter (P = 0.0001) and increased number of pancreatic 1Department of Internal Medicine, Yonsei University Wonju College cannulations (P = 0.0001) were independent risk factors for the of Medicine, Wonju, Korea; occurrence of PEP. 2Department of Internal Medicine, Gachon University, Gil Medical Conclusion: In conclusion, PEP is the most frequent and devastating Center, Incheon, Korea; complication after ERCP. PEP is associated with higher morbidity and 3Department of Internal Medicine and Liver Research Institute, mortality beside its effect in increasing the consumption of hospital Seoul National University College of Medicine, Seoul, Korea; resources. Age less than 35 years, narrower median CBD diameter 4Department of Internal Medicine, Yonsei University College of and increased number of pancreatic cannulations are independent Medicine, Seoul, Korea; risk factors for the occurrence of PEP. Patients with these risk factors 5Department of Internal Medicine, Samsung Medical Center, are candidates for prophylactic and preventive measures against PEP. Sungkyunkwan University School of Medicine, Seoul, Korea; 6Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea; P-134 7Center for Liver Cancer, National Cancer Center, Goyang, Korea; 8Department of Internal Medicine, Soon Chun Hyang University NOVEL STANDARDIZED STAPLING TECHNIQUE FOR LAPAROSCOPIC Cheonan Hospital, Soon Chun Hyang University College of DISTAL PANCREATECTOMY: A PRELIMINARY STUDY Medicine, Cheonan, Korea

Hideki Sasanuma, Yasunaru Sakuma, Akira Saito, Yuji Kaneda, Obejectivs: Everolimus is a standard treatment option for Atsushi Miki, Kazuhiro Endo, Masaru Koizumi, Alan Lefor, advanced pancreatic neuroendocrine tumors (pNETs). This multi- Naohiro Sata. center study evaluated the efficacy and safety of everolimus in low Jichi Medical University, Department of Surgery and intermediate grade advanced pNETs. Shimotsuke, 329-0498, Japan Methods: Tumors were graded according to the World Health Organization 2010 classification system. Patients with low or

Surgery, Gastroenterology and Oncology, 22 (3), 2017 255 ABSTRACTS

intermediate grade pNETs who received everolimus as first or P-137 second-line chemotherapy between 2002 and 2014 were included. Results: A total of 40 patients with metastatic or recurrent pNETs COMPARATIVE STUDY OF RINGER LACTATE VERSUS NORMAL were included in this study. The median age was 54.5 years (range; SALINE INFUSION IN EARLY ACUTE GALLSTONE INDUCED 19-83 years). Twelve patients (30%) experienced recurrence. There PANCREATITIS. were 11 patients (27.5%) with low grade pNETs and 29 (72.5%) A. Jain, S. Ramasamy, S. Neogi, S.K. Tudu, A. Goel, S. Prajapati. with intermediate. Everolimus was administered as first-line therapy Maulana Azad Medical College, New Delhi, 110002, India in 30 patients (75%) and as second-line therapy in 10 patients (25%). The median progression-free survival (PFS) of patients with low and Objective: To compare Ringer Lactate vs. Normal Saline infusion in intermediate grade pNETs was significantly different (median not patients with early Acute Gall Stone induced Pancreatitis with reached vs. 11 months, p = 0.015). On multivariate analysis, tumor reference to severity of pancreatic necrosis. grade (intermediate grade; hazard ratio = 5.46, 95% confidence Methods: We evaluated 40 patients with early acute gallstone interval 1.32 to 22.51, p = 0.019) was the only independent induced pancreatitis between September 2015 to march 2017. prognostic factor for PFS in pNETs. The most common adverse Patients were given minimum of 1000 ml of RL or NS per day events were stomatitis, skin rash and anemia. depending on their Groups of study for first 72 hrs. Rest of the fluid Conclusions: WHO 2010 grade is the most important determinant requirement was fulfilled by using 5% dextrose. After 3 days for PFS in patients undergoing everolimus treatment for pNETs infusion of fluids were individualised for each patient according to with an acceptable incidence of adverse events. the need. Contrast enhanced CT scan was done on day 7 of onset of symptoms to look for the percentage of necrosis as per Modified CT Severity Index. P-136 Results: The mean age of acute gallstone induced pancreatitis was 37.45 with no significant sex difference. Mean CTSI of Ringer CLINICAL OUTCOMES OF REPEATED SURGERY FOR RELAPSING Lactate group was 4 and the mean CTSI of Normal Saline group was SYMPTOMS OF CHRONIC PANCREATITIS 4.6 on the seventh day CT scan with the p value of 0.52. Correlation K. Kamei, I. Matsumoto, K. Kawaguchi, M. Matsumoto, between Modified CTSI score and BISAP scores is derived using T. Murase, S. Satoi, T.Nakai and Y.Takeyama. spearman‘s rho test. R value was 0.62 i.e. positive correlations Department of Surgery, Kindai University Faculty of Medicine between CTSI and BISAP score were present. Osaka, Japan,589-0014 Conclusion: We can conclude from the study that in acute gallstone induced pancreatitis patients, it is probably the amount Background and Aim: For patients with chronic pancreatitis, repeated of fluid not the type of fluid which determines the outcome. There surgery for refractory and/or relapsing symptoms is sometimes is no statistically significant difference in effect of both Ringer required. However, actual indication and clinical outcomes of repeated lactate and Normal Saline. Any of them can be used for early resus- surgery remain undetermined. citation in patients of acute gall stone induced pancreatitis, keeping Patients and Methods: Fifteen patients who underwent repeated in mind the importance of total fluid requirement. BISAP scoring on surgery for chronic pancreatitis between 2005 and 2016 were admission in all patients can help us predict clinically the severity of retrospectively reviewed and clinical outcomes were analyzed. pancreatitis and wherever severe pancreatitis is predicted, close Results: The studied population included 12 men and 3 women with and intensive fluid resuscitation is required. a median age of 47 years. The main etiology was alcohol abuse (n=13) and the remaining 2 patients presented idiopathic pancreati- tis. Reasons for repeated surgery were relapse of pancreatitis (n=7), P-138 refractory pain (n=4), biliary stricture (n=3), and pseudocyst forma- tion (n=1). For these patients, following procedures were performed MAJOR PANCREATIC SURGERY FOR VON HIPPEL-LINDAU as appropriate: Frey procedure (n=6), distal pancreatectomy (n=3), DISEASE ON THE BACKGROUND OF NEW RECOMMENDATIONS. pancreaticoduodenectomy (n=2), choledochoduodenostomy (n=2), FIVE CASES Partington procedure (n=1), and total pancreatectomy (n=1). Median Egorov V.I., Petrov R.V., Beltsevich D.G. operation time was 265 minutes (range, 94-501), estimated blood 1Bakhrushins Brothers City Hospital, 2Endocrinological loss was 828ml (range, 107-2810). Global morbidity rate (grade ≥2) Scientific Centre, Moscow Russia 107076 was 33.3% (5/15) including 3 patients with early onset and 2 patients with late onset. Length of hospital stay was 12 days (range, 5-36). Background: Pancreas is involved in 15% of patient with von Eight patients (53.3%) achieved relief of pain after repeated surgery. Hippel-Lindau disease (VHL). Major pancreatic surgery for VHL is Multivariate analyses revealed that early postoperative morbidity is recommended if symptomatic large (>5 cm) serous cystadenomas correlated with presence of pancreatic divism or pancreaticobiliary or neuroendocrine pancreatic tumors (pNENs) > 2 or >3 cm appear. maljunction (X2=8.3, P=0.004) and pain relief is strongly associated Aim: To assess indications and results of major pancreatic surgery with discontinuation of alcohol (X2=17.3, P<0.0001). in patients with VHL Conclusions: Repeated surgery for refractory chronic pancreatitis can Methods: Retrospective analysis of 5 major pancreatic resections be performed safely with acceptable efficacy and morbidity rate. using BB Moscow City Hospital database (2013-16). Presence of pancretic divism or pancreaticobiliary maljunction may Results: Twelve VHL patients is under surveillance. First case: total be a risk factor for early postoperative morbidity and discontinuation duodenopancreatectomy for head and tail pNENs on the back- of alcohol is inevitable to expect pain relief after surgery. ground of total pancreatic involvement by serous cystadenomas of different size was performed to the 54-year old woman, who 6 years ago was treated by right-sided nephrectomy performed for clear-cell cancer. 8 months later she had died due to dissemination of renal cancer. A 45-year old woman with multiple cerebellar and spine hemangioblastomas, pNENs in the head and body and tail, 5

256 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

years after right adrenalectomy for pheochromocytoma, centre- P-140 preserving pancreatectomy and left adrenalectomy for pheochro- mocytoma. Non-complicated postoperative period. A 47-year old DEVELOPMENT OF PANCREATIC ENDOCRINE AND EXOCRINE man with multiple spine hemangioblastomas, large (5-6 cm) pNENs INSUFFICIENCY IN NON-DIABETIC PATIENTS AFTER DISTAL in the head and 10 years after bilateral adrenalectomy for PANCREATECTOMY: A NATIONWIDE DATABASE STUDY pheochromocytoma was successfully treated by pancreatico- Jin-Ming Wu, Te-Wei Ho, Ming-Tsan Lin, Yu-Wen Tien dudenectomy. One case of distal pancreatectomy (DP) for NENs Department of Surgery, National Taiwan University Hospital and combined with bilateral adrenalectomy and left renal resection and National Taiwan University College of Medicine, Taipei, Taiwan, another case of DP combined with left adrenalectomy, triple left 7 Chung-Shan South Rd. Taipei 10002, Taiwan, ROC kidney resection and right kidney resection. All the patients were discharged and at the moment they are functional, working and Objective: The aim of this population-based study was to fully compensated. determine the occurrence of diabetes mellitus (DM) and exocrine Conclusion: Timely and possibly parenchyma-sparing pancreatic pancreatic insufficiency (EPI) in non-diabetic patients who receive resections are the operations of choice for pNENs on the back- distal pancreatectomy (DP). ground of VHL. Research design and methods: Data from the Taiwan National Health Insurance Research Database was collected from the period from 2000 to 2010. Of 3,264 patients that received DP, we identi- P-139 fied 1,410 patients without DM, and 966 without DM and without EPI. CORRELATIONS BETWEEN THE HEMATOCRIT, LEUCOCYTOSIS Results: Of 1,410 non-diabetic DP patients, 312 (22.1%) developed AND PRO-INFLAMMATORY CYTOKINES IN PATIENTS WITH newly-diagnosed DM after DP. Multiple logistic regression analysis ACUTE NECROTIC PANCREATITIS showed that dyslipidemia (hazard ratio [HR] = 1.640; 95% V.V. Petrushenko, D.I. Grebeniuk, K.M. Pankiv, A.S. Levanchuk, confidence interval [CI]: 1.362–2.763; P < 0.001) and chronic O.M. Bilyk, O.M. Zatserkovna. pancreatitis (HR = 2.428; 95% CI: 1.889–3.121; P < 0.001) were Chair of Endoscopic and Cardiovascular Surgery, Vinnytsya significantly associated with the development of DM after DP. In National Medical University n.a. Pirogov, Vinnytsya, 21018, addition, 380 patients (39.3%) developed EPI, and pancreatic Ukraine cancer was a statistically significant risk factor (HR = 4.663; 95% CI: 2.108–6.085; P < 0.001). Objectives: The aim of our study was to estimate correlations Conclusions: Dyslipidemia and chronic pancreatitis are risk factors between values of hematocrit, leucocytosis and pro-inflammatory for the development of DM after DP. Pancreatic cancer is a risk cytokines (PIC) in patients with acute necrotic pancreatitis (ANP). factor for the development of EPI after DP. Clinicians should be Methods: The results of analysis of complex examination and alert for symptoms of glucose and fat intolerance in patients that treatment of 108 patients with confirmed diagnosis of ANP was put have received a DP. into the basis of our study. There were 78 (72.22%) of men and 30 (27.78%) of women in this study. The average age was 41.4±3.3 years. The levels of IL-1β, IL-6, IL-8 and TNF-α were measured in P-141 blood serum and peritoneal exudate. Results: The PIC play a key role in pathogenesis of ANP and its sys- IMPACT FACTORS FOR PERIOPERATIVE MORBIDITY AND temic complications. First of all, the cells in the point of inflammation MORTALITY AND REPERCUSSION ON LONG-TERME SURVIVAL produce them. It was confirmed by our investigations with IL-1β, IN PANCREATIC HEAD RESECTION. IL-8 and TNF-α levels measurement in peritoneal exudates. Their levels in this fluid was significantly higher than in blood serum S. Potrc, A. Ivaneczn T. Jagri, B. Krebs, B. Ilijevec, U. Marolt. (p<0.01). In patients with high level of PIC in blood serum fluid accumulation in parapancreatic areas and in the abdominal cavity Background: Different factors can impact the occurrence of occurred more frequently as well as multi-organ dysfunction. In morbidity and mortality after pancreatic head resections. The focus case of values IL-1β ≥12,0 pg/ml and TNF-α ≥20,0 pg/ml we of the present study was to reveal any impact factors for peri- observed the most severe course of ANP. It was with hyperleuco- operative morbidity and mortality as well as repercussion of peri- cytosis, hyperthermia, expressed multi-organ dysfunction and operative morbidity on long-term survival in pancreatic head widespread necrosis in pancreas as well as in parapancreatic areas. resection. The body temperature depends on concentration of PIC in blood Patients and methods: In a retrospective study, clinic-pathological serum, mostly of TNF-α level (r=0.57, р<0.01). There was a direct factors of 240 patients after pancreatic head (PD) or total resection correlation between the concentration of IL-1β, IL-6, IL-8 and were analyzed for correlations with morbidity, 30- and 90-day TNF-α and quantity of neutrophils and lymphocytes (p<0.05). The mortality, and long-term survival. According to Clavien-Dindo direct correlation was detected between the levels of all PIC and classification, all complications with grade II and more were hematocrit value. This correlation was revealed for IL-1β (r=0.92, defined as overall complications (OAC). OAC, all surgical (ASC), p<0.001), IL-6 (r=0.49, p<0.05), IL-8 (r=0.62, p<0.001) and TNF-α general (AGC) and some specific types of complications like leaks (r=0.62, p<0.01). from the pancreatoenteric anastomosis (PEA) or pancreatic fistula Conclusions: The hypovolemia appearance and development of (PF, type A, B and C), leaks from other anastomoses (OL), bleeding inflammatory reaction make microcirculation impairments more (BC) and abscesses (AA) were studied for correlation with severe. They are typical signs of early stages of severe ANP. clinic-pathological factors. Two chronologically successive groups of patients (P1: from January 1, 2008 to December 31, 2012 (96 pts); P2): January 1, 2013 to March 31, 2017 (144 pts)) were com- pared for perioperative morbidity, and 30- and 90-day mortality. Results: In the 9-year period, altogether 240 patients had pancreatic

Surgery, Gastroenterology and Oncology, 22 (3), 2017 257 ABSTRACTS

resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC arterial lesions which demanded emergency relaparotomy (n=3). 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of Multivariate analysis revealed tumor size < 15mm (p=0.01), soft 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase parenchyma (p=0.006), stage III TNM (p=0.01), moderate differen- on drains, and pancreatic fistulas B and C correlated significantly with tiated ductal adenocarcinoma (p=0.03) and poorly differentiated different types of complications. Overall 30- and 90-day mortality ampullary carcinoma (p<0.0001) as independent risk factors for were 5 and 7.9% and decreased to 3.5 and 5% in P2. postoperative pancreatic fistula. Conclusion: High amylase on drains and consequently PF B and C, Conclusions: A continous effort to improve perioperative manage- OAC, PL and BC were independent indicators of morbidity, ment can be responsible for reducing the morbidity and mortality whereas PL and BC revealed as independent predictor for 30-day rates after pancreatoduodenectomy. Hemorrhage associated with mortality, and OAC and PF C for 90-day mortality. pancreatic fistula in particular can represent a major problem requiring immediate surgery and intensive care. P-142 P-144 SURGICAL OUTCOMES OF PANCREATICODUODENECTOMY IN ELDERLY PATIENTS. A CASE-CONTROL STUDY CLOSURE OF PANCREATIC STUMP WITH ROUND LIGAMENT Waleed Askar, Ayman El Nakeeb. OF LIVER AFTER DISTAL PANCREATECTOMY S. Chen, G. Chen, X. Han, X. Hou, Y. Zhao Background: Although mortality and morbidity for pancreatico- duodenectomy (PD) have improved significantly over the last years, Peking Union Medical College Hospital, Chinese Academy of the concern for elderly undergoing PD still present. This study Medical Sciences & Peking Union Medical College, Beijing, reviewed the surgical outcome of elderly patients who underwent China, 100005. PD. Objective: Post-operative pancreatic fistula (POPF) has been a Patient and methods: Patients were divided into three groups; major complication after distal pancreatectomy. Numerous Group I (patients with age <60years), Group II (patients with age methods have been proposed to reduce the rate and severity of 60-69 years) and Group III (patients > 70 years. The primary out- POPF. We propose that sealing the pancreatic stump with a come was the rate of total postoperative morbidities. Secondary ligamentum teres hepatis patch could prevent POPF after distal outcomes included total operative time (hours), hospital mortality, pancreatectomy. A single-center randomized trial was conducted length of postoperative stay (days), and survival rate. to evaluate the efficacy of this technique. Results: 828 patients underwent PD for resection of periampullary Methods: We randomly assigned patients with pancreatic tumor tumor in this study. Group I included 579 (69.9%) patients while undergoing distal pancreatectomy into two groups. In the study group II, included 201 (24.3%) patients and group III included 48 group, the round ligament of liver was mobilized and used to seal (5.8%) patients. The overall incidence of complications was higher the pancreatic stump after pancreatic transection with linear in elderly group (25.9% in group I, 36.8% in group II, and 37.5% in stapler. In the control group, the pancreas is only transected and group III P= 0.006). Delayed gastric emptying developed significantly sealed with stapler. We performed both open and laparoscopic in group II than the other two groups. There was no significant surgeries. POPF rate, total operation time and other complications difference in the incidence of POPF, biliary leakage, pancreatitis, were observed. pulmonary complication and hospital mortality. Results: Round ligament patch sealing achieved lower total POPF Conclusion: PD can be performed safely in selected elderly rate (8% vs 29.7%; p=0.018) according to the 2016 updated defini- patients. Advanced age alone should not a contraindication to do tion of pancreatic fistula by ISGPS. This procedure did not prolong PD. the total operation time (182.6±63.6min vs 201.1±71.1min; p=0.242). There was no difference in operation time between open and laparoscopic procedures. P-143 Conclusions: Sealing the pancreatic stump with round ligament of CRITICAL APPRAISAL ON PANCREATIC FISTULA liver can prevent POPF effectively. This procedure is also valid AFTER 84 CONSECUTIVE PANCREATODUODENECTOMIES under laparoscopic conditions. This technique is simple and effective and deserves further evaluation in larger cohorts. S. Vâlcea, B. Dumitriu, M. Vartic, M. Beuran Clinical Emergency Hospital, Bucharest, 014461, Romania P-145 Objectives: The aim of this study was the analyse the complications after pancreatoduodenectomies with emphasis to pancreatic DISTAL PANCREATECTOMY: ANALYSIS OF 120 PATIENTS PERTAINING fistula, morbidity and mortality. TO INDICATIONS, COMPLICATIONS AND SURGICAL RESULTS Methods: From May 2012 to May 2017, perioperative and post- R. Dama, R. Pradeep,G.V.Rao, D.N.Reddy operative data from 84 consecutive patients who underwent a pancreatic head resection were recorded prospectively with Ethics Asian Institute of Gastroenterology, Hyderabad-500082, India. Comittee approval. Data were analysed according to the procedure Objectives: Distal pancreatectomy is resection of pancreas to the performed: Whipple or Traverso-Longmire resection and total left of splenoportal confluence with splenectomy (DPS) or without pancreatectomy (n=3). Duct-to-mucosa pancreatico-enteric (DP). We analyse our surgical results of distal pancreatecatomy anastomosis was performed in all cases (n=81). with respect to indications, complications. Results: The prevalence of pancreatic fistula was 8,3 % and was not Methods: Data of 120 patients of distal pancreatectomy, between dependent on the procedure (Whipple vs. Traverso). Total morbidity jan 2005 to may 2017, was systematically analysed. The pancreatic rates were 52,4 % and mortality rate associated with pancreatic stump was suture closed with a separate suture for the pancreatic fistula of 3,5 % due to conservative treatment failure of severe duct (PD), if identified. Stapled transection was done in 20 patients.

258 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

Drain was always kept. Results: 67/120 males and 53 females. Average age was 48 years (12-72). Mean operating time was 140 minutes and blood loss P-147 (300ml). 90/120 patients underwent DPS. 30 patients had DP (spleen preserving). 25 patients had laparoscopic approach. IMCOMPLETE EXTERNAL PANCREATIC DUCT STENT DRAINAGE Multivisceral resections in 21 patients included stomach, colon, gb, TO REDUCE POSTOPERATIVE PANCREATIC FISTURA AFTER adrenal and kidney. Associated procedures were lateral pancreati- PANCREATICODUODENECTOMY cojejunostomy -12,duvals procedure- 5, excision of fistulous Lee Dongha, Sachiyo Shirakawa, Hirochika Toyama, Yoshio Terai, tract-3. Two patients had portal vein resection Hideo Mukubou, Hironari Yamashita, Yoshihide Nanno, Takuya Indications: Focal pancreatitis with strictures, collections or Mizumoto, Yuuki Ueda, Masahiro Kido, Kimihiko Ueno, Tetsuo pseudocysts - 30, SPEN and pancreatic adenocarcinoma 10 each, Ajiki, Takumi Fukumoto, Yonson Ku. NET- 8 , trauma -2, splenic artery aneurysm -4, serous- 26 and Kobe University Hospital Hepato-Biliary-Pancreatic Surgery, mucinouscystadenoma -19, surrounding organ pathologies -11. KOBE-SHI HYOGO, 650-0017, Japan Average stay was 10 days. 20/120 (16.7%) patients had post op new onset Diabetes mellitus. Two patients had mortality (1.67%)- due Objectives: Imcomplete external pancreatic duct stent drainage to septic collection and bleed. 28 patients (23%) had postoperative after pancreaticoduodenectomy is the standard procedure in our pancreatic fistula, 20 pts required ercp and pd stenting. 10 pts hospital. We regularly clamp the stent before discharge to improve (8.3%) required postoperative percutaneous drainage (PCD). longer postoperative hospital stay, discomfort and restraint. This Saio- 8 pts, wound infection - 13. Postoperative bleed in 5 patients. report intend to reveal management of the stent and clinical Conclusion: Distal pancreatectomy with varied indications, is a safe course associated with clamping the stent. procedure with less morbidity and acceptable mortality. Pancreatic Methods: 37 patients who underwent pancreaticoduodenectomy fistula may require pcd, or ercp and pd stenting. at Kobe University Hospital, from December 2015 to August 2016, were enrolled. All patients performed Blumgart anastomosis for pancreaticojejunostomy by the use of imcomplete external P-146 pancreatic duct stent(3 or 4Fr with knot). We clamped the stent when we recognized no leakage of the pancreaticojejunal DUODENUM-PRESERVING PANCREATIC HEAD RESECTION FOR anastomosis or the cure of postoperative pancreatic fistura. LOW-GRADE MALIGNANT TUMORS. Results: Out of 37 patients, median age 69(range 32-81), sex ratio (M:F 26:11), there is pancreatic cancer in 20 patients (54%).There A.Horiguchi, M.Ito. Y.Asano, S.Arakawa, M.Shimura,T.Ochi, is the incidence of pancreatic fistura of GradeB by ISGPF criteria in H.Yasuoka, T.Kawai. 4 patients(11%).The stent was clamped in postoperative day Fujita Health University school of Medicine Banbuntane 12(range 7-83). The Stent was re-opened because of fever in 6 Hotokukai Hospital gastroenterorlogical Surgery. Nagoya, patients, and 5 out of 6 patients had fluid collection around the 454-8509 anastomosis for pancreaticojejunostomy in CT image. Among these Introduction: Surgical treatment for benign or low-grade 6 patients, 1 patient was discharged to leave stent re-opened, but malignant tumors of the head of the pancreas is often performed 5 patients could re-clamp the stent 8 days later after re-opened using “traditional” procedures such as pancreatoduodenectomy (range 5-22). Statistically,there was no pancreatic cancer(p＝0.004) (PD. However, this approaches result in the loss of the upper and the number of leukocytes on the day before clamp was gastrointestinal and biliary anatomy with subsequent impairment significantly higher than others(p＝0.002). Whether the stent was of exocrine and endocrine functions, and the loss of the upper re-opened or not, the diameter of pancreatic duct, the amount of gastrointestinal and biliary anatomy in PD. Therefore, avoiding drainage on the day before clamp and postoperative hospital stay unnecessary loss of pancreatic tissue and further deteriorations in showed no difference. endocrine and exocrine pancreatic functions are important Conclusions: External pancreatic duct stent drainage is an effective challenges for surgeons managing benign and low-grade malignant method for prevention of severe pancreatic fistura and leakage. tumors of the pancreas. For patients, it would be beneficial for their Stent clamping is also useful for adjusting drainage span. If we QOL if PD could be avoided. To apply duodenum preserving carefully examine postoperative clinical course, we can safely pancreatic head resection (DPPHR) as radical procedure for benign clamp the stent and discharge patients with no discomfort and or low-grade malignant tumors, it is needed to completely resect restraint of the stent. pancreatic head as well as to preserve the bile duct and peripancre- atic vessels. DPPHR is technically difficult and time-consuming due to reconcile these antinomic techniques, which is complete P-148 resection in the pancreatic head and preservation of both the bile duct and the pancreaticoduodenal vessels. ISOLATED ROUX LOOP PANCREATICOJEJUNOSTOMY VERSUS Results: We studied retrospectively 38 cases that underwent SINGLE LOOP PANCREATICOJEJUNOSTOMY AFTER PANCREATI- DPPHR, 50 patients who underwent PD with benign or low grade CODUODENECTOMY: A RETROROSPECTIVE COHORT STUDY malignant pancreatic head tumors. The blood loss in DPPHR was A. Chhaidar, W. Farhat, M.A. Said, A. Mizouni, M. Ben Mabrouk, significantly lower than that in PD. There was no significant A.Ben Ali. difference in operative factors and postoperative complications. Sahloul hospital, Sousse4022, Tunisia. Both exocrine and endocrine function and the long-term results following DPPHR were superior to those following PD. Objectives: The aim of this study was to compare the postoperative Conclusion: In benign or low-grade malignant tumors of the head outcome and the occurrence rate of postoperative pancreatic fistula of the pancreas, DPPHR should be favored over the PD, if there is (PF) between isolated Roux loop pancreaticojejunostomy (IRPJ) and no compromise with oncologic radicallity. single loop pancreaticojejunostomy (SLPJ) after pancreatico- duodenectomy (PD).

Surgery, Gastroenterology and Oncology, 22 (3), 2017 259 ABSTRACTS

Methods: Data of patients who underwent IRPJ were compared with 7.92% (n=8) and haemorrhage of the anastomotic side in 2.97% those of a pair-matched equal number of patients undergoing SLPJ. (n=3). POPF were graded A in 12.5% (n=1), B in 62.5% (n= 5) and C The matching was performed according to age, gender, nature of the in 25% (n=2). Conservative treatment was undertaken in 50% (n=4) lesion indicating PD and the texture of the pancreas. The primary of the cases of POPF, mini-invasive in 25% (n=2) and operative in outcome measure was the rate of postoperative pancreatic fistula 25% (n=2), due to related complications as haemorrhage and (POPF). Secondary outcomes included operative time, day to infected intraabdominal collection. resumption of oral feeding, postoperative morbidity and mortality Conclusions: According to the obtained results this surgical and exocrine and endocrine pancreatic functions. technique for pancreatic anastomosis shows excellent short term Results: Seventy patients treated by PD were included in the study. outcome with satisfactory postoperative morbidity and mortality The two groups were comparable in both pre- and intra-operative rates. parameters. The median total operative time was significantly longer in the SLPJ group (329 min versus 386 min; p=0,001). P-150 Postoperative pancreatic fistula developed in 8 of 35 patients in the SLPJ group and 3 of 35 patients in the IRPJ group (p = 0.101). Four SHORT-TERM OUTCOME OF LAPAROSCOPIC DISTAL SLPJ patients and one IRPJ patient had POPF of type B or C (p = PANCREATECTOMY; COMPARISON BETWEEN 0.773). Re-laparotomy was significantly more frequent in the SLPJ SPLEEN-PRESERVING AND EN-BLOC SPLENECTOMY group (25.7% versus 8.5%; p=0.04). Time to resumption of oral feeding was shorter in the IRPJ group (p = 0.03). Steatorrhea at 1 T. Morikawa, M. Iseki, M. Ishida, T. Takadate, T. Hata, S. Maeda, year was reported in 2 of 35 RYR patients and 4 of 35 SLPJ patients K. Ariake, K. Masuda, T. Aoki, K. Fukase, H. Ohtsuka, M. Mizuma, (p = 0.414). N. Sakata, K. Nakagawa, H. Hayashi, F. Motoi, T. Naitoh, T. Kamei, Conclusions: The use of IRPJ does not seem to decrease the M. Unno occurrence rate of postoperative PF in patients undergoing PD. But Department of Surgery, Tohoku University Graduate School of It was associated with a decrease in the incidence of re-laparotomy. Medicine, Sendai, Miyagi, 980-8574 Japan. This technique allowed for early oral feeding and the maintenance Introduction: Laparoscopic distal pancreatectomy is now the of oral feeding even if POPF developed. standard treatment for low-malignant tumor in the pancreas body or tail. Although many institutes perform laparoscopic spleen- preserving distal pancreatectomy (LSPDP), its benefit is still P-149 controversial. The aim of this study is to compare LSPDP with laparoscopic distal pancreatectomy with splenectomy (LDP) in the MODIFIED DOUBLE LAYER T-L PANCREATO-JEJUNOSTOMY light of safety. – ANALYSIS OF THE FIRST 100 CASES Methods: We evaluated the characteristics and the operative N. Vladov, I. Takorov, M. Iakova, I. Vasilevski, V. Mihailov, outcomes of all patients who underwent LSPDP or LDP at our Ts. Lukanova, Ts. Trichkov, R. Kostadinov, E. Odisseeva institution from July 2009 to January 2017. Department of Hepato-Pancreato-Biliary and Transplant Results: We performed 55 LDPs (LSPDP, n = 12; LDP, n = 43) during Surgery – Military Medical Academy, 1606 Sofia, Bulgaria the study period. There was no significant difference in the Hepato-Pancreato-Biliary and Transplant Surgery – Military characteristics such as age, sex, body mass index and ASA score. Medical Academy, Sofia, Bulgaria The operation time of LSPDP was significantly longer than LDP (LSPDP, 470 ± 43 minutes; LDP, 352 ± 22 minutes, p=0.018), Objectives: Pancreatic resection, in particular pancreatoduodenec- meanwhile blood loss of each group was similar (LSPDP, 203 ± 74 tomy, is a complex procedure. Despite of the significant improve- ml; LDP, 207 ± 39 ml, p=0.96). Only 1 patient who received LDP was ments in the surgical techniques and postoperative care that have converted to open surgery because of strong adhesion. The rate of lowered the mortality rate, the surgical morbidity after pancreato- postoperative complications, including pancreatic fistula were not duodenectomy is still high. Patients undergoing surgery often suffer significantly different between the 2 groups. Splenic infarction was from complications. One of the most significant is postoperative not observed in all patients at the time of discharge. The length of pancreatic fistula (POPF). The choice of method for pancreatic hospital stay was not different significantly (LSPDP, 19.3 ± 3.8 days; anastomotic is still difficult and may be based on the preference of LDP, 17.5 ± 2.0 days, p=0.69). Ten of 12 patients who were treated the surgeon, as this anastomosis involves the highest rate of surgical by LSPDP, were histologically diagnosed as NET. complications. Conclusion: According to our data, LSPDP is feasible and almost Methods: In the Department of HPB and Transplant Surgery in has similar outcomes to LDP. Military Medical Academy, Sofia, has been adopted and modified a certain method for the pancreato-jejunostomy – double layer with P-151 external continuous 5/0 monofilament suture and inner duct-to- seromuscularis interrupted monofilament suture 6/0 with protec- THE CLINICAL USEFULNESS OF PACREATODUODENECTOMY tive “perdue” drainage 4-8 Fr. For the period, October 2014 – USING RETROMESENTERIC APPROACH IN PANCREATIC HEAD December 2016 this anastomosis has been used in 101 pancretico- CANCER duodenectomies. A prospective study of these 101 patients has Nobuhisa Takase, Taiichiro Miyake, Eri Maeda, Kouji Hisano, been done, including types of postoperative complications, Keisuke Fukui, Tohru Nishimura, Kouichiro Abe, Akihito Kouzuki, morbidity and mortality rate. Tomohiro Tanaka, Naoki Harada, Manabu Takamatsu, Kunihiko Results: An analysis has shown a morbidity of 27.72% (n=28), as Kaneda. the observed complications were classified according Clavien– Dindo classification – grade I – 0.99% (n=1), grade II – 8.91% (n=9), Department of Surgery, Kakogawa Central City Hospital grade IIIa – 1.98% (n=2), grade IIIb – 6.93% (n=7), grade IVa – 1.98% 439, Honmachi, Kakogawa-cho, Kakogawa, Hyogo prefecture, (n=2), grade IVb – 0.99% (n=1), grade V – 5.94% (n=6). The compli- 675-8611, Japan cations associated with the pancreatico-jejunostomy were POPF in In recent years, combination of radical operation and perioperative

260 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

adjuvant chemotherapy for pancreatic cancer is leading P-153 substantially improved treatment outcomes, while the optical surgical approach for pancreatic cancer, especially in pancreatic TWO CASES OF LEFT-SIDED PORTAL HYPERTENTION head cancer, is still controversial. It is widely accepted as important AFTER PANCREATICODUODENECYOMY TREATED WITH IVR evidence that curative resection (R0) is considered as a curative approach, whereas the rate of positive margins resection (R1) for H. Kushiya, T. Noji, D. Abo, T. Kawamura, D. miyasaka, pancreatic cancer amounts to about 20 %. We herein report K. Tanaka, Y. Nakanishi, T. Asano, Y. Kurashima, Y. Ebihara, pacreatoduodenectomy being aware of mesopancreas for S. Murakami, T. Nakamura, T. Tsuchikawa, K. Okamura, pancreatic head cancer using retromesenteric approach including T. Shichinohe, S. Hirano. Cattel-Braasch Maneuver and artery-first approach. Briefly, Cattel- Department of Gastroenterological Surgery II, Division of Surgery, Braasch Maneuver, which involves dissection along the right-sided Hokkaido University Faculty of Medicine, Sapporo, 060-8638, white line of Told fusion fascia and small bowel mesenteric root. It Japan. removes normal lotation of the small intestine, resulting in facili- Objectives: To report two cases of left-sided portal hypertension tate anatomical grasp with simplification. Artery-first pancreatico- after pancreaticoduodenectomy. duodenectomy is a technique to ligate the feeding arteries mainly Case #1: A 70-year-old female who underwent pancreatico- composed of superior mesenteric artery before the division of the duodenectomy (PD) for pancreatic head cancer combined with pancreas. The present study includes two groups of patients. A first resection of the confluence of the portal vein (PV) and the splenic group of 14 patients with retromesentetic approach and a second vein (SV). Reconstruction was performed between PV and the group of 13 patients with standard Whipple procedure. The superior mesenteric vein (SMV), and SV and the inferior mesenteric retromesenteric procedure makes it possilbe to maintain a clear vein, respectively. Seven years after surgery, she suffered severe operative view and blood loss reduction with early arterial flow anemia, which seemed to be caused by gastrointestinal bleeding. ligation to the pancreas head region compared with standard Although active bleeding was not found on upper, lower, nor Whipple procedure. Furthermore, the number of lymphadenecto- small bowel endoscopy, CT revealed varices at the portion of the my around the superior mesenteric artery (SMA) significantly pancreaticojejunostomy (PJ). Angiography revealed splenic venous increased in retromesenteric approach. These results implied that flow was drained into the varices and then ran into the portal vein. combination of perioperative multidisciplinary therapy and Then, a diagnosis of bleeding varices of PJ due to left-sided portal pacreatoduodenectomy using retromesentetic approach for hypertension (PH) was made. After partial splenic artery emboliza- pancreatic cancer may evade R1, resulting in better prognosis. tion (PSE) was performed to reduce the venous flow into the varices, her anemia was improved. Eleven months after, another session of PSE was necessitated for recurrent anemia. She has not P-152 suffered any episodes of anemia within 1 year since then. Case #2: An 80-year-old male who underwent PD for pancreatic THE MICROSURGICAL TECHNIQUES IN head cancer combined with resection of the confluence of PV and PANCREATOJEJUNOSTOMY SV with reconstructing between PV and SMV only. Eighteen Walid Elhaj. months after surgery, the patient developed melena with negative findings on upper, lower nor small bowel endoscopy. CT scan Background: The rate of POPF following pancreaticoduodenectomy revealed varices at PJ which communicated with the jejunal and the PD range from 7-28%. Prolonged hospital stay, Postoperative bleed- portal veins. He underwent percutaneous transhepatic obliteration ing and reoperations are higher in POPF patients by 40% while the of the varices. As the result, he remained without melena until he mortality is almost doubled. In spite of numerous pancreatico- died of pancreatic cancer 17 months after the embolization. enterostomy techniques advocated by different authors especially in Conclusion: Left-sided portal hypertension following PD with the last two decades, the rates of POPF remain unchanged. We bleeding varices could be treated by procedures of interventional refined the duct to mucoas anastomosis by using combined continu- radiology with minimal invasiveness. ous interrupted microsurgical technique as safe and fastest option. Methods: From November 2014 to April 2017, 64 patients had pancreaticoduodenectomy for malignant periampullary and P-154 duodenal tumors in Soba and Ibn Sina Hospitals. The data was collected prospectively.The primary end point was the occurrence EN BLOC SIMULTANEOUS PANCREAS AND KIDNEY COMPOSITE and grade of POPF. GRAFT TRANSPLANT WITH LIMITED VASCULAR ACCESS Results: Patients who had duct to mucosa pancreatojejunostomy had a lower rate of postoperative pancreatic fistula (grade A) 2%.In S.E. Wang, Y.M. Shyr. comparison to patients in the control group where the rate is Division of General Surgery, Department of Surgery, relatively higher 7.6 % of grade A and B (P_value 0.02). Taipei Veterans General Hospital, National Yang Ming University Conclusion: DMA technique is widely adopted as valuable and Taipei, Taiwan safest techniques for PJ. Meticulous microsurgical techniques has Purpose. Objectives: Limited vascular access could be encountered the potentials to refine and to fasion more anatomical and physio- in an obese or re-transplant patient. We described modifications logical anastomosis. that facilitated an en bloc simultaneous pancreas and kidney (SPK) composite graft transplant in 4 diabetic patients with renal failure under hemodialysis.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 261 ABSTRACTS

Materials and Methods: At the back-table, the superior massive GJ bleeding. The coil embolization might fail due to coil mesenteric artery and splenic artery of the pancreas graft were migration into the necrotic pancreas graft. reconstructed with a long "Y" iliac artery graft. The smaller left renal artery is anastomosed end-to-side to the larger and longer common limb of the arterial Y graft and the shorter portal vein is P-156 anastomosed end-to-side to the longer graft left renal vein. Thus, this en bloc composite graft allowed to facilitate “real” SPK trans- PANCREAS TRANSPLANT AT TAIPEI VETERANS GENERAL plant using single common graft artery and vein for anastomosis to HOSPITAL one recipient arterial and venous site. The en bloc pancreas and Y.M. Shyr, S.E. Wang. kidney composite graft was implanted by suturing the graft left Division of General Surgery, Department of Surgery, renal vein to IVC and graft common iliac artery the recipient distal Taipei Veterans General Hospital, National Yang Ming University aorta. Exocrine drainage was provided by anastomosis of the graft Taipei, Taiwan duodenum to a roux-en-y jejunum limb in an side-to-side fashion. Immunosuppressants included basiliximab, tacrolimus, mycophe- Objectives: Type 1 diabetes eventually leads to nephropathy, neu- nolate mofetil, and methylprednisolone. ropathy, retinopathy and angiopathy after 10 – 30 years. Currently, Results: The mean operative time was 7 hours with mean cold pancreas transplant is the treatment of choice in tight control of ischemic time of 6 hours and mean warm ischemic time of 47 min. blood sugar for IDDM patients, and further to stabilize, prevent or The mean hospital stay was 20 days, with a serum creatinine level even to reverse the diabetic complications. We will present our of 1.4 ng/ml and a blood glucose level of 121 mg/dL. There was no experience in pancreas transplant which was initiated on rejection episode or postoperative complication after the en bloc September 19, 2003. SPK transplant. Methods: From September 2003 to October. 2016, there were 133 Conclusion: En bloc pancreas and kidney composite graft might be pancreas transplants performed for 128 patients at Taipei Veterans an option for patients with limited vascular access. This technique General Hospital, with 36 SPK, 16 PAK, 62 PTA, 19 PBK and 1 PAL (1) facilitates “real” simultaneous pancreas and kidney (SPK) trans- (pancreas after liver transplant). plant with only single common artery and vein for implanting the Results: Most (78.5%) of our pancreas transplants were for IDDM composite graft; (2) minimizes dissection of vessels and conserves patients. The blood sugar usually returned to normal level within 5 recipient vessels. hours (median) after revascularization of the pancreas grafts. The fasting blood sugar maintained within normal range thereafter throughout the whole clinical course in most cases. There were 2 P-155 surgical mortality. The technical success rate was 96.5%. Excluding the 4 cases with technique failure, overall 1-year pancreas graft PANCREAS REJECTION WITH GRAFT NECROSIS PRESENTING survival is 98.5% and 5-year is 94.1%, with 100% 1-year for SPK, WITH EPISODIC MASSIVE INTESTINAL BLEEDING 97.1% 1-year for PTA, 100% 1-year for PAK and 100% 1-year for Y.M. Shyr, S.E. Wang. PBK. Division of General Surgery, Department of Surgery, Conclusion: Pancreas transplant provided an ideal insulin-free Taipei Veterans General Hospital, National Yang Ming University solution for DM, especially IDDM. Pancreas transplant could be Taipei, Taiwan performed with similar successful rate irrespective of the type of pancreas transplant at our hospital. Purpose: This study is to present our unusual experience of episodic massive intestinal bleeding due to pancreas rejection with graft necrosis. P-157 Materials and Methods: A case of NIDDM with uremia underwent simultaneous pancreas and kidney transplant in 2005. With 3 times A JEJUNAL DIVERTICULA CAUSING A LIFE - THREATENING BLEEDING: of acute rejection on the kidney and pancreas grafts, he eventually A CASE REPORT went back to hemodialysis 7 years later. Results: The pancreas graft failed due to acute rejection on the Abdelmoniem M., M. Makkawi, Mohamed Eltoum, Hamid Azoz. pancreas graft 9 years after SPK transplant. Therefore, all immuno- suppressants were discontinused. Unfortunately, the pancreas Introduction: Jejunal diverticulum is a rare and usually asympto- graft became necrotic, and thereafter, intermittent gastrointestinal matic. More commonly it is usually seen as incidental findings on (GI) bleeding occurred. The angiography detected bleeding from CT images or during surgery. Complications such as bleeding, arterial Y-graft, and the extravasated blood flew through the graft perforation, obstruction, malabsorption, blind loop syndrome, duodenojeunostomy anastomosis into the bowels and presented volvolus and intussusception may warrant surgical intervention. with GI bleeding. The bleeder was controlled by coil embolization. Objectives: The aim of this study was to draw the attention to Hemorrhagic shock due to massive re-bleeding happened 1.5 jejunal diverticula and their complications. months after coil embolization. The emergent angiography showed Case report: We reported a 62 year- old woman presented to the coil migration into the necrotic pancreas graft and active re- emergency department with recurrent rectal bleeding, lower bleeding again from the same arterial Y-graft. The bleeder was abdominal pain and weight loss for the last 8 months, she was pale, temporarily controlled by a covered-stent in recipient common iliac clammy and hypotensive with a systolic blood pressure of 70 artery, and emergency explant of the failed and necrotic pancreas mmHg, she was initially resuscitated with IV fluids and whole graft was performed and the arterial Y-graft was ligated securely to blood, then she proceeded to colonscopy which showed sigmoid prevent re-bleeding. tumour, biopsies taken revealed adenocarcinoma of the Conclusion: Bleeding from arterial Y-graft could occur after rejec- colon.After staging of the tumour, the decision was then made to tion and necrosis of pancreas graft due to sudden withdrawal of proceed to exploratory laparotomy with pre- operative plan of immunosuppressants, which might present with intermittent segmental colectomy.Intra- operatively we perform segmental

262 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

sigmoid colectomy with end to end anastomosis, but on formal Results: Our study included 2 children aged of 1 and 2 years old, laparotomy we found 2 gaint diverticula in the proximal jejenum, who were victims of accidental ingestion of soda (strong base). The small bowel resection and end to end anastomosis was done with initial examination had shown pharyngeal bucco burns with a good post- operative outcome. stable respiratory and haemodynamic state. The initial behavior for Conclusion: Jejunal diverticula is more common than reported, both children, was to put the digestive tract at rest, electrolyte affect usually older patients and must be consider in differential hydrolytic delivery and corticosteroid therapy. Endoscopic explo- diagnosis of recurrent hematochezia, a high degree of suspicion is ration was performed within 24 hours after ingestion. It showed a necessary in view of the high mortality and morbidity rates resulting caustic esophagitis grade IIIA with stage IIIB caustic gastritis. Oral from a delayed diagnosis of the disease. The treatment of choice is feeding was started after 21 days with total digestive intolerance surgical excision of the affected segment. (vomiting). The TOGD carried out at 2 months of ingestion showed a filiform passage of the constrast product in the pylorus in relation to pyloric caustic stenosis. Surgery was indicated and consisted in a P-158 pylorplasty with a feeding jejunostomy. The surgical follow-up was INTUSSUSCEPTION IN ADULTS: THE CAUSES WERE NOT MALIGNANT. marked by good dietary tolerance with good weight gain. Conclusion: Caustic pyloric stenosis is rarely observed. Unlike M.E. Azoz adults, where partial gastrectomy is often indicated, conservative Faculty of medicine and health sciences, Emam Elmahadi treatment in children consisting in pyloroplasty may offer better University-kosti, PO box 209, (Sudan). results. Objective: To evaluate 8 adults with intussusception and to clarify the underline cause, the pattern of presentation and management P-160 of this uncommon entity. Methods: A retrospective review of patients who their ages more CHRONIC GASTRIC LEAKS AFTER SLEEVE GASTRECTOMY: than 18 years with a diagnosis of intestinal intussusceptions in Kosti RISK FACTORS OF RADICAL SURGICAL TREATMENT. Teaching Hospital (Sudan) between 2005 and 2013. Patients with N. Wallach1,2, A. Pasquer1,2, E. Pelascini1, G. Poncet1,2, rectal prolapse, prolapse of or around an ostomy and gastro- E. Disse2,3, M. Robert1,2 enterostomy intussusception were excluded. All the cases presented 1Department of Digestive Surgery, Specialized and Integrated acutely in A&E department and managed surgically in form of Center for Obesity Management, Hospices Civils de Lyon, resection and anastamosis. Hôpital Edouard Herriot, 5, place d’Arsonval, 69437 Lyon, Results: There were 8 cases of adult intussusception. The age was France ranged from 22 to 55 years. There were 4 males and 4 females. 2Université Claude Bernard Lyon 1, Lyon, France Seven patients (87.5%) presented with features of mechanical 3Department of Endocrinology, Diabetes and Nutrition, intestinal obstruction and one (12.5%) patient presented with pain Specialized and Integrated Center for Obesity Management, and tenderness in right iliac fossa as a case of acute appendicitis. Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, 165, All the intussusceptions were in the small intestine. Seven (87.5%) chemin du Grand Revoyet, 69495 Pierre Bénite, France patients had ileocecal intussusceptions and one (12.5%) patient had jejunojejunal intussusceptions. The pathological cause of Introduction: 2% of the sleeve gastrectomy (SG) lead to gastric leak intussusception was identified in 7 (87.5%) cases as fallow sub- (GL). Surgical treatment (total gastrectomy) is the treatment of mucosal lipoma in one patient, submucoal heamangioma in one chronic GL. The aim of this study is to determine the risk factors patient, leiomyoma in one patient, bilharzioma in one patient, (RF) of chronic GL. inflammatory polyp in one patient and two patients had abdominal Material and methods: This retrospective monocentric study tuberculosis. One pregnant woman had no pathology in resected compares the patients of our service specialized in bariatric surgery, segment. There was no mortality in this series. who had a GL after SG. We realized 264 SG between december 2008 Conclusion: Intussusception in adults is a rare entity and diagnosis and december 2016, and 4 patients had a GL. 18 patients with a GL may be challenging because of nonspecific symptoms. Surgeons went from other hospitals, 22 patients were included in the study. should be familiar with the various treatment options, because the We compared the datas of 10 patients who had a gastrectomy and real cause of the intussusception often is accurately diagnosed by 12 patients who have not been operated. laparotomy. Treatment usually requires resection of the involved Results: The RF of chronic GL are a gastro-cutaneous fistula, an bowel segment. intra-peritoneal abscess and a large fistule (more than 1cm) (respectively 16 % vs 80%, p = 0.003, 25% vs 70%, p = 0.035, 25% vs 70%, p = 0.035). A previous gastric surgery (16% vs 60%, p = P-159 0.074), aged patients (average of 39.6 years vs 48 years p = 0.073), ISOLATED PYLORIC STENOSIS CAUSED BY CAUSTIC INGESTION. high BMI (45.5 vs 50.7kg/m², p = 0.213) and denutrition (prealbu- 2 CASE REPORTS mine rate 0.21 vs 0.16g/L, p = 0.076) seems to be RF of total gastrectomy. Chibani I., Jouini R., Ben Ahmed Y., Charieg A., Nouira F, Jlidi S. Conclusion: The RF of chronic GL are gastro-cutaneous fistula, Department Of Pediatric Surgery B, Children Hospital intra-peritoneal abscess and large fistula. Others studies are 2000 Tunis, Tunisia. required to have better knowledges about the RF of chronic GL and the necessity to execute a gastrectomy for GL after SG. Objective: To emphasize the importance of conservative treat- Keywords: gastric leak, sleeve gastrectomy, chronic. ment in caustic pyloric stenosis in children. Methods: It is a retrospective study concerning 2 children operated in our department for caustic pyloric stenosis.

Surgery, Gastroenterology and Oncology, 22 (3), 2017 263 ABSTRACTS

P-161 with pN0/1, the 5-year survival rate surpassed 85% for patients with pT1N2/3 gastric cancer and the efficacy of adjuvant CONVERSION OF SLEEVE GASTRECTOMY TO ROUX-EN-Y chemotherapy was unclear. Our study confirms that careful obser- GASTRIC BYPASS FOR LACK OF WEIGHT LOSS vation without adjuvant chemotherapy is a better treatment option for patients with pT1N2/3 gastric cancer. A. Simerabet, B. Ghavami, M. Boubekeur 1Service de Chirurgie Générale EHU 1er novembre 1954 - Oran Algérie. P-163 2Service de chirurgie clinique de la Source - Lausanne, Suisse. Obesity has become the most common nutritional problem in COMPARATIVE RESULTS OF MULTIMODAL THERAPY AND SURGICAL industrialized countries. The economic cost of obesity and its TREATMENT OF ESOPHAGEAL CANCER IN KAZAKHSTAN consequences is 2-5% of health spending in rich countries. The D. Dauletbayev, E. Abzalbek, E. Izhanov, M. Akhetov. sleeve is the most practiced operation in the world and especially Almaty Oncological Center, Almaty, A15T6C8, Kazakhstan in an emerging country such as Algeria or the follow-up and multi- Kazakh Research Institute of Oncology and Radiology, Almaty, disciplinary concertation remains difficult. A05A2B4, Kazakhstan The aim of this observation is to report a complication of the sleeve requiring a surgical recovery (lack of weight loss, regain of weight, Objectives: The aggressive course of esophageal cancer, the early disabling gastro-esophageal reflux) discuss the follow-up after this dissemination and metastases forces to search the new approaches surgery, and the conduct to be held with regard to this complica- of the treatment of tumors. Since 2006, Kazakh Research Institute tion. As with any restrictive surgery, the medium and long term of Oncology and Radiology is developing multimodal therapy results depend on several factors. Weight recoveries are more (MMT) for patients with esophageal cancer, which includes neo- related to ingestion of caloric food, lack of physical activity. adjuvant chemoradiotherapy, following esophageal resection. Therefore if there is a lack of collaboration of the patient or an Methods: Current investigation includes 130 patients with histo- inability for him to compel himself to radical changes, as long as it logically proved locally advanced esophageal cancer. The treatment accepts a new operative risk and metabolic follow-up with the daily group includes 65 who underwent MMT combined with surgery; intake of vitamin supplements and micro-elements, an additional the control group – 65 patients operated without preliminary malabsorptif gesture may be proposed. MMT. There were 89 men (68.5%) and 41 women (31.5%); age of patients ranged from 33 to 72. In the treatment group, before operation patients received 3 course chemotherapy: Docetaxel 75 P-162 mg/sqm, Cisplatin 75 mg/sqm (Days 1, 21, 42) and course of radio- therapy with single focal dose 2 Gy and total focal dose 50 Gy (Days ANALYSIS OF PATIENTS WITH PT1N2/3 GASTRIC CANCER: 42-77). Before every course patients estimated for efficiency of PROGNOSTIC FACTORS AND ELIGIBILITY FOR ADJUVANT treatment and side effects. As the final step, patients underwent CHEMOTHERAPY for Ivor-Lewis esophagectomy (Day 98). Patients in control – Ivor- Luis esophagectomy only. Y. Kageyama, T. Yamada, S. Arai, Y. Mori, K. Ehara, Y. Results: From treatment group, efficiency of pre-operative therapy Kawashima, H. Sakamoto. amounted to 56.9%. 14 patients (21.5%) presented with full tumor Department of Gastroenterological Surgery, Saitama Cancer Center, resorption. 23 patients (35.4%) had partial regression of tumor, and Saitama, 362-0806, Japan another 2 patients (3.0%) had tumor progression and were Objectives: Previous reports have shown that the prognosis for excluded from treatment protocol. 62 patients were operated after pT1N2/3 gastric cancer is poorer than that for other early gastric MMT. Post-operative complications observed in 37 cases (59.6%) cancers. The purpose of this study was to clarify the prognosis and of treatment group and in 38 cases of control group. 4 cases of eligibility for adjuvant chemotherapy in patients with pT1N2/3 in-hospital mortality: 2 patients from treatment group, 2 patients gastric cancer. from control group. Five-year survival in treatment group – 32.7%; Methods: A total of 1232 patients with pT1 gastric cancer who in control group – 18.9%. Five-year recurrence-free survival – underwent gastrectomy without preoperative chemotherapy and 28.8% and 17.0%, respectively. hospital mortality at Saitama Cancer Center between 2002 and Conclusion: Multimodal therapy combined with esophageal resec- 2015 were included in the analysis. The 5-year survival and clinico- tion improves early and late results of treatment of locally pathological features associated with recurrence were retrospec- advanced esophageal cancer, comparing esophageal resection tively investigated. only. MMT gives no negative impact for post-operative complica- Results: Among 1232 patients, 1174 were classified as pN0/1 tions rate, but significantly improves the five-year survival and (95.3%) and 58 as pN2/3 (4.7%). For the patients classified as pN0/1 recurrence free-survival. and pN2/3, the 5-year overall survival rates were 91.3% and 88.0% (P = 0.55), the 5-year disease-specific survival rates were 98.3% and 89.2% (P < 0.05), and the 5-year relapse-free survival rates were P-164 89.5% and 84.9% (P = 0.52), respectively. Among the pN2/3 patients, 29 (50.0%) underwent adjuvant chemotherapy. Six EN BLOC GASTRECTOMY WITH SUBTOTAL COLECTOMY IN CASE patients with submucosal invasion experienced recurrence, and OF MULTIPLE PRIMARY GASTRIC, DUODENAL AND COLON CANCER none of them survived. On univariate and multivariate analyses, - A CASE REPORT age was the only significant prognostic factor and adjuvant P. Markov, L. Dryayeva. chemotherapy was not significant. Kuban State Medical University, Krasnodar, 350063, Russia Conclusions: In this study, although the prognosis for patients with pT1N2/3 gastric cancer was poorer than the prognosis for those Introduction: Patients with multiple primary cancer of three or

264 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

more sites are registered in 0,1% of all cancer cases, and 35% of included surgery, arterial chemoembolization or sunitinib these have a gastric cancer. The most common synchronous treatment. Case A patient had undergone two laparotomies for neoplasm associated with gastric cancer is colorectal cancer. We peritoneal dissemination before the launch of imatinib. He present the case of synchronous multiple primary cancer of maintained long-term complete response, however, his treatment stomach, proximal part of duodenum and multicentric colon adherence subsequently deteriorated, and he was diagnosed as cancer, localized in the cecum, descending colon and sigmoid. having peritoneal recurrence at 14 years after the start of the oral Case report: A 57-years-old male patient admitted to our institution therapy; this was treated by tumor excision. The patient currently complaining of pain in epigastrium, vomiting and rapid weight loss. remains recurrence-free with imatinib, while maintaining effective Using the method of esophagogastroduodenoscopy the presence of plasma drug concentrations. ulcero-infiltrative tumor of gastric body was verified and small tumor Discussion: 1) In our study population, initiation of appropriate (9 mm) in proximal part of duodenum, just 2 sm behind the pylorus adjuvant chemotherapy in patients at a high risk for recurrence was also found. By the transabdominal ultrasonography an infiltra- might have prolonged the post-recurrence survival. 2) Multi- tive lesion of colon was suspected and colonoscopy revealed three disciplinary treatment for recurrent lesions can contribute to tumors of colon: in cecum, descending colon and sigmoid colon. improvement of the prognosis. 3) Maintenance of long-term drug The biopsy presented a different type of adenocarcinomas in all adherence is important to prevent recurrence. specimens. By a multislice computed tomography of the thorax and the abdomen any malignant dissemination were excluded. An en bloc total gastrectomy with omentectomy, D2 lymphadenectomy P-166 and subtotal colectomy were performed. The proximal part of duodenum was also resected. Histopathological examination HEALING OF LARGE CHRONIC GASTRIC ULCERS THAT HAVE verified invasive, diffuse gastric adenocarcinoma, аdenocarcinoma A POOR REGENERATION IN CASE OF LOCAL INJECTION OF of the duodenum within the mucosa and multicentric invasive PLATELET-RICH PLASMA colon adenocarcinoma. The patient underwent systemic post- V.V. Petrushenko, I.V Radoha, D.I. Grebeniuk, V.S. Sobko, operative chemotherapy. Two years after the surgical procedure, Khrebtii Y.V. the patient is alive, with no signs of recurrence. Chair of Endoscopic and Cardiovascular Surgery, Vinnytsya Conclusions: In patients with gastric cancer additional diagnostics National Medical University n.a. Pirogov, Vinnytsya, 21018, is required to identifaed possible other tumors, especially gastro Ukraine intestinal tumors. Combined en bloc resection is adequate surgical procedure for synchronous multiple primary gastric and colonic Objectives: The aim of study was to estimate efficiency of local cancer. injection of platelet–rich plasma in patients with large chronic gastric ulcers that have a poor regeneration. Methods: The 19 patients with large chronic gastric ulcers that P-165 have a poor regeneration were included into study. In this cohort of patients there were 9 (47.4%) women and 10 (52.6%) men. An EVALUATION OF THE THERAPEUTIC EFFICACY OF IMATINIB IN average age of patients was 46.6±10.5 years. Inclusion criteria were PATIENTS WITH ADVANCED OR RECURRENT GASTROINTESTINAL age older than 18 years; diagnosis of large chronic gastric ulcers STROMAL TUMOR that have a poor regeneration (absence of positive changes after 12 weeks of anti–ulcer therapy), which was confirmed by Satoshi Suzuki, Kaoru Sakamoto, Yasuhiro Shirahata, Kenji Usui, endoscopy and histological review; absence of signs of malignancy; Yu Nagai and Eriko O-ta. size of ulcer – 2–3 sm; absence of clinically significant concomitant Department of Surgery, Tsuruoka Municipal Shonai Hospital, diseases. The 9 patients were included into main group (standard Tsuruoka City, Yamagata Prefecture, 997-8515 Japan anti–ulcer therapy and endoscopic injection of platelet–rich Objectives: The object of this study is to clarify the therapeutic plasma). The group of comparison consisted of 10 patients (stan- efficacy of imatinib and the importance of multidisciplinary dard anti–ulcer therapy only). On 1st, 7th and 14th day endoscopy treatment by evaluating prognosis of patients with advanced or with biopsy and measurement of the ulcers square was performed. recurrent gastrointestinal stromal tumor (A-R GIST). Results: The data we have received demonstrate a tendency of Subjects and methods: We performed a retrospective assessment decrease of ulcers’ square in main group as well as in group of of 10 patients with A-R GIST who had been treated with imatinib at comparison (p<0.01) with time flow. We also compared sizes of our hospital during the 10-year period. The primary GIST lesion was ulcerative defects in both groups at every point of the study. On the located in the small intestine in 7 patients, in the stomach in 3, and 1st day of investigation there were no differences (p>0.05) the site of recurrence was the liver in 5, peritoneal dissemination in between ulcers’ square in both groups. On the 7th day we found 4, and the intraabdominal lymph nodes in 1. out more rapid decrease of size in main group (p>0.05). However, Results: The mean interval from the first treatment to recurrence this tendency had no statistical significance. On the 14th day was 17.3 month. All the patients had c-kit-positive, and assessment difference was larger and it was statistically significant this time for recurrence revealed that all were at a high risk. Only 2 of the (p<0.01). patients received imatinib as adjuvant chemotherapy. The duration Conclusions: Unitary local endoscopic injection of platelet–rich of survival in the 10 patients ranged from 13 to 187 months (Case plasma on the background of anti–ulcer therapy permits to accel- A). The median progression-free survival and overall survival after erate a process of the ulcerative defects epithelization significantly recurrence were 39 and 53 months, respectively. After the (p<0.01) during 14 days. establishment of imatinib resistance, the treatment alternatives

Surgery, Gastroenterology and Oncology, 22 (3), 2017 265 ABSTRACTS

P-167 diagnosis. The induction of miR-187 or miR-187* was found to enrich the proliferation, migration and anchorage-independent LOW-DOSE ERIBULIN ACTS ANTITUMOR EFFECTS IN GASTRIC growth of GC cells. The repression of the expression of endogenous CANCER BY INHIBITING FIBROSIS VIA SUPPRESSION OF EMT miR-187 or miR-187* was able to reduce such oncogenic pheno- types. BARX2 is the target of miR-187. Knockdown of endogenous S. Fushida, T. Kurata, H. Saito, T. Yamaguchi, M. Okazaki, BARX2 increased the oncogenicity of GC cells. BARX2 overexpres- T. Tsukada, J. Kinoshita, K. Oyama, T. Ohta. sion was able to reduce such oncogenic phenotypes. In addition, Gastroenterological Surgery, Kanazawa University Graduate miR-187* enhanced the oncogenicity of GC cells through School of Medical Sciences, Kanazawa 920-8641, Japan suppressed WWOX. The expression levels of miR-187/BARX2 and Objectivs: Scirrhous gastric cancer and peritoneal carcinomatosis miR-187*/WWOX tended to be opposing in tumor tissue. (PC) has extensive fibrosis and invasive growth, results in chemo- Conclusions: Our results demonstrate that miR-187/miR-187* resistance. These potential are acquired by interaction with stromal suppressed BARX2/WWOX expression and enhance the oncogenicity cells including cancer-associated fibroblasts (CAFs) in cancer of gastric carcinoma cells. The levels of miR-187 and miR-187* in microenvironment. Eribulin is a non-taxane microtube dynamics plasma could act as invaluable markers for the detection of gastric inhibitor and has an ability of EMT inhibition. The aim of this study carcinoma. is to investigate eribulin effects for tumor progression and fibrosis in gastric cancer (GC). Method: MKN45 was used as GC cell line and human peritoneal P-169 mesothelial cells (HPMCs) isolated from omentum as CAFs. Eribulin and 5-FU were applied as antitumor agents. In vitro, growth inhibi- NEGATIVE IMPACT OF SKELETAL MUSCLE WASTING AFTER tion assay, invasion assay, western blotting, immunofluorescence NEOADJUVANT CHEMOTHERAPY FOLLOWED BY SURGERY ON have been performed. In vivo, subcutaneous fibrotic tumor SURVIVAL IN PATIENTS WITH THORACIC ESOPHAGEAL CANCER xenografts co-inoculating MKN45 and HPMC were administered Y. Tsubosa, S. Mayanagi, M. Niihara, K. Omae. low-dose eribulin alone or eribulin convined with 5-FU. Shizuoka Cancer Center Hospital, Shizuoka, 411-8777, Japan Results: Eribulin showed proliferative inhibition and IC50 was 5nM for MKN45 and 8nM for HPMCs. Low-dose (<0.1nM) eribulin Background: Skeletal muscle wasting during curative treatment is inhibited the EMT change by decreasing smad2 phosphorylation. an important issue faced by esophageal cancer patients. However, In vivo, eribulin reduced tumor fibrosis and showed synergistic it has not been clarified whether skeletal muscle change during antitumor effect with 5-FU. neoadjuvant chemotherapy followed by surgery adversely affects Conclusion: Low-dose eribulin should be promising treatment tool prognosis. for scirrhous GC and PC. Objective: This study aimed to determine the relation between skeletal muscle change and survival in patients with advanced esophageal cancer who underwent neoadjuvant chemotherapy P-168 followed by surgery. Methods: We retrospectively analyzed 66 patients with thoracic miR-187 PROMOTES CARCINOGENESIS AND SERVES esophageal cancer who underwent neoadjuvant chemotherapy AS A PLASMA MARKER FOR GASTRIC CARCINOM followed by esophagectomy. We herein investigated the correla- tion between the change in the total muscle in cross-sectional area P.S. Hung, K.W. Chang, C.S. Chou, C.Y. Chen, W.T. Chen, at the third lumbar vertebra before and 4 months after surgery, C.Y. Kuo, W.L. Fang, K.H. Huang, S.S. Lo. and the postoperative recurrence, and the overall survival. National Yang Ming University Hospital Results: Of the 66 patients, 39 (59%) showed a skeletal muscle Yilan City, 26042 Taiwan decreased from baseline to 4 months after esophagectomy. The Objectives: Gastric carcinogenesis (GC) is a multistep and change of skeletal muscle index from baseline to 4 months after multifactorial process. MicroRNAs (miRNAs) are small RNAs that surgery was -1.2 cm2/m2. The Multivariate analysis showed that negatively regulate their target genes expression and involved in squamous cell carcinoma subtype (HR 0.384; p = 0.032) and gastric carcinogenesis. We have demonstrated that miR-370 is skeletal muscle change (HR 1.16; p = 0.012) were found to be highly expressed in plasma of GC patients and promoted GC independent prognostic factors for overall survival. Additionally, progression (Oncogene, 2011). Our initial microarray u identified skeletal muscle change was found to be also an independent that miR-187 and miR-187* were up-regulated in GC tissues. The prognostic factor for recurrence-free survival (HR 1.11, p=0.042). roles of miR-187 and miR-187* in gastric tumorigenesis are Conclusions: Our findings suggest that skeletal muscle wasting studied. from baseline has a negative impact on cancer recurrence and Methods: Resected GC tumor tissue samples together with paired survival. non-cancerous mucosa sample from gastric patients were harvested at surgery. The plasma and urine samples were harvested P-170 before surgery. The expression of miR-187 and miR-187* and target genes were measured by quantitative RT-PCR or western blot. The OUTCOMES OF CONVERSION THERAPY FOR INITIALLY molecular functions of miR-187 and miR-187* were analyzed with UNRESECTABLE GASTRIC CANCER miRNAs mimic or blocker transfection. The Fisher’s exact test, t-test, two-way ANOVA, ROC analysis, and various bioinformatic modules S. Yoichi, M. Masayuki, S. Kensuke, M. Kohei, T. Sho, K. Yasuko, were used for the statistical analysis. S. Ryuta, U. Shinnosuke, T. Tazaki, K. Mohei, S. Masaru, I. Yuji, Results: miR-187 and miR-187* were up-regulated in tissue, the N. Atsushi plasma and urine samples of patients with the disease. The plasma JA Hiroshima General Hospital, Hatukaichi city, 7380042, Japan miR-187 and miR-187* levels were validated as biomarkers for GC Objectives: With the advances in chemotherapy for unresectable

266 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

gastric cancer, a number of conversion therapy have been success- Conclusion: Conversion surgery following the response of fully demonstrated in advanced gastric cancer. But, the indication chemotherapy was performed in some advanced gastric cancer of conversion, chemotherapy regimens and period, and timing of with liver metastasis. But even today, chemotherapy regimen, the operation are controversal. timing of conversion is controversal. We experienced advanced Patient and methods: Between April 2002 and July 2016, 133 gastric cancer with liver metastasis that became pathological CR by patients with initially unresectable gastric cancer introduced preoperative HER+XP chemotherapy. chemotherapy in our hospital. We divided four categories based on biology and heterogeneous characteristics from Dr Yoshida`s category classification, and examined treatment content and results. P-172 Results: 33 cases (24.8%) received conversion therapy after chemotherapy. Chemotherapy only group contained multiple non- SUBCLONING AND CHARACTERIZATION OF HIGHLY METASTATIC curative factor, especially multiple liver metastasis and peritoneal CELLS DERIVED FROM HUMAN ESOPHAGEAL SQUAMOUS CELL dissemination. Prognostic factors for these cases are presence of CARCINOMA KYSE150 CELLS BY IN VIVO SELECTION conversion therapy and Ro resection. Median survival time (MST) M. Okuda, J. Inoue, N. Fujiwara, T. Kawano, J. Inazawa. of the conversion group was significantly superior than that of Department of Gastrointestinal Surgery, Tokyo Medical chemotherapy group (34.6M vs 7.9M, P>0.001). and Dental University (TMDU), Tokyo, 113-8510, Japan. Then, we classified 133 cases into four categories (category1/2/3/4 :22/60/10/41). Conversion rate was 81.8%:11.7%:60%:4.9% in each Objectives: Esophageal cancer is the eighth most common cancer category, so many cases converted in category 1,3. R0 resection and the sixth most common cause of cancer-related deaths world- rate was higher in category1,2 (category1/2/3/4:88.9%/ 57.1%/ wide. Despite the research progress in understanding the disease, 33.3%/0%). MST in conversion group and chemotherapy group at the mechanism underlying the metastasis is still unclear. each category was 59.8M:11.1M in category1, 23.1M:9.6M in Methods: Here, we successfully generated a highly metastatic cell category 2, 14.1M:7.5M in category3 and 25.4:6.9M in category4. subline, designated as KYSE150-LuM, derived from an esophageal MST in conversion group at category1 was significantly superior squamous cell carcinoma cell line (KYSE150) by in vivo selection. To than chemotherapy group. The prognostic factors in category1 elucidate the mechanisms driving metastasis, we characterized the conversion group was under preoperative Stage II, R0 resection gene expression differences between LuM cells and parent and presence of post-ope M factor. KYSE150 cells. Conclusions: Conversion therapy is effective for some advanced Results: IL-6, IL-1b, and LCN2, previously associated with tumor gastric cancer, especially category1 cases with down staging by growth and metastasis, were up-regulated in LuM cells. Recent chemotherapy and R0 resection. As for category 2-4 in the present studies on cancer have increasingly focused on the tumor micro- treatment strategy, conversion dosen`t improve prognosis, so environment, from which these cytokines are released. further improvement for chemotherapy and combined modality Conclusions: The fact that these three cytokines (IL-6, IL-1b, LCN2) therapy is needed. were up-regulated in LuM cells indicates that these highly metasta- tic cells obtained through in vivo selection will be a useful resource for further studies on elucidating the mechanisms underlying the P-171 tumor microenvironment which is associated with cytokine-related tumor growth and metastasis. Moreover, LuM cells could dissemi- PATHOLOGICAL COMPLETE RESPONSE AFTER PREOPERATIVE nate to the lung in shorter period of time in vivo, indicating their HER+XP THERAPY FOR SYNCHRONOUS LIVER METASTASIS FROM utility for in vivo experiments of metastasis and new therapeutic ADVANCED GASTRIC CANCER targets in a shorter period of time than currently possible. M. Masayuki, S. Yoichi, S. Kensuke, M. Kohei, T. Shou, K. Yasuko, S. Ryuta, U. Shinnosuke, T. Tatsuya, K. Mohei, S. P-173 Masaru, I. Yuji, N. Atsushi. JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, SURGICAL OUTCOMES FOR ESOPHAGEAL CANCER WITH M1 LYM 738-8503, Japan AFTER ESOPHAGECTOMY Case: A 70-years-old man, who complained epigastric pain and S. Matono, T. Tanaka, N. Mori, H. Hino, K. Saisho, R. Nishida, visited nearby hospital. Gastroscopy revealed mass in the stomach, Y. Akagi. so he was introduced to our hospital. At gastroscopy, Type 3 tumor Surgery, Kurume University School of Medicine, Kurume, was present and biopsy showed moderately differentiated adeno- 830-0011, Japan. carcinoma. Computed tomography(CT) and Magnetic resonance imaging(MRI) showed solitary liver metastasis in S7, so we Objectives: The prognosis of patients with distant lymph nodes diagnosed with stageⅣ gastric cancer. HER2 was positive metastasis (M1 LYM) for esophageal cancer is generally poor. In (Immunohistochemistry:IHC score 3+), therefore we started those patients, the effectiveness of surgery remains controversial. HER+XP(trastuzumab, capacitabine and cisplatin) regimen as a The aim of this study was to estimate the role of esophagectomy of preoperative chemotherapy. After 4 courses, primary tumor patients with M1 LYM. decreased and liver metastasis was disappeared at CT and MRI. Patients: Thirty-seven patients (11%) were postoperatively Then we performed open distal gastrectomy with combined diagnosed as M1 LYM among 336 patients who underwent R0 resection of mesocolon and liver S7. Liver metastasis was white esophagectomy for thoracic esophageal squamous cell carcinoma degeneration, and mesocolon adhered strongly to stomach. at our institution, between 1995 and 2014. Histopathologically, there were no Histopathologically cancer cells Results: There were 36 males and 1 females, with a median age of at both stomach and liver. The histological effect was complete 62 years. Of these, 5 (14 %) had pT1 cancer, 10 (27%) had pT2 remission. After operation, he discharged postoperative day 10. cancer, 20 (54%) had pT3 cancer, and 2 (5%) had pT4 cancer. The

Surgery, Gastroenterology and Oncology, 22 (3), 2017 267 ABSTRACTS

type of M1 LYM classified the supraclavicular nodes alone (n=27), P-175 and other type (n=10). The 3- and 5-year overall survival rates were 51 % and 32 %, respectively. By univariate analysis, an improved THE CLINICAL OUTCOMES AND THE PATHOGENETIC survival was associated with pT status (pT1/2, P=0.0305), tumor BACKGROUND OF GASTRIC MALT LYMPHOMA IN SOUTH KOREA length (<7cm, P=0.0072), and the number of lymph nodes metas- tasis (LNM) (≤ 2, P=0.0017). Age, gender, tumor location, post- S.M Lee, D.Y Cheung, S.W. Ahn. operative treatment, histopathological grading, lymphovascular Department of Internal Medicine, the Catholic University of Korea invasion, the number of resected LNs, and the type of M1 LYM each College of Medicine, Seoul, South Korea. did not affect survival. By multivariate analysis, the number of LNM Objectives: Gastric MALT lymphoma is well known slowly (≤ 2 vs. 3≤, HR 0.350; 95% CI 0.108–0.942; P=0.0369) was only an progressing malignancy and has a pathogenic trigger, Helicobacter independent prognostic factor. The 5-year survival rate for those pylori infection, commonly with gastric adenocarcinoma. Literatures patients who had 2 or less LNM was 53%, compared with 19% for report about 6 times higher incidence of adenocarcinoma in gastric those who had 3 or more (P=0.0017). In M1 LYM patients except MALT lymphoma patients compared to that of general population. supraclavicular LN alone, the 5-year survival rates in patients who However, the development of gastric MALT lymphoma and adeno- received postoperative treatment was 29%, while the patients carcinoma seems to have different pathways. In this study, authors without postoperative treatment survived less than 2.1 years investigated the clinical course of gastric MALT lymphoma and the (P=0.0538). pathogenic background in the view point of Correa’s hypothesis. Conclusions: Esophagectomy may be effective in some patients Methods: Study was conducted by review of electronic medical with M1 LYM who had 2 or less LNM or received postoperative record of patients who were diagnosed with gastric MALT treatment. lymphoma at an academic institute, the Yeouido St. Mary's Hospital, Seoul, Korea, from January 2001 to May 2017. Clinical course was evaluated with analysis of demographic features, treat- P-174 ment modality and clinical outcomes. pathogenetic background was investigated in by Helicobacter pylori infection status, histology THE 8TH EDITION AJCC ON GASTRIC CANCER STAGING and serology. CLASSIFICATION WORKS IN A LOCALLY ADVANCED Results: A total of 46 subjects were enrolled and analyzed during DISEASE-PREVALENT COHORT the study period. The mean age was 57.19-year-old (range 36 ~ 85). The male to female ratio was 1.19 (25/21). Endoscopic appearances Ta-Sen Yeh, Shu-Fang Huang, Ti-Hsuan Chien, Wen-Liang Fang, varied; thirteen subjects presented ulcerative mass (28.26%), 12 Chun-Yi Tsai, Jun-Te Hsu, Chun-Nan Yeh, Tse-Ching Chen, (26.09%) as flat atrophic patch of discoloration, 16 (34.78%) erosive Ren-Chin Wu and Cheng-Tang Chiu. patches, 2 (4.35%) multiple polypoid lesion and 3 (6.52%) Department of Surgery, Chang Gung Memorial Hospital, subepithelial tumor like. Helicobacter pylori infection was proved Chang Gung Memorial University in 82.6 % (38 / 46). Atrophy and intestinal metaplasia were 5 Fu-Hsing Street, Kwei-Shan Taoyuan 33305, Taiwan accompanied in background mucosa in 28.26% (13/46). Serum Backgrounds: The recently released 8th edition of AJCC gastric pepsinogen I and II, as serological marker for atrophy, was cancer pathological staging system (AJCC8) was derived from the evaluated in 17 subjects. Only 9 of 17 (52.94%) showed compatible IGCA database, which has yet been validated, particularly in with gastric atrophy (pepsinogen I / II ratio of less than 3 or cohorts with higher proportion of advanced disease. pepsinogen I of less than 70). The lymphoma stage by Lugano stage Patients and Methods: A total of 5,386 gastric cancer patients was I1E (80.43%), I2E (2.17%), II1E (15.22%) and IIIE (2.17%). treated at Chang Gung Memorial Hospital (CGMH) and Veteran genetic alternation, t(11:18), was proved in 4 of 15 patients General Hospital in Taipei (TVGH) were enrolled. Clinicopathological (23.53%). The treatment of gastric MALT lymphoma varied. 32 data of the IGCA series and the CGMH/TVGH cohort were compared. patients were treated with Helicobacter eradication therapy. Four Cumulative survival curves of the CGMH/TVGH cohort as stratified by patients received chemotherapy with cyclophosphamide, the AJCC7 and the AJCC8 were compared. Lymph node ratio (LNR) adriamycin, vincristine, prednisolone (CHOP) regimen, five patients was analyzed in patients with N3b disease. received Radiotherapy and three patients underwent surgery. Results: Patients in the CGMH/TVGH cohort were older and had (Figure 1) Of the 46 patients with MALT lymphoma, except for two more advanced tumor stage (stage III, 49% versus 26%, p<0.001) who was referred to another hospital, 44 patients (100%) had than those in the IGCA cohort. The median survival of stages IIIA, IIIB, complete remission. The mean time to remission was 130.81 days, and IIIC as defined by the AJCC 8 were 49, 27 and 15 months, respec- and there was no difference in remission frequency according to tively, with narrower 95% confidence intervals, in comparison with each treatment method. Patients were followed up for 3.5~114.9 62, 30 and 18 months, respectively, as defined by the AJCC7. The months (mean 40.86 months) and there was no recurrence in AJCC8 exhibited better homogeneity and discriminatory ability, patients. compared to the AJCC7. Six hundred and four patients with N3b Conclusions: Gastric MALT lymphoma is well associated with heli- disease were stratified by LNR into three subgroups, and their cobacter pyloric infection and showed high prevalence of current median survival were 31, 17, and 11 months, respectively (p<0.001). infection (82.6%). However, the mucosal background of gastric LNR appeared as a powerful outcome predictor of N3b disease MALT lymphoma showed low prevalence of atrophy and intestinal (HR, 3.3). metaplasia, which in highly prevalent of and precedent to adeno- Conclusions: The AJCC8 performs well in patients with high propor- carcinoma. It suggests that the pathogenic pathway of gastric MALY tion of advanced gastric cancer. Additionally, we recommend that lymphoma and adenocarcinoma has different directions. The LNR is a useful supplementary prognostic indicator for N3b disease. treatment for gastric MALT lymphoma varies according to kind of clinical conditions, and the result could achieve clinical remission regardless of treatment modalities.

268 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

P-176 after standardization from 2010 to 2015. Standardization focused on: preoperative renutrition and respiratory physiotherapy; THE EFFECT OF ADDITIONAL LYMPH NODE DISSECTION ALONG thoracic epidural analgesia, a lung-protective ventilation and a THE SUPERIOR MESENTERIC VEIN TO D2 GASTRECTOMY FOR monitored and guided fluid management during esophagectomy; DISTAL GASTRIC CANCER an early extubation in intensive care unit (ICU) followed by non-invasive ventilation sessions. The primary outcome was Yutaka Tanizawa1, Etsuro Bando1, Taiichi Kawamura1, overall morbidity. Secondary outcomes were death, hospital and Tomoyuki Irino1, Rie Makuuchi1, Sanae kaji1, Hayato Omori1, ICU length of stay. A propensity score analysis was performed to Yusuke Kinugasa2, Katsuhiko Uesaka2, and Masanori Terashima1 take into account potential confounding factors. Division of Gastric Surgery1 and Digestive Surgery2, Shizuoka Results: 109 patients were included, 51 before standardization and Cancer Center, Shizuoka, 411-8777, Japan. 58 after, with no significant differences in baseline characteristics Background: The role of lymph node (LN) dissection along superior between the two groups. Anesthetic practices dramatically mesenteric vein (No. 14v) in advanced distal gastric cancer (ADGC) is changed between the two periods. Standardization of anesthetic the matter of debate even in Asian countries. care decreased overall morbidity in unadjusted analysis (OR 0.162, Aim: To clarify the efficacy of No.14v LN dissection (No.14vLND) 95% CI: 0.051-0.51, p < 0.001). The propensity adjusted odds ratio for ADGC. of overall morbidity was 0.261 (95% CI: 0.079-0.861, p = 0.03). We Methods: A total of 323 patients with ADGC underwent R0 also found a non-significant trend toward reduced mortality at day gastrectomy with D2+14vLND between Oct. 2002 and Oct. 2016 90 (from 5.9% to 1.7%), and decreased in ICU length of stay (from was included in this study. Clinicopathological data were analyzed 9.7 to 7.4 days), without effects on hospital length of stay (25 days). retrospectively. The risk factors of No.14v LN metastasis (LNM) of Conclusions: Our results suggest that standardization of anesthetic these patients were investigated by multivariate logistic regression care practices decreases postoperative overall morbidity after analysis, and the following indicators were enumerated: age, sex, esophagectomy with thoracotomy. This study should encourage macroscopic type, tumor size, tumor depth, duodenal invasion, anesthetic teams to homogenize their practices. This finding could cross-sectional location, histological type, and clinically suspected also be seen as a first step for enhanced recovery after esophageal infrapyloric (N0.6) LNM. We adopted the index of estimated surgery implementation. benefit from LN dissection (IEBLD) to compare the efficacy of No.14vLND with the other LNs along with the named vessels of the P-178 celiac axis (No.7, 8a, 9, 11p, and 12a). This index is calculated by multiplying the frequency of LNM to each station by the 5-year COMPARISON ANALYSIS OF THREE DIFFERENT TYPES OF survival rate of patients with positiveLNs at each LN station. MINIMALLY INVASIVE PROCEDURES FOR GASTROINTESTINAL Results: The incidence of No.14vLNM was 6.5 % and the 5-year STROMAL TUMORS survival rate of patients with No.14v LNM was 33.8%. Multivariate analysis revealed that age (<69 years; p=0.016) and cN in No.6 LN Xiaonan, Yin. Bo, Zhang. (cN+; p=0.026) were independent risk factors of No.14v LNMs. The Department of Gastrointestinal Surgery, West China Hospital, IEBLD for each LN stations was as follows: No.7: 4.3, No.8a: 7.2, No.9: Sichuan University, Chendu 610041, Sichuan Province, China. 2.4, No.11p: 1.5, No.12a:0.8, No.14v: 2.2. Only of patients with cN+ Objectives: This study aimed to evaluate the safety, feasibility, and in No.6 LN, the IEBLD for each LN stations was as following: No.7: 7.8, prognosis of three different types of minimally invasive procedures No.8a: 6.3, No.9: 2.2, No.11p: 3.9, No.12a:1.4, No.14v: 5.9. for treating gastric gastrointestinal stromal tumors (GISTs). Conclusions: The IEBLD for No.14v LN was similar to that of Methods: The clinical data, perioperative conditions, and the No.11p or No.12a LN. Therefore, No.14vLND had an effect on follow-up results of patients who underwent laparoscopic resec- survival in patients with ADGC. Especially, for patients with cN+ in tion (LAP), laparoscopic and endoscopic cooperative surgery No.6 LN, No.14vLND should be considered. (LECS), or endoscopic submucosal dissection (ESD) for gastric GISTs were retrospectively collected and analyzed. P-177 Results: A total of 103 patients were enrolled in this study, and the numbers of cases who underwent LAP, LECS, and ESD were 40, 16, and 47, respectively. Compared with patients in the LAP group, ESOPHAGECTOMY WITH THORACOTOMY. IMPACT OF patients in the LECS or ESD group had a smaller tumor size (P<0.05, STANDARDIZATION OF ANESTHETIC CARE. PRACTICES <0.001) and a higher percentage of intragastric growth pattern ON PATIENT OUTCOMES (P<0.001, <0.001). Significant differences were found in operative H. Tete, Y. Bouffard, F. Subtil, M.C. Le Goff, A. Pasquer, C.E. Ber, time among the three groups (P<0.001). ESD group had the J. Crozon, T. Walter, G. Poncet, T. Rimmele. shortest operative time, followed by the LECS and LAP groups. Edouard Herriot Hospital, Lyon, 69008, France. Patients who underwent ESD had significantly lower intraoperative blood loss than those who underwent LAP (P<0.001) and LECS Objectives: Esophagectomy with thoracotomy is a high-risk proce- (P<0.01). No statistical difference was found in the postoperative dure with significant perioperative morbidity and mortality. Recent recovery and complications among the three groups, except for years have focused on improving management in perioperative patients who underwent ESD, who had shorter nasogastric tube anesthetic care with many practices having shown their benefit in retention compared with patients who underwent LAP resection the literature. The main objective of this study was to assess the (P<0.01). impact of a change in anesthetic practices on the overall morbidity Conclusions: Minimally invasive surgery for gastric GISTs is safe and of patients undergoing esophagectomy with thoracotomy. feasible. The final choice regarding a minimally invasive approach Methods: In this monocentric retrospective before-after clinical should be based on the tumor size, tumor location, pattern of study, we compared patient outcomes between a period before tumor growth, and experience of laparoscopic surgeons. standardization of anesthetic practices from 2003 to 2009, and

Surgery, Gastroenterology and Oncology, 22 (3), 2017 269 ABSTRACTS

P-179 laparoscopic approach and 67 for the classical technique. The intro- duction of the diet was started on day 1 for both groups. Concerning GASTRIC CANCER – FEASIBILITY OF ENDOSCOPIC TREATMENT the use of analgesics during postoperative follow up, paracetamol AFTER DOWNSTAGE WITH PROTON-PUMP INHIBITORS: REPORT was used during 2 days for the patients operated by laparoscopy OF A CASE and 1 day for the other group. Morphine was not administered to L.C.P.F. Michel, C.F. Reis, R.R. Imada, B.A. Messias, V.C. Marcos, any patient. There was no significant difference in the duration L.M. Silveira, D. Pessotti Junior, J.F.A. da Silva, M.B.S. Corradi. of hospitalization for both groups. All patients were discharged Hospital Samaritano de São Paulo, São Paulo, Brazil. on day 2. Conclusion: Despite the size of our sample, our results lead us to The objective is to describe a case of gastric adenocarcinoma out- wonder if the laparoscopic approach is currently an alternative in side the Japanese guideline indication for endoscopic treatment, the treatment of hypertrophic pyloric stenosis of. Indeed, the which was downgraded with the use of proton-pump inhibitors classical technique has excellent results. A larger sample and better (PPI) enabling the performance of endoscopic submucosal experience would allow us to better evaluate. dissection (ESD) and also to describe the favorable evolution with conservative treatment for one of the possible complications of ESD - perforation. P-181 We report the case of a 63-year-old oriental patient, asymptomatic, submitted to esophagogastro-duodenoscopy (EGD) due to family MINIMALLY INVASIVE SURGERY OF ESOPHAGEAL CANCER IN history of gastric cancer. The first EGD showed a 25mm ulcerated KAZAKHSTAN irregular lesion, macroscopically classified Borrmann II, in the D. Dauletbayev, E. Abzalbek, E. Kenespayev, D. Toksanbayev. posterior wall of stomach's grater curvature associated with Almaty Oncological Center, Almaty, A15T6C8, Kazakhstan. atrophic gastritis. The biopsy revealed well-differentiated tubular adenocarcinoma, limited to intramucosa. Echo-endoscopy Objectives: The complicated post-operative course of patients with confirmed the partially ulcerated lesion confined to mucosa, esophageal cancer forces surgeons to create minimally invasive without lymphnodes methastasis. The patient underwent a 15-day approaches of esophageal resection. therapy with PPI, with downstaging of the lesion to IIC according to Methods: We have provided minimally invasive esophagectomies the classification of the Japanese Society of Endoscopy, which for 63 patients with histologically proved esophageal cancer, in the made the lesion elegible for ESD, considering the expanded age between 35 and 68. 19 operations were full mini-invasive, 44 – criterias for endoscopic resections. The patient had a gastric perfo- hybrid (combined mini-invasive and open surgery). Full mini- ration during ESD which was treated with endoscopic closure using invasive esophagectomies were presented as McKeown triple- endoclips. He remained hospitalized in Intensive Care Unit (ICU) for approach (right-side thoracoscopy + laparoscopy + cervicotomy, N 2 days and was discharged on the 6th post-operative day. The = 11); Ivor-Lewis (right-side thoracoscopy + laparoscopy, N = 5); anatomopathological exam of the surgical specimen revealed transhiatal (laparoscopy + cervicotomy, N = 3). Hybrid procedures gastric adenocarcinoma with free vertical and lateral margins, and were presented by Ivor-Lewis operations (right-side thoracotomy + no evidence of vascular or neural invasion. EGD surveillance 03 laparoscopy). months after the procedure showed no recurrence of the cancer. Results: With improvement of techniques, the duration of operation Minimally invasive treatment is a tendency for early gastric neopla- decreased from 580 to 310 minutes for full mini-invasive esophagec- sia. With promising success, we observe the possibility of downstag- tomy, and from 370 to 230 minutes – for hybrid operation. Blood loss ing some lesions through the use of PPI, showing the feasibility of was minor in all cases. All patients intraoperatively have received a endoscopic treatment and avoiding, thus, a more invasive method. jejunostomy catheter; using it, enteral feeding started in the day of We were also able to show the good results of a less invasive surgery. Physical activation started 1 or 2 days after surgery. treatment (endoclips) in the case of one of the most common Complications, somatic or surgical, observed in 41.2%. The most complications of ESD - perforation. significant was anastomotic failure in 3 cases (4.7%), one patient with anastomotic failure died in early post-operative period. Conclusion: Minimally invasive esophagectomy allows to provide P-180 surgery with minimal trauma and blood loss, due to best visualiza- tion of tissues. Also, minimally invasive esophagectomies allows to LAPAROSCOPIC MANAGEMENT OF HYPERTROPHIC PYLORIC decrease the intensity of pain and activate patients earlier. STENOSIS SHALL WE START WITH IT?

Chibani I., Ben Ahmed Y., Charieg A., Nouira F., Jouini R., Jlidi S. P-182 Department of Pediatric Surgery B, Children Hospital 2000 Tunis, Tunisia SINGLE/ REDUCED PORT LAPAROSCOPIC SURGERY FOR GASTRIC Objective: To evaluate the laparoscopic approach in the treatment GASTROINTESTINAL STROMAL TUMORS of hypertrophic stenosis in terms of postoperative follow-up S.Y. Pow, J.H. Tang, K.T. Lim, A. Cheng, C.H. Tan. compared to the classical approach. Khoo Teck Puat Hospital, Singapore, 768828, Singapore. Methods: This is a retrospective study of a series of 14 patients operated in our department for hypertrophic pyloric stenosis Objective: Gastrointestinal stromal tumors (GISTs) are rare tumors during 2016. of the gastrointestinal tract that arise from primitive mesenchymal Results: Over a period of 1 year, 14 patients were operated for cells and are commonly located in the stomach and small intestine. hypertrophic pyloric stenosis. We opted for a laparoscopic approach Surgical resection remains the mainstay of treatment as in 4 of them. The mean age was 45 days. The average duration of chemotherapy and radiotherapy are rarely effective. Single/ surgery was almost similar for the 2 groups: 75 minutes for the reduced port laparoscopic approaches reduce invasiveness and

270 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

improve post-operative recovery and cosmesis. Here, we report risk stratification criteria, could better forecast the prognosis of our institution’s experience with two cases where such an GISTs. approach was undertaken. Methods: The first patient presented with a lesser curve high posterior body GIST for which she underwent a single port laparos- P-184 copic transgastric wedge resection. The second patient presented with a fundus GIST for which she underwent a reduced three-port ACUTE OESOPHAGEAL VARICES BLEEDING IN SUDANESE PATIENTS laparoscopic wedge resection. Operative duration for both proce- – A STUDY OF 1047 PATIENTS IN A SINGLE SPECIALIZED CENTRE dures were reasonable and microscopic margins were negative on Nessrein El Hassan Nimir, Nassir Alhaboob Arabi*, Abdulmagid final histological examination of the resected specimens. Mohammed Musaad, Elsaggad Eltayeb Ahmed, and Muataz Salah Results: Post-operative recovery was unremarkable for both Eldin Abdelaziz, Sawsan Abulgasem. patients. There were no immediate complications and they were Department of GI Surgery, Ibn Sina hospital, Khartoum, Sudan. both discharged well on post-operative day three. Conclusions: Transgastric approach is ideal for endophytic tumors Background: Acute oesophageal variceal bleeding is life especially those located at the posterior wall or near the cardio- threatening and management challenge. The aim of this study is to esophageal junction (CEJ). It allows for minimal gastric resection determine the management and outcome of acute oesophageal along with the tumor hence resulting in less risk of strictures. variceal bleeding in Sudanese patients. Single/ reduced port laparoscopic wedge resection of gastric GISTs Methods: Cross sectional hospital based study done on Ibn Sina can be performed safely especially when tumours are located at specialized Hospital, a specialized centre that received 2300 to the gastric fundus or along the greater curve. However, the 2600 patients per year of those with GI bleeding, data collected superiority of this approach is not definitive compared with the and analysed using SPSS. conventional laparoscopic approach with limited studies published Results: The incidence was 61.3%. Male to female ratio was 3:1 and in current literature on long term outcome and patient satisfaction. the mean age was 65.07 years, about 56.6% of the patients had Prospective randomized studies comparing both methods are both hematemesis and melena, and 4.4% of patients presented necessary to confirm the benefits of this new approach. Whether with melena only. Half of the patient had low Hb%. Oesophageal conventional or reduced port approach is undertaken, surgical varices were grade four and three in more than 90%, most of them principles of gastric GIST resection should never be compromised. had active bleeding, and 22% had fundal varix. Sclerotherapy was used in the majority of patients to stop bleeding (more than 10 ml), band ligation in 10.1%, both sclerotherapy and band ligation in P-183 1.8%, and Cyanoacrylate (histoacryl) for those with fundal varix. Sengestaken tube was applied in 9.4%. HTN found in 9.8%, DM in A META-ANALYSIS OF PROGNOSTIC VALUE OF KIT/PDGFRA 11.2%, renal impairment in 3.2%, heart disease in 2.2%, liver failure MUTATIONS IN GASTROINTESTINAL STROMAL TUMORS in 17.7%, and cancers in 1.8% and it associated with increased mortality. History of Bilharzias’ infection found in 45%, and history Xiaonan Yin., Bo Zhang. of previous hematemesis found in 47.4%. There was 9.4% smokers, Department of Gastrointestinal Surgery, West China Hospital, 7.9% alcoholic, and 9.7% snuffers. There was 9.6% of the patients Sichuan University, Chendu 610041, Sichuan Province, China. used aspirin and 1.1% was on warfarin, and 84.3% of the patients Objectives: Gain-of-function mutations of tyrosine kinase receptor were discharged home, and those with co-morbid disease had a KIT or platelet-derived grow factor alpha (PDGFRA) have been high mortality. Rockall score was less than 2 in 49.7%. There is confirmed as a critical factor in the pathogenesis of gastrointestinal statistical correlation between hematemesis and aspirin usage, stromal tumors (GISTs). However, the prognostic role of mutation terlipressin usage, liver disease, rocall score and outcome P value < status in GISTs is still controversial. 0.05. Methods: We identified all relevant studies by searching PubMed, Conclusion: Sclerotherapy and band ligation with terlipressin Medline and Embase. Eligible studies were included in our study. A injection were important in cessation of bleeding. cumulative meta-analysis was performed using review manager Key Words: UGIB, Oesophageal varix, Portal hypertension. 5.3. Odds ratio (OR) and 95% CI were calculated by using a fixed or random effect model. Results: A total of 30 eligible articles involving 7883 patients were P-185 identified and analyzed. GIST patients with KIT mutation had a significantly poorer progression-free survival (PFS) compared to AVAILABILITY AND SAFETY OF FEEDING DUODENOSTOMY those with PDGFRA mutation or lacking KIT or PDGFRA mutation. S. Takeda, N. Iwata, M. Koike, H. Oya, M. Kanda, D. Kobayashi, Overall survival (OS) was significantly better in patients with KIT C. Tanaka, M. Fujiwara and Y. Kodera. exon 11 mutations than in those with KIT mutation in other exons. Department of Gastroenterological Surgery (Surgery II), Compared to patients bearing other mutations of KIT exon 11, PFS Nagoya University Graduate School of Medicine, Nagoya, was significantly worse in those bearing KIT exon 11 deletions, 466-8550, Japan. particularly KIT codon 557-558 deletions. In advanced subgroup analyses, a better survival outcome was detected in mutant GISTs, Background: The impact of nutritional support on the outcome of especially KIT exon 11-mutant GISTs after receiving imatinib gastroenterological surgery is well known and, in highly invasive therapy. That showed that KIT exon 11 mutations had a better surgery such as esophageal cancer surgery, management by enteral response to imatinib treatment. nutrition effectively mitigates postoperative complications. However, Conclusions: Our meta-analysis indicates that KIT or PDGFRA feeding via jejunostomy could cause several complications including mutations have a predictive value on the survival outcomes of ileus, which leads to relaparotomy and could be potentially life- GISTs. The gene mutation status, combined with currently available threatening. To reduce these complications, we began to place the

Surgery, Gastroenterology and Oncology, 22 (3), 2017 271 ABSTRACTS

enteral feeding catheter via duodenostomy in 2009. P-187 Objective: The aim of this presentation is to report the operative procedure and our experience of feeding duodenostomy. DUODENAL RESECTION FOR RETROPERITONEAL SARCOMA AND Method: Two hundred and twenty one patients with esophageal GIST: SHORT-TERM OUTCOMES cancer who underwent radical esophagectomy with retrosternal or F.C.M. Cananzi, L. Samà, A. Marzorati, L. Conti, E.M. Minerva, posterior mediastinal gastric tube reconstruction at Department of A. Zuccarelli, L. Cozzaglio, V.L. Quagliuolo. Gastroenterological Surgery (Surgery II), Nagoya University Humanitas Clinical and Research Center, Rozzano, 20089 (MI), Hospital from January 2009 through December 2015 were Italy identified in the database. All of the patients underwent feeding via duodenostomy and their records were reviewed for the following Objectives: Surgery is the mainstay of retroperitoneal sarcomas catheter-related complications: site infection, dislodgement, (RPS) and gastrointestinal stromal tumours (GISTs) treatment. peritonitis, and mechanical obstruction. Duodenal resections are sometimes necessary to achieve radicality, Operative procedure: The plastic cannula needle in the introducer but surgical short-term outcomes are unclear due to lack of data and kit was passed from the pyloric ring to the duodenal bulb and the rarity of disease. The aim of this study was to review our experience feeding tube was placed. The round ligament of the liver and the in patients with RPS and GISTs involving the duodenum, and to surrounding adipose tissue was ligated just above the umbilical analyse the surgical approach and outcome. region and mobilized from abdominal wall which was punctured Methods: We identified all patients who underwent surgery with with the plastic cannula needle, through which the catheter was duodenal resection for RPS and GISTs, at our Institute between guided. The end of the adipose tissue was fixed to the puncture site 2000 and 2016. Medical records, operative reports, radiological at the duodenum so that the catheter could be guided from the charts and pathology were reviewed. Demographics, clinical, abdominal wall into the duodenum covered fully with adipose pathologic and treatment variables were analysed. tissue. Results: Thirty-one patients (19 males, 13 females) were treated: Results: Catheter site infection was seen in 2 cases, of which 1 16 for GISTs and 15 for RPS. The median age was 58 years. developed peritonitis after removal of the feeding tube. However, Preoperative treatment was given to 10 patients: chemotherapy neither of them required re-lapalotomy. No mechanical ileus was (6) or combined chemo-radiotherapy (4). Sixteen duodenal wedge observed. resections (WR) and 15 segmental resections (13 of which included Conclusion: Neither mechanical ileus nor relaparotomy was seen Treitz’s loop resection) were performed. Multi-organ resection was during enteral feeding via duodenostomy, hence, feeding duo- performed in 71% of cases. The median time to flatus and bowel denostomy seems to be critically safe and useful. movement was 3 and 5 days. Oral refeeding started after a median of 5 days. Median post-operative hospital stay was 11 days. The overall 30-day postoperative morbidity rate was 65%, while the P-186 duodenal-related complication rate was 28%. Morbidity rates were higher in segmental resections compared to WRs: delayed gastric CHARACTERISTICS AND PROGNOSIS OF EMERGENCY emptying/paralytic ileus 4/15 vs 1/16; duodenal leak 3/15 vs 0/16; GASTROINTESTINAL STROMAL TUMORS volvulus 1/15 vs 0/16. All 3 patients with duodenal leak had previ- ous abdominal surgery and 2 also chemotherapy. No correlations Xiaonan Yin., Bo Zhang. were found between complications and type of anastomosis or Department of Gastrointestinal Surgery, West China Hospital, duodenal portion resected. Sichuan University, Chendu 610041, Sichuan Province, China. Conclusions: Duodenal resections for RPS and GISTs have significant Objectives: The study aimed to investigate the clinical manifesta- rates of morbidity and should be performed in specialized centres. tion, management and prognosis of emergency gastrointestinal When possible, WR is preferred to segmental resection as it is stromal tumors (GISTs). associated with a lower morbidity rate. Methods: A retrospective analysis was conducted in 189 GISTs with acute clinical presentation. Recurrence-free survival (RFS) and overall survival (OS) were evaluated using the Kaplan-Meier curves P-188 and multivariate Cox-regression analysis. Results: Among the 189 cases of GIST, 150 cases demonstrated OESOPHAGEAL PERFORATION SECONDARY TO ACCIDENTAL clinical symptoms of acute gastrointestinal bleeding, 14 cases of SWALLOWING OF DENTAL PROSTHESIS acute intestinal obstruction, 13 cases of acute intraperitoneal R. Jain, A. Goel, S. Neogi, S. Ramasamy. bleeding, and 12 cases of rupture and peritonitis. The stomach Maulana Azad Medical College, New Delhi, 110002, India. was the dominating site with acute presentation, followed by duodenum. The R0 resection rate was 94.2%. The three- and five- Introduction: Foreign body impaction is 3rd most common in year RFS were 80.6% and 76.7%, respectively. And the three- and oesophagus after the nose and throat. Oesophageal foreign bodies five-year OS for the entire cohort were 92.5% and 88.8%, are seen in almost all age groups, but are most common in children respectively. In multivariate analysis, clinical presentation and in adults who are alcoholics, edentulous and psychiatric patients. (P=0.008), tumor size (P=0.007) and NIH risk classification Most of them can be easily removed by endoscopy. Symptoms (P=0.001) were independent prognostic factors for RFS. Clinical depend on the size and nature of the foreign body as well as the site presentation (P=0.008) and NIH risk classification (P=0.020) were and duration of impaction. Serious potential complications like independently associated with OS. perforation, necrosis, mediastinitis, and fistulation necessitate rapid Conclusions: Emergency GISTs are more likely to manifest as acute and accurate diagnosis and immediate management. gastrointestinal bleeding, and locate in the stomach. Emergency Case Report: A 40-year-old gentleman swallowed his denture patients with rupture and peritonitis, or high risk GISTs are accidentally, which subsequently became lodged in his oesophagus. independently associated with worse RFS and OS. An attempt was made to retrieve the denture endoscopically

272 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

but was unsuccessful as the hook was firmly adherent to the P-190 oesophagus. We performed thoracic oesophagotomy and success- fully extracted the foreign body. The patient showed an uneventful TRICHOBEZOAR IN CHILDREN. NOT ONLY A SURGICAL CASE! postoperative recovery and could be discharged on post-operative Chibani I., Ben Ahmed Y., Charieg A., Nouira F., Jouini R., Jlidi S. day nine. Department of Pediatric Surgery B, Children Hospital, 2000 Discussion: About 70% of denture impaction cases occur in the Tunis, Tunisia. oesophagus. Presentation of denture ingestion depends on the site of impaction and complications occurred, if any. Potential compli- Objective: The importance of multidisciplinary management in the cations of denture ingestion are bleeding, necrosis, perforation, treatment of trichobezoar in children. penetration to adjacent organs and obstruction. Initial investiga- Methods: Retrospective study held in our department, involving 3 tion of choice is chest x-ray, on which 80 % of the foreign bodies can patients treated for trichobezoar. be identified. The main body of dental prostheses is made of acrylic Results: Our study involved 3 girls, aged from7 to 15 years old. resin, poly-methyl-methacrylate and porcelain, which are all Trichotillomania was stated in 1 case. Symptoms were made of radiolucent, but it includes radiopaque metallic clips and hooks chronic abdominal pain in one patient and small bowel obstruction which enable visualisation. Three different modalities are available in 2 patients. Physical examination had found epigastric mass in one for the management of denture ingestion: observation, endoscopic case. Ultasonography as well as computed abdominal tomography retrieval and surgery. The gold standard for dentures impacted were performed for all patients. They showed a gastroduodenal in oesophagus without any complications is endoscopy; in compli- bezoar in one patient and a small intestine localisation in the other cated cases, surgery is unavoidable. 2 patients. Surgery was indicated in all cases. Bezoards were extracted by gastrostomy in one patient and enterotomy in the other 2 patients. All our patients were addressed to a pediatric P-189 psychiatrist. One of them refused to get a psychological follow-up. She had a recurrent trichobezoar complicated with peritonitis and SPLENIC PENETRATION OF PERFORATED GASTRIC ULCER AND was urgently reoperated on. She died as a result of septic shock. The CORRELATION WITH SPLEEN LYMPHOMA: A CASE REPORT. 2 others girls have evolved well and did not present a recurrence. Conclusion: The treatment of trichobezoar in children is often P.L. Mellucci Filho, F.L. Pereira, L.T. Siqueira, A.L.T. Santana surgical. It must be urgent to avoid septic complications. Moroever, Presidente Prudente Regional Hospital, Presidente Prudente, the management of trichotillomania must be complete and include 19050680, Brazil. a psychological follow-up, avoiding the risk of reccurence, which Background: Peptic ulcer disease affects over 4 million people may be in some cases fatal. every year. Gastric perforation is one of the most serious complica- tions, rarely resulting in confined perforations. Primary spleen lymphoma is another rare occurrence. The association between P-191 the two diseases has not yet been described. Methods: We present a case study of perforated a peptic ulcer ULTRASOUND-GUIDED INGUINAL INTRANODAL blocked by the spleen, fully described from radiology diagnosis by LYMPHANGIOGRAPHY WITHOUT DUCT EMBOLIZATION: tomography scanning to post surgery pathological study and bio- AN EFFECTIVE APPROACH markers expression. A. Paisant, V. Brun, N. Lombard, L. Beuzit, M. Rayar, B. Meunier. Results: A 55-year-old male patient was admitted for epigastric University Hospital of Rennes, France pain and haematemesis. Upper endoscopies revealed Bormann III City of Rennes, 35000 France ulcerated lesion in two occasions, two biopsies stated chronic gastric ulcer. Tomographies show large infiltrative gastric lesions Objectives: Chylothorax is a serious postoperative complication affecting the spleen, pancreas tail, diaphragm and left adrenal with a high risk of death. Further surgical investigation is difficult gland, with oral contrast penetration in the spleen. Gastrectomy and minimally invasive lymphography has been developed to treat with splenectomy and distal pancreatectomy was performed. leakage. The aim of this study was to evaluate the feasibility of Immunochemistry results point toward non Hodgkin diffuse lrge ultrasound-guided inguinal intranodal lymphangiography without B-Cell lymphoma. thoracic duct catheterization for treating chylothorax. Conclusions: Peptic ulcer complications present high mortality and Methods: Between July 2012 and January 2017, all patients with classic clinical presentations are oftenly identified by physicians. chylothorax unresponsive to medical treatment underwent the Even though most perforations are presented as classic acute percutaneous inguinal procedure. Efficacy was assessed after 3 abdomen (peritonitis), different complications must not be weeks. overlooked and differential diagnosis must be thought of. Confined Results: Five patients were analyzed. The procedure was technically perforations are uncommon, but expected complications that can successful in all patients (100%). Four out of 5 patients were cured be easily diagnosticated with complementary imaging such as (80 %). ultrasonography and tomography, meaning better prognosis if Conclusion: Ultrasound-guided intranodal lymphangiography with- detected early. out thoracic duct catheterization is an effective method for treating postoperative chylothorax.

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P-192 death rate were lower in pT2 patients than in T3 patients (P = 0.0191, P = 0.0105), with no difference between pT1b and pT2 LAPAROSCOPIC NISSEN FUNDOPLICATION: RESULTS patients (P = 0.7162, P = 0.8663). AND COMPLICATIONS Conclusions: Surgical outcomes of pT2 ESCC after R0 esophagectomy Piperos Th., Theodoulou Kak, Nikou Th., Zoulamoglou Men, were significantly better than those of pT3 cancer, and were Tsiaousis I., Papakonstantinou L., Troupis Th., Mariolis-Sapsakos Th. comparable to those of pT1b ESCC that is generally considered as superficial cancer. Aim: The aim of our study is the presentation and analysis of our results in hiatal hernia repair with laparoscopic fundoplication. Material-Method: Our study is retrospective and includes the P-194 period 2012-2016. Concerns 128 patients (75 females- 53 males) with hiatal hernia grade III. The age of patients ranged from 23-72 THE ASSOCIATION BETWEEN METHODS OF PREPARATION years with average 48 years. All patients were diagnosed with OF GASTRIC TUBE AND THE INCIDENCE OF MORBIDITIES gastroscopy and upper GI imaging with barium. The symptoms OF ESOPHAGOGASTROSTOMY. were difficulty of swallowing, epigastric pain, heart burn, cough. There were no findings of Barrett Esophagus. Y. Miyawaki, H. Sato, M. Chuman, K. Aratani, M. Kasuya, H. Results: All patients were undergone to laparoscopic Nissen fundo- Gunji, S. Sakuramot, K. Okamoto, S. Yamaguchi, I. Koyama. plication. The technique included 2 sutures for closure of hiatal Saitama Medical University International Medical Center, defect and 2 sutures for loose fundoplication. The dissection Saitama, 350-1298, Japan. included fully transaction of the hepatogastric ligament with Objectives: Gastric tube (GT) is superior in terms of elevation and identification of caudate lobe. The duration of operation was 90- handiness of the maneuver, so GT is most often selected as a 110 minutes. In one case we convert the operation at open reconstruction conduit. Although it is thought that some leakages because of bleeding. There were no major postoperative complica- of esophagogastric anastomosis induced by ischemic or congested tions. 13 patients had atelectasia with conservative management. peripheral blood flow in reconstruction coduit, the association Functional results were excellent. Repeat of endoscopy to 6 between inadequate blood flow in conduit and the incidence of months. postoperative morbidities such as anastomotic leak or stricture is Conclusions: Laparoscopic Nissen fundoplication is the surgery of not clear. The aim of this study was to evaluate the association choice for patients with severe hiatal hernia. It’s appropriate the between methods of preparation of GT and the incidence of exclusion other pathology of stomach, duodenum and esophagus. morbidities of esophagogastrostomy. It’s required surgical team with experience with standard tech- Patients and method: Between February 2013 and March 2017, nique (loose plication of fundus) to achieve excellent functional consecutive 138 patients who had undergone one-stage right results without complications. transthoracic esophagectomy with reconstruction using GT were enrolled into this study. All cases were performed by end to end P-193 hand-sewn anastomosis. The patients comprised 116 males and 22 females with a median age of 70 years. In 102 patients, a narrow GT SURGICAL OUTCOMES OF T2 ESOPHAGEAL SQUAMOUS CELL (Gr.N) was used for reconstruction between February 2012 and CARCINOMA: COMPARISON WITH T1B OR T3 CANCER March 2016. In 36 patients, a stretched GT (Gr.S) was used after April 2016. The anastomotic leak and stenosis were evaluated, T. Tanaka, S. Matono, N. Mori, H. Hino, R. Nishida, K. Saisho, Y. Akagi. retrospectively. Department of Surgery, Kurume University Results: The following results were obtained: anastomotic leak, 23 Kurume, 830-0011, Japan patients (16.7%): anastomotic stenosis, 35 patients (25.4%). Objectives: Although T2 esophageal squamous cell carcinoma Anastomotic leak occurred in 20 patients (19.6%) with Gr.N and, 3 (ESCC), which is considered as advanced cancer, is treated similarly patients (8.3%) with Gr.S (p < 0.01). Anastomotic stenosis occurred to T3 cancer, treatment outcomes of T2 ESCC has not been clearly in 31 patients (30.4%) with Gr.N and 5 patients (13.9%) with Gr.S (p understood. The aim of the study was to examine the difference in < 0.01). surgical outcomes among T1b-T3 ESCC, and to clarify the outcomes Conclusion: The frequency of anastomotic leak or stenosis was low of T2 ESCC. in patients with Gr.S compared to those with Gr.N. Although the Methods: A total of 316 patients with pT1b-T3 ESCC who under- right artery is separated in preparation of Gr.N for the purpose of went transthoracic R0 esophagectomy with 2/3-field lymphadene- making up for elevation, the incidence of anastomotic morbidities tomy between 2000 and 2015 were identified through a prospec- is relative low. The result is indicated that the adequate blood flow tively collected database. Median follow-up of 98 months. is supplied to the anastomosis from right gastroepiploic artery Results: Patients’ median age was 65 years (39-87) and 89% were alone. male. pT stage was T1b in 88 patients (28%), T2 in 57 (18%), and T3 in 171 (54%). Nodal involvement was present in 60% of patients with T2 cancer compared with 38% for pT1b (P=0.0088), and 75% P-195 for pT3 patients (P=0.0316). The 5-year overall- and disease- specific survival (OS, DSS) were 57% and 69%, respectively, for all EFFICACY AND SAFETY OF ENDOSCOPIC MUCOSAL RESECTION patients. The 5-year OS/DSS for pT1b, pT2, and pT3 were 67%/80%, FOR NONAMPULLARY DUODENAL TUMORS. 63%/78%, and 50%/61%. Both OS and DSS for pT2 cancer were J. M. Lee, Y. S. Park, D. H. Lee, C. M. Shin, H. Yoon, J. H. Hwang, superior to those for pT3 (P = 0.0464, P = 0.0124), and no D. J. Oh, S. H. Lee. difference was seen between pT1b and pT2 cancer (P = 0.3839, P = Department of Internal Medicine and Seoul National University 0.8816). Recurrence rate was 27% in pT1b patients, 25% in pT2, Bundang Hospital, Seongnam, Gyeonggi-do 13620, South Korea. and 42% in pT3. Death from the disease occurred in 18% in T1b, 19% in T2, and 37% in T3 patients. Recurrence rate and the ESCC Objectives: Although the prevalence of nonampullary duodenal

274 Surgery, Gastroenterology and Oncology, 22 (3), 2017 ABSTRACTS

tumors (NADT) is not high, the number of NADT is increasing as Tokyo Medical and Dental University, Tokyo, Japan. widespread use of upper gastrointestinal endoscopy. There is no 2Department of Clinical Anatomy, established treatment for NADT due to insufficient data. This study Tokyo Medical and Dental University, Tokyo, Japan aims to evaluate the efficacy and safety of endoscopic mucosal Objectives: We previously reported the performance of medi- resection (EMR) for NADT by analyzing the clinical outcome of EMR astinoscopic esophagectomy with lymph node dissection (MELD) procedure and surgical approach in the treatment of NADT. under pneumomediastinum using a transcervical and transhiatal Methods: A total of 43 consecutive patients with 43 NADT approach as a method of radical esophagectomy. For more complete underwent EMR and a total of 13 consecutive patients with 14 NADT lymph node dissection, it is necessary to dissect via not only left underwent surgical approach between April 2008 and February 2017 cervical but also right cervical approach in pneumomediastinum. We at Seoul National University Bundang Hospital in Korea. herein report the dissection method for upper mediastinum using a Results: Median tumor size which has conducted EMR was cervico-pneumomediastinal approach including right cervical 10.8mm. Lesions which were performed EMR consisted of 34 low approach in pneumomediastinum and the short surgical outcome. grade adenoma (79%), 6 neuroendocrine tumor (14%), 3 high Methods: This method was applied to six cases for esophageal grade adenoma (7%). En bloc resection was achieved in 41 lesions cancer. The right recurrent nerve was first identified using an open (95%). There were 1 case of delayed bleeding (2%) after EMR which approach. Pneumomediastinum was then initiated to allow for the was done hemostasis by clipping and 2 delayed perforation (5%) upper thoracic paraesophageal lymph nodes (105) and the right after EMR which resolved by supportive care. 2 delayed perfora- recurrent nerve lymph nodes (106recR) to be completely dissected tions were all occurred in lesions which has conducted EMR by along the right mediastinal pleura, the right vagus nerve, the piecemeal resection. The mean period of hospital days for EMR proximal portion of the azygos vein and the right bronchial artery. was 2.6 days. In case of surgical approach, median tumor size was Left recurrent nerve lymph nodes (106recL) and the left tracheo- 13.6mm. There were 13 neuroendocrine tumor (93%), 1 high grade bronchial lymph nodes (106tbL) were dissected using a cross-over adenoma (7%). There was 1 fluid collection complication (8%) technique, as described previously. after open wedge resection. The mean period of hospital days for Results: This operation using bilateral cervical approach in surgical approach was 7.1 days. pneumomediastinum were performed for six cases. The median Conclusions: In our study, EMR was an efficacy and safety treat- operation time and bleeding is 580 minutes and 475.5 ml, respec- ment for NADT. But EMR should be done by skillful endoscopists tively. The median post-operative stay is 13.5 days. because of the difficulty of procedure for NADT. Also additional Conclusions: MELD is therefore considered to be a more minimally data on the long term outcome of ESD and multi-center large invasive and useful modality for radical esophagectomy than the prospective studies of EMR will be needed to establish treatment thoracic approach, although the field of view is different from that of for NADT in the future. the thoracic approach.

P-196 P-198 ENUCLEATION OF GIANT ESOPHAGEAL LEIOMYOMA: CASES WITH REVIEW OF LITERATURE ANALYSIS OF MORTALITY IN ACCUTE SEPTIC CHOLANGITIS Vinay Kumar Shaw, Azhar Perwaiz, Amanjeet Singh, P. Valsangiacomo, M. Perdomo, E. Moreira, L. Ruso. Adarsh Chaudhary. Maciel Hospital. Montevideo. 11100. Uruguay. Objetives: Biliary sepsis is 1% of receipts in CTI and 10% of sepsis. Esophageal leiomyoma is a rare neoplasm but it is the most common Mortality in septic acute cholangitis (SAC) has dropped significantly benign tumour of esophagus. Majority of them are asymptomatic, in the past 30 years, from 80% to 35%. The aim of our study is to however, surgical removal is preferred especially if the tumour is analyze the factors that determine mortality. large or causing symptoms. Extra mucosal enucleation is the treat- Methods: Registration retrospective SAC patients admitted to the ment of choice but many studies have suggested that esophageal ICU of the Hospital Maciel. Period: January 2002 - August 2015. resection may be required for giant esophageal leiomyoma (GLM). Variables analyzed: age, sex, history, origin, evolution time, bilirubin, Esophagectomy is too morbid a procedure for a benign disease and etiology, while unclogging, shock, culture, SAPS II, treatment. can be avoided in selected cases of giant esophageal leiomyoma. Our Results: 81 patients were analyzed. Average age: 64 years. Female: cases of giant esophageal leiomyoma was managed with local 58%. Hometown: 40% derived from other centers. The mean dura- excision and we present it with review of available literature tion of 7 days. Total bilirubin income: 11mg / dl. SAPS II average Key words: Giant esophageal leiomyoma, enucleation of leiomyoma score: 46. 33% of patients on admission were in shock. Etiology: 92% esophagus. was for stones. Positive blood cultures: 26%, Klebsiella was the pre- dominant germ. ESBL Klebsiella development by 50%. Ampicillin / P-197 sulbactam was the empirical antibiotic used in 59% and multiple antibiotics plans in 48%. Average time to biliary unblocking: 4 days. NONTRANSTHORACIC RADICAL ESOPHAGECTOMY USING CERVICAL Mortality was 37%. Statistically significant factors for mortality AND TRANSHIATAL APPROACH UNDER PNEUMOMEDIASTINUM were: age over 65, initial shock, male and biliary unblocking time. Conclusions: The presence of initial shock, in elderly patients and Yutaka Tokairin1, Kenro Kawada1, Akihiro Hoshino1, gall were tardy unblocking the determinants of mortality; whose Takuya Okada1, Masafumi Okuda1, Yutaka Nakajima1, Keiichi Akit2 decline is linked to the inicial, early and minimally invasive manage- and Yasuaki Nakajima1. ment of obstruction . 1Department of Gastrointestinal Surgery,

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