ELECTRONIC POSTER (EP03A-EP03F) e BILIARY

EP03A - Electronic Poster: 3A - Biliary ductal margin in cases of hilar cholangiocarcinoma (HCCA). This retrospective study was to investigate the Cholangiocarcinoma effectiveness of additional resection of the invasive cancer EP03A-001 positive proximal ductal margin (PM) under different level OUTCOMES OF LEFT of preoperative CA19-9. TRISECTIONECTOMY AND RIGHT Methods: Patients who underwent hepatectomy for HCCA HEPATECTOMY FOR PERIHILAR from 2000 to 2017 were analyzed. Surgical variables, CHOLANGIOCARCINOMA resection margin status and length of the PM (LPM), prognostic factors, and survival were evaluated. 1 1 2 2 I. Hosokawa , H. Shimizu , H. Yoshitomi , K. Furukawa , Results: A total of 228 patients were enrolled: 175 PM(-) 2 2 1 3 T. Takayashiki , S. Kuboki , K. Koda , M. Miyazaki and without additional resection (group A), 21 PM(-) resulted 2 M. Ohtsuka by additional resection (group B), and 32 final positive 1 Department of Surgery, Teikyo University Chiba Medical proximal ductal margin: PM(+) (group C). The median 2 Center, Department of General Surgery, Chiba Univer- survival of group B (20.99 months) was not significantly 3 sity Graduate School of Medicine, and Mita Hospital, different with that of group A (23.00 months; P=0.16), and International University of Health and Welfare, Japan both of them were significantly better than that of group C Background: Right hepatectomy (RH) is a standard surgical (11.60 months) even in different subgroup of pr-CA 19-9 procedure for perihilar cholangiocarcinoma (PHC) with right- (P< 0.05). The survival of patients with LPM>10mm was sided predominance in many centers. Although left trisec- significantly better than that of patients with LPM10mm tionectomy (LT) is aggressively performed for PHC with left- especially when pr-CA 19-9>150U/ml (P< 0.05). Only sided predominance in high-volume centers, the surgical and when LPM>10mm, the survival of group B could be survival outcomes of LT are unclear. The aim of this study comparable with group A (P>0.05). was to compare the outcomes of LT vs. RH for PHC. Conclusion: HCCA patients could get survive benefit Methods: Consecutive patients who underwent surgical from the negative PM resulted by additional resection. The resection for PHC at Chiba University Hospital from 2008 survival could be comparable with that of negative PM to 2016 were retrospectively reviewed. The outcomes of without additional resection in HCCA patients. The patients with PHC who underwent LT were compared with LPM>10 mm is potentially more associated with the those who underwent RH following one-to-one propensity survival rather than whether additional resection of the score matching. The primary end points of the study were positive PM is performed under different level of pre-CA major complications (Clavien-Dindo grades III-IV), 90-day 19-9. mortality, R0 resection, recurrence-free survival (RFS) and overall survival (OS). Results: Of 171 consecutive PHC resection patients, 111 EP03A-003 were eligible for the study; 41 (36.9%) underwent LT, and 70 (63.1%) underwent RH. In a matched cohort (LT; n=27, THE EFFECT OF PREOPERATIVE RH; n=27), major complication rates (67% vs. 52%; SERUM CA 19-9 AND THE LENGTH OF p=0.42), 90-day mortality rates (15% vs. 0%; p=0.11) and PROXIMAL RESECTION MARGIN OF R0 resection rates (56% vs. 44%; p=0.58) were similar in BILE DUCT ON RESECTED HILAR both groups. The 3-year RFS rates (27% vs. 47%; p=0.27) CHOLANGIOCARCINOMA and OS rates (45% vs. 60%; p=0.17) were similar in both groups. On multivariate analysis, CA19-9 145 U/mL, W. -J. Ma, F. -Y. Li and N. -S. Chen Department of Biliary Surgery, West China Hospital, initially resectable disease, and a histological tumor grade of Sichuan University, China G1 were identified as independent predictors of a favorable prognosis in patients who underwent LT and RH for PHC. Introduction: This study was to clarify the survival ben- Conclusions: In patients with PHC, LT could achieve efits of R0 resection of hilar cholangiocarcinoma (HCCA) similar surgical and survival outcomes as RH. following different length between gross tumor and prox- imal ductal resection margin (LPM) under different level of preoperative CA 19-9. Methods: EP03A-002 All patients who underwent hepatectomy for HCCA from 2000 to 2017 were analyzed. Surgical variables, EFFECTIVENESS OF ADDITIONAL the LPM, prognostic factors, and survival were evaluated. RESECTION OF THE INVASIVE Results: A total of 228 patients were enrolled for CANCER-POSITIVE PROXIMAL BILE comparative analysis. The LPM of 44 patients were  5 DUCT MARGIN IN CASES OF HILAR mm (group A), 58 patients were 5 mm < LPM  10 mm <  CHOLANGIOCARCINOMA (group B), 88 patients were 10 mm LPM 20 mm (group C), 38 patients were 20 mm < LPM (group D). W. -J. Ma, F. -Y. Li and N. -S. Cheng When preCA19-9150.0U/ml, the overall survival (OS) of Department of Biliary Surgery, West China Hospital, group A was significantly worse than that of group C and Sichuan University, China D, but not significantly differ from that of R1 resection Introduction: There is still debate concerning the survival (P>0.05). The OS of group B, C, and D were significantly benefits of additional resection of the positive proximal better than R1 resection (P< 0.05). When preCA19-

HPB 2018, 20 (S2), S685eS764 S686 Electronic Poster (EP03A-EP03F) e Biliary

9>150.0 U/ml, the OS of group D was significantly better Results: The mean rate of FLR hypertrophy after RALPPS/ than group A, B, C and R1 resection (P< 0.05). PVE before and after matching was 42%/32% and 49%/ Conclusion: The LPM is associated with the survival of 31%, respectively. The mean duration of hypertrophy after HCCA in different level of preCA19-9. When preCA 19- RALPPS/PVE before and after matching was 16/20 days 9150.0 U/ml, the proximal margin wider than 10 mm and 14/17 days, respectively, without significant differences. potentially achieve a higher R0 resection rate and better sur- Major morbidity rate (IIIa grade, Clavien-Dindo) after the vival benefits; When preCA 19-9>150.0U/L, the LPM wider stage 1 was significantly larger for RALPPS before match- than 20 mm may achieve a significant better survival benefit. ing. There were no differences in morbidity of stage 1 after matching as well as for stage 2 before and after matching. Conclusions: According to preliminary short-term results EP03A-004 estimation RALPPS may be considered as an effective and CHOLANGIOCARCINOMA safe minimally invasive variant of ALPPS for rapid FLR hypertrophy in patients with h-CCA and i-CCA. Further PRESENTING WITH HUMORAL prospective studies are needed to confirm discovered ben- HYPERCALCEMIA OF MALIGNANCY efits of RALPPS in patients with cholangiocarcinoma. TREATED WITH SURGERY M. Ahuja1, S. Shah1 and N. Shah2 1GI Surgery, and 2Endocrinology, PD Hinduja Hospital EP03A-006 Mahim, India THE GREAT IMPOSTURE: Humoral hypercalcemia of malignancy (HHM) is caused EOSINOPHILIC CHOLANGITIS by over secretion of PTH related peptide from malignant Y. Krishna1, J. Schammel2, C. Schammel3, D. Schammel3, tumors. HHM can be essentially caused by any tumor, A. Young3 and S. Trocha1 however its induction by Cholangiocarcinoma(CCC) is 1Surgery, Greenville Health System, 2University of South extremely rare and is associated with a poor prognosis. Carolina School of Medicne Greenville, and 3Pathology, We report a case of a 63-year-old male, who presented Pathology Associates, United States with both HHM & CCC (Serum Ca on presentation was Introduction: Eosinophilic Cholangitis (EC) is a rare, benign < 14.2 mg/dl with undetectable PTH levels 3). He under- disease often mistaken for cholangiocarcinoma and only went an uneventful Right hemi-hepatectomy in view of the definitively diagnosed on liver resection. EC displays biliary tumor being resectable on imaging. His serum Calcium tree infiltration by eosinophils with fibrosis and stricture levels reduced serially in the post-operative period, thus formation, causing sclerosing cholangitis that mimics a mass- achieving normalization at discharge (Ca- 8.2mg/dl). like tumor. Typically an isolated lesion, concomitant pe- < There are extremely few case reports ( 10) in literature ripheral eosinophilia and/or extra-biliary involvement of the on CholangioCarcinoma associated HHM. Majority of kidneys, ureters, pancreas or lymph nodes has also been those patients were not operable candidates and only one noted. In the liver, these lesions clinically and radiologically underwent a resection but expired two months later. In resemble cholangiocarcinoma, resulting in extensive hepa- conclusion, we report a case of HHM with CCC treated tobiliary resections for a presumed malignancy. successfully with a curative liver resection. Methods: We present two cases of presumed chol- angiocarcinoma that underwent liver resection with a final diagnosis of EC. A retrospective review and comprehen- EP03A-005 sive review of the literature was completed. SAFETY AND EFFICACY OF RALPPS IN Results: Initial presentation in both cases was biliary CHOLANGIOCARCINOMA PATIENTS obstruction with suspicious lesions on imaging, resulting in left hepatic lobectomy and cholecystectomy. EC is a benign D. Akhaladze, R. Alikhanov, O. Melekhina, I. Kazakov, process that can be confirmed on tissue diagnosis and S. Iskhagi, P. Kim, A. Vankovich, E. Zamanov, successfully managed medically and should be considered N. Elizarova and M. Efanov when evaluating biliary obstruction. Hepato Pancreato Biliary Surgery, Moscow Clinical Sci- Conclusion: This is the first documented small case series fi enti c Center n.a. A.S. Loginov, Russian Federation with an extensive literature review of EC. Additionally, we Objective: Estimation of the short-term results of split-in- propose a diagnostic decision algorithm to evaluate the situ resection with radio-frequency ablation (RFA) instead possibility of EC and potentially avoid surgery for this of liver partition on the first stage (RALPPS) in patients with benign disease. hilar (h-CCA) and intrahepatic (i-CCA) cholangiocarcinoma compared with portal vein embolization (PVE). Summary background data: Unsatisfactory immediate EP03A-007 outcomes of Associating liver partition and portal vein liga- ABNORMAL EXPRESSION OF ANXA2 tion for staged hepatectomy (ALPPS) in surgery of chol- PREDICTS CHOLANGIOCARCINOMA’S angiocarcinoma suggested that patients with biliary cancer should not be treated by ALPPS. Short-term results of ALPPS POOR PROGNOSIS AND EXACERBATES variants with reduced surgical trauma on the first stage in MALIGNANCY VIA ACTIVATING b- patients with cholangiocarcinoma were not yet estimated. CATENIN SIGNALING Methods: RALPPS and PVE were applied in 10 and 18 R. Yang1, D. Wang1, S. Han1, L. Huo1, D. Ding1, patients respectively. Future liver remnant (FLR) was R. Peng1,G.Ji1, Y. Zhang1,Y.Yu1,2 and X. Li1,2 estimated by CT. The propensity score matching method 1Nanjing Medical University, and 2Jiangsu Province was used in compared groups. Hospital, China

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S687

Background: Cholangiocarcinoma (CCA), due to its EP03A-009 anatomic location and pathogenesis difference, is clas- sified as intrahepatic CCA (iCCA), perihilar CCA CORRELATION BETWEEN (pCCA) and distal CCA(dCCA). Annexin A2 (ANXA2), BLUMGART-JANARGIN STAGING AND a calcium-dependent phospholipid-binding protein, is RESPECTABILITY FOR HILAR reported to be associated with several epithelial tumors. CHOLANGIOCARCINOMA, A In this study, we aimed to clarify the effect of ANXA2 RETROSPECTIVE REVIEW on iCCA, pCCA and dCCA malignancy, and potential 1 2 2 2,3 mechanism. G. Leow , D. Chua , Y. X. Koh , B. K. P. Goh , J. H. Kam2,3,4, J. Y. Teo2,3, E. K. Tan2, A. Y. F. Chung2,3, Methods: CCAs and adjacent tissues were collected 2,3 2,3 from patients who underwent surgical resection. RNA C. Y. Chan and S. Y. Lee 1Yong Loo Lin School of Medicine, National Univer- expression level of ANXA2 in CCAs (including iCCA, 2 pCCA and dCCA) and cell lines were assessed by sity of Singapore, Singapore, Hepatopancreaticobili- ’ fi ary and Transplant Surgery, Singapore General realtime PCR. ANXA2 s clinical signi cance in three 3 CCA subtypes were analyzed by immunohistochemistry Hospital, Singapore, Duke-National University of Singapore (NUS) Medical School, Singapore, and using our in-house samples. The biological function and 4 molecular mechanism of ANXA2 in regulating CCAs General Surgery, Sengkang General Hospital, malignancy was further investigated in vitro and in Singapore vivo. Introduction: Hilar cholangiocarcinomas (HCCA) are Results: The RNA expression level of ANXA2 in CCAs tumours involving the biliary confluence. At present, cancers was much higher than that in adjacent normal radical surgery offers the only chance of long term sur- tissues (iCCA vs normal, p=0.0017; pCCA and dCCA vs vival. However this may be challenging given the normal, p=0.0037), meanwhile CCAs patients with high- complexity of hilar anatomy. Blumgart and Jarnagin ANXA2 expression have a shorter overall survival time. described a pre-operative staging system incorporating In vitro and in vivo functional studies showed that the effect of local tumour extent and its impact on ANXA2 overexpression promotes CCAs cell prolifera- adjacent structures and has been demonstrated to corre- tion, migration and invasion through interacting with late better with actual surgical resectability. The primary GSK-3b/APC/Axin complex to facilitate b-catenin nu- aim of this study is to describe the correlation between clear localization. pre-operative Blumgart-Jarnagin staging and its correla- Conclusion: Our study revealed that ANXA2 can promote tion with surgical resectability. cholangiocarcinoma cells metastasis via activating b-cate- Methods: Patients who underwent surgical resection nin signaling. In addition, high ANXA2 expression is a for hilar cholangiocarcinoma at the Singapore General worse prognostic biomarker in CCA. Hospital (SGH) between 1st January 2002 to 1st January 2013 were identified from a prospectively maintained institutional database. All patients were staged based on the criteria described by Blumgart and Jarnagin. Correlation with surgical resectability was then determined. Results: A total of 19 patients were identified. Overall resectability was 57.8% (n=11). Patients with Blumgart- Janargin stage T1 had the highest rates of resectability at 80%. Patients with stage T2 and T3 disease had resectability rates of 25% and 40% respectively. Median overall survival was 13.6 months. Table 1 shows the Blumgbart-Janargin stage and the corresponding patient outcomes. Conclusion: The Blumgart-Jarnagin staging system is useful in predicting tumour resectability for HCCA.

Table 1 T1 T2 T3 Total Number 10 4 5 19 Resectability (n, %) 8 (80) 1 (25) 2 (40) 11 (57.8) R0 resection (n, %) 7 (70) 1 (25) 1 (20) 9 (47.4) Hepatic resection (n, %) 6 (60) 1 (25) 2 (40) 9 (47.4) Metastasis (n, %) 0 (0) 1 (25) 2 (40) 3 (15.8) Median survival (months) 18.3 11.5 5.6 13.6

ANXA2 prognosis and mechanism

HPB 2018, 20 (S2), S685eS764 S688 Electronic Poster (EP03A-EP03F) e Biliary

EP03A-011 Results: Mean patient age was 69.4 (range, 54-86) years, including 37 men. All patients had pathologically confirmed METASTASIS OF AMPULLARY distal cholangiocarcinoma. Univariate analysis showed that T, CARCINOMA TO THE SPLEEN: A CASE LMR, ly, v, ne, M, EM, PV, and stage were independent REPORT prognostic factors for DFS and OS. A was also a prognostic M. T. Phan1 and V. Truongquoc2,3,4 factor for OS. Multivariate analysis revealed that although ly 1General Surgery, University of Medicine and Pharmacy, and EM were independent prognostic factors for DFS, only fi Hochiminh City, 2University of Medicine and Pharmacy, EM was a prognostic for OS. Signi cant differences in OS and 3Hepato-Biliary and Pancreatic Surgery Departmant, Cho DFS were found between EM levels 0 and 1 or 2 (p=0.018). Ray Hospital, and 4Cho Ray Hospital Conclusions: Thus among the clinicopathological param- eters, EM was confirmed as a prognostic factor for distal Introduction: Secondary metastatic tumors of the spleen cholangiocarcinoma. are rare. The primary tumors that known to metastasize spleen are breast, lung, skin. There have been no reports of ampullary cancer metastasizing to the spleen in the previ- EP03A-013 ous day. We introduced here an oligometastasis in which POST-HEPATECTOMY LIVER FAILURE ampullary carcinoma metastasizing to the spleen. IS ASSOCIATED WITH TUMOR Method: Case report. We describe a case of ampullary RECURRENCE IN PATIENTS WITH cancer metastasizing to the spleen at Cho Ray Hospital. HILAR CHOLANGIOCARCINOMA Results: The patient was a 65 year - old woman who had been performed a pancreatoduodenectomy and splenec- E. C. Lee, S. -J. Park, J. R. Shim, H. M. Park, S. D. Lee, tomy. The preoperative imaging revealed a tumor of S. -S. Han, S. H. Kim, B. G. Na, J. -H. Park and S. -W. Park ampullary and a suspicious splenic mass related malig- Center for Liver Cancer, National Cancer Center, Re- nancy. The post-operative pathology revealed the ampul- public of Korea lary carcinoma metastasizing to the spleen. The operating Purpose: For curative resection of hilar cholangiocarcinoma time was 7 hours, postoperative hospital stay was 7 days, (HCCA), major hepatectomy with a high risk of hepatic there was no any complication. insufficiency is often performed in combination with extra- Conclusions: This is the first report about a metastasis of hepatic bile duct resection. However, the association be- ampullary carcinoma to the spleen. This was also an tween post-hepatectomy liver failure (PHLF) and oncologic oligometastasis case. Pancreatoduodenectomy and sple- outcomes in HCCA patients has not been described. nectomy is a suitable approach in this case. The patient will Materials and methods: Between October 2001 and be received supported chemotherapy after that. December 2013, 105 patients who underwent radical extra- hepatic bile duct resection and major hepatectomy for HCCA were included in this study. Clinically relevant PHLF was fi EP03A-012 de ned as liver failure corresponding to grade B or C of the International Study Group of Liver Surgery (ISGLS) criteria. DISSECTED MARGIN IS A SIGNIFICANT Results: The rates of 1-, 3-, and 5-year recurrence-free sur- PROGNOSTIC FACTOR FOR DISTAL vival (RFS) were 49.8%, 19.5%, and 19.5%, respectively, for CHOLANGIOCARCINOMA patients with PHLF (n = 47) and 73.9%, 47.3%, and 41.9%, S. Suzuki1, M. Shimoda1, J. Shimazaki1, T. Maruyama1, respectively, for those without PHLF (n = 58) (P =0.001).In K. Nishida1, K. Suzuki1, T. Tago1, N. Koike2 and addition, there was significant difference in overall survival N. Harada2 (OS) between the two groups (P < 0.001). In multivariate 1Gastroenterological Surgery, Ibaraki Medical Center, analysis, PHLF was a significant prognostic factor for RFS Tokyo Medical University, and 2Gastroenterological Sur- (hazard ratio [HR] 2.320, 95% confidence interval [CI] 1.341 gery, Hachioji Digestive Disease Hospital, Japan -4.012;P = 0.003) and OS (HR 2.000, 95% CI 1.181 - 3.379; Introduction: Although distal cholangiocarcinoma pa- P = 0.010). Patients with PHLF had a higher cumulative tients have a better prognosis than those with periampullary incidence at all recurrence sites, with intrahepatic recurrence fi cancers, early recurrence of the former may result in poorer showing statistical signi cance (P = 0.039). prognosis. We determined the clinicopathological factors Conclusion: PHLF is an independent prognostic factor for that could predict survival and recurrence of these patients. recurrence and survival after curative resection in HCCA Methods: Fifty distal cholangiocarcinoma patients who patients. In particular, PHLF is strongly associated with underwent pancreaticoduodenectomy between 2005 and intrahepatic recurrence. 2014 were examined retrospectively. Clinicopathological parameters (age, sex, body mass index (BMI), presence of EP03A-014 biliary tract decompression, macroscopic types, histologi- THE PROGNOSTIC COMPARISON OF cal types, tumor size, TNM classification, lymph node THE LONGITUDINAL MARGIN STATUS metastasis ratio (LMR), lymphatic invasion (ly), venous IN DISTAL BILE DUCT CANCER: R0 ON invasion(v), perineural invasion (ne), proximal bile duct margin (HM), dissected margin (EM), portal system inva- FIRST BILE DUCT RESECTION VS. R0 sion (PV), arterial system invasion (A), stage, and residual AFTER ADDITIONAL RESECTION tumor) were analyzed as predictors of disease-free survival Y. J. Park1, D. W. Hwang1, J. H. Kim2, J. H. Lee1, (DFS) and overall survival (OS). Cox proportional hazard K. B. Song1, S. H. Shin1, E. S. Jun1, S. C. Kim1, models were used for univariate and multivariate analyses, K. -M. Park1 and Y. -J. Lee1 and Kaplan-Meier survival curves were compared using 1Division of Hepato-Biliary and Pancreatic Surgery, log-rank tests. Department of Surgery, and 2Department of Radiology

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S689 and Research Institute of Radiology, Asan Medical Center, intrapancreatic CBD, causing mild luminal narrowing University of Ulsan College of Medicine, Republic of and dilatation of upper biliary tract and also showed Korea irregular wall thickening and enhancement of gallbladder Achieving R0 resection in surgery of distal bile duct body and fundus. cancer (dCBD cancer) is known to be an important prog- Results: Under diagnosis of distal CBD cancer and gall- nostic factor. We aimed to compare survival difference bladder cancer, she underwent pylorus-preserving pancrea- between R0 on first bile duct resection (Primary R0) and R0 ticoduodenectomy with routine lymph node dissection and after additional resection (Secondary R0). Also, this study s4b and S5 liver wedge resection. In operation finding, there aimed to identify the survival difference according to the were diffuse nodular sclerosing change from mid CBD to final longitudinal margin status (LMS). distal CBD and there were diffuse wall thickening of gall- Retrospective cohort study was conducted for the 193 bladder body at liver bed side. Based on pathologic finding patients who underwent Whipple’s operation for dCBD and immunohistochemical staining, lesion was diagnosed cancer confined to the intra-pancreatic portion at single histologically as lymphoid hyperplasia. center between January 2008 and January 2016. Their Conclusion: Lymphoid hyperaplasia of biliary system is a preoperative imaging studies were reviewed by indepen- rare disease, and preoperative diagnosis is extremely dent radiologist. The patients were sorted into two groups difficult. Although it is benign condition, we should according to longitudinal margin status (LMS): Primary R0 consider surgical excision for this lesion that cannot be (n=159), Secondary R0 (n=15), and three groups according excluded for malignancy. to final LMS: no evidence of residual carcinoma (FR0, n=174); carcinoma in situ or high grade dysplasia (FR1- CIS, n=12); and invasive carcinoma EP03A-017 (FR1-INV, n=7). Survival and prognostic factors were RIGHT TRISECTIONECTOMY WITH analyzed. CAUDATE LOBETOMY FOR PERI- There was no significant differences in 5-year survival rates of primary R0 and Secondary R0 (60.8% vs. 46.1%, HILAR CHOLANGIOCARCINOMA P=0.966). The 5-year survival rate of FR1-CIS group was C. Liu, X. -D. Shi, Q. -B. Tang, L. -B. Xu and X. -H. Yu significantly better than that of FR1-INV(59.5% vs. 14.3%, Department of Biliary Surgery, Sun Yat-sen Memorial P=0.018) and it was comparable to survival of FR0 group Hospital, Sun Yat-sen University, China (59.3%). LMS of bile duct was an independent prognostic Introduction: An extended right trisectionectomy factor, along with lymph node metastasis, tumor size, (segments IV-VIII,I) is a standard procedure for peri- perineural invasion, body mass index. hilar cholangiocarcinoma(IIIa-IV). Biliary drainage and In surgical resection for dCBD cancer, there is no sur- portal vein occlusion are considered as management in vival difference between Primary R0 and Secondary R0. improving liver function and the volume of future liver Achieving FR0 through additional resection may have remnant. benefit for the patient’s prognosis. As a second choice, Methods: We report our experience of PTCD combined achieving FR1-CIS would be way to improve prognosis with right PVE (or RPV occlusion by tumor) in extended compared to FR1-INV. right trisectionectomy of peri-hilar cholangiocarcinoma. Results: First case. Female, 28-years-old. At admission serum TBIL was 126.4umol/L. The tumor located in seg- EP03A-015 ments 4-5,8, with involvement of RPV. S2+3/ SIMULTANEOUS LYMPHOID SLV=35.73%. Pre-operative TBIL was 48.2 umol/L after HYPERPLASIA OF GALLBLADDER AND right and left sided PTCD for 40 days. The S2+3 of future liver remnant was increased by 41.97% after right PVE for BILE DUCT MIMICKING CARCINOMA: 24 days (S2+3/SLV=50.72%). The procedures of operation A CASE REPORT included anatomical right tri-sectionectomy and caudate C. K. Cho lobe resection. Pathological results showed that chol- Surgery, Chonnam National University Medical School, angiocarcinoma invaded RPV externa. Second cases. Male, Republic of Korea 59-years-old. At admission serum TBIL was 142.2umol/L Introduction: Lymphoid hyperplasia is a rare benign after left sided PTCD for 22 days before admission. Pre- lymphoproliferative disorder. It can occur in various operative TBIL was 73.6 umol/L after left sided PTCD for organs. However, lymphoid hyperplasia arising from 40 days. Both CT and MR showed that peri-hilar tumor extrahepatic bile duct and gallbladder simultaneously is invaded caudate lobe, right and bifurcation of PV, right extremely rare. hepatic artery, and suspiciously invaded retrohepatic IVC. Methods: A 72-year-old woman visited hospital with RPV almost was occlusion. The procedures of operation general weakness, dyspepsia and weight loss for 3 included anatomical right trisectionectomy and caudate months. She had medical history of diabetes mellitus and lobe resection, resection of the bifurcation of PV and depressive mood disorder and had been treated for liver retrohepatic IVC. Pathological results showed that chol- abscess ten years ago. On physical examination, there angiocarcinoma invaded intimas of right and bifurcation of was no icteric sclera and no tenderness in the upper PV, retrohepatic IVC. abdomen. Viral hepatitis markers and all tumor markers Conclusion: Preoperative PTCD combined with PVE(or were within normal limits. Magnetic resonance chol- RPV occlusion by tumor) may be considerable strategy in angiopancreatography (MRCP) showed 3cm length wall improving resectability of extended right trisectionectomy thickening and enhancement of suprapancreatic and in peri-hilar cholangiocarcinoma.

HPB 2018, 20 (S2), S685eS764 S690 Electronic Poster (EP03A-EP03F) e Biliary

EP03A-018 preoperative PVCS followed by surgery. Diagnostic accuracy was examined by comparing results of preoperative PVCS and THE PROGNOSTIC FACTORS AND postoperative histopathologic LRM of surgical specimens. PROGNOSTIC IMPACT OF Results: Forty-five patients underwent pancreaticoduode- METASTATIC LYMPH NODE COUNT nectomy (PD), hemi-hepatectomy (HH), or PD-plus-HH. AFTER CURATIVE RESECTION FOR PVCS was performed since 2015, and 16 patients underwent DISTAL CHOLANGIOCARCINOMA PVCS. The incidence of positive LRM was 8/29 (27.6%) in patients without PVCS and 3/16 (18.8%) with PVCS. The H. J. Kim, C. K. Cho and H. J. Kim overall incidence of positive LRM was not significant. Surgery, Chonnam National University Medical School, However, in two of the three patients with positive LRM, Republic of Korea diagnosed appropriate surgical method after PVCS was PD- Background: The staging system for distal chol- plus-HH, but could not be performed due to patient side cause th angiocarcinoma was changed in AJCC 8 edition. The aim of advanced age. Another patient presented with wide-spread of this study was to investigate the survival outcome and carcinoma-in-situ in both lobe of the liver, which had been prognostic factor of distal cholangiocarcinoma after cura- diagnosed by preoperative PVCS. Therefore, the accuracy of tive resection, and to evaluate the new N-stage system of preoperative PVCS was satisfactory for diagnosing LRM. th AJCC 8 edition. Conclusions: Appropriate surgery cannot be always Methods: All patients who underwent pancreaticoduode- performed in CCA patients because of advanced age, nectomy or bile duct resection with curative intent for distal insufficient hepatic function, or inadequate remnant liver cholangiocarcinoma between 2004 and 2017 at Chonnam volume. However, preoperative PVCS, undoubtedly National University Hwasun Hospital were reviewed together with CT, can be helpful to detect LRM and select retrospectively. Survival outcome was evaluated using surgical method in patients with CCA. Kaplan-Meier method, and the Cox proportional hazards model was used for multivariable analysis. Results: 248 patients were included. Overall survival rates EP03A-020 for 1, 3, and 5 years were 81.4%, 49.5%, and 34.9% respectively. Median survival time was 35.0 months. In AN APPROACH TO PATIENT-SPECIFIC univariate analysis, the prognostic factors influencing sur- TREATMENT OF INTRAHEPATIC vival were elevated serum total bilirubin(5mg/dL), infil- CHOLANGIOCARCINOMA (ICC): DRUG trative appearance, histologic differentiation, T-stage, SCREENS WITH PATIENT-DERIVED lymph node involvement, new N-stage of AJCC 8th edition, th SPHEROIDS IDENTIFY MTOR AS A TNM stage of AJCC 7 edition, perineural invasion, VIABLE AND DRUGGABLE TARGET lymphovascular invasion, and margin involvement. Among 1 1 1 1 them, histologic differentiation, N-stage of AJCC 8th edi- K. Toriguchi , M. Lin , E. Nakakura , C. Corvera , 2 1 1 tion, and margin status were identified to be independent B. Hann , D. Donner and R. Warren 1 2 prognostic factors in multivariate analysis. Surgery, and HDF Comprehensive Cancer Ctr, Uni- Conclusions: Histologic differentiation, new N-stage of versity of California, San Francisco, United States AJCC 8th edition, and margin status were the independent Introduction: Few effective drugs are available for chol- prognostic factors. The new N-stage of AJCC 8th edition angiocarcinoma, a deadly liver cancer. We are generating was superior to predict the prognosis after curative resec- tumor spheroids from patient hepatectomy specimens in tion for distal cholangiocarcinoma, compared to AJCC order to screen drugs for efficacy against ICC. staging system of 7th edition. Methods: Surgically resected tumors from four ICC pa- tients were subcutaneously injected into immune-deficient mice to generate patient-derived xenografts (PDX). Next EP03A-019 generation DNA sequencing and RNAseq trascriptome PREOPERATIVE PERORAL VIDEO- analyses were done on tumor and isolated spheroids which CHOLANGIOSCOPY TO DIAGNOSE were then dispensed into multi-well, ultra-low adherent LONGITUDINAL EXTENSION MARGIN plates using a sphere picker guided by artificial intelligence. IN PATIENTS WITH Over thirty drugs that target diverse signaling pathways were evaluated for their ability to inhibit spheroid growth. CHOLANGIOCARCINOMA Results: Spheres from each patient were differentially Y. Onishi1, H. Nakano2,3, Y. Yoshida1, T. Matsushita2, responsive to drugs. Among the small molecule agents S. Kobayashi3 and T. Otsubo3 tested, none of the patient spheres were responsive to the 1Gastroenterology, 2Surgery, Shizuoka Medical Center, allosteric inhibitors of mTOR, rapamycin, everolimus and and 3Gastroenterological Surgery, St. Marianna University temsirolimus, whereas some patient spheres were respon- Background and aim: Preoperative assessment of longi- sive to dactolisib, a dual PI3K/mTOR inhibitor. However, tudinal spread of cholangiocarcinoma (CCA) is crucial to spheres from each of the patients were responsive to select surgical method for performing R0 resection. MLN0128, an active site directed mTOR inhibitor (Figure Enhanced CT is essential but is not sufficient to detect 1). Immunoblotting showed that treatment with MLN0128 longitudinal resection margin (LRM). Preoperative peroral inhibited phosphorylation of the mTOR target S6 kinase, video-cholangioscopy (PVCS) can be helpful but has not demonstrating that the inhibitor was “on target”. been necessarily indispensable. We examined whether Conclusion: Cholangiocarcinoma spheroids from four pa- PVCS can supportive to diagnose LRM for CCA. tient tumors responded differently to targeted small mole- Methods: Between 2011 and 2017, there were 45 patients cule drugs. The spheres were used to evaluate drug efficacy with distal extrahepatic or peri-hilar CCA who underwent quickly and identified the mTOR inhibitor MLN0128 as

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S691 having potent activity against spheroids from each patient. Background: The techniques of left hepatic trisectionec- We are now evaluating the spheroid model to determine tomy combined with caudate lobectomy and bile duct whether it might be predictive of patient responses to drugs, resection for hilar-cholangiocarcinoma are not standardized as a step in precision medicine for our patients. and still challenging method. Methods: Under preoperative diagnosis of hilar chol- angiocarcinoma, 13 patients underwent “anatomic” left he- EP03A-021 patic trisectionectomy with en bloc resection of the caudate THE VOLUME OF THE FUTURE LIVER lobe and the extrahepatic bile duct, in which the posterior REMNANT AND PREOPERATIVE glissionean pedicle was isolated and taped by extrahepatic glissonean approach. This procedure helps us to understand CHOLANGITIS ARE MAJOR the root of the future remnant liver region anatomically, PREDICTORS UF PERIOPERATIVE therefore we can easily transect liver parenchyma correctly MORBIDITY AND MORTALITY IN along with the inverted tape that leads the dissection plane to PERIHILAR CHOLANGIOCARCINOMA the limiting point of the remnant bile duct. Results: Liver resection was successfully performed in all J. Bednarsch1, Z. Czigany1, I. Amygdalos1, patients. Vascular resection and reconstruction was D. Morales Santana1, F. Meister1, J. Böcker1, T. F. Ulmer1, performed in 8 patients (PV: 3, PV+HA: 5). One patient died C. H. C. Dejong2, U. P. Neumann1 and G. Lurje1 within postoperative 90 days. All patients were histologi- 1Department of Surgery and Transplantation, University cally diagnosed as having cholangiocarcinoma. The prox- Hospital Aachen, Germany, and 2Department of Surgery, imal resection margins were cancer-negative in all patients. Maastricht University Medical Center (MUMC), Conclusions: Extrahepatic glissonean pedicle isolation Netherlands technique is helpful for performing the left hepatic trisec- Background: Perihilar cholangiocarcinoma (PHCC) is a tionectomy with caudate lobectomy. relatively rare malignancy that is typically diagnosed at an Video: We will show you the scheme of this concept and advanced disease stage. Major liver resection with portal vein actual case video. resection (PVR) has evolved as the mainstay of treatment for patients with PHCC. Despite recent advancements, surgical morbidity and mortality (SMM) is higher compared to other malignancies. Here we aim to identify computed tomography EP03A-023 (CT) based liver volumetry and future liver remnant (FLR) MALIGNANT TRANSFORMATION assessment as a suitable method to predict SMM. ARISING WITHIN UNUSUAL AND RARE Methods: Between 2010 and 2016, 91 patients with PHCC HEPATIC LESIONS - DUCTAL PLATE underwent surgery in curative intent at our institution. The MALFORMATION AND BILIARY associations of SMM and FLR with clinico-pathological FIBROADENOMA characteristics were assessed using univariate and multivar- iable survival analyses. Three different methods of FLR CT- D. Chua, L. S. Lee, S. S. Tan and A. Chiow volumetry, the calculated-FLR (c-FLR; ratio of FLR to total General Surgery, Changi General Hospital, Singapore liver volume), standardized FLR (s-FLR; defined as the ratio Introduction: Cholangiocarcinoma is the second most of FLR to estimated liver volume by body surface area) and common hepatobiliary malignancy following hepatocellu- FLR to bodyweight ratio (FLR/BW) were tested for validity. lar carcinoma. Risk factors include chronic intraductal Results: Multivariable analysis identified preoperative gallstones, primary sclerosing cholangitis, liver fluke in- cholangitis (B=-1.53, p=0.013) and c-FLR (B=-5.89, fections and fibropolycystic disease of the liver. p=0.012) as two independent predictors for SMM Method: We present 2 cases of intrahepatic chol- (R2=0.25, Clavien-Dindo  4). Based on these findings we angiocarcinoma arising from unusual and rare hepatic le- designed a futility-score (FLR< 40% OR preoperative sions- a fibropolycystic disease form of ductal plate cholangitis) to predict in-house mortality with high sensi- malformation and biliary adenofibroma, whose association tivity (92%) and specifity (52%). with malignancy are rarely reported in the literature. Conclusions: In patients with PHCC, the preoperative Results: assessment of the FLR (FLR< 40%) as well as preoperative Case 1: A 38-year old female was referred for an inci- cholangitis are two independent risk factors for SMM. c-FLR dental liver lesion noted during elective laparoscopic total should be the preferred method of CT-based liver volumetry. hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids. MRI confirmed an exophytic, multi- loculated cystic 5.9 Â 5.7 Â 4.8 cm segment VI liver mass. EP03A-022 She underwent a laparoscopic wedge resection of the LEFT HEPATIC TRISECTIONECTOMY segment VI liver lesion. Histology confirmed an intra- WITH CAUDATE LOBECTOMY BY hepatic cholangiocarcinoma arising from a ductal plate malformation. EXTRAHEPATIC GLISSONEAN Case 2: A 66-year old female with known Child’sA PEDICLE ISOLATION TECHNIQUE FOR hepatitis C cirrhosis was noted on surveillance ultrasound HILAR CHOLANGIOCARCINOMA to have a segment IVb lesion which was subsequently Y. Abe1, M. Shinoda1, M. Kitago1, H. Yagi1, G. Oshima1, characterized on MRI liver to be suspicious of HCC. Serum O. Itano2 and Y. Kitagawa1 alpha fetoprotein (AFP) was normal. She underwent an 1Surgery, Keio University, and 2Hepato-Biliary-Pancre- uneventful laparoscopic segmentectomy of IVb. Histology fi fi atic & Gastrointestinal Surgery, International University con rmed a biliary broadenoma with an intrahepatic of Health and Welfare, Japan cholangiocarcinoma arising within.

HPB 2018, 20 (S2), S685eS764 S692 Electronic Poster (EP03A-EP03F) e Biliary

Conclusion: Fibropolycystic disease form of DPM and BAF Introduction: Due to the improvement of chemothera- are unusual and rare histology-based diagnosis without peutic agents, some initially unresectable locally advanced characteristic imaging diagnostic features. Such lesions intrahepatic cholangiocarcinomas (UR-ICCs) have been should be sampled thoroughly to exclude associated malig- reported to become resectable after chemotherapy. How- nancies. Complete surgical resection remains the manage- ever, the outcome of patients undergoing such strategy ment of choice in dealing with such rare pre-cursor lesions. remains poorly clarified. Methods: UR-ICC cases were defined as those in which therapeutic resection could not be achieved because of EP03A-024 extensive vascular invasion and/or inadequate remnant OUTCOMES AFTER SURGICAL liver volume. Downsizing chemotherapy and subsequent surgical resection were completed in 10 patients. These TRETAMENT OF RECURRENT patients were clinically reviewed. CHOLANGIOCARCINOMA Results: As chemotherapeutic agents, gemcitabine was M. Gastaca, L. Fernandez, M. Prieto, P. Ruiz, A. Ventoso, used in three patients and gemcitabine plus cisplatin in I. Palomares, E. Alonso and A. Valdivieso seven. The mean interval from induction of chemotherapy Hepatobilary and Liver Transplant Unit, Cruces Univer- to surgical resection was 6.1 Æ 3 months. On the basis of sity Hospital, Spain RECIST criteria, before surgical resection, seven patients Introduction: The aim of the study was to describe the showed partial response and three had stable disease. The outcomes after surgical treatment of recurrence chol- types of hepatic resection performed were 6 trisectionec- Æ angiocarcinoma (RC). tomy, 3 hemihepatectomy caudate lobectomy, and 1 Method: Retrospective study of the RC treated at our S1+S4 resection. Bile duct resection was performed in 8 center between 1995 and 2015. A total of 142 chol- patients and vascular resection in 3. R0 resection was ’ angiocarcinomas (CC) were operated on. 93 patients (71%) achieved in all patients. Pathologically, according to Evans developed RC with a median follow-up of 1.9 years (0- criteria, the effect of chemotherapy was grade IIa in 1 case, 15.2). Patients were divided into 3 groups: group A, 41 grade IIb in 5, grade III in 3, and grade IV in 1. The median patients who received chemotherapy only (QT); group B, survival time after the induction of chemotherapy and after 34 patients with symptomatic treatment and group C, 18 surgical resection was 46.2 and 40.5 months, respectively. patients who were operated with curative intention and Survival in these patients was comparable with that in pa- constituted the study group. tients with resectable ICC undergoing surgical resection. Results: In Group C, hiliar CC was the most common Conclusions: Preoperative downsizing chemotherapy pro- primary tumor (11 cases). Localization of RC was locore- vides patients with UR-ICC the chance for long-term survival gional in 50%of the patients, followed by liver (22.2%). if the conversion to the surgical resection becomes possible. Median time to RC was 18.9 months (2-82) in group C. In 12 patients surgery with curative intention was possible but in 6 cases an exploratory laparotomy was performed. EP03A-026 Clavien-Dindo IIIb complications occurred in 33.3%. SURGICAL MANAGEMENT OF THE Three patients died. Median survival were as follows: EARLY-STAGE PAPILLARY-TYPE Group A, 1.3 years (1.2-1.5), Group B 0.3 years (0-0.6) and NEOPLASM OF THE BILE DUCTS Group C 1.2 years (0-2.9) (A vs C p=0.5; B vs A-C 1,2 1 3 2 p=0.001). After multivariate analysis, independent factors L. Castellana , D. Pagano , R. Virdone , S. Rizzo , 2 4 1 related to patient survival after RC were: adjuvant QT after A. Russo , F. di Francesco and S. Gruttadauria 1 resection of the primary CC, HR 1.79 [1.08-2.95] p=0.022, Department of Abdominal Surgery and Organ Trans- time to RC >1 year, HR 1,85 [1.17-2.91] p=0.008 and plantation Unit, Department for the Treatment and Study of treatment of the RC (QT or surgical resection), HR 2,27 Abdominal Diseases and Abdominal Transplantation, Isti- [1,41-3,66] p=0.001. tuto di Ricovero e Cura a Carattere Scientifico (IRCCS) - Conclusions: Surgical resection of cholangiocarcinoma Istituto Mediterraneo per i Trapianti e Terapie ad alta recurrence did not provide better outcomes than QT. Specializzazione (ISMETT)/University of Pittsburgh Medical Centre Italy (UPMCI), 2Department of Oncology, A.O.U.P. ’P.Giaccone’, 3Dipartimento Biomedico di Medicina EP03A-025 Interna e Specialistica, Unità di Medicina Interna 2, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, OUTCOME OF PATIENTS WITH and 4Department of Abdominal Surgery and Organ INITIALLY UNRESECTABLE LOCALLY Transplantation Unit, Department for the Treatment and ADVANCED INTRAHEPATIC Study of Abdominal Diseases and Abdominal Trans- CHOLANGIOCARCINOMA TREATED BY plantation, Istituto di Ricovero e Cura a Carattere Scien- fi DOWNSIZING CHEMOTHERAPY AND ti co (IRCCS) - Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT)/University of SUBSEQUENT SURGICAL RESECTION Pittsburgh Medical Centre Italy (UPMCI), Italy 1 1 1 M. Ohtsuka , H. Yoshitomi , K. Furukawa , Introduction: Papillary-type neoplasms of the bile ducts T. Takayashiki1, S. Kuboki1, S. Takano1, D. Suzuki1, 1 2 2 represent rare entities and sometimes-accurate diagnosis by N. Sakai , A. Kato and M. Miyazaki common radiological and sampling methods is not satis- 1Department of General Surgery, Graduate School of 2 factory. The aim of this study is to report our experience in Medicine, Chiba University, and Mita Hospital, Interna- two patients with papillary biliary tumor, in which both tional University of Health & Welfare, Japan surgical decision-making and optimal clinical outcome

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S693 were achieved thanks to the contributions of choledoscopy Polymodal treatment led to a survival of 39 months at the and prompt radical liver resection procedures, respectively. moment and can extend survival and therefore patients Methods: Laboratory tests and imaging evaluations were should undergo regular follow-up after resection of ICC. pre-operatively achieved in both cases before to proceed with The patient is alive and in very good physical condition. sampling tools. In the first case US-guided biopsy, endo- The role and success of preoperative chemotherapy remains scopic ultrasound-fine needle aspiration (EUS-FNA) and controversial. brush-cytology/intraductal aspiration (IDA) during endo- scopic retrograde cholangiopancreatography(ERCP) were performed without conclusive results. In the second case, EP03A-028 after a no-diagnostic EUS-FNA, a positron emission to- IRRESECTABILITY OF INTRAHEPATIC mography revealed increased radiotracer uptake at the know lesion (maximal standardized uptake value equal to 4.6), CHOLANGIOCARCINOMA - REASONS, suggesting a malignant process. Both patient underwent a DIFFERENCES AND FURTHER choledoscopy that allowed to characterize histologically the TREATMENT lesions and consequently to plan surgery with radical left F. Bartsch, J. Baumgart, M. Paschold, S. Heinrich and liver lobectomy, after positioning of a right PTBD. H. Lang Results: Samples obtained through choledoscopy revealed General-, Visceral- and Transplant Surgery, Medical high-grade dysplasia in both patients; in the second case the Center of the Johannes Gutenberg-University Mainz, direct view offered by choledoscopy allowed the detection Germany of papillary structures then confirmed by pathological report. Intrahepatic cholangiocarcinoma (ICC) is a rare tumor Histological findings relative to surgical specimen revealed: and diagnosis is often made in advanced stage. Explora- intraductal papillary neoplasm of the biliary tree(IPNB) in tions and finding of irresectability is common with about the first case and invasive papillary adenocarcinoma in the 25e50%. The aim of this study is to analyse reasons of second one, although well differentiated. Both patients are irresectability and their impact on further treatment and alive and well after 9 and 5 months, respectively. survival. Conclusion: Choledoscopy allows a direct view of intra- All patients undergoing surgical exploration for ICC luminal biliary lesions and a specific oncologic targeting of (n = 176) were recorded prospectively (2008e2016). liver resection plan. Analyses focussed on irresectability, its reasons, differ- ences between findings, the further treatment and sur- vival. Overall survival was analysed using Kaplan Meier EP03A-027 model. POLYMODAL TREATMENT OF In total we performed potentially curative resections in ADVANCED INTRAHEPATIC 127/176 patients (74.5%) while in 49 patients (25.5%) CHOLANGIOCARCINOMA AND resection was not reasonable or possible. Most common RECURRENCE e A CASE REPORT primary palliative treatment of the irresectable group was chemotherapy (n = 42) followed by transarterial chemo- F. Bartsch, J. Baumgart, M. Paschold, S. Heinrich and embolization (TACE, n = 4), selective internal radio- H. Lang therapy (SIRT, n = 2) and radiation (n = 1). We further General-, Visceral- and Transplant Surgery, Medical Center grouped the reason for irresectability in cirrhosis/small of the Johannes Gutenberg-University Mainz, Germany for size (Grp1), multifocality (Grp2), extrahepatic spread Intrahepatic cholangiocarcinoma (ICC) is often detected (Grp3) and advanced/infiltrating growth (Grp4) and were in an advanced stage and extended resections are frequently not able to show significant differences in overall sur- necessary. In patients with borderline resectability preop- vival for these groups (p = 0.468). The best median erative chemotherapy may lead to tumor regression. We survival had Grp1 with 13.7 months followed by Grp2 report on a case with extended ICC receiving polymodal with 10.2, Grp4 with 9 and Grp3 with the worst median pre- and postoperative treatment. survival of 7.5 months. No patient underwent re-explo- A 61-year-old woman presented with an advanced ICC. ration and resection later on. Different centers had classified the tumor extent as irresect- Independent of the reason of irresectability there was no able. After chemotherapy with Gemcitabine and Cisplatin for difference in survival between any of the four groups. 3 months the tumor showed to be stable or slightly regress- Median survival in irresectable tumors is poor, which again ing. We re-evaluated the imaging and indicated resection. In demonstrates the need for exact staging in order to avoid October 2014 a right trisectioectomy (Sg. 4a, 5, 6, 7, 8; explorative laparotomy. Segment 4b was partially obtained) was performed and a complete resection could be achieved (TNM: pT2b (3), pN0 (0/6), M0; V1; G2; R0). We were able to discharge the pa- th EP03A-029 tient on the 19 postoperative day. Regular follow-up con- PREOPERATIVE CHEMOTHERAPY trols were obtained every 3 months and in August 2015 a hyper-vascularized lesion was detected and microwave FOR INTRAHEPATIC ablation performed in December 2015. Another hypodense CHOLANGIOCARCINOMA lesion appeared in July 2016 and repeated atypic resection F. Bartsch, M. Paschold, J. Baumgart, S. Heinrich and was performed in August 2015. In March 2017 a new hyper- H. Lang vascularized lesion was detected and the decision made to General-, Visceral- and Transplant Surgery, Medical watch and wait. In the last follow-up control in November Center of the Johannes Gutenberg-University Mainz, 2017 the lesion was almost stable in size. Germany

HPB 2018, 20 (S2), S685eS764 S694 Electronic Poster (EP03A-EP03F) e Biliary

Intrahepatic cholangiocarcinoma (ICC) is often diag- EP03A-030 nosed in advanced tumor extent because of late onset of symptoms. Thus, many tumors are irresectable at initial GABA SIGNALING INHIBITS TUMOR presentation. The role of preoperative chemotherapy in PROGRESSION BY SUPPRESSING initially irresectable ICC is still controversial. The aim was STAT3-MEDIATED EMT IN HUMAN to analyse the effect of preoperative chemotherapy on INTRAHEPATIC overall and recurrence-free survival. CHOLANGIOCARCINOMA All patients undergoing surgical exploration for ICC (n = 176) were recorded prospectively (2008e2016). Analyses K. Kawasaki, S. Kuboki, H. Nojima, H. Yoshitomi, focussed on application of preoperative chemotherapy and K. Furukawa, T. Takayashiki, M. Miyazaki and re-evaluation after initially assumed irresectability. Overall M. Ohtsuka and recurrence free survival were analysed using Kaplan Department of General Surgery, Graduate School of Meier model. Perioperative deaths were excluded in sur- Medicine, Chiba University, Japan vival analyses. Background: GABA acts as a suppressive neurotrans- Out of 176 explorations 10 patients had received pre- mitter through its specific receptors, GABA-A receptor operative chemotherapy. 8 patients underwent curative (GABA-AR) and GABA-B receptor (GABA-BR). Recent intended resection while in 2 patients resection was not studies have demonstrated that GABA signaling inhibits reasonable due to a too small or impaired future liver cancer progression; however no studies have focused on remnant. Comparing overall survival after resection with (n GABA expression in intrahepatic cholangiocarcinoma = 8) and without preoperative chemotherapy (n = 119) no (ICC). significant difference could be shown (p = 0.754; median Methods: Roles of GABA signaling in ICC was evaluated OS 17.9 months with [range 1e90] vs. 17.5 months using surgical specimens collected from 61 ICC patients without [range 6e48]). underwent R0/R1 resection. Results: Low GABA-AR expression in ICC was associ- ated with increased intrahepatic metastasis, and was an independent factor for poor prognosis in ICC patients after operation. In addition, low GABA-BR expression in ICC was a significant poor prognostic factor. They share GABA as a specific ligand, overall survival in ICC patients in relation to the expression levels of GABA-AR and GABA- BR was evaluated. When patients were divided into 4 groups based on the expression levels of these receptors, low GABA-AR expression as well as low GABA-BR expression in ICC was an independent prognostic factor for poorer prognosis. However, no differences were seen in overall survival among other three groups, suggesting that one GABA receptor compensate the shortage of another GABA receptor. GABA-AR and GABA-BR expression was negatively correlated with STAT3 activity evaluated by nuclear p-STAT3(Ser727) expression, vimentin expression, and MMP-9 expression in ICC, demonstrating that GABA signaling inhibits ICC invasiveness by inhib- iting STAT3-mediated EMT. Conclusion: GABA binds to GABA-AR and/or GABA- BR, and suppresses tumor invasiveness and metastasis of ICC by inhibiting EMT through STAT3 inactivation; therefore, GABA signaling is a promising therapy for pa- Figure 1 tients with advanced ICC.

The same result was achieved for recurrence-free sur- EP03A-031 vival (n = 0.797). Out of 49 irresectable tumors, diagnosed MALIGNANT INTRADUCTAL at exploration, 42 received chemotherapy, but none reached PAPILLARY NEOPLASM OF THE BILE secondary resectability. DUCT WITH INTRAHEPATIC RUPTURE Patients who received preoperative chemotherapy I. S. Choi, J. I. Mon and J. S. Lee reaching exploration and curative intended resection General Surgery, Konyang University Hospital, Republic have a comparable overall and recurrence-free survival of Korea to patients with initially resectable tumors. Therefore, it is important to perform regular re-staging imaging in Mucin producing intraductal papillary neoplasm of the bile patients who undergo chemotherapy for irresectable ICC duct(IPMN-B) has previously been reported in various terms and discuss these cases interdisciplinary at a tertiary including intraductal papillary neoplasia of the liver, mucin- center for liver surgery. hypersecreting biliary papillomatosis, and mucin-producing

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S695 cholagiocarcinoma. Malignant IPMN-B is a referred as Conclusion: The results showed R0 resection and LN intraductal growth type of intrahepatic chlangiocarcinoma metastasis to be the significant prognostic factors. LN (ICC),whichisararediseaseandrevealamorefavorable dissection for frequently metastatic sites might be necessary prognosis. Therefore we reported malignant intraductal to make a longer prognosis. In addition, R0 resection may papillary neoplasm of the bile duct with intrahepatic rupture. be mandatory to achieve long-term survival for patients Case report: A 52-year male was admitted for RUQ pain with distal bile duct cancer. and fever. Vital sign was stable and he showed mild tenderness of RUQ abdomen. Initial laboratory test revealed WBC 14700, Hg 11.7, Plt 132000, and AST/ALT of 1880/ EP03A-033 1770IU/L, T B 2.23mg/dL, AFP of 1.47ng/mL, ca19-9 of CLINICAL VALUE OF COMPLEX 16.2 U/mL, and Initial ABDO CT was shown subcapsular hemobilia in right liver with internal enhancing mass in left HEPATOBILIARY RESECTION FOR bile duct, so diagnosed malignant IPMN-B with intrahepatic ELDERLY PATIENTS IN AN AGING rupture. Pet-CT was shown no distant metastasis and the SOCIETY high FDG uptake in the tumor with in left bile duct. The S4 K. Akashi, T. Ebata, T. Mizuno, Y. Yokoyama, T. Igami, bile duct with mass was attached to middle hepatic vein, so J. Yamaguchi, S. Onoe and M. Nagino fi we performed a modi ed left hepatectomy with segmental Division of Surgical Oncology, Department of Surgery, resection of middle-hepatic vein and reconstruction with Nagoya University, Japan gore-tex. Operation time was 7hr 30 min and blood loss was Introduction: The purpose of the study is to evaluate the 350cc. It diagnosed well differentiated, 6x4x2.5cm sized, influence of patient age on surgical outcome of PCC and to intraductal papillary carcinoma of the bile duct. There was clarify the value of complex hepatobiliary resection for no metastasis of regional lymph node. The patient had no elderly patients in an aging society. postoperative complications and was discharged. Methods: Between April 1977 and December 2015, Conclusion: Through precise preoperative diagnosis and medical records of consecutive patients with PCC who wide complete resection of malignant IMN-B, a more underwent resection were retrospectively reviewed, with favorable prognosis can be expected. special attention to patient age. Results: During the study interval 831, patients underwent resection for PCC. Before 2001 no octogenarians underwent EP03A-032 the surgery, but their proportion increased to 9 % after 2010. LYMPH NODE METASTASIS IN MIDDLE Further analyses were performed using 643 resected patients between 2001 and 2015. Charlson Comorbidity Index and AND LOWER BILE DUCT CANCER: preoperative laboratory data were similar between the two PROGNOSTIC IMPACT AND groups. Bile duct resection without hepatectomy was DISTRIBUTION applied in 10% in the octogenarians. Combined pancreato- A. Urakami1, N. Ishida1, M. Takaoka1, T. Yamatsuji1 and duodenectomy or portal vein resection was less frequently K. Yoshida2 performed in the octogenarians. Less advanced tumor was 1Department of General Surgery, and 2Department of more frequently in the octogenarians compared to the other Pancreatology, Kawasaki Medical School, Japan patients. The proportion of R0 resection was higher in the octogenarians than in the others (95.0% vs. 78.3%, P = Background: Lymph node (LN) metastasis is one of the 0.008). The ratio of patients who died of other diseases was progonostic factors in middle and lower bile duct cancer. higher in the octogenarians (29.2 % vs 6.0%, P < 0.001). Aim: To evaluate the prognostic significance of clinico- Overall survival was almost identical between the two pathological factors and the distribution of LN metastasis in groups (40.9% vs. 38.9% at 5 years). middle and lower bile duct cancer. Conclusions: Surgery for PCC can be performed with low Methods: We reviewed the medical records of 72 patients mortality irrespective of age, under careful patient selec- of surgically treated middle and lower bile duct cancer tion, and offers long-term survival even in octogenarians. between 1994 and 2016. Age, gender, operative procedure, Elderly patients with PCC should not be precluded from depth of invasion, LN metastasis (n), tumor size, pancreatic surgery due to age. invasion, portal venous invasion(pv), exposed margin (em), hepatic side ductal margin, radial margin (rm), histological differentiation, tumor infiltration, lymphatic invasion, and perineural invasion were investigated. The distribution of EP03A-035 LN metastasis was classified, and the frequency of metas- PERIHILAR CHOLANGIOCARCINOMAS tasis was investigated. (KLATSKIN’ S TUMORS) AND Results: There were 59 male and 13 female. The overall 5- KLATSKIN MIMICKING LESIONS. AN year survival rate was 49.9% and MST was 49 months. Four factors; pv, n, em, and rm were analyzed to be sig- UNRESOLVED DILEMMA nificant prognostic factors by univariate analysis. Those K. Tsalis, D. Konstantaras, S. Simeonidis and I. Mantzoros four factors were reanalyzed by multivariate analysis. Two D’ Surgical Department, Aristotle University of Thessa- factors, n (p=0.04326) and rm (p=0.00479) were found to loniki, Greece be the significant prognostic factors. There were 28 Introduction: Perihilar cholangiocarcinoma(Klatskin’s (38.4%) LN positive patients. LN#13 (posterior pancreati- tumor), is a rare malignancy that arises in the confluence of coduodenal) showed the highest rate of metastasis, the hepatic ducts of the porta hepatis and it has a rather followed by LN#12 (hepatoduodenal ligament), and LN#8 poor prognosis. There are number of lesions that mimic (common hepatic artery). these tumors and lead to misdiagnosis, resulting in major

HPB 2018, 20 (S2), S685eS764 S696 Electronic Poster (EP03A-EP03F) e Biliary complex operations with high morbidity and considerable Introduction: Recently we have reported that inhibition of mortality. These lesions are known as “Klatskin-mimicking Notch1 by xanthohumol, prenylated chalcone, reduced the lesions”. growth of cholangiocarcinoma cell lines. In this study, we Methods: We analyzed our prospectively established bile determine the role of keap1/Nrf2-Notch-STAT3 in the duct tumor database. The last 20 years we treated 73 pa- regulation of cholangiocarcinoma cell proliferation. tients who were referred to our tertiary center with a pri- Methods: Human CCA cell lines were treated with mary diagnosis of perihilar cholangiocarcinoma. All of the increasing concentrations of xanthohumol and Western patients underwent thorough evaluation before the decision analysis was carried out for the levels of keap1/Nrf2-Notch- of treatment was made. STAT3 axis proteins as well as apoptotic markers. Notch1, Results: Seventy three patients were managed as having a Keap1, and Nrf2 loss-of gene function by shRNAs and perihilar cholangiocarcinoma but in only 59 of them the their effects were analyzed. final histopathological examination confirmed the preop- Results: Dose dependent reduction of Keap1 with corre- erative diagnosis. In 14 patients the final diagnosis differed sponding level of Notch1 reduction with xanthohumol from the primary cause of referral and the lesions were treatment was observed. Importantly, this is associated with a regarded as “Klatskin-mimicking lesions”. Five patients reduction in phosphorylated STAT3 without affecting the had intrahepatic lithiasis, 4 patients had Mirizzi syndrome, levels of total STAT3 proteins. Notch1 depletion signifi- one patient had portal lymphadenopathy secondary to rectal cantly reduced the levels of STAT3 phosphorylation. Growth cancer, one patient had non functioning neuroendocrine suppression due to apoptosis was evidenced by an increase in tumor, 1 intrahepatic gastrinoma , and two patients had the pro-apoptotic marker, cleaved PARP and caspase-3. IgG4 cholangiopathy. Conclusion: Xanthohumol treatment reduced keap1, Conclusion: Clinicians should always have a high suspi- Notch1 and phosphorylated STAT3 proteins. Notch1 spe- cion of “Klatskin-mimicking lesions” when they evaluate a cific depletion showed reduction in STAT3 phosphoryla- patient for the possibility of a perihilar cholangiocarcinoma tion suggested that Notch1 affects STAT3 pathway. This so that they can avoid misdiagnosis and propose a proper provides evidence to the role of keap1/Nrf2-Notch-STAT3 treatment. Based in our experience we propose an algo- signaling pathway in cholangiocarcinoma. This is the first rithm for the management of these patients study to show the importance of keap1/Nrf2-Notch-STAT3 signaling axis for the cholangiocarcinoma cell proliferation.

EP03A-036 DOES 3-D PRINTED MODELING OF EP03A-038 INTRAHEPATIC SURGICAL TREATMENT OF CHOLANGIOCARCINOMA HELP IN CHOLANGIOCARCINOMA AT A SINGLE THE ACTUAL PERFORMANCE OF INSTITUTION OVER 2 DECADES RESECTION? A CASE REPORT J. Stauffer1, K. Croome2, L. Tsamalaidze1, J. Burns2, 1 2 3 4 3 fi H. Asbun , D. Lee , P. Kasi , D. Harnois and K. Mody M. Assi , M. Chung and G. Wright 1 2 3 4 Surgery, Michigan State University, United States Surgery, Transplant Surgery, Oncology, and Trans- plant Hepatology, Mayo Clinic, United States Introduction: Surgical resection of intrahepatic chol- angiocarcinoma can be very challenging. We sought to Introduction: Bile duct adenocarcinoma develops at determine if 3-D printed model of the liver/tumor model various regions and surgical treatment of chol- would aid in the performance of curative resection. angiocarcinoma (CCA) includes pancreaticoduodenectomy Method: Patient’s preoperative imaging (CT and MRI) (PD), liver resection (LR), extrahepatic bile duct resection was used to create a 3-D printed model of the liver and (EHBDrxn), LR+EHBDrxn, and orthotopic liver trans- tumor. Specifically, liver parenchyma was transparent/ plantation (OLT). This study reviews the surgical treatment lucent, while the tumor and other vital structures were of CCA including surgical outcomes, recurrence, and overall colored in different hues to aid at the time of surgery. survival at a single institution over a 22-year time period. Results: We were able to carry out our surgical resection. Methods: 170 patients undergoing surgical resection of 3-D printed model was helpful in intraoperative decision CCA from 1995 to 2016 were reviewed. Patients with making. It was easier to carry out the surgical resection with gallbladder or mixed hepatocellular variant malignancies the model in the OR room e than utilizing 2 dimensional were excluded. 90-day complications, recurrence, and preoperative imaging that is conventionally used. survival were compared between types of CCA and sur- Conclusion: 3-D printed model of the liver and intrahepatic gical interventions for CCA. cholangiocarcinoma has some potential in aiding the sur- Results: Extrahepatic, hilar, and intrahepatic CCA was geons in the operative room. noted in 31 (18.2%), 75 (44.1%), and 64 (37.6%) respec- tively. The mean age and BMI was 61.7 years and 27.2 respectively and were predominately male (121, 71.2%). Surgical treatment included PD, LR, EHBDrxn, EP03A-037 LR+EHBDrxn and OLT in 31 (18.2%), 40 (23.5%), 6 ROLE OF KEAP1/NRF2/NOTCH-STAT3 (3.5%), 37(21.8%) and 56 (32.9%) respectively. Mean SIGNALING IN operative time and blood transfusions given was 334 mi- CHOLANGIOCARCINOMA nutes and 4 units respectively. Average length of stay was 11.5 days and overall major complications occurred in 59 S. Kunnimalaiyaan, T. C. Gamblin and (34.7%) including reoperation in 13 (7.6%) and mortality in M. Kunnimalaiyaan 6 (3.5%). Mean tumor size was 4.2 cm and 39 (22.9%) Surgery, Medical College of Wisconsin, United States

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S697 patients had node positive disease. Recurrence was noted in Methods: Patients who had undergone IHC resection at the 74 (43.5%) at a mean of 23 months. Overall survival was Singapore General Hospital between 1997 to 2017 were found in 61 (35.9%) at a mean of 39.7 months. identified from a prospective database. HBV status and Conclusion: Surgical treatment of CCA is optimal. OLT other relevant clinicopathological data was collected. for hilar and incidental intrahepatic CCA results in the best Results: 91 patients were identified, of whom 36 (39.6%) survival. were HBV positive. The mean age was 65.3 years (s.d. 13.1), 62.6% were males and 81.3% were Chinese (Indian: 3.3%, Malay: 5.5%, Others: 9.9%). Among HBV patients, EP03A-040 significantly more patients (61.1%) had cirrhotic livers PRE-OPERATIVE IMAGING compared to HBV-negative patients (24.0%), with p value fi CHARACTERISTICS IN HEPATITIS B e 0.08. There was no signi cant difference in both groups in terms of pre-operative bilirubin, mean Ca19-9, size and ASSOCIATED, HISTOLOGY-PROVEN number of lesions. There was no significant difference in RESECTED INTRAHEPATIC survival rates between HBV positive and negative patients CHOLANGIOCARCINOMA who underwent resection for ICC (log rank test P = 0.273). N. Cheng1, J. Y. Teo2, N. Khoo2 and D. Cheah1 The median 3-year survival rate for HBV positive patients 1National University of Singapore, Singapore, and is 82.0% and 63.0% for HBV negative patients. Median 5- 2Singapore General Hospital, Singapore year survival rate for HBV positive patients is 50.0%, and 43.0% for HBV negative patients. Introduction: Despite being different diseases, intrahepatic Conclusion: HBV is correlated with greater incidence of cholangiocarcinoma(ICC) can show imaging characteristics cirrhosis, mixed hepatocellular-cholangiocarcinoma and similar to hepatocellular carcinoma (HCC) on Computed involved margins. There was no significant difference in Tomography scans (CT) and Magnetic Resonance Imaging biochemical markers, size and number of lesions, and (MRI). Also, hepatitis B has been associated with both HCC survival. However, in view of the relatively small sample and ICC. The objective of this study is to evaluate the as- size, type 2 error cannot be ruled out. sociation of specific imaging characteristics (arterial enhancement, portal venous washout) to that of Hepatitis B virus infected (HBV) patients with ICC. Methods: Data on patients with HBV-associated ICC, un- EP03A-042 TH dergoing surgical resection at the Singapore General Hospital VALIDATION OF THE AJCC8 were identified from a prospectively-kept database. Pre-oper- EDITION STAGE IN DISTAL BILE DUCT ative cross-sectional imaging characteristics were analyzed. CANCER Results: 34 patients with HBV-associated ICC underwent resection between 1 January 2000 to 31 December 2016. D. J. Park, I. W. Han, J. S. Heo, D. W. Choi and The mean age was 60.79 (+/À12.25) years with a total of 20 S. H. Choi males, of which 29 were Chinese, 1 was Malay and 4 were Samsung Medical Center, Republic of Korea foreigners. In addition, the median number of lesion was 1 Purpose: This study evaluated discriminatory value of th (range 1 to innumerable), mean maximum size of lesions newly proposed AJCC 8 staging system compared to the th (mm) was 49.38mm (+/À32.00mm) and mean AFP value AJCC 7 staging system for distal bile duct cancer. was 340.29 (+/À1738.78). Of the 29 patients who did CT, Methods: We retrospectively reviewed database of 172 13 who did MRI and 9 who did both, 23 showed arterial patients who underwent surgery for distal bile duct cancer enhancement and 13 showed portal venous washout, while at a single institute from January 2002 through June 2011. 12 showed both on at least one imaging modality. Clinicopathologic characteristics and survival rates were th th Conclusions: Many HBV patients with ICC showed imaging analyzed based on 7 and 8 edition of AJCC staging characteristics of arterial enhancement and a significant pro- system, respectively. portion had portal venous washout. In the population of HBV Results: Among pathologically-stage patients, P values for th positive patients, ICC can mimic HCC on preoperative im- pairwise comparisons among different 8 AJCC stage were aging, and should be borne in mind as a differential. significant(P< 0.05) for stage IIa vs IIb only(P=0.012). C- index for adenocarcinoma was: 0.717 according to the 7th edition of AJCC and 0.717 according to the clinical 8th EP03A-041 edition of AJCC. CLINICOPATHOLOGICAL Conclusions: There was no prognostic improvement following new 8th edition of AJCC compared to 7th edition CHARACTERISTICS OF HEPATITIS B of AJCC. (HBV) ASSOCIATED RESECTED INTRAHEPATIC CHOLANGIOCARCINOMA (IHC) EP03A-043 D. Cheah1, N. Cheng1, J. Y. Teo2 and N. Khoo2 OPTIMAL SURGICAL PROCEDURE FOR 1National University of Singapore, and 2Singapore Gen- T1 AMPULLARY CANCER BASED ON eral Hospital, Singapore TREATMENT OUTCOME AND Introduction: The incidence of IHC has been rising over PATHOLOGICAL ANALYSIS the past two decades in Asia. While many risk factors are known, its link with HBV is less clear. This study aims to N. Kimura, K. Ishido, D. Kudo, S. Sakuraba, T. Kagiya, explore the effect of HBV on the clinicopathological Y. Wakasa and K. Hakamada characteristics of pre-resected IHC. Gastroenterological Surgery, Hirosaki University, Japan

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Introduction: Pancreaticoduodenectomy (PD) has been Results: 26,2% patients (11) with diagnosis of DCC established as the standard surgical procedure for ampul- experienced major post-operative complications (Clavien lary cancer. Alternatively, ampullectomy (PR) has also  3A), vs 14,8%(44) with PADC (p = 0,074). The POPF been performed for benign tumors and early cancers (T1). rate, overall and grade B-C was 59,5% and 56% in DCC, The aim of this study was to evaluate the prognostic in- 19% and 53% in PDAC (p < 0,000 and p = NS) respec- dicators for recurrence and survival after curative resection tively. The median OS in DCC patients was 39,2Æ6 for ampullary cancer and to investigate whether PR can months better than PDAC (23 Æ 2 months, p=0,006). The substitute for PD in T1 ampullary cancer. median DFS was 25Æ8 months for DCC patients vs 12 Æ Methods: Eighty-eight consecutive patients with 1months for PDAC. Interestingly in the DCC group the ampullary cancer underwent initial curative resection (73 developing of POPF didn’t statistically affect the OS (45 vs PD, 15 PR) between 1985 and 2016. Clinicopathologic 36 months, p = 0,45) or DFS(37 vs 28 months, p = NS). In factors for recurrence and survival were evaluated this group the patients with lower stage experienced more retrospectively. postoperative complications and POPF (p = 0,01). Never- Results: In univariate analysis, preoperative biliary thless 54,4%(6/11) of patients with Clavien  3A under- drainage, high level of CA19-9, non-exposed protruded went chemotherapy. type, moderate or poor differentiation, pT2-4, lymph node Conclusions: Despite the higher rate of postoperative metastasis (pN1), microvascular invasion, lymphovascular complications after pancreaticoduodenectomy for DCC the invasion, and perineural invasion were significant factors procedure ensures a better survival respect PDAC. Also for both recurrence and survival (p < 0.05). In multivariate postoperative complications seem not to affect the OS and analysis, high CA19-9 (p = 0.036), moderate or poor dif- DFS of the patients. In DCC patients strategies to minimize ferentiation (p = 0.041), pT2-4 (p = 0.040), and pN1 (p = the severity of complications could improve their outcomes 0.008) were independent factors for recurrence, and high in particular in early stages. CA19-9 (p = 0.030) and pN1 (p = 0.006) for survival. High CA19-9 (p = 0.030) and pT2-4 (p = 0.048) predicted pN1. Of the 37 patients with pT1, four (10.8%) had pN1. Six EP03A-045 (40.0%) of 15 patients (12 pT1, 3 pT2) undergoing PR had LAPAROSCOPIC LEFT HEPATECTOMY recurrence. Conclusions: High CA19-9 and pN1 were the most FOR KLATSKIN TUMOUR important predictor for poor prognosis after radical surgery J. Bezsilla for ampullary cancer, therefore, more effective systemic B-A-Z County Central Hospital, Hungary adjuvant therapy should be considered in such patients. We Introduction: Surgical management of hilar chol- suggest that PD is the optimal surgical procedure even for angiocarcinoma remains the only treatment option with T1 cancer. PR should be selected carefully due to the high curative intent and potential influence on overall survival. rate of recurrence. Methods: In our case report, we describe a complete laparoscopic resection of Klatskin’s tumour which consists of left hepatectomy with intracorporeal biliary reconstruc- EP03A-044 tion with Roux-en-Y hepaticojejunostomy. SURVIVALS OF DISTAL Results: A 28-year-old woman presented with obstructive CHOLANGIOCARCINOMA AND jaundice without other symptoms. Her CEA, Ca-125, AFP and Ca 19-9 values were normal. CT, ERCP and MRCP PANCREATIC ADENOCARCINOMA showed a Bismuth type III.b. neoplastic lesion, without AFTER vascular involvement. Diagnostic laparoscopy was PANCREATICODUODENECTOMY: performed with ultrasonography. Cholecystectomy with POST-OPERATIVE COMPLICATIONS resection of the extrahepatic biliary ductal system and REALLY MATTER? transection of prestenotic right biliary branch was done. Left branches of the hepatic artery and portal vein were fi1 1 2 3 C. Ridol , G. Capretti , F. Gavazzi , M. Cereda , clipped and hepatoduodenal lymphadenectomy were 2 1 1 G. Nappo , B. Branciforte and A. Zerbi performed. Segment II-IV were removed without caudate 1 Humanitas University, Humanitas Clinical and Research lobectomy and left hepatic vein was clipped. After removal 2 3 Center, Humanitas Research Hospital, and University of the specimen through a minilaparotomy and construction a Milano-Bicocca, Italy Roux-en-Y loop bilioenteric anastomosis was performed Introduction: Patients who underwent a pancreaticoduo- using total laparoscopic procedure. The operation time was denectomy for cholangiocarcinoma (DCC) and pancreatic 255 minutes with intraoperative blood loss of 200 ml. The ductal adenocarcinoma (PDAC) behave differently for pathologic result showed a GII., pT2b, pN0 primary hilar survival and postoperative complications. The correlation cholangiocarcinoma with all resected margins and nodes between these two outcomes is still debated. free of tumour (0/4), with perineural but no vascular in- Methods: We analyzed data prospectively collected from vasion. The postoperative hospital stay was uneventful and 575 consecutive patients underwent a pancreaticoduode- the patient was discharged on day 14. The patient had nectomy from January 2010 to June 2017 in our center. Of adjuvant gemcitabine, 5-FU combination chemotherapy. these, 42 patients were resected for DCC (8%) and 301 for The patient is well at 12-month visit with normal results of PDAC (52%). Descriptive and inferential analysis were liver function test and MRCP. conducted. Overall survival (OS) and disease free survival Conclusion: Laparoscopic resection is a feasible surgical (DFS) were analyzed with Kaplan-Meier method. approach in selected patients with hilar cholangiocarcinoma.

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S699

EP03A-046 EP03A-049 IS GANGLION 5 BIOPSY INEFFICIENT EPIDERMAL GROWTH FACTOR IN A HILAR CHOLANGIOCARCINOMA RECEPTOR AS PROGNOSTIC FACTOR DIAGNOSIS? A MINI SERIES OF IN CHOLANGIOCARCINOMA DIFFICULT INOPERABLE CASES L. D. P. Lima1, V. Resende1, P. T. V. Vidigal2, 2 2 O. Ginghina, R. Iosifescu, A. Spanu, S. Omer, M. Zamfir, C. J. Machado , R. Vieira Gomes and 2 D. Baboi, R. Mirica, A. Stoica and N. Iordache M. Angela Rodrigues 1 2 St John Emergency Hospital, Romania Surgery, and Universidade Federal de Minas Gerais, Introduction: The difficulty to set a histopathological Brazil diagnosis in patients with cholangiocarcinoma is a Introduction: The role of EGFR in hepatic malignancies is challenge not clearly understood. The purpose of this study was to Methods: We present 7 cases of cholangiocarcinoma for evaluate if the overexpression of EGFR in chol- witch was performed an excisional biopsy of ganglion 5. angiocarcinomas (CCA) is associated with clinical and For this patients the histopathological diagnosis was not pathological factors and survival. able to be performed neither by endoscopic of ecoendo- Methods: EGFR expression was assessed by immunohis- scopic maneuver. 5 cases were made by laparoscopic tochemistry in 35 resected specimens of CCA. Survival approach and 2 by open procedure. curves were analysed by the Kaplan-Meier method. The Results: All the results from the biopsies were inconclusive Log rank test was used to compare positive and negative and indicated inflammation groups. Conclusions: Although the mini series was not on a Results: A significant EGFR expression was found in 10 large number of cases, the examination of ganglion 5 (28.6%) of the 35 CCA, 8 with a score of 3 and 2 with a was not edifying in establishing the histopathological score of 2. Advanced stages (III and IV) presented higher results in patients with cholangiocarcinoma and present EGFR expressions (p = 0.071). The clinical characteristics metastasis. with the highest association with positive expression were female (p = 0.06) and the absence of comorbidities (p = 0.07). Overall survival at 12, 24, 36 and 48 months were EP03A-048 100%, 82.5%, 59% and 44.2%, respectively. Positive EGFR survival at 12, 24, 36 and 48 months was 100%, PREOPERATIVE PLATELET TO 75%, 50% and 0%, while negative EGFR was 100%, 87.5, LYMPHOCYTE RATIO AS AN 65.6% and 65.6%, respectively. INDICATOR OF POOR PROGNOSIS IN Conclusions: EGFR expression occurred in 28.6% of the PATIENTS WITH INTRAHEPATIC studied CCA and was associated with a shorter patient CHOLANGIOCARCINOMA survival rate. K. Ramen and Y. Shan First Affiliated Hospital of Wenzhou Medical University, China EP03A-050 Introduction: Intrahepatic cholangiocarcinoma (ICC) is a IF ONE IS NOT GOOD, TWO IS WORSE: rare and fatal malignancy with very poor prognosis.The SYNCHRONIC COMMON BILE DUCT present study was aimed to investigate the prognostic sig- ADENOCARCINOMA AND LARGE CELL nificance of the PLR in ICC patients. NEUROENDOCRINE TUMOR Methods: Data from 90 intrahepatic cholangiocarcinoma S. K. Pimentel1,2, C. Popovicz2, P. A. De Almeida2, patients who underwent surgery between 2007 and 2016 D. G. Sakamoto3, R. M. Azevedo3 and R. O. P. Campos3 were evaluated retrospectively. Platelet and lymphocyte 1Sugisawa Medical Center, 2Surgery, Universidade Fed- counts were obtained 3 days before surgery. The optimal eral do Parana, and 3Sugisawa Medical Center, Brazil cut off value for the PLR of 153 was calculated using receiver operating curve analysis. Overall survival was Introduction: Bile duct cancer, also known as chol- assessed using the Kaplan Meier method. angiocarcinoma, is responsible for approximately 3% of all Results: The 1-, 3-, 4- year overall survival rates of all gastrointestinal malignancies. Although this type of cancer cases were 55.6%, 13.3% and 2.2% respectively. The is rare, it is highly lethal since the diagnosis is usually made median survival time was 13.5 months. Our results showed at the advanced stage of the disease. Regarding the histo- that PLR represents an independent adverse prognostic logical type, there is a great variety of presentation, some factor in for both overall survival and recurrence free sur- types being extremely rare. The most frequent is the well- differentiated adenocarcinoma (AC) that accounts for vival. The 3 year OS and RFS rates after resection were 3 10.9% and 4.3% for the group with PLR greater than 153, approximately 80% of the cholangiocarcinomas .In compared with 15.9% and 13.6% for the group with PLR contrast, the neuroendocrine tumor (NET) has a small number of reported cases, particularly in extrahepatic less than 153 respectively. The results clearly show a dif- 3 ference in survival. biliary ducts, which are extremely rare when primary . Conclusion: Preoperative platelet to lymphocyte ratio Isolated cases of these histological types are rare, but the may be used as a prognostic factor for survival in intra- synchronous occurrence of more than one type is even hepatic cholangiocarcinoma in patients who underwent more unusual. Due to its rarity, the aim of this report is to hepatic resection. Further investigation on the subject is present a case of synchronic common bile duct tumors, with required. its histology adenocarcinoma "in situ" and large cell neuroendocrine tumor.

HPB 2018, 20 (S2), S685eS764 S700 Electronic Poster (EP03A-EP03F) e Biliary

Methods: Report of a rare case of synchronic common bile Background: The role of staging laparoscopy (SL) in pa- duct tumors, adenocarcinoma and large cell neuroendocrine tients with intrahepatic cholangiocarcinoma (IHC) remains tumor in a 51 year old man, with classical findings of distal unclear. Despite extensive preoperative staging, a subset of bile duct malignancy which after a apparently successful patients presents with unresectable IHC at laparotomy. The radical surgery had a very complicated follow up with early aim of this study was to assess the yield and sensitivity of SL aggressive metastatic disease recurrence. in patients with IHC and to potentially identify predictors for Conclusion: Even with the increasing number of bile duct detecting metastasized or locally advanced IHC at SL. adenocarcinoma diagnosis, it is still a rare cause of diges- Methods: We retrospectively collected records of all pa- tive tract malignancy. The concomitance of adenocarci- tients with potentially resectable IHC, presenting at our noma with NET in the extrahepatic bile duct makes this institution from 2000e2017. The yield and sensitivity of case unique. SL was calculated. Reasons for unresectability at SL or laparotomy were recorded. Results: Among a total of 65 patients with potentially EP03A-051 resectable IHC, 36 underwent SL on the suspicion of distant EVALUATION OF PERIOPERATIVE metastases. Unresectable disease was found in 14 patients (yield 38,9%). Two patients did not undergo laparotomy due TREATMENT STRATEGY FOR to progression after SL. Of the remaining 20 patients who INTRAHAPETIC underwent laparotomy, 7 patients had unresectable disease. CHOLANGIOCARCINOMA ON The overall sensitivity of SL for resectability was 70%. CLINICOPATHOLOGICAL ANALYSIS Conclusion: Despite improved imaging techniques, stag- ing laparoscopy showed to be still useful in detecting N. Kimura, S. Sakuraba, K. Ishido, D. Kudo, unresectable IHC in our cohort. Y. Wakasa and K. Hakamada Gastroenterological Surgery, Hirosaki University, Japan Introduction: Intrahepatic cholangiocarcinoma (IHCA) EP03B - Electronic Poster: 3B - Biliary generally has poor prognosis and surgical resection is the only curative treatment. However, 5-year survival rate is Gallbladder Cancer still around 30%. Cases in our department were analyzed to EP03B-001 explore better treatment plans. SAFETY AND INDICATION OF Methods: Total of 33 patients with IHCA underwent sur- SURGICAL TREATMENT FOR gical resection between June 2000 and October 2016 in our ELDERLY PATIENTS WITH hospital. Five (15.9%) were of intraductal growth type (IG), 23 (71.8%) were of mass forming type (MF), 1 (3%) was of GALLBLADDER CARCINOMA periductal infiltrating type (PI), and 4 (12.5%) were of M. Utsumi, H. Aoki, Y. Une, Y. Mushiake, H. Kashima, MF+PI. We examined the cases excluding the 5 cases of IG F. Taniguchi, T. Arata, K. Katsuda and K. Tanakaya considered to have relatively favorable prognosis. Department of Surgery, National Hospital Organization, Results: Three patients underwent TACE preoperatively Iwakuni Clinical Center, Japan and 9 patients received adjuvant chemotherapy. Five-year Introduction: With average life expectancy rising glob- survival rates of overall survival (OS) and disease-free ally, gallbladder carcinoma (GBC), a common malignancy survival (DFS) were 42.1% and 20.2%, respectively. Uni- with a poor prognosis is predicted to show higher incidence variate analysis revealed that tumor differentiation (P = in elderly patients in the future. We analyzed surgical in- .049) and lymph node metastasis (P = .031) were signifi- dications and their safety in elderly GBC patients aged  cantly associated with OS, while bile duct invasion (P = 75 years and compared surgical outcomes between elderly .005) and lymph node metastasis (P = .001) were signifi- and younger GBC patients. cantly associated with DFS. Tumor differentiation (P = Methods: We retrospectively compared clinicopatholog- .003) and lymph node metastasis (P = .031) remained ical data and treatment outcomes in 22 patients aged  75 independently associated with long-term survival by years (elderly group) and 22 patients aged < 75 years multivariate analysis. All 3 cases that were initially deemed (younger group) among 44 consecutive GBC patients who unresectable were resectable by preoperative TACE, but underwent curative resection at Iwakuni Clinical Center did not improve survival. between February 2008 and September 2017. Conclusions: Prognostic factors were similar to previous Result: The proportion of preoperative comorbidities was reports. Preoperative TACE was superior in local control significantly higher in the elderly than in the younger group but did not improve survival. For future treatment strategy, (P = 0.02), as was the number of patients with pancreato- preoperative TACE and systemic chemotherapy may be biliary malfunction. The American Society of Anesthesi- useful for acquiring curative resection and better survival. ologists score was higher in the elderly than in the younger group (P = 0.06), and they also showed a significantly shorter operation time. Postoperative delirium (P = 0.05) or EP03A-052 postoperative hypoalbuminemia (P = 0.03) was more STAGING LAPAROSCOPY IN PATIENTS common in the elderly than the younger group. Liver function, body mass index, tumor staging, blood loss, and WITH INTRAHEPATIC postoperative complications did not significantly differ CHOLANGIOCARCINOMA between the groups. Both groups showed no operative L. C. Franken, R. J. Coelen, E. Roos, M. G. H. Besselink, mortality. Overall 3-year survival rates were comparable O. R. C. Busch and T. M. van Gulik between the groups (younger 68% vs. elderly group 61%, Academic Medical Center Amsterdam, Netherlands log-rank test P = 0.55).

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Conclusion: Surgery can be safely performed in elderly Results: A total of 37 patients with gallbladder cancer were GBC patients who can benefit as much as younger patients identified between July 2009 and September 2016 with at through careful patient selection. least 6 months of follow-up. Ten (27%) patients were females and 27 (73%) were males. The mean age at time of diagnosis with gallbladder cancer was 53.4 Æ 13.7 years. The mean EP03B-002 follow up period was 1.3 Æ 1.3 years. The overall patient METASTATIC POLYP OF THE survival from time of diagnosis until the last follow-up was 54.1%. Predictors of outcome were checked using univariate GALLBLADDER FROM RENAL CELL and multivariate Cox’s regression analyses that revealed CARCINOMA PLR< 200 and surgical resection are associated with better S. -E. Wang and Y. -M. Shyr survival. Patients who had metastatic disease showed Taipei Veterans General Hospital, Taiwan, Republic of significantly higher NLR and PLR at time of diagnosis. China Conclusion: NLR and PLR can be simple and valuable Background: Gallbladder metastasis from renal cell car- prognostic markers of gallbladder cancer. cinoma (RCC) is extremely rare. The purpose of this study is to clarify the characteristics of metastatic RCC to gallbladder. EP03B-004 Methods: The pooled data for analysis were collected from APPROACH TO T2 GALLBLADDER gallbladder metastasis from RCC cases encountered by our CANCER ACCORDING TO THE TUMOR institution along with sporadic cases reported in 35 English LOCATION AND ITS SURGICAL articles from 1991 to 2015. Results: A total of 50 cases of metastatic RCC to the EXTENT gallbladder were recruited for study, including 49 from K. J. Kang, K. S. Ahn, Y. H. Kim, T. -S. Kim and literature and 1 from our institution. 57% of the primary J. W. Lee RCC was from the right kidney and 43% of the left. The Surgery, Keimyung University Dongsan Medical Center, median interval between diagnoses of primary and meta- Republic of Korea static RCC to gallbladder was 36 months, with the longest Background: The clinical behavior of T2 gallbladder duration up to 324 months. Most 70% were asymptomatic. cancer varies among patients. The aims of this study were The size of metastatic RCC to gallbladder ranged from 0.8 to identify prognostic factors for survival and recurrence, cm to 9 cm, with median of 2.6 cm. Majority (91%) of the and to determine the optimal surgical strategy for T2 gall- metastatic RCCs presented as a polypoid mass with narrow bladder cancer. stalk, and 82% were hypervascular lesion. The overall 1 Methods: We conducted a retrospective analysis of 78 year, 3 year and 5 year survival rate was 91.5%, 76.2% and patients with T2 gallbladder cancer who underwent surgical 59.3% respectively, with a median of 26.5 months. Number resection for gallbladder cancer. of the metastatic site, timing of metastasis gallstone, Results: Twenty-eight (35.9%) patients underwent simple symptom, tumor size and operation type of cholecystec- cholecystectomy and 50 (64.1%) underwent extended tomy seemed to have no impact on survival. cholecystectomy. Among 56 patients without LN metas- Conclusions: Metastatic RCC to the gallbladder should be tasis (n = 20) or unknown LN status (no LN dissection, n = taken into account for a gallbladder polypoid mass with 36), the 5-year disease-free survival rates were 81.6%, and narrow hypervascular stalk during the diagnosis and/or 69.8% (P = 0.080). In an analysis according to tumor follow-up of primary RCC. location, patients with tumors located on the hepatic side (n = 36) had a higher recurrence rate than patients with tumors located on the peritoneal side only (n = 35) (P = 0.043). On EP03B-003 multivariate analysis, R1 resection and lymph node PROGNOSTIC VALUE OF metastasis were significant, independent prognostic factors NEUTROPHIL/LYMPHOCYTE AND for poor diseasefree and overall survival. Conclusion: R0 resection and LN dissection are an PLATELET/LYMPHOCYTE RATIOS IN appropriate curative surgical strategy in patients with T2 GALLBLADDER CANCER gallbladder cancer. Tumors located on the hepatic side R. Abu-Nuwar1, W. Elmoghazy1,2, A. Elaffandi1,3 and show worse prognosis than tumors located on the peritoneal H. Khalaf1 side only, hepatic resection should be considered. 1Surgery, Hamad Medical Corporation, Qatar, 2Surgery, Sohag University, Egypt, and 3Surgical Oncology, Na- tional Cancer Institute Cairo University, Egypt EP03B-005 Objective: To look the prognostic role of inflammatory EFFECTS OF PREOPERATIVE markers in gallbladder cancer. SARCOPENIA ON PROGNOSIS AFTER Patients and methods: All patients diagnosed with gall- RESECTION OF GALLBLADDER bladder cancer in our institute were included in this study except for patients presented with cholangitis. Patients were CANCER diagnosed through imaging and biopsy. The NLR was E. C. Lee, S. -J. Park, J. R. Shim, H. M. Park, S. D. Lee, defined as the absolute neutrophil count in peripheral blood S. -S. Han, S. H. Kim, S. -W. Park, J. -H. Park and divided by the absolute lymphocyte count and PLR was B. G. Na defined as the platelet count divided by the absolute Center for Liver Cancer, National Cancer Center, Re- lymphocyte. Both ratios were calculated at time of diagnosis. public of Korea

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Background and aim: The impact of sarcopenia on the Results: Sixty-seven patients were included in the study. prognosis for patients with gallbladder cancer (GBC) is Median age of presentation was 50 years and 83.6% (n=56) unclear. The aim of this study was to determine the prog- were females. Groups 1 and 2 had 19(28.4%) and nostic significance of sarcopenia in patients with GBC. 48(71.6%) patients respectively. Modality of presentation Methods: From March 2001 to December 2013, 158 pa- was referral with histopathological report(early) and pre- tients with GBC who underwent curative intent surgery sentation after onset of clinical symptoms(late) in 39 and 28 were included in this study. Patients were classified into patients respectively. Incidence of higher pT stage(p = two groups according to the presence or absence of 0.01), metastatic disease(p < 0.01) and palliative sarcopenia, which was based on the calculated skeletal management(p = 0.03) was higher in group 2. Thirty-three muscle mass index (SMI) using abdominal computed underwent DL. 21/33 underwent curative surgery(9- tomography. extended-cholecystectomy;8- hepatic-duct-resection;4- Results: The 1-, 3-, and 5-year overall survival (OS) rates multiorgan-resection). Overall mean survival rate was 23.5 were 63.6%, 41.9%, and 36.4%, respectively, for patients months. Longer survival was seen in group 1(95%CI:20.3- with sarcopenia, and 84.3%, 62.6%, and 54.3%, respec- 50.4months;p=0.05), early presentation(95%CI:16.6- tively, for those without sarcopenia (P = 0.006). However, 38.6months;p = 0.04) and after curative surgery(95% recurrence-free survival (RFS) rates did not show any dif- CI:37.6-63.6months;p < 0.01). Administration of chemo- ference according to sarcopenia status (P = 0.490). Multi- therapy in metastatic IGBC had longer survival(95% variate analysis showed that sarcopenia (hazard rate [HR] CI:6.90-17.5months;p < 0.01). 1.704, P = 0.024) was a significant prognostic factor for Conclusion: Significant proportion of IGBC were falsely patient survival, as well as disease stage (IV: HR 7.181, P < incidental emphasizing the requirement of assiduous pre- 0.001), radicality (HR 2.830, P = 0.001), adjuvant therapy operative workup before cholecystectomy. Diligent follow- (HR 0.537, P = 0.017), and intraoperative blood loss  1L up of histology and early appropriate management may (HR 1.851, P = 0.023). translate to improved outcomes. Conclusion: This study confirmed that a significant asso- ciation existed between preoperative sarcopenia and sur- vival in patients with GBC. Because sarcopenia is the only EP03B-007 prognostic factor that can be evaluated before surgery, its SURGERY IN INCIDENTAL GALL evaluation would enable early preventive therapy, allowing e the maintenance of muscle mass and patient-specific BLADDER CANCER SIGNIFICANCE treatment planning according to their physiologic reserves, OF RESIDUAL DISEASE i.e., skeletal muscle mass. R. K. Chaudhary and R. Shah Surgical Oncology, Mahavir Cancer Sansthan and Research Centre, India EP03B-006 Introduction: In patients diagnosed with incidental gall- “INCIDENTAL CARCINOMA bladder cancer (iGBC), the benefit of re-resection remains GALLBLADDER e ARE THEY ALL unclear. The aim of this study was to analyze outcomes in TRULY INCIDENTAL?” AN patients who underwent completion radical cholecystec- tomy following a diagnosis of iGBC and to determine EXPERIENCE OF A TERTIARY CARE factors associated with residual disease on final histopa- CENTER FROM INDIA thology and recurrence free survival. R. N. N. Santhosh Irrinki, T. D. Yadav, V. Gupta, Methods: A retrospective analysis of patients with inci- P. Kumar and K. Gautham dental GC between June 2010 and January 2017 was Department of General Surgery, Post Graduate Institute of performed. Data covering demographic features, histologi- Medical Education and Research, India cal features of initial surgery and presence of residual dis- fi Background: Sizeable proportion of incidental gallbladder ease on nal histopathology and recurrence were analyzed. cancer(IGBC) have suspicious findings on preoperative Results: Twenty eight patients underwent completion ultrasound or intraoperative finding during index chole- surgery following diagnosis of T1b/T2 gallbladder cancer cystectomy (false IGBC). The aim of the study is to at initial cholecystectomy, 9 of whom (34.6%) were found compare the presentation spectrum and outcomes of pa- to have residual disease. Sixteen percent (2/12) and 44% (7/ tients having true(group 1) and false IGBC(group 2). 16) of patients with T1b and T2 cancers had residual dis- fi Methodology: Retrospective analysis of IGBC patients ease on re-resection respectively (p value not signi cant). fi admitted between January 2013 to December 2017 was Preoperative imaging ndings were not predictive of re- done. Criteria of false IGBC was(any one) 1.Suspicious sidual disease at surgery. Presence of residual disease at preoperative ultrasound and/or intraoperative of index second surgery in T1b/T2 disease was associated with < cholecystectomy; 2.Presentation with symptoms or metas- worse recurrence free survival (p 0.05) and overall sur- < tasis within one month; 3.pT3/pT4 lesions. Clinical and vival (p 0.05) compared to no residual disease at surgery. PET/CT characters were noted. Potential resectable Conclusion: Residual disease on re-resection is a grave IGBCpatients underwent diagnostic laparoscopy(DL) and sign. Residual disease correlated with T-stage and was the definitive surgery. Chemotherapy(Inj.Gemcitabine 800 mg/ most relevant prognostic factor for survival. Re-resection m2 and Inj.Oxaliplatin100 mg/m2) was administered in the for iGBC may be a mere staging procedure (subject to more adjuvant and palliative setting. number of patients and longer follow up).

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S703 EP03B-007 overview of data parameters No Residual Disease Residual Disease p Value at Second Surgery at Second Surgery Cholecystectomy Laparoscopic 15 5 0.2089 Open 4 4 T Stage T1b 10 2 0.1359 T2 9 7 Pre-op CT Imaging Operable Residual Disease 2 3 0.1484 No residual disease 17 6 Recurrence yes 1 6 0.0004 no 18 3

EP03B-008 EP03B-010 SURGICAL MANAGEMENT FOR BLOOD PARAMETERS AS SURROGATE PATIENTS WITH T3+ GALLBLADDER MARKER TO PREDICT DISEASE STAGE CANCER: IS AGGRESSIVE IN GALL BLADDER CANCER: AN INDIAN OPERATION WORTHWHILE OR INSTITUTE BASED PILOT STUDY FUTILE? A. Gupta1, S. Gupta2, A. Gupta1, M. Gupta2, B. Ravi1 and 1 H. Ito, Y. Takahashi, Y. Mise, Y. Inoue, T. Ishizawa and R. Kant 1 A. Saiura Department of Sugery, AIIMS Rishikesh, India, and 2 Department of HBP Surgery, Cancer Institute Hospital, Radiation Oncology, AIIMS Rishikesh, India Japanese Foundation for Cancer Research, Japan Aim: To investigate the role of blood parameters LMR Background: Advanced gallbladder cancer (GBCA) (Lymphocyte to Monocyte ratio), Platelet to lymphocyte ratio T3 or greater often infiltrates multiple surrounding (PLR) and Neutrophil to lymphocyte ratio (NLR) as markers organs, and R0 resection for such disease demands to predict disease stage in Gall Bladder Cancer (GBC). extensive surgery with multi-organ resection. The Methods: Clinical data of 40 patients diagnosed GBC was prognosis of GBCA has been reported poor in general evaluated. Mean, SD and percentages were calculated for all and the indication for aggressive resection remains to the variables used in data and correlation was used to evaluate be defined. the correlation between NLR, PLR, LMR And Haemoglobin Methods: The patients with GBCA T3 or greater who with CEA,CA 19-9,Stage of disease and NLR, PLR, LMR underwent surgical resection with curative intent from with each other to which is directly or indirectly related to Jan. 2006 through Oct. 2017 were included and the each other. ROC curve was also evaluated to know the cut off risk factors for recurrence and death were evaluated. values of NLR, PLR, LMR with different stages of disease. The median follow-up for the survivors were 37 Results: Stage II and III were 7 (17.5%) each group and months. 26(65%) Stage IV. 4 patients had CA 19-9 more than 15000 U/ Results: During the study period, 40 patients (38%) ml . Mean NLR was 4.37, PLR = 174.9 and LMR = 6.93 There with pT3/4 tumors were identified among total 104 pa- was a significant correlation between NLR, PLR, LMR and Hb tients with GBCA underwent curative resection. with stages of disease There was significant correlation be- Seventeen patients (43%) who presented with jaundice tween LMR AND PLR (p = 0.004) but there was no correla- had preoperative biliary drainage. Twelve patients (30%) tion between NLR and PLR LMR p = 0.298 and p = 0.229 underwent pancreaticoduodenectomy addition to liver respectively. Also there was no statistical significance in stages resection (HPD) and 23 patients (58%) underwent liver of disease and LMR (a: p =0.533b: p = 0.533, c: p = 0.321). resection greater than hemi-hepatectomy. Thirty-one Conclusion: Correlation existed between NLR, PLR and patients (78%) achieved R0 resection and the median LMR with tumour stages in GBC. Indo-gangetic belt is recurrence free survival (RFS) and overall survival (OS) endemic for GBC so these tools may be used as surrogate were 12 months and 22 months, respectively. The markers in adjunct to established markers to assess stages multivariate analyses revealed metastasis to the para- of GBC because of their cost effectiveness. aortic lymph nodes (PALNs) as the only significant risk factor for recurrence, and R1 resection as the only EP03B-012 prognostic factor for death. While preoperative jaundice, GALLBLADDER CANCER: INCIDENCE, regional lymph node metastasis or multi-organ resection TREATMENT AND LONG TERM were not necessarily associated with worse long-term SURVIVAL outcomes, none of the patients with PALNs metastasis (n=5) survived beyond 3 years. O. A. Nutu, M. García-Conde Delgado, I. Justo Alonso, Conclusion: Aggressive resection can be a reasonable A. A. Marcacuzco Quinto, Ó. Caso Maestro, therapeutic option for patients with T3+ GBCA unless L. Alonso Murillo, J. Calvo Pulido, P. Del Pozo Elso, PALNs metastasis is suspected. A. Manrique Municio and C. Jiménez Romero Hepatobiliopancreatic Unit and Abdominal Organs Transplantation, 12 de Octubre University Hospital, Spain

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Introduction: Gallbladder cancer is the most common Conclusion: Radical cholecystectomy is associated with malignancy of the biliary tract, accounting for the 80-95% good local control. Clinical trials need to be conducted to of biliary tract cancers, and the sixth in frequency among frame adjuvant treatment guidelines to decrease distant gastronintestinal cancers, with a fatal prognosis and a 5 year failure. survival rate only 5%. This tumor ussualy remains asymp- tomatic until aggresive disease has progresed at he diag- nosis, being the surgical resection the only potential cure. EP03B-014 Methods: We performed at our institution a retrospective CLINICOPATHOLOGICAL FEATURES study between January 2000 and January 2016. We have OF LONG-TERM SURVIVORS AFTER identified 92 patients with an histopathological diagnosis of gallbladder cancer. RADICAL RESECTION FOR Results: The average age was 72Æ11 years and 64 869%) GALLBLADDER CANCER cases were women. The signs and symptoms at diagnosis K. Yuza, J. Sakata, T. Ando, K. Toge, Y. Hirose, were: abdominal pain (78%), weight loss (77%), nausea T. Katada, K. Miura, K. Takizawa, T. Kobayashi and and vomiting (76%) and jaundice (45%). All 92 patients T. Wakai underwent surgical resection, achieving a curative intent in Division of Digestive and General Surgery, Niigata Univer- 59 (64%) of them. Among the surgical procedures sity Graduate School of Medical and Dental Sciences, Japan fi performed as a rst line therapy , simple cholecystectomy Introduction: The aim of this study was to clarify the was performed in 69 (75%) and an extended cholecystec- characteristics shared by long-term survivors (5 years or tomy in 11 (11%) patients. In 15 patients, an incidental more) after radical resection for gallbladder cancer. tumor was found after a simple cholecystectomy; all of Methods: A retrospective analysis was conducted of 174 them underwent a second line surgery, with curative intent patients who underwent radical resection for gallbladder in only 10 of them. Adjuvant therapy was used in 30 (33%) cancer. We compared the clinicopathological characteris- patients. Overall survival was 12,5 months, being the 1, 3 tics between long-term survivors (n = 82) who survived for and 5 years survival, 57%, 30% and 20% respectively. 5 years or more and short-term (< 5 years) survivors (n = Conclusion: Surgical resection with curative intent is the 92). All the patients were followed-up for at least 5 years or only treatment to achieve survival in patients. until death. Results: The 5-year overall survival rate in all 174 patients was 47% (median survival time, 4.6 years). Age (hazard EP03B-013 ratio [HR] 1.8, P = 0.005), depth of invasion (HR 1.9, P = SURVIVAL OUTCOMES AFTER 0.017), distant metastasis (HR 2.5, P < 0.001), perineural RADICAL CHOLECYSTECTOMY FOR invasion (HR 1.9, P = 0.006), and residual tumor status (HR CARCINOMA GALL BLADDER 2.7, P < 0.001) were identified as independent prognostic factors by multivariate analysis. We compared the clini- J. S. Bhanu1, R. S. Ayloor1 and R. Ranganathan2 copathologic characteristics of long- and short-term survi- 1Department of Surgical Oncology, Cancer Institute vors after resection for gallbladder cancer. Significant (WIA), India, and 2Department of Biostatistics, Cancer differences were found with regard to age, depth of inva- Institute (WIA), India sion, lymph node metastasis, distant metastasis, lymphatic Introduction: The aim of the study was to analyze the invasion, venous invasion, perineural invasion, residual survival outcomes of patients undergoing radical chole- tumor status, histology type, and histological grade. There cystectomy for carcinoma gall bladder. was no long-term survivor in patients with residual tumor. Methods: Patients who underwent curative surgical Of 84 patients with lymph node metastasis, 25 survived for resection between 2005 and 2015 for carcinoma gall more than 5 years after resection. fi th bladder were analyzed. The UICC TNM classi cation 7 Conclusions: R0 resection is required to achieve long-term edition was used in the study. survival in gallbladder cancer patients. Regional lympha- Results: The number of patients who underwent radical denectomy provides a survival benefit for some patients cholecystectomy during the study period was 18, this with nodal disease. included 10 males and 8 females. The mean age of the study population was 51 years. Twelve patients underwent upfront radical cholecystectomy, whereas five patients had prior simple cholecystectomy (Open-2, laparoscopy-3) after EP03B-015 which malignancy was detected. Five patients had pT2 dis- ROLE OF POSITIVE PERITONEAL ease and one patient had pT1b disease. At definitive surgical LAVAGE CYTOLOGY IN CARCINOMA procedure, 12 patients underwent radical cholecystectomy GALL BLADDER: A PROSPECTIVE and the remaining underwent completion staging cholecys- OBSERVATIONAL STUDY OF 60 tectomy. One patient underwent port site excision. The mean tumor size was 22.5 mm (Range 7 to 35 mm). All patients PATIENTS WITH THE PREOPERATIVE had adenocarcinoma histology and the most common grade DIAGNOSIS was II (44.2%). The mean number of nodes dissected was A. Vijayashanker1, T. D. Yadav1, V. Gupta1, 11.9 (Standard deviation Æ 7.14). The stage-wise distribu- R. Srinivasan2, A. Das3, S. K. Sinha4 and tion: stage I- 6 patients, stage II- 9 patients, stage IIIA- 2 I. Naga Santhosh1 patients, stage IIIB- 1 patient. Resected margin was free in all 1Department of General Surgery, 2Department of Cytology cases. Three patients received adjuvant chemotherapy and and Gynaepathology, Post Graduate Institute of Medical one patient received chemoradiation. The recurrence rate was Education and Research, India, 3Department of Histopa- 16.67%. The five year disease free survival was 62%. thology, and 4Department of Gastroenterology, Post

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Graduate Institute of Medical Education and Research, Background: The differential diagnosis of gallbladder India (Gb) lesions is challenging. The aim of the present study Introduction: Positive peritoneal lavage cytology ( PLC) was to evaluated the clinical usefulness of abdominal ul- in patients with carcinoma stomach is considered M1 dis- trasonography (US) for differential diagnosis of gallbladder ease according to AJCC classification (7th edition, 2010). lesions. Status of PLC positivity in carcinoma gall bladder (CGB) is Methods: We retrospectively assessed US images and untested yet. pathology reports of 85 patients (57 women, age 63.4Æ11.2 Method: The study included 60 patients who underwent years) who were admitted to our clinic between January treatment in PGIMER, Chandigarh, India (June 2015eJuly 2014 and December 2017 with primary diagnosis of Gb 2016). After staging laparoscopy (SL), abdomen was lesion. explored and 50ml of normal saline instilled in the peritu- Results: All patients at admission had US examination, moral region, right paracolic gutter and pelvis. The lavage which resulted in suspicion of different stages of Gb cancer fluid was aspirated, mixed with an anticoagulant and spun in 63 cases (74.1%), benign Gb lesions in 10 cases (11.8%), to obtain a sediment that was subjected to Liquid Based biliary duct cancer (BTC) in 3 cases (3.5%) and uncertain Cytology. Papanicolaou and May Grunwald Giemsa slides diagnosis in 9 cases (10.6%). The correlation of US and were studied for malignant cells. During SL, if metastatic, histopathology results showed 73.0% compatibility, 16.4% lavage was done laparoscopically. When resectable, pa- discrepancy and 10.6% uncertainty. Among correct US tients underwent R0 resection. diagnosis Gb cancer was confirmed in 52 cases (82.5%). Statistical analysis showed significant difference in Gb wall thickness between correctly diagnosed Gb cancer and benign Gb lesion groups (p = 0.001). In descriptive analysis other misdiagnosed features that mimicked Gb cancer were analysed, such as: pathologically changed Gb wall; liver, common hepatic duct (CHD) or other surrounding tissues infiltration; enlargement of lymph nodes. Conclusion: US examination has high sensitivity for detection of advanced Gb cancer what can facilitate treat- ment decision. Thickness of the Gb wall can be an important factor for distinguishing benign and cancerous process. Misdiagnosis of Gb cancer and BTC is possible when tumor mass is in the middle part of CHD or within liver parenchyma and infiltrate the Gb.

Mesenchymal cell(star), malignant cell (arrow) EP03B-017 IS AGE ALONE A PREDICTOR FOR RECEIPT OF ADJUVANT Results: There were 25 resectable, 2 unresectable, 22 metastatic and 11 cases of xanthogranulomatous chole- CHEMOTHERAPY IN PATIENTS WITH cystitis. 6 out of 49 CGB patients had positive PLC ( RESECTED GALLBLADDER CANCER? 12.2%).1 patient had resectable G3pT2N0M0 adenocarci- S. K. Mukkamalla1, J. Hardaway2, R. Rathore1 and noma, 1 had unresectable celiac lymph nodal metastasis P. Somasundar2 and 4 had peritoneal metastasis on SL. The median disease- 1Hematology & Oncology, and 2Surgical Oncology, Roger specific survival for metastatic disease was 4 months. The Williams Medical Center, United States same for resected population (negative PLC) was not Introduction: Role of adjuvant therapy for resected gall- reached. The disease-free survival of the only resected bladder cancer remains unclear. There are no randomized patient with positive PLC was 5 months, comparable to that trials to guide clinicians in this regard and retrospective of metastatic patients. The survival difference between studies remain split on efficacy of adjuvant treatment options. fi patients with positive and negative PLC was not signi cant. Method: The National Cancer Data Base (NCDB) was Conclusion: Although positive PLC may suggest queried for patients with non-metastatic, resected gall- advanced disease, the correlation between PLC and sur- bladder cancer diagnosed between 2004 and 2013. Baseline fi vival or disease stage is not statistically signi cant yet. characteristics were compared using chi-square test and factors associated with adjuvant chemotherapy adminis- tration were analyzed using multivariate logistic regression EP03B-016 model. USAGE OF ULTRASONOGRAPHY IN Results: A total of 4486 patients were identified. Majority > GALLBLADDER LESIONS. ANALYSIS of the patients were 65 years of age (65.2%). In the full cohort analysis, patients who received adjuvant chemo- OF 85 CASES: A SINGLE CENTRE therapy were more likely to be: younger, of Hispanic STUDY ethnicity, with no comorbidities, diagnosed from 2010- J. Ligocka, W. Patkowski, R. Lechowicz and 2013, with poorly differentiated histology, pT3, pN1, un- K. Zieniewicz dergoing radical resection and receiving adjuvant radiation Department of General, Transplant and Liver Surgery, (p < 0.05). Subgroup analysis of patients receiving Medical University of Warsaw, Poland chemotherapy was done which demonstrated higher odds

HPB 2018, 20 (S2), S685eS764 S706 Electronic Poster (EP03A-EP03F) e Biliary of single-agent chemotherapy administration among pa- Results: Forty one cases of gallbladder cancer were tients who: were elderly, diagnosed from 2004e2009, had included over 20 months. 21.9% patients had an attack of well differentiated histology, pT1 & pN0 disease, belonged cholangitis pre-operatively. Overall in gallbladder cancer to the lowest income quartile and received adjuvant radia- (n=41), six parameters predicted malignant lymphadenop- tion (p < 0.05). [Table 1] athy in univariate analysis. Amongst them, pre-operative Conclusions: In patients with resected gallbladder cancer, parameters were lymphnode size > 10mm on CT, ill- receipt of adjuvant chemotherapy is affected by several defined borders and conglomeration; while intra-operative patient- and disease-specific factors and not just age alone. parameters were node size > 10mm, hard consistency and nodal necrosis (p< 0.05). However in multivariate analysis, lymphnode size > 10mm measured intraoperatively was the only significant predictor of malignant lymphadenop- athy. In patients with pre-operative cholangitis, none of the pre-operative or intra-operative parameter could predict malignant lymphadenopathy. However in patients without pre-operative cholangitis, nodal necrosis predicted malig- nant involvement in multivariate analysis. Conclusion: Overall, lymphnode size >10 mm measured intraoperatively significantly predicted malignant lymph- adenopathy in gallbladder cancer. Usual pre-operative im- aging or intra-operative lymph nodal features predicting malignant lymphadenopathy cannot be relied upon in presence of cholangitis.

EP03B-019 ROBOTIC SURGERY FOR CARCINOMA GALL BLADDER -SINGLE INSTITUTE EXPERIENCE OF 32 CASES FROM INDIA M. Goel1, K. Khobragade2, S. Kurunkar2, A. Kanetkar2 and S. Patkar2 1Surgical Oncology, and 2Surgical Oncology, Tata Me- morial Hospital, India Table 1 Introduction: Da Vinci robotic system has minimized the ergonomic limitations associated with laparoscopy in hepatobiliary surgery. Aims and objectives: To determine the safety, feasibility EP03B-018 and perioperative outcomes with the Da Vinci robotic EFFECT OF CHOLANGITIS ON surgical system for the radical resection of gall bladder PREDICTORS OF LYMPHADENOPATHY cancer (GBC). Material and methods: Patients who underwent robot IN GALLBLADDER CANCER assisted surgery for suspected or incidental GBC between R. Kulkarni, V. Gupta, S. Kumar, P. Joshi, V. Gupta and July 2015 to October 2017 were analysed. Patient de- A. Chandra mographics peri-operative and short-term oncological Department of Surgical Gastroenterology, King George’s outcomes were recorded. Medical University, India Results: Thirty-two patients underwent robot assisted Introduction: Lymphnode involvement is a poor prog- surgery for suspected or proven GBC. Ten patients un- nostic factor in gallbladder cancer. On pre-operative CT derwent robot assisted simple cholecystectomy and 22 lymphnode size > 10mm, irregular shape, heterogenous patients underwent robot assisted radical cholecystectomy. enhancement, conglomeration suggests malignant The median surgical time was 255 minutes (range= 90e involvement. However conditions like cholangitis can also 520) minutes), the median intra-operative blood loss was lead to reactive lymphadenopathy leading to pitfall for pre- 125 ml (range= 20e1500ml).The average post-operative operative staging. hospital stay was 4 days (range= 2e13 days). R0 resection Methodology: In this prospective study, regional was achieved in all patients. The final histopathology of lymphnodes were evaluated in gallbladder cancer patients patients undergoing radical surgery for gall bladder carci- using CT features like size, shape, borders, enhancement noma showed pT2 disease in thirteen patients, pT3 (3), pT1 pattern and conglomeration while intra-operative features (3), pTis (2) and one patient had chronic cholecystitis. The like size, consistency, extra-nodal deposits and cut-section nodal yield of 8 nodes (range = 1e15). Robotic surgery was were recorded. Malignant involvement of lymphnode was successfully accomplished in 30 patients with a conversion decided by histopathology. Pre-operative and Intra-opera- rate of 6.2% (2/32). All patients were discharged without tive predictors of malignant lymphadenopathy were deter- complications except one who had iatrogenic jejunal mined. Sub-group analysis was done to evaluate the effect perforation. With an average follow up of 7.9 months of pre-operative cholangitis on these predictors. (range = 1e25months), all the patients were disease free.

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Conclusions: Robotic radical cholecystectomy is safe and and human epidermal growth factor receptor-2 (HER2) are feasible with equivalent oncological outcomes to open potent mitogens belonging to a family of receptor tyrosine surgery. kinases, that are thought to participate in signal trans- duction mediating tumor cell proliferation. In the present study, we evaluated the association of functional poly- EP03B-020 morphisms in VEGF, PDGFB and HER2 genes with GBC INCIDENCE OF EXTRA-ABDOMINAL progression and survival. Methods: VEGF -1154 G>A, -2578 C>A, PDGFB SITE OF METASTASIS AT +286A>G and +1135A>C polymorphisms were investi- PRESENTATION IN PATIENTS WITH gated by amplification refractory mutation system (ARMS) CARCINOMA GALL BLADDER PCR. VEGF +936C>T and HER2 Ile655Val poly- J. Agarwal1, T. D. Yadav1, V. Gupta1, B. R. Mittal2, morphisms by restriction fragment length polymorphism A. Lal3 and S. Radhika4 (PCR-RFLP) and VEGF-2549 Ins/Del by PCR in DNA 1General Surgery, 2Nuclear Medicine, 3Radiodiagnosis, extracted from venous blood of 80 GBC patients who were and 4Cytology, PGIMER Chandigarh, India operated before 2010 (to ensure at least 5 years follow up) and in whom follow up data was available. Introduction: Gall Bladder carcinoma is very common in Results: +286GA genotype of PDGFB showed significant North India with an incidence of 9.8 per 1,00,000 per year risk protective association with regional lymph node which is one of the highest in the world with a resectability metastasis (OR=0.27, p value=0.03). In Kaplan-Meir sur- rate of less than 20%. vival analysis, genotypes VEGF-1154 GA (Chi- Methods: This is a prospective study carried out in the square=10.18 and P=0.0006), +936 CC (Chi-square=7.332 Department of Surgery, PGIMER, Chandigarh from July and P=0.026) and PDGFB+1135CC (Chi-square=7.424 2016 to December 2017. The study included 102 patients of and p value=0.024) showed significantly longer survival Carcinoma Gall Bladder admitted in the Institute during the but there was no significant survival correlation with HER2 investigation period. Patients were assessed by detailed polymorphism. clinical, radiological and histological modalities. Conclusion: VEGF and PDGFB gene polymorphisms may Results: Out of 102 patients included in the study, 14 pa- play a role in progression (lymph node metastasis) and tients (13.72%) were found to have FNAC proven extra- survival in GBC. abdominal metastasis. These metastasis were found in supraclavicular lymph nodes in 10 patients, in lung in 2 patients, in left upper cervical lymph node in 1 patient and in the orbit in 1 patient. Incidence of PET suspicious extra- EP03B-022 abdominal metastasis was 50/102 (49%). Mostly, skeletal, ROLE OF RED CELL DISTRIBUTION brain and lung lesions were not amenable to FNAC due to WIDTH AND OTHER BLOOD CELL small size of the lesion and presence at difficult location. Out of 102 patients, 15 patients had incidental carcinoma INDICES IN DIFFERENTIATING gall bladder, out of which 8 had suspicion of extra- BETWEEN BENIGN AND MALIGNANT abdominal metastasis. DISEASES OF GALLBLADDER Conclusion: To the best of our knowledge there is no A. John1, L. Kaman2, A. Behera2, D. Dahya2 and R. Das3 publication which determines the exact incidence of extra- 1General Surgery, 2General Surgery, and 3Hematology, abdominal site of metastasis in Gall Bladder Cancer. The PGIMER Chandigarh, India incidence in our series at presentation is very high. The Introduction: This study aims to examine the relevance of detection of such metastasis alters the therapeutic approach Red cell Distribution Width and other blood cell indices as and also emphasizes the need for doing routine preopera- a biomarker in differentiating between benign and malig- tive PET scan for such patients. nant diseases of the gallbladder. Methods: Between January 2015 and April 2017, 135 subjects who fit the inclusion criteria were recruited. EP03B-021 Baseline evaluations were carried out. Patients having ANGIOGENIC FACTORS benign gall stone disease underwent laparoscopic or open POLYMORPHISMS IN GALL BLADDER cholecystectomy. Operable cases of carcinoma were taken CANCER (GBC) PROGRESSION AND up for surgery. Resected specimen underwent histopatho- logical analysis. SURVIVAL Results: Of 135 subjects 48 had carcinoma Gallbladder and 1 1 1 2 A. Behari , K. Mishra , V. K. Kapoor , M. S. Khan and 87 had benign gallstone disease. In the benign group mean 3 S. Agrawal red cell distribution width was 15.3 Æ 1.7% whereas in the 1 Surgical Gastroenterology, Sanjay Gandhi Post Grad- carcinoma group was 16.4 Æ 3.0% (p = 0.002). Sensitivity 2 uate Institute of Medical Sciences, India, Biosciences, and specificity for a cut-off value of 16.05% was at 48% 3 Integral University, India, and Medical Genetics, Sanjay and 71% respectively. The mean Neutrophil Lymphocyte Gandhi Post Graduate Institute of Medical Sciences, India Ratio of patients of the benign group was 2.2 Æ 0.9 versus Introduction: Gall bladder cancer (GBC) is the common- carcinoma group was 3.8Æ2.9 (p < 0.001). The mean est biliary tract cancer and the most common gastro-intes- Platelet Lymphocyte Ratio of patients in benign group was tinal cancer among women in north Indian population. 120.3 Æ 56.3 versus 149.7 Æ 95.8 in the carcinoma group Angiogenesis plays an important role in growth, progres- (p = 0.002). The mean prognostic nutritional index of pa- sion, and metastasis of tumors. Vascular endothelial growth tients in the benign group was 53.6 Æ 6.3 whereas in the factor (VEGF), platelet derived growth factor-B (PDGFB) carcinoma group was 47.8 Æ 8.4 (p < 0.001).

HPB 2018, 20 (S2), S685eS764 S708 Electronic Poster (EP03A-EP03F) e Biliary

Conclusions: Red cell Distribution Width and other in- histopathology report of Gallbladder cancer. We here report flammatory markers like Neutrophil Lymphocyte Ratio and our experience of 106 cases of IGBC. Platelet Lymphocyte Ratio have a role in predicting carci- Methods: Out of total 346 Gallbladder cancer patients, 106 noma Gall Bladder from benign disease in the preoperative were IGBC (30.63%) almost one-third. Most cases were in period, which may help in the surgical management. fourth or fifth decade (62.2%). Majority were female (90.5%). Around one third (34%) belonged to rural back- ground. An important was that 36.7% of cases presented EP03B-023 within three months after surgery while there were 19 cases STUDY OF EXPRESSION OF HER2/NEU which came after 6 months and 14 cases even came after one year. These cases presented when disease became IN METASTATIC GALLBLADDER symptomatic, many with metastatic disease. Out of total PATIENTS: LOOKING FOR 106 cases, 63 cases (59.4%) turned out to be metastatic. 23 FEASIBILITY OF TARGETED THERAPY cases (21.6%) of cases were early stage. IN CARCINOMA GALLBLADDER Conclusion: We concluded that Late referral to specialist or patient ignoring surgeons advice to consult Oncologist P. Suryavanshi1, V. Kumar2, A. Chaturvedi2 and S. Gupta2 and presenting only when they became symptomatic, 1General Surgery, King George’s Medical University, especially in rural area and they were few cases in which India, and 2King George’s Medical University, India there were ultrasonographic findings suspicious of ma- Introduction: Carcinoma Gallbladder is an aggressive lignancy. Prognosis of IGBC can be improved proper fi disease without no speci c clinical signs and variable guidelines for preoperative imaging, prompt refer to presentation, making it a challenge to diagnose at early specialist after cancer detection or suspicion, proper patient stage. Unfortunately most cases in India are diagnosed at a counselling especially for rural patients.. later stage when chances of cure are dismal. Cytotoxic chemotherapy are not very effective in metastatic setting and have variable response. Without any effective palliative therapy, survival of inoperable/metastatic carcinoma gall- EP03B-025 bladder patients is very poor. With various studies showing GALLBLADDER MURAL effectiveness of addition of Herceptin with chemotherapy INTRADUCTAL PAPILLARY in Metastatic Carcinoma Stomach, we tried to analyse Her2/neu expression in advanced/metastatic Carcinoma MUCINOUS NEOPLASM: A CASE gallbladder patients in North Indian population, with REPORT regards to feasibility of Herceptin addition. Q. Z. Ruan, I. Mukherjee, J. Villanueva and K. Agrawal Methods: A total of 63 Advanced inoperable/metastatic Surgery, Staten Island University Hospital, United States carcinoma gallbladder patients were included in this study. Introduction: Intraductal Papillary Mucinous Neoplasm Her2/neu analysis was done on tumor tissue. HER-2/neu (IPMN) is a relatively uncommon disease entity manifest- staining criteria in the study was similar to HER-2 staining ing in the exocrine pancreas involving its ductal compo- criteria used in ToGA trial. 2 + expression was considered nents. It involves a wide variety of epithelial changes which to be negative as FISH was not done. range from benign adenoma to invasive adenocarcinoma in Results and conclusion: A total of 28/63 (44.4%) of pa- the biliary system, largely confined to the exocrine tients strongly expressed 3+ positivity. there was no rela- pancreas. We present a case with the incidental discovery fi tion found in disease speci c survival in Her2 positive and of tissue suggestive of mural IPMN following routine Her2 negative group. Among the rest negative cases, as per cholecystectomy. protocol, cases with 2+ expression shoul undergo FISH. Method: Patient FG is a 46-year old female who presented Approximately half of the advanced/metastatic Carcinoma to the surgery service with longstanding right upper Gallbladder cases may be a suitable candidate for addition quadrant abdominal pain. She had undergone multiple in- of Herceptin along with chemotherapy. vestigations with little insight into her symptoms. A hepatobiliary iminodiacetic acid (HIDA) scan was even- tually performed which showed a gallbladder ejection EP03B-024 fraction of 8%, suggestive of biliary dyskinesia. An elective INCIDENTALLY DETECTED laparoscopic cholecystectomy was performed successfully GALLBLADDER CANCER: A COMMON with no intraoperative complication. The gallbladder did not appear to be chronically inflamed and it was no opened SCENARIO IN NORTH INDIA in the operating room on removal. 1 2 2 2 P. Suryavanshi , V. Kumar , A. Chaturvedi , S. Gupta , Results: It was found that the gallbladder harboured an 2 2 C. Kori and N. Akhtar adenomyomatous nodule which was deemed to be low- 1 2 General Surgery, and King George’s Medical Univer- grade, and evolved the mural IPMN pattern. A section of sity, India the adenomatous nodule displayed a cystically dilated Introduction: Incidentally detected gallbladder cancer gland lined by dysplastic mucinous epithelium in papillary (IGBC) hereby refers to histopathological diagnosis of configuration. Gallbladder cancer after simple cholecystectomy Discussion: Although this manifestation has been termed performed for Cholecystitis with no previous suspicion of “adenomyoma”, it is more of a hamartomatous process Gallbladder cancer on preoperative workup. Simple cho- rather than a true neoplasm itself. These are often incidental lecystectomy is being widely performed at many peripheral findings and rarely develop neoplastic changes. However, centers in the North India for simple Cholecystitis and lesions such as these in the gallbladder are exceptionally increasing such cases are seen at tertiary centers with rare. Overall, they closely resemble pancreatic IPMN and

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S709 its clinical significance is worthwhile to be characterized in from malignant gallbladder lesions with a particular focus future studies. on xanthogranulomatous gallbladder masses. Methods: All of the patients presenting to our institution with suspicious gallbladder lesions from January 2011 to EP03B-026 December 2017 were reviewed. Patients with confirmed DOES LYMPH NODE POSITIVITY histopathology and diffusion weighted MRI were included. A blinded radiologist to the diagnosis calculated the ADC RATIO CORRELATE WITH SURVIVAL values. The data was analyzed by Spearman correlation and FOLLOWING CURATIVE RESECTION t-test. FOR GALLBLADDER CARCINOMA: A Results: A total of 81 patients were identified with appre- PROSPECTIVE STUDY hensive gallbladder lesions other than gallstones .38 pa- tients were identified with confirmed histopathology and S. Banerjee1, D. Lamichhane1, P. Roy2, R. Thambudorai1, diffusion weighted MRI [14 (36.8%) gallbladder adeno- M. Roy1 and V. Sitaram1 carcinoma, 9 (23.7%) xanthogranulomatous cholecystitis 1GI-HPB Surgery, and 2Pathology, Tata Medical Center, and 15 (39.5%) with other inflammatory lesions and India polyps]. The mean ADC value for the malignant lesions Background: In gallbladder carcinoma, lymph node was 1179.3 (95% CI: 983.2e1375.3) and for the benign metastasis is an important predictor of survival. This study lesions 1365.3 (1201.6e1528); however Spearman corre- assessed the survival with respect to ratio of metastatic lation and T-test showed no significant difference (P value: nodes to total number of nodes harvested (lymph node 0.16). ratio, LNR). Conclusion: Benign lesions tended to have ADC values > Methods: Between Jan 2012 to May 2017, 128 patients 1200, and higher than the malignant lesions, but the dif- underwent curative intent resection for gallbladder cancer. ference was not significant. We concluded that the ADC In order to achieve a minimum of 3 years follow up, data of value may be helpful as a surrogate marker in the diagnosis 44 patients (Jan 2012 to May 2014) were analysed. LN of gallbladder cancer; however larger sample sized studies location was divided into N1 (hepatoduodenal, including may be useful in depicting the significant difference. 13a (PSPD) and common hepatic artery) and N2 (celiac, SMA and aorto-caval). As the median LNR was 10%, the LNR was divided into three groups: 0%,  10% and > 10%. Survival data was calculated using Kaplan-Meier and EP03B-028 Cox regression model used to analyse between groups. SURGICAL OUTCOME OF T2 Results: 39 patients were available for the study. In total, GALLBLADDER CANCER BASED ON 633 (mean 16) nodes were retrieved. Among this, 31 nodes LOCATION OF TUMOR AND SURGICAL were positive in 14 patients. LNR was 10% in 4 (28%) TREATMENTS and > 10% in 10 (71%) patients. The median follow-up Y. J. Hwang1, H. J. Kwon1, S. G. Kim1,H.Ha2, was 50 months (IQR 43-58). 14 patients died during 2 2 3 4 follow-up. The median disease-free (DFS) and overall Y. S. Han , J. M. Chun , A. Seo , M. K. Kang and G. -S. Yoon3 survival (OS) were 43.7months (IQR 14-52) and 46 months 1 2 3 4 (IQR 20-54) respectively. The median DFS of patients with Surgery, Surgery, Pathology, and Radiation Oncology, LNR >10 % is 14.6 months and LNR  10% is Kyungpook National University Chilgok Hospital, 21.4months; patients with negative nodal disease did not Kyungpook National University School of Medicine, Re- reach median survival (p=0.014). The OS of patients with public of Korea LNR  10 was 14 months (95% CI: 4.7-24.5). Introduction: This study aimed to determine the prog- Conclusion: LNR>10 % was associated with adverse nostic impact of tumor location and suggest the optimal prognosis in gallbladder cancer. surgical stretagy in T2 gallbladder cancer (GBCA). Methods: 131 patients with T2 GBCA underwent R0 resection from 1994 to 2014. The location was categorized as “hepatic side” versus “peritoneal side” and “fundus” EP03B-027 versus “body” versus “neck” through preoperative image. ADC VALUES IN DIFFUSION Results: Among the 131 patients with T2 GBCA, the most WEIGHTED MRI: THE VALUE OF significant predicting factor for the survival and recurrence WHICH IN DEPICTING GALLBLADDER is the nodal status. The 5-year survival rate (5-YSR) was 96.8% for the N0 patients and 79.4% for the N1 patients. CANCER FROM OTHER MIMICKERS Survival was no statistical difference according to location. 1 2 3 2 A. Abutaka , I. Sulieman , S. Mohamed , A. Elaffandi , With respect to surgical procedure, 5-YSR for patients with 2 2 W. Shehata and H. Khalaf peritoneal-side cancer was no significant difference ac- 1 2 Hamad Medical Corporation, Liver Unit, HPB and cording to hepatic resection (HR). However, the 5-YSR 3 Transplant Surgery, and Radiology Department, Hamad was 96.2% for hepatic-side patient with HR, and 60% for Medical Corporation, Qatar those without HR HR was important factor associated with Introduction: Differentiating between benign and malig- survival in patients with hepatic-side cancer (p = 0.021). 5- nant gallbladder masses remains challenging. ADC values YSR was no statistical difference according to bile duct on MRI (DWI) are helpful in diagnosing malignant con- resection (BDR) in the patients with fundus and body- ditions (with a cut-off value of 1200) and have been sug- located tumor. Although the difference was not statistically gested as a diagnostic tool in gallbladder lesions. We significant, survival of neck-located patients with BDR was investigated the value of ADC in differentiating benign better than that of patients without BDR. 5-YSR was 100%

HPB 2018, 20 (S2), S685eS764 S710 Electronic Poster (EP03A-EP03F) e Biliary for patient with neck-located cancer with BDR, and 79.5% Methods: Consecutive patients with IGC undergoing re- for those without BDR. exploration between 1990- 2014 were identified. Those Conclusions: Considering the location of tumor, the patients submitted to a radical definitive resection were optimal procedure for each patients should be considered. analyzed. Demographics and tumor-treated related vari- In patients with hepatic-side cancer, HR is effective pro- ables were correlated with RD and survival. Cancer specific cedure for improving survival. BDR is considered to be survival correlated with the site of RD, local (gallbladder additional procedure for improving survival in selected bed) or regional (lymph nodes & bile duct). patient with neck-located cancer. Results: Of 265 patients with incidental gallbladder cancer submitted, re-resection was performed in 168 and RD was found in 58 (34.5%).Comparison of demographic, clinical EP03B-029 and surgical variables showed differences in type of ROBOTIC RADICAL resection, more than 5 nodes resected, T stage and disease stage (< 0.0001).Site of RD was regional in 34 (20.2%), CHOLECYSTECTOMY WITH local in 24 (14,3%).The T stage ( p< 0.001)and disease HISTOLOGICAL SURPRISE stage(p= < 0.001) were independent predictors of RD. S. Sabnis, P. Senthilnathan, V. P. Nalankilli, Presence of RD at any site reduced the disease specific S. Srivatsan Gurumurthy, N. Anand Vijai and survival (DSS) (19.6 month vs 62.7 month p< 0.001) in C. Palanivelu comparison with non RD patients. There was no difference Surgical Gastroenterology & HPB Surgery, Gem Hospital in DSS according the location of RD, with all anatomic and Research Center, India sites been equally poor (p= 0.27). RD at any site predicted < Introduction: Gallbladder cancer is the most common DSS (p 0.001), independent of all other tumor related malignant tumor of the biliary system. The only potentially variables. curative option for patients with gallbladder cancer is Conclusions: Residual disease is a critical prognostic radical resection. This is one of the early reports first that factor in patients with IGC treated by radical resection. describes the successful application of robotic radical Outcome was poor in the presence of RD regardless of the cholecystectomy in a locally gallbladder cancer patient. anatomic location. Future studies with new adjuvant pro- Methods: A 46-year-old gentleman with no comorbidities tocols are needed to improve survival in this setting. presented with dull aching right hypochondrial pain for 1 month. His per abdomen examination, liver function and renal function tests were essentially normal. CECT EP03B-031 abdomen showed locally advanced mass in gallbladder DOES PALLIATION OF JAUNDICE BY infiltrating segment 4b and 5. With this he was diagnosed to PTBD IMPROVE THE PHYSICAL have locally advanced carcinoma of gallbladder. Robotic QUALITY OF LIFE IN PATIENTS WITH radical cholecystectomy was contemplated with lympha- denectomy. On staging laparoscopy showed no evidence of INOPERABLE GALL BLADDER intraabdominal metastasis. Cystic duct arose from right CANCER AND SURGICAL hepatic duct. Frozen section of cystic duct showed no ev- OBSTRUCTIVE JAUNDICE (SOJ)? idence of malignancy. Liver resection of Segment 4b and 5 S. Chauhan, S. Kumar, S. Masood, A. Pandey and was done using the help of CUSA and bipolar diathermy. D. Kumar The procedure was successfully completed in 320 minutes. Surgical Gastroenterology, Ram Manohar Lohia Institute Blood loss was 150 ml. There was no intraoperative com- of Medical Sciences, India plications and drain was removed on post-operative day 5, Aim: To ascertain the quality of life in patients undergoing then discharged on the same day. Histopathology report PTBD for palliation of surgical obstructive jaundice (SOJ) revealed - moderately differentiated squamous cell carci- in inoperable cases of carcinoma gall bladder with jaundice. noma with no malignancy in 7 lymph nodes examined, Method: From January 2016 to November 2017, 32 pa- (pT3N0M0). He was subjected for adjuvant therapy. tients of inoperable carcinoma gallbladder with jaundice Conclusion: The robotic radical cholecystectomy in locally underwent PTBD with palliative intent. 18 such Patients advanced carcinoma gallbladder is safe and feasible. With followed up and were assessed by FACT-HEP and EORTC robotic surgery system well suited for subtle dissections in QLQ BIL 21 questionnaire pre-procedure, post-procedure, a deep and narrow space, this has the potential to be viable. and one month post-procedure. Thereafter patients were followed up monthly. Patients unwilling to enroll for the study or those lost to follow up were excluded. EP03B-030 Results: Mean age 54.17 yrs , M:F ratio = 1:1, type of RESIDUAL DISEASE IN INCIDENTAL PTBD, complications, procedure related mortality, cost of GALLBLADDER CANCER: RISK procedure, mean follow up was recorded. All the data along STRATIFICATION AND OUTCOME with the Questionnaire split analysis was done using the SPSS version 23. FACT HEP- factors that showed 1 1 1 2 L. Gil , J. Lendoire , F. Duek , J. Hepp , improvement - physical, social/family, emotional ,func- 2 1 X. Darexabala and O. Imventarza tional well being (p < 0.000) . Additional concerns related 1 2 Hospital Argerich, Argentina, and Clinica Alemana, to symptoms also showed significant improvement (p < Chile 0.000). PTBD tube related problems did not significantly Background: Residual disease (RD) has become the most affect QOL (p < 0.000). EORTC QLQ BIL21 - Improve- relevant prognostic variable after resection for incidental ment was seen in Eating symptom (p < 0.001), jaundice (p gallbladder cancer. < 0.000), tiredness (p < 0.11), pain (p < 0.001), anxiety (p

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S711

< 0.000) and tube related symptom also did not adversely Europe. Currently, there are no targeted therapies for alter the quality of life (p < 0.000). treating gallbladder carcinoma. Mutation burden and ge- Conclusion: Even in a hopeless situation like inoperable netic landscape of gallbladder cancer remains poorly un- gallbladder cancer with SOJ, although no survival benefitis derstood. We employed whole-exome sequencing strategy seen by this palliative treatment, the QOL is significantly to map somatic mutations in gallbladder carcinoma. improved despite the procedure related complications and Methods: The study was conducted in postgraduate high cost of treatment. institute of medical education and research Chandigarh, India and Institute of Bioinformatics Bangalore India. Tumour specimens were collected from surgeries performed EP03B-032 at Postgraduate Institute of Medical Education and Research MULTIMODALITY APPROACH TO (PGIMER), Chandigarh. Paired tumor/normal samples were subjected to whole-exome sequencing on Illumina HiSeq GALLBLADDER CANCER: OUR platform. The samples were sequenced at a mean coverage EXPERIENCE AT A TERTIARY CARE of 80X. CENTRE IN NORTHERN INDIA Results: Exome sequencing revealed several somatic mu- A. Pandey, K. Noman, S. Masood, S. Chauhan, A. Gupta, tations in gallbladder carcinoma. Mutation burden in the S. Kumar and D. Kumar coding region of gallbladder carcinoma ranged from 60-80 fi Surgical Gastroenterology, Dr. Ram Manohar Lohia mutations per tumor. Signi cantly mutated genes included Institute of Medical Sciences, Lucknow, India tumor protein 53 (TP53), erb-b2 receptor tyrosine kinase 2 (ERBB2), erb-b2 receptor tyrosine kinase 3 (ERBB3) and Introduction: This study was done to assess the varied catenin beta 1 (CTNNB1). Recurrent mutations in ERBB presentations in patients with gallbladder cancer (GBC), pathway has been previously reported in gallbladder outcome following radical surgery and various modalities carcinoma. of palliation and to assess the survival of these patients. Conclusion: Our study provides insights into somatic Methods: Retrospective analysis of the data of all GBC mutation burden in gallbladder carcinoma and reveals patients over 4 years. Outcome was assessed during follow- frequently mutated genes and pathways that could be up visits and telephonic interviews. Patients with metastatic potentially targeted for therapeutic intervention. disease at presentation were not included. Results: 140 cases of GBC were analysed, with a 1:2 male to female ratio. Three most common modes of presentation were weight loss (55.7%), upper abdominal pain (45%) and EP03B-035 jaundice (40%). Seven patients were diagnosed with inci- CLINICOPATHOLOGICAL dental GBC following cholecystectomy. Most common CORRELATION OF 18F-FDG PET IN radiological findings suggestive of GBC were focal or diffuse thickening of gallbladder wall (37 and 76 patients CHARACTERIZING GALL BLADDER respectively), IHBRD (65), presence of regional/distant WALL THICKENING lymph nodes (34) and local infiltration (28). Majority of K. Vishnu1, V. Gupta1, T. D. Yadav1, B. R. Mittal2, patients were admitted for palliation of jaundice for hilar N. Kalra3 and K. Vaiphei4 blocks (52 patients). 46 patients were found to be resectable 1Department of Surgery, 2Department of Nuclear Medi- and underwent radical cholecystectomy. The average sur- cine, 3Department of Radiodiagnosis, and 4Department of vival of patients at the end of 1 year was 45% following Histopathology, Post Graduate Institute of Medical Edu- radical surgery and 10% following palliative modalities. cation and Research, India Conclusions: Although GBC is an uncommon disease Introduction: Thick walled gallbladder is difficult to worldwide, it has a high incidence in Northern India, an characterize on conventional imaging. 18F-FDG PET was endemic zone of gallstone disease. Patients usually have an used to differentiate benign and malignant wall thickness advanced disease at presentation. However, patients with and compared with histopathology. fi focal masses were found to bene t from surgery the most Methods: Thirty patients with GB wall thickening (focal > and had better survival. A greater awareness of the early 4 mm and diffuse > 7 mm), underwent ultrasound, CT scan symptoms of GBC and a screening programme is needed and 18F-FDG PET. Histopathology of the specimen was for early detection of GBC. compared with imaging findings. Results: The mean age was 48.22 Æ 31.33 years with a M:F 1:4. Twenty patients had diffuse and 10 had focal EP03B-033 thickening. On conventional imaging, lesion was benign in LANDSCAPE OF SOMATIC MUTATIONS 13, malignant in 15 and indeterminate in two. On 18F-FDG IN GALLBLADDER CARCINOMA FROM PET, lesion was benign in 12, malignant in 13 and inde- terminate in 5. Histopathology was malignancy in 12; INDIAN PATIENTS benign in 18- chronic cholecystitis in 11, xanthogranu- T. Yadav lomatous in 4, IgG4 related in 2 and polyp in 1. The mean General Surgery, Post Graduate Institute of Medical Ed- GB wall thickness was 7.79 Æ 3.59mm (10.34 malignant ucation and Research, India and 6.10 in benign, p = 0.001). At a cut off of 8.5mm the Introduction: Gallbladder carcinoma is one of the most sensitivity and specificity of detecting malignancy was 94% aggressive malignancies with poor prognosis. High inci- and 67%. The mean SUV uptake was 7.46 (benign 4.51, dence of gallbladder cancer is observed in women malignant 14.26, p=0.0102). At a cut off of 5.95 the compared to men. The incidence rates are particularly high sensitivity and specificity of detecting malignancy was 92% in some of the countries in Latin America, Asia and central and 79%. For 18F-FDG PET overall sensitivity was 91%,

HPB 2018, 20 (S2), S685eS764 S712 Electronic Poster (EP03A-EP03F) e Biliary specificity 79%, PPV 77%, NPV 92% and diagnostic ac- tissues showed inflammatory changes only. The right curacy was 84%. hepatectomy, CBD excision and left hepatico-jejunostomy Conclusion: 18F-FDG PET is a reliable method of dif- was done. The patient had a minimal bile leak and mild ferentiation between benign and malignant thickening of wound infection. The histopathology revealed chronic in- the gall bladder particularly when wall thickness and SUV flammatory changes with remnants of dead worms in the value is taken into account. peripheral ducts. She is normal at 18 month follow up. Conclusion: Biliary ascariasis in the setting of obstruction can evoke enough chronic inflammation and fibrosis so as Statistical analysis of imaging in thick walled GB to form a mass that can masquerade gall bladder cancer. Imaging modality USG CECT PET CT Sensitivity(%) 57.14 100.00 90.91 Specificity(%) 62.50 72.22 78.57 EP03B-037 PPV(%) 40.00 66.67 76.72 SUSPICIOUS GALLBLADDER MASSES; NPV(%) 76.92 100.00 91.67 THE VALUE OF INFLAMMATORY Diagnostic accuracy(%) 60.86 82.14 84.00 MARKERS IN DEPICTING GALLBLADDER CANCER A. Abutaka1, I. Sulieman2, A. Elaffandi2, W. Shehata2 and H. Khalaf2 1Hamad Medical Corporation, and 2Liver Unit, HPB and Transplant Surgery, Hamad Medical Corporation, Qatar Introduction: Gallbladder cancer remains a diagnostic dilemma among patients presenting with gallbladder mass lesion. The value of inflammatory markers in differentiating between benign and malignant lesions have been reportedly found to be equivocal. We aim to investigate the value of in- flammatory markers in patients presenting gallbladder mass lesions. Methods: All of the patients presenting to our institution with suspicious gallbladder lesions from January 2011 to December 2017 were reviewed. Patients with confirmed histopathology. Inflammatory markers included Neutrophil/ Lymphocyte ratio (NLR) and Platelet/Lymphocyte ratio (PLR) were collected for all patients. The data was analyzed FDG uptake in benign & malignant lesions of GB by Spearman correlation and Wilcoxon rank-sum test. Results: A total of 81 patients were identified with appre- hensive gallbladder lesions. 76 patients had confirmed EP03B-036 histopathology and recorded neutrophils, lymphocytes and platelets count at the time of diagnosis. [35 (46%) gall- A CURIOUS CASE OF AN bladder cancer, and 41 (54%) gallbladder inflammatory UNIMAGINABLE MIMICKER FOR conditions]. The mean NLR for malignant lesions was 3.8 GALL BLADDER CANCER (95% CI: 2.5 - 5.0) and for the benign lesions was 2.8 (95% N. Dash1 and V. L. Nag2 CI: 2.1 - 3.6). The difference between the NLR values 1Department of Gastrosurgery and Liver Transplantation, showed high trend but the P value is not statistically sig- 2 fi AIIMS, and Department of Microbiology, AIIMS Jodhpur, ni cant (0.06). The mean PLR for malignant lesions was India 192.0 (95% CI: 143.4 - 240.7) and for the benign lesions was 149.4 (95% CI: 117.0 - 181.9). The difference was not Background: There are a number of mimickers described significant (P value: 0.12). for gall bladder (GB) cancer. We herein describe a case that Conclusion: We found that inflammatory markers; namely could only be diagnosed only after irreversible surgical the NLR, may be helpful as a surrogate marker in the steps were committed for gall bladder cancer. diagnosis of gallbladder cancer; however larger sample sized Methods: The Case: A 24 year female from north India studies may be useful in depicting the significant difference. was admitted with pain abdomen, obstructive jaundice , significant weight loss, and a hard gall bladder lump for 2 months. The total bilirubin, AST/ALT, Alkaline phospha- tase and albumin were 8.8/7mg/dl, 95/ 67 IU/dl, 1355IU/dl EP03B-038 and 3 gm/dl respectively. Imaging showed a GB neck mass IS THE ROUTINE with proximal IHBR dilatation and encashment of right HISTOPATHOLOGICAL ANALYSIS OF hepatic artery and right portal vein. Due to an inadequate ALL GALLBLADDERS JUSTIFIED? liver remnant, PTBD and right portal vein embolization 1 2 2 1 was done prior to surgery. Intra-operatively a large hard GB A. Fanshawe , R. Goodall , C. Coughlan and H. Sheth 1 2 mass was found with infiltration of right hepatic artery and Department of Surgery, and Ealing Hospital, London portal vein. While dividing the right duct, a live adult round North West Healthcare NHS Trust, United Kingdom worm was found in the right hepatic duct and obstructed 66,000 cholecystectomies are performed annually in the CBD. Multiple frozen sections sent from GB and adjacent UK. Nationwide, all gallbladders are routinely sent for

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S713 histological analysis to exclude incidental malignancy. This Conclusion: Laparoscopic approach for T1a & T2 early comes at significant cost to an overstretched National Health gallbladder cancer resulted in less complication & mortality Service. This study set out to assess the utility of routine compared with open radical cholecystectomy. We believed histopathological analysis following cholecystectomy. that Laparoscopic approach may be feasible and safe for We performed a large, single-centre, retrospective anal- selected patients. ysis of all gallbladder specimens examined between February 2013 and December 2016 at our district general hospital. Specimens obtained in elective and emergency EP03B-040 cases, through laparoscopic or open surgery, were included. EXTENSIVE RESECTIONS IN A total of 752 gallbladder specimens were analysed. The mean age at the time of resection was 51 years, and the CARCINOMA GALL BLADDER: WORTH female:male ratio was 2.8:1. Seven (0.93%) specimens IT OR NOT? were reported to show suspicious histopathological fea- R. Kilambi1,2, A. N. Singh1, S. Pal1, N. R. Dash1 and tures; epithelial atypia (1), low-grade epithelial dysplasia P. Sahni1 (2), high-grade epithelial dysplasia (1), papillary adenoma 1Gastrointestinal Surgery and Liver Transplantation, All (1), MALT lymphoma (1) and invasive adenocarcinoma India Institute of Medical Sciences, and 2Department of (1). In all seven cases, there was no clinical suspicion of Hepato-Pancreato-Biliary Surgery, Institute of Liver and gallbladder malignancy prior to surgery or suspicious pre- Biliary Sciences, India fi operative ultrasound scan ndings. Gross macroscopic Background: Improvements in surgical techniques and changes were noted at the time of resection in three cases. advances in perioperative management, combined with the Four patients required further investigation and subsequent dismal survival of untreated patients of carcinoma gall- follow-up. All specimens deemed to be suspicious derived bladder have led to an increasing number of surgeons from patients over 50 years of age at the time of resection. opting for extensive resections in an attempt to improve Pre-operative investigations and macroscopic appearance outcomes. However, the data on aggressive surgical man- at cholecystectomy may be inadequate in identifying pa- agement of this disease is limited. We present our experi- tients with clinically important pathology. Routine histo- ence of extensive surgical resections over the last decade. fi logical analysis allows early identi cation. However, further Methods: Data was collected about all patients with car- work will assess whether more selective requests may help cinoma gallbladder undergoing extensive resections achieve the balance between cost-saving and safety in the (resection of any additional organ or vessel other than liver context of a resource-limited healthcare service. and biliary tract) at the Department of GI Surgery, AIIMS, between January 2004 and June 2017 from a prospectively maintained database and analyzed. EP03B-039 Results: Of the 250 patients operated for carcinoma gall- THE COMPARISON BETWEEN bladder, 66 underwent extensive resections. There were 41 LAPAROSCOPIC AND OPEN RADICAL (62.1%)anicteric and 25 (37.9%)icteric carcinoma gall- e CHOLECYSTECTOMY AT T1B & T2 bladders with a median age of 52 (23 70) years and 47 (71.2%) females. The additional organs resected included GALLBLADDER CANCER portal vein (2), right hepatic artery(4) stomach and/or du- I. S. Choi, J. S. Lee and J. I. Mon odenum(42) and colon(30). Another 18 patients undergo- General Surgery, Konyang University Hospital, Republic ing gastrointestinal resections also had bile duct resection. of Korea Seven patients underwent completion extended cholecys- Purpose: Gallbladder cancer is the most common malig- tectomy with gastrointestinal resections. Right extended nancy of the biliary tract. Laparoscopic and open radical hepatectomies were performed in 12patients and hepato- surgery (including liver resection and regional lymphade- pancreaticoduodenectomies in 7. Perioperative mortality nectomy) are applied for some early gallbladder cancers. and morbidity occurred in 14 (21.2%) and 41 (62.1%) pa- For patients with T1b & T2 cancers discovered incidentally tients, respectively. Of the 52 patients discharged, 46 were on cholecystectomy specimens, we present our experience available for long-term survival analysis. The median managing gallbladder cancer by using laparoscopic and recurrence free and overall survival were 12(10e14) and open surgical approach for T1b & T2 Stage. 15(11e18)months, respectively after a median follow up of Method: We collected the 54 patients with T1b & T2 stage 14 (4e75)months. who underwent laparoscopic and open radical cholecys- Conclusion: Extensive resections are associated with tectomy from Mar. 2002 to Dec. 2017. We divided them acceptable perioperative mortality and long term survival in into two groups, the Laparoscopic group (43) and open the otherwise nihilistic scenario of locally advanced carci- group (11). The aim of the study was to see any compli- noma gallbladder. cation between the two groups. Result: A total of 54 cases were included in this study. 43 cases were the Laparoscopic group and 11 cases were open EP03B-041 group . The age and also ASA score > 3 were higher in ARE ALL INCIDENTAL GALLBLADDER laparoscopic than open radical cholecystectomy. Consid- CANCERS TRULY INCIDENTAL? OR, ering operative time & EBL, it takes longer and much more bleeding than laparoscopic group and hospital stay days ARE SOME MISSED CANCERS? were needed more in the open group. Among the compli- A. Agarwal, A. Verma, A. Hussain and Hepatobiliary cations and mortality, there were more cases at open radical Surgical Oncology, Dr. RML Institute of Medical Sciences, cholecystectomy group than laparoscopic group. India

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Incidental gallbladder carcinoma (IGBC) is an incidental not. Out of 43 who underwent interval laparoscopic cho- finding of cancer on histopathological examination (HPE) lecystectomy, mean operative time was 134.9 minutes of gall bladder specimen removed for benign gall bladder (S.D+/À57.8). Five (11.6%) patients were converted to diseases. The incidence of IGBC ranges from 0.19e3.3%. open cholecystectomy, 2 (4.6%) developed CBD injury and However, many such tumours are of advanced T stage on 7 (16.2%) developed SSI. Out of 22 patients who were HPE. Some of these tumors are possibly missed on either followed after tube removal, 3 (13.6%) developed recur- pre-operative evaluation and/or during cholecystectomy. rence of symptoms and 19 (86.4%) remained symptom This study was done to find the proportion of patients of free. Catheter related problems occurred in 4 (18%) patients IGBC who had preoperative and/or intra-operative suspi- and our mean follow up was 19 months (S.D +/À 8). cious of GBC but underwent simple cholecystectomy. Conclusion: Percutaneous cholecystostomy is a good Materials and methods: Data from 56 consecutive IGBC alternative for patients unfit to undergo immediate surgery. patients presented to our centre between April 2016eMay Laparoscopic cholecystectomy after tube placement be- 2017 was analysed. A review of preoperative imaging and comes technically challenging as is seen by the increased operative notes was done to ascertain any suspicion of rate of conversion, bile duct injury and wound infection. malignancy-in-retrospect. Recurrence of symptoms after tube removal are in a low Results: Preoperative USG was suspicious in 39% (22/56) range, therefore percutaneous tube placement can be of patients. CECT scan done in 13 of these patients considered a definitive management who are high risk for confirmed gallbladder wall abnormalities in 10 cases. Ma- surgery. jority of procedures were open cholecystectomy (39/56), suspicious intraoperative findings were documented in 15 (26.7%) patients. Time to referral after primary surgery was EP03C-007 within one month in 30.3% (17/56), between one to two INSTRUCTION OF LAPAROSCOPIC months in 35.7% (20/56), between 2 and six months in 23.3% (13/56) and after six months in 10.7% (6/56). CHOLECYSTECTOMY IN ACUTE Seventeen patients (30.3%) were advised completion sur- CHOLECYSTITIS USING A SINGLE- gery. Seven patients (13%) underwent completion surgery. INCISION LAPAROSCOPIC SURGERY Rest of the patients were found to be inoperable. DEVICE Conclusion: Radiologists and surgeons should keep a high K. Asai, M. Watanabe, T. Saito, M. Kujiraoka, index of suspicion of GBC, especially in high incidence H. Moriyama, T. Enomoto, Y. Saida and S. Kusachi areas. Whenever, there is any suspicion, patients should be Surgery, Toho University Ohashi Medical Center, Japan promptly referred appropriately. Even when detected inci- dentally, prompt referral maximises chances of curative Introduction: We basically performed early laparoscopic resection. cholecystectomy (LC) for acute cholecystitis (AC). Recently, early LC has been performed more frequently by surgical trainees who have not yet been certified as mem- bers of the Japan society for endoscopic surgery. Here we EP03C - Electronic Poster: 3C - Biliary report instructions on LC using a single-incision laparo- Gallstones scopic surgery (SILS) device. EP03C-004 Patients and methods: We analyzed 275 AC patients who ROLE OF PERCUTANEOUS underwent LC at our department and divided them into two CHOLECYSTOSTOMY TUBE groups: one group underwent LC performed by certified PLACEMENT IN THE MANAGEMENT surgeons (n = 135), and the other group underwent LC performed by surgical trainees (n = 140). Regarding the OF ACUTE CALCULUS port setting, two trocars (5 and 12 mm) were inserted in the CHOLECYSTITIS IN HIGH RISK navel port using the SILS device. The 5-mm trocar in the PATIENTS navel port was manipulated by the instructing surgeon’s H. Bari1, I. Pal2 and A. Ali2 right hand. Hemostasis was achieved using soft coagula- 1Surgery, Shaukat Khanum Cancer Hospital, and 2Sur- tion, appropriate counter traction, and instruction inside the gery, Aga Khan Univeristy Hospital, Pakistan operative field. We also divided surgical trainees’ cases as Introduction: For acute cholecystitis standard of care is an those before and those after the introduction of the SILS urgent laparoscopic cholecystectomy. In patients with un- device. Results: controlled medical illnesses, a percutaneous chol- Conversion to open surgery was needed in 6.1%, ecystostomy tube along with antibiotic therapy can be an and postoperative complications occurred in 3.6%. alternate. We evaluate the use of percutaneous chol- Regarding the comparison between LC performed by fi ecystostomy tube in patients with acute calculus chole- certi ed surgeons and surgical trainees, there were no sig- fi cystitis but considered unfit for immediate surgery. ni cant differences in terms of operative time, intra- operative bleeding, conversion to open surgery, and Materials and methods: This was a retrospective review of adult patients who underwent percutaneous chol- postoperative complications. Furthermore, after intro- ecystostomy tube placement from 2010 to 2016. ducing the SILS device, there were no conversions to open Results: Sixty-Five patients met the inclusion criteria. surgery and postoperative complications in the surgical Mean age was 58.5 years .Forty-Four patients (67.7%) were trainee group. Conclusion: males. More than 60% of the patients had ASA III/IV. 43 Early LC using the SILS device was achiev- patients underwent interval cholecystectomy and 22 did able by surgical trainees in patients with AC.

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EP03C-008 Morbidity and mortality after surgical repair of bile duct injury according to Clavien Dindo classification was: I - 2 ROLE TRANSFISTULAR SANATION OF (3%), II - 1 (1,5%), III - 61 (91%) and mortality - V - 4 THE GALLBLADDER IN ACUTE (6%). We followed up 58 patients (92.1%) of 63. Mean CALCULOUS CHOLECYSTITIS IN follow-up duration was 25,7Æ36,7 months. In late post- PATIENTS WITH HIGH OPERATIONAL- operative time 23 (39,7%) patients developed bile duct ANESTHETIC RISKS strictures. Therefore, 13 (56,5%) patients underwent rest- enting or balloon dilatation and 10 (43,5%) patients un- S. Lukmonov derwent hepaticojejunostomy. Faculty Surgery, Tashkent Medical Academy, Uzbekistan Conclusions: Endoscopic retrograde chol- Aim: Improve treatment outcomes in patients with acute angiopancreatography (ERCP) is the main diagnostic tool calculous cholecystitis with high operational and anesthetic for suspected injuries. Stenting with a covered self- risk. expanding metal stent is a promising method for the pa- Materials and methods: Analyzed group consisted of 30 tients with partial divisions or strictures of bile ducts. Both patients with acute calculous cholecystitis with high opera- hepaticojejunostomy and end-to-end anastomosis showed tional and anesthetic risk. In the present group of patients good results while treating complete divisions of ducts. were women: 23 (76.6%). The mean age was 72.1 years. All patients were divided into 2 groups. Group I included pa- tients who underwent only cholecystostomy. II group consisted of patients who were treated with a 2-step process. EP03C-010 Treatment results: Of the 7 patients of the first group after ACUTE CHOLANGITIS IN PATIENTS hospital discharge, relapse occurred in 4 cases (57.1%). In WITH OBSTRUCTIVE JAUNDICE the second group stage of the treatment I included chol- V. Syplyviy, D. Ievtushenko, A. Ievtushenko and A. Guz ecystostomy and conservative measures (antibiotic therapy, Kharkiv National Medical University, Ukraine sanitation biliary tract). After drainage of the gallbladder Introduction: Acute cholangitis is common and poten- intraoperatively (macrostomy) or puncture (microstomy) tially life-threatening complication of gallstone disease. e fi after 5 7 days were mandatory stulography. In TSG has Method: 184 patients with benign obstructive jaundice made electrocoagulation of gallbladder mucosa for oblit- were included. Men - 68 (37 %), women 116 (63 %). The eration of the lumen. In analyzing the results of treatment average age was 64,1 + 1,0 years, ranged from 31 to 88. with TSG during the year, recurrence of acute cholecystitis Cardiovascular diseases were the most common comor- were observed. A monitoring ultrasound at 12 in place of bidity. All patients underwent surgical treatment. fi fl the gall bladder was de ned only linear at compact Results: Acute cholangitis diagnosed in 62 (33,7 %) pa- structure without echo-free and echo-producing and in- tients. All patients classified according Tokyo Guidelines clusions, indicative of the obliteration of the gallbladder 2013 - grade I - 53.3 %, II - 41.9 % and III (severe) - 4.8 %. with the formation of connective tissue in its place and Recovery of bile duct leads to fast normalization of bilirubin there is no recurrence of stone formation. levels, but the activity of AST and ALT remains high. Such Conclusion: Not in one case after TSG not observed changes correlate with morphological findins. With recurrence of cholecystitis, which allows us to evaluate the increasing in the duration of jaundice from 7 to 30 days, effectiveness of treatment methods in the ACCH in patients amount of connective tissue increases from 5.05 Æ 0.96 to with serious underlying medical conditions. 11.4 Æ 1.39, size of hepatocytes decreases from 66.55 Æ 2.07 to 59.55 Æ 2.15 that lead to increase of parenchyma-to- stroma ratio from 0.37 Æ 0.009 to 0.5 Æ 0.012 (p < 0.05). EP03C-009 Postoperative complications were observed in 16 (15,2%) POSTCHOLECYSTECTOMY BILE DUCT patients with cholanditis. Grade 1-2 (Clavien-Dindo) - in 13 INJURIES: DIAGNOSTICS AND (12,38 %) patients, Grade 3b - in 3 (2,85 %). Acute SURGICAL TREATMENT pancreatitis and bleeding were the most common compli- cations. E. coli, P. aeruginosa, K. pneumoniae isolated from A. Sileikis and K. Strupas bile in patients with mild or severe cholangitis. Vilnius University, Lithuania Conclusions: Cholangitis leads to significant changes in Introduction: Bile duct injuries (BDIs) still occur during peripheral blood, disturbances of the liver function, laparoscopic cholecystectomy. We would like to present subcompensation or decompensation of at least one body ’ our 15 years experience in the management of BDIs, system occurs in 46.7 % of patients. evaluate our results of treatment. Methods: Medical records of 67 patients who have expe- rienced BDIs after laparoscopic cholecystectomy were retrospectively reviewed. All injures were classified ac- EP03C-012 cording to European Association for Endoscopic Surgery XANTHOGRANULOMATOUS ATOM (anatomic, time of detection, mechanism) classifi- CHOLECYSTITIS: PSEUDO TUMOR OF cation and investigated by manifestation of the injury, GALL BLADDER surgical repair technique, early and late complications. 1 1 1 1 2 Results: In 28 (41,8 %) patients the surgical treatment of A. Gupta , R. Kant , B. Ravi , A. Gupta and P. Joshi 1 2 BDI was completed with ERCP and stenting, in 14 (20, Department of Sugery, and Department of Pathology, 1%) cases defect of bile duct was closed by suture, end-to- AIIMS Rishikesh, India end ductal anastomosis was performed for 6 (13,4%) pa- Introduction: Xanthogranulomatous cholecystitis is an tients and hepaticojejunostomy in 19 (28,3%) patients. uncommon inflammatory disease of gall bladder with

HPB 2018, 20 (S2), S685eS764 S716 Electronic Poster (EP03A-EP03F) e Biliary reported prevalence of 0.7% in US and 10% in India and Introduction: Mirizzi syndrome occurs approximately on Japan. Its final diagnosis can be made only after malig- 0.5 to 4% of the patients with cholelithiasis. nancy is ruled out on histopathological examination of Methods: 34 patients underwent surgical treatment. resected gall bladder. Results: Mirizzi I diagnosed in 6 patients - cholecystec- Case presentation: 60 years female presented with com- tomy performed. Mirizzi II (9 patients) - cholecystectomy plaints of pain in right upper abdomen, loss of appetite for 3 with plastics of fistula, in 6 - external drainage of CBD, 1 - months. Physical examination was normal. Abdominal choledochoduodenostomy performed. Mirizzi III (4 pa- examination revealed tenderness in right upper quadrant tients) - in 2 patients cholecystectomy with plastics of and a hard, non tender globular mass suggestive of gall CBD. In 2 cases hepaticojejunostomy in our modification bladder lumpBlood parameters were normal. Contrast performed. Mirizzi IV (5 patients) subtotal cholecystec- enhanced CT scan abdomen reported grossly distended gall tomy, in 4 with reparation of CBD. In 1 patient - hepati- bladder with 12 mm calculus at neck, pericholecystic fat cojejunostomy in our modification. Mirizzi Va (8 patients), stranding, asymmetric wall thickening and few lymph 4 (50 %) patients came with signs of acute cholecystitis nodes. Serum CA19.9 -103 IU/l.. Diagnostic laparoscopy with formation of subhepatic or subdiaphragmatic ab- that ruled out intraperitoneal disease followed by chole- scesses. In all cases, cholecystoduodenal fistula was cystectomy and wedge resection of liver. Intraoperatively, detected. All 4 patients underwent subtotal cholecystec- gall bladder was found to be hard, elongated, densely tomy with reparation of CBD using gallbladder tissue and adhered to GB fossa with multiple calculi in it. Histo- plastics fistula. 4 (50%) patients delivered with symptoms pathologically greyish-yellow streaks in the gallbladder of obstructive jaundice. In 1 case cholecystocolic, in 3 - wall, transmural inflammation with dense lymphoplasma- cholecystoduodenal fistula diagnosed. Subtotal cholecys- cytic infiltration and fibrosis, perineural plasma infiltrate, tectomy with CBD plastics and plastics of enteric fistulas one of the areas showing storiform fibrosis, suggesting performed. Mirizzi Vb (2 patients): delivered in severe xanthogranulomatous or IgG4 cholecystitis. No malig- condition with of endotoxic shock and symptoms acute nancy present. Serum IgG levels were raised but IgG4 small bowel obstruction. During intervention large levels were normal. Immunohistochemistry for IgG4 concrements (4 and 5 cm) were found causing small bowel plasma cells in the specimen was negative. obstruction. Enterotomy with removal of concrements Conclusion: Xanthogranulomatous cholecystitis is a per- performed. fect mimicker of carcinoma gall bladder and diagnosis is Conclusions: Surgical treatment of patients with Mirizzi difficult, both pre and intraoperatively. It is a differential for syndrome requires individualized tactics. IgG4 cholecystitis also which though rare isolated entity, is usually a part of spectrum of IgG4 related sclerosing diseases. EP03C-015 EARLY LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE MILD EP03C-013 BILIAR PANCREATITIS ASYMPTOMATIC CHOLECYSTOCOLIC FISTULA TREATED BY LAPAROSCOPIC A. M. Dumrauf, M. E. Lenz Virreira, M. V. De Souza E Sà, I. A. Chiarlo and A. Aldet SURGERY WITH ACCURATE Cirugia Hepatobiliopancreatica, Hospital Italiano de La DIAGNOSIS BEFORE SURGERY Plata, Argentina S. E. Hwang Introduction: The International Association for the Study Surgery, Daejeon Sun Hospital, Republic of Korea of Pancreatic Disease recommends cholecystectomy as Cholecystocolic fistula (CCF) is a rare and late compli- early as possible, once the acute mild biliar pancreatitis cation of gallbladder disease. The cause of CCF is known to episode is solved; however, the American and British So- be due to peptic ulcer, gallbladder disease, malignant ciety of Gastroenterology recommends it between 2 and 4 tumor, trauma, and postoperative complications. The weeks. The objective of this work is analyze the results of proper method of treatment is to perform cholecystectomy cholecystectomy performed early in patients with mild and to identify and alleviate the CCF. However, This sur- acute biliary pancreatitis. gery is not always possible due to technical difficulties and Method: Retrospective observational study between disease severity. CCF is difficult to diagnose preoperatively January 2015 and December 2017. The variables under and CCF operation without an accurate preoperative diag- study were hospitalization days, age, sex, morbility, mor- nosis can lead to more complicated surgery and can lead to tality, pain at the time of surgery, pre-operative amylase- surgeons in more difficult situations or to endanger patients. mia, intraoperative cholangiography, conversion rate, We would like to report the asymptomatic CCF success- persistence of SIRS in the pre-operative period, recurrence fully treated by laparoscopic surgery with accurate diag- of the disease, and indication or not of CT scan. nosis before surgery. Results: A total of 77 patients were admitted with a diag- nosis of acute pancreatitis, of those, 41 were diagnosed with a diagnosis of PAB. 6 patients underwent surgery before 48 EP03C-014 hours and 35 after 48 hours. Those operated before 48 hours were admitted to the operating room with amylasemia lower MIRIZZI SYNDROME: SURGICAL than 300 UI/l. Of the 35 patients who underwent surgery TREATMENT OPTIONS after 48 hours, the average amylasemia was 96 UI/l. 17 V. Syplyviy, D. Ievtushenko and A. Ievtushenko patients (41,4%) underwent CT scan. All of the patients Kharkiv National Medical University, Ukraine underwent CIO and only 2 presented choledocholithiasis

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S717 that could be resolved by transcistic route. Both groups were database to evaluate the incidence and risk factors of gall- discharged on the first postoperative day, without any stone after gastrectomy for gastric cancer. complications. And only one of the patients became open Methods: All consecutive patients who underwent gas- surgery, no deaths were recorded in this series. trectomy for gastric cancer in South Korea in 2008-2010 Conclusions: Acute mild biliary pancreatitis can be were identified. Incidence of gallstone formation 5 years resolved early without complications during the post- after gastrectomy in males and females, in various age operative period or mortality. groups, and after different types of gastrectomy was determined. Multivariate logistic regression analysis served to identify gallstone risk factors. Results: Of the 47,752 patients, 2,506 (5.2%) developed EP03C-016 gallstone during the 5 year follow-up period. At 12, 24, 36, LAPAROSCOPIC CHOLECYSTECTOMY and 48 months, the cumulative incidences were 1.2%, USING COLOR ICG FLUORESCENCE 2.2%, 3.3%, and 4.3%, respectively. Males had a higher SYSTEM FOR A PATIENT WITH incidence than females (5.8% vs. 4.1 %, p < 0.001). Older ACCESSORY HEPATIC DUCT patients (60e89 years) had a higher incidence than younger patients (30e59 years) (6.1% vs. 4.3%, p < 0.001). Gall- Y. Shimizu, Y. Seyama, K. Mori, T. Koseki, stone was most common after total gastrectomy (6.6%), T. Maeshiro and S. Miyamoto followed by proximal gastrectomy (5.4%), distal gastrec- Surgery, Tokyo Metropolitan Bokutoh Hospital, Japan tomy (4.8%), and pylorus-preserving distal gastrectomy Introduction: We sometimes face to accessory hepatic (4.0%) (p < 0.001). Multivariate analysis showed that male ducts, and anomaly of hepatic duct of right posterior sex (Odds Ratio [OR]=1.39), an older age (OR = 1.44), and segment may cause the complication in laparoscopic cho- total gastrectomy (OR=1.40 vs. distal gastrectomy) were lecystectomy. Recently, we have been able to use color significant independent risk factors for postgastrectomy ICG fluorescence method by superimposing fluorescence gallstone. image on a color image. Here, we introduce a case of Conclusions: The cumulative incidence of gallstone 5 accessory hepatic duct, in which color ICG fluorescence years after gastrectomy for gastric cancer was 5.2%. Male method was effective in laparoscopic cholecystectomy. gender, an older age, and total gastrectomy were significant Method: A 50-year-old female was presented with upper risk factors. More careful monitoring for gallstone may be abdominal pain. She was pointed out gallbladder stone and necessary in patients with such risk factors. common bile duct stone, and underwent an elective lapa- roscopic cholecystectomy after endoscopic treatment. In MRCP and ERC before the operation, the hepatic duct of EP03C-018 posterior segment was close to the cyst duct, but anomaly of the biliary system was not clearly detected. We used CLINICAL DIFFERENCES OF YOUNG colore ICG fluorescence system (PINPOINT, NovadaqÒ) POPULATION UNDERWENT in this operation. LAPAROSCOPIC CHOLECYSTECTOMY Result: At the beginning of surgery, we gave ICG 2.5 mg COMPARED TO OLDER POPULATION intravenously. After exposing Calot triangle, we encoun- Y. S. Choi, S. W. Suh and S. E. Lee tered the cord which we suspected accessory hepatic. We Surgery, Chung-Ang University, Republic of Korea could confirm that it was a bile duct by colored ICG fluo- rescence method by changing the mode at hand. Referring Introduction: Laparoscopic cholecystectomy (LC) in preoperative image, we confirmed it was accessory hepatic young population is relatively uncommon, despite being duct which drained S6. We divided the neck of the gall- one of the most common surgical procedures in adults. bladder to keep the B6. Although clinical characteristic of adult patients with Conclusion: The color ICG fluorescence endoscopic gallbladder (GB) disease is well established, scanty infor- method was simple and useful to obtain real-time infor- mation have been for youth. In the present study, we aimed mation of biliary system, especially in a patient with an to comprehensively review the young population under- anomalous hepatic duct. went LC compared to older population. Methods: A total 2,115 patients who received LC for GB stones were retrospectively analyzed. The patients were categorized into two clinical groups according to the age EP03C-017 of patients: (young (<24) group and the elder group). INCIDENCE OF GALLSTONES AFTER We compared two groups according to its clinical GASTRIC RESECTION FOR GASTRIC characteristics. fi CANCER: A NATIONWIDE CLAIMS- Results: In univariate analysis, signi cant factors between two groups were found in the concomitant of chol- BASED STUDY edocholithiasis and American Society of Anesthesiologists G. H. Seo1, Y. J. Chai2 and C. -S. Lim2 score I/II. By multivariate analysis, the concomitant of 1Health Insurance Review and Assessment Service, Re- choledocholithiasis (OR 1.152, 95% CI, 0.663 - 2.001, p < public of Korea, and 2Department of Surgery, Seoul Na- 0.001) were independent factors between young group and tional University Boramae Medical Center, Republic of the elder group. Korea Conclusions: In our study, young population with gall- Introduction: Gallstone formation is one of the most stone disease had more prevalence of choledocholithiasis. common problems after gastrectomy. This retrospective Therefore, young patients with gallstone disease require cohort study used the South Korean nationwide claims special attention for choledocholithiasis.

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EP03C-019 Case report: A 71 year-old woman underwent an un- eventful elective laparoscopic cholecystectomy. The pa- POST CHOLECYSTECTOMY tient then experienced several years of unexplained night SYNDROME A REAL SYNDROME OR sweats and fevers, and abdominal imaging subsequently PRE OPERATIVE INADEQUATE WORK demonstrated a large, complex intra-abdominal collection UP SYNDROME? containing a new calcified focus in Morrison’s pouch. Fluid aspiration yielded Actinomyces israeli, which was re- B. Vasavada and H. Patel fractory to long-term antibiotics, repeated percutaneous Hepatobiliary and Liver Transplantation, Shalby Hospi- drainage and multiple surgical washouts. Novel treatments tals, India were sought, leading to repeated irrigation of the abscess Introduction: Post cholecystectomy syndrome or persis- with absolute ethanol under radiological guidance to ster- tence of same symptoms in postoperative problem is a real ilise and sclerose the cavity. The abscess subsequently problem with some studies showing incidence in the range resolved and the patient remains asymptomatic and free of of 40 percent. abscess recurrence 18 months later. Methods: We assumed that post cholecystectomy syn- Discussion: Actinomycosis from dropped gallstones is a drome in absence of known complications like bile leaks or rare complication following cholecystectomy, but should cbd injuries are due to inadequate pre operative work up for be considered in patients with recurrent abscesses or col- GERD, dyspepsia and Irritable bowel syndrome. we lections refractory to treatment. Percutaneous drainage and refused cholecystectomy to all patient with asymptomatic alcohol injection into the abscess can be considered for gall stones,GERD or IBS. We offered laproscopic chole- these cases: this is the first published case of this technique cystectomies within 48 hrs in acute cholecystitis and in for this indication. same admission in mild pancreatitis and after 4 weeks in presence of necrotising pancreatitis. Results: We did 64 laproscopic cholecystectomies in last one year. We observed 48 patients with gall stones without EP03C-021 acute cholecystitis and pancreatitis and fulfilling either IBS CHOLECYSTECTOMY AFTER criteria, GERD or who improved with PPIS. In cholecys- ENDOSCOPIC SPHINCTEROTOMY FOR tectomy group 32 was for acute cholecystitis, 25 for biliary CHOLEDOCOLITHIASIS: THE EARLIER pancreatitis, 7 for symptomatic cholelethiasis excluding THE BETTER above criteria. 2 patients developed bilomas, which settled 1 1 2 down with pcd insertion.no patient in surgery group devel- A. Doussot , B. Borraccino , C. Michiels , A. Sudry-Faure3,P.Rat1, P. Ortega Deballon1 and O. Facy1 oped post cholecsytecomy syndrome. 3 patients referred to 1 us from out side for post cholecystectomy syndrome found to Digestive Surgical Oncology, University Hospital of Dijon, France, 2Gastroenterology - GI Endoscopy, Uni- have Rome 3 or Rome 4 positive in pre operative evaluation 3 in retrospect. In observation group 44 patients improved with versity Hospital of Dijon, France, and Biostatistics, designated treatments. 4 patients had persistence of University Hospital of Dijon, France nonspecific symptoms. No patient in observation group Introduction: Endoscopic sphincterotomy (ES) stands as developed acute cholecystitis or pancreatitis in one year. the gold standard for achieving common bile duct (CBD) Conclusion: To avoid post cholecystectomy syndrome a clearance in the setting of choledocolithiasis. Although detailed pre operative work up is necessary for IBS and cholecystectomy is routinely warranted to prevent recurrent GERD and unnecessary cholecystectomies should be biliary event (RBE) after ES, the appropriate timing be- avoided. tween ES and cholecystectomy remains to be evaluated. Methods: All patients referred between 2006 and 2013 for ES and who underwent CBD clearance for chol- EP03C-020 edocolithiasis were included. RBE occurrence and risk factors were scrutinized. Cholecystectomy performed within REFRACTORY INTRA-ABDOMINAL 7 days after ES was defined as early. Further, the impact of ACTINOMYCOSIS SECONDARY TO cholecystectomy timing on outcomes was analysed. DROPPED GALLSTONES TREATED Results: Overall, 479 patients underwent ES for chol- SUCCESSFULLY WITH ABSOLUTE edocolithiasis (n = 137, 28.6%), biliary cholangitis (n = ETHANOL e A CASE REPORT 255, 53.2%), and mild acute biliary pancreatitis (n = 87, 1,2 1,2 1,3 18.2%) respectively. At presentation, 99 patients had A. P. Maurice , M. Dickfos , M. Chandrasegaram , cholecystitis (20.7%). After ES, 357 patients (74.5%) un- R. Franz3, V. Joseph4,5 and N. Brown4,5 1 2 derwent cholecystectomy within a median interval of 31 Division of Surgery, University of Queensland, Depart- days (range, 0-1405). Cholecystectomy was early in 90 ’ ment of General Surgery, Royal Brisbane and Women s patients (25.2%) and late in 267 patients (74.8%). ASA Hospital, 3Department of Surgery, 4Department of Radi- 5 score was the only variable independently associated with ology, The Prince Charles Hospital, and Division of cholecystectomy timing. Overall, RBE was observed in 92 Radiology, University of Queensland, Australia patients (19,2%) including acute cholecystitis (n = 38, Introduction: Iatrogenic gallbladder perforation and 41.3%) and choledocolithiasis (n = 41, 44.6%). Median spillage of gallstones occurs in up to 30% of laparoscopic time to RBE after ES was 38 days (range, 3-2410). Upon cholecystectomies. Dropped stones can lead to refractory multivariable analysis, ASA>2, cholecystitis at presenta- abdominal abscesses. We present the first reported case of tion, the occurrence of post-ES pancreatitis and late cho- this condition to be treated successfully with direct ethanol lecystectomy remained independently associated with injection into the abscess cavity. RBE. Regarding cholecystectomy outcomes, intraoperative

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S719 difficulty, postoperative morbidity and in-hospital stay Aim and objective: To accurately document in prospective were increased after late cholecystectomy. fashion exactly where people’s symptoms with biliary pain Discussion: Early cholecystectomy after ES should be occur in acute settings and thus re-evaluate the site of the performed within seven days whenever possible in order to pain in people with biliary disease. reduce RBE occurrence and to improve cholecystectomy outcomes. Methods: Patients presenting to a tertiary private hospital emergency department with non-traumatic chest or abdominal were asked to complete a pain location and EP03C-022 characteristics survey. The survey consisted of a pain NEED FOR UNPLANNED ERCP AFTER mannequin to mark the location of their pain and a brief questionnaire. LAPAROSCOPIC CHOLECYSTECTOMY Results: 123 patients completed surveys, 33 of which were IN PATIENTS WITH NORMAL biliary pathologies. A majority of these patients reported PREOPERATIVE SCREENING TESTS their pain as “8 out of 10” or higher (73.4%). 58% patients ’ S. Begum and M. R. Khan had constant pain, 82% felt as though they couldn t get General Surgery, Aga Khan University Hospital, Pakistan comfortable and 60% felt like moving around. The location of patients worst pain was recorded as 21.2% retrosternal, Introduction: Patients undergoing laparoscopic cholecys- 18.2% right upper quadrant and 12.1% epigastric. There tectomy for gallstones are screened by routine biochemistry was a diffuse spread of pain across the chest and upper and ultrasonography to detect common bile duct (CBD) abdomen and no reported lower abdominal pain. stones. Despite normal screening results, some patients Conclusion: The typical presentation of biliary pathology may present with complications of unexpected bile duct with severe, “can’t get comfortable”, recurring pain was stones in the postoperative period requiring unplanned reinforced by this study. A majority (21.2%) of patients in procedures. The objective of our study was to determine the this study reported their worst pain as retrosternal in frequency of patients with retained CBD stones after location as well as the more typical RUQ and epigastric laparoscopic cholecystectomy requiring unplanned ERCP. locations showing it is important to consider biliary pa- Materials and methods: Medical records of all the patients thology as a differential for chest pain in the emergency who underwent laparoscopic cholecystectomy from setting. January 2001 to December 2015 were reviewed. Patients with preoperative abnormal screening test, known CBD stones or ERCP before laparoscopic cholecystectomy were excluded. The patients with normal screening tests who EP03C-024 required unplanned ERCP for unexpected retained CBD stones were identified and were included in the study. MANAGEMENT OF MIRIZZI Results: A total of 4540 patients underwent laparoscopic SYNDROME: A SINGLE INSTITUTION cholecystectomy during the study period. Twenty-five pa- REVIEW tients (0.5%) were readmitted with CBD stones with female P. Basu, Y. X. Koh, D. Goh, P. C. Cheow, C. Y. Chan, < predominance of 68% (n = 17). Small ( 3 mm) and mul- S. Y. Lee, L. L. P. J. Ooi, A. Y. F. Chung and B. K. P. Goh tiple gallstones were seen in 19 patients (76%), while 6 Department of Hepatopancreatobiliary and Transplant fi patients (24%) had solitary stone. Intra-operatively dif cult Surgery, Singapore General Hospital, Singapore Calot’s anatomy was encountered in 14 (56%) patients with Introduction: Mirizzi syndrome (MS) arises from impac- short and wide cystic duct in 9 (24%) patients. Majority of tion of gallstone in Hartmann’s pouch, causing external the patients (n s= 13, 52%) presented within six months of compression of the bile duct to formation of chol- initial surgery. ERCP showed stones in 68% patients and ecystobiliary or cholecystoenteric fistulas. Surgical man- sludge in 32% patients. agement can be complex and may lead to complications Conclusion: Despite normal pre-operative liver biochem- such as bile duct injury. Currently, there are no guidelines istry and imaging, a small proportion of patients can present on the management approach to the different clinical man- with retained stones requiring ERCP after cholecystec- ifestations of MS. This study evaluates the management and tomy. This may be an important consideration for the pa- outcome of identified cases of MS in a single institution. tients and treating physicians. Method: Surgically treated cases of MS in Singapore General Hospital from November 2001 to December 2014 were identified and their electronic medical records EP03C-023 analysed retrospectively. MS was categorised according to BILIARY ANGINA: THE NATURE OF Beltran MA’s proposed classification system (World J BILIARY PAIN REVIEWED Gastroenterol 2012;18(34):4630-4650). Results: 78 cases of surgically treated MS were identified, 51 A. Kermond, N. O’Rourke, D. Cavallucci and (65%) of which were type 1, 23 (29%) type 2 and 4 (5%) type A. Jansen Van Rensberg 3. Magnetic resonance cholangiopancreatography was the Royal Brisbane Women’s Hospital, Australia most sensitive imaging modality to suggest MS (85%), Background: The diverse presentation of biliary disease followed by computed tomography (38%) and lastly ultra- poses a diagnostic challenge. Pain associated with biliary sound (11%). Endoscopic retrograde cholangiopancreatog- disease can occasionally imitate other disorders, such as raphywasperformedin54casesoutofwhich,37(69%)were cardiac disease. Such misdiagnosis leads to unnecessary accurately diagnosed as MS. Laparoscopic surgery was interventions and use of resources. performedin31cases,19outofwhichwereconvertedto open. Intraoperative cholangioscopy was performed in 33

HPB 2018, 20 (S2), S685eS764 S720 Electronic Poster (EP03A-EP03F) e Biliary cases, cholangiogram in 33 and 42 patients had T-tube Background: Transverse abdominal plane block (TAP) is placement. 7 (9%) patients had intraoperative, 15 (19%) post- a new technique of regional block described to reduce operative and 13 (17%) late complications. postoperative pain in laparoscopic cholecystectomy (LC). Conclusion: MS poses a challenge for the encountering Recent reports describe an easy technique to deliver local clinician. Pre-operative diagnosis is key to appropriate anesthetic agent under laparoscopic guidance. surgical planning, via laparoscopic or open techniques, to Methods: This randomized control trial was designed to avoid complications. compare the effectiveness of additional laparoscopic- guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with EP03C-025 coagulopathy, pregnancy and allergy to local anesthetics. SERUM PROCALCITONIN LEVEL All cases were four ports LC. Interventions - Both groups CORRELATES WITH SEVERITY OF received standard port site infiltration with 3-5ml of 0.25% ACUTE CHOLECYSITITS bupivacaine. The test group received additional laparo- scopic guided TAP block with 20ml of 0.25% bupivacaine J. Y. Jang1, W. Lee2, J. Cho1, C. -Y. Jeong3 and subcostaly, between the anterior axillary and mid clavicular S. -C. Hong3 lines. As outcome measures the pain score, opioid 1Surgery, Gyeongsang National University Hospital, requirement, episodes of nausea and vomiting and time to 2Surgery, Changwon Gyeongsang National University mobilize was measured at 6 hourly intervals. Hospital, and 3Gyeongsang National University College of Results: The two groups were comparable in the age, Medicine, Republic of Korea gender, body mass index, indication for cholecystectomy Introduction: The objective of this study is to evaluate the difficulty index and surgery duration. The pain score at six role of serum procalcitonin level (SPL) in predicting the hours (P = 0.043) and opioid requirement at six hours (P = fl severity of in ammation and presence of bacteremia in 0.026) was higher in the TAP group. These were similar in acute cholecystitis patients. subsequent assessments. Other secondary outcomes were fi Methods: One hundred and forty- ve patients who under- similar in the two groups. went cholecystectomy for acute cholecystitis or gallbladder Conclusion: Laparoscopic-guided transverses abdominis stones were included in this study. Blood samples were ob- plane block does not give an additional pain relief or other tained in the emergency room before operation to determine favorable outcomes. It can worsen the pain scores. complete blood count and SPL. Severity of cholecystitis was evaluated on the basis of the Tokyo Guidelines 2013 (TG13) and Parkland grading scale. Blood culture was carried out for EP03C-027 the patients who presented fever and/or chilling. IS OUR USE OF ERCP IN THE Results: According to TG13, there were 90 patients clas- sified as grade 1 (mild), 44 as grade 2 (moderate), and 11 as MANAGEMENT OF PATIENTS WITH grade 3 (severe). Based on Parkland grading scale, there OBSTRUCTIVE JAUNDICE JUSTIFIED? were 21, 34, 31, 14, and 34 patients in grade 1, 2, 3, 4, and 5 M. Hassanain1, Y. Alanazi2, S. Alseneidi2, F. Alghamdi2, group respectively. SPL was 0.5 Æ 2.3, 6.0 Æ 11.5, and M. Alghufaily2 and A. Alharbi2 19.4 Æ 25.8 in TG grade 1, 2, and 3, and the p value was 1Department of Surgery, and 2College of Medicine, King <0.001. SPL in Parkland grade 1, 2, 3, 4, and 5 group was Saud University, Saudi Arabia Æ Æ Æ Æ Æ 0.2 0.4, 1.5 6.1, 4.8 16.2, 20.4 35.6, and 8.0 Introduction: Healthcare caregivers are focused on quality 15.7 repectively, and the p value was 0.008. Blood culture of care and the application of evidence-based practice. In was carried out in 108 patients and 18 patients presented this study we aim to measure the adherence of our clinical bacteremia. At the cutoff value of 0.48, SPL could predict teams to evidence-based management of patients with the presence of bacteremia with sensitivity of 66.7% and obstructive jaundice due to gallstones. We examined clin- fi speci city of 65.2%. ical outcomes, rate of unnecessarily ERCPs and related cost Conclusions: SPL was helpful in predicting the severity of with root cause analysis. acute cholecystitis and was well correlated with TG13 Methods: A retrospective study utilizing prospectively severity assessment criteria and Parkland grading scale. collected data from the operative records and endoscopy department. We included all adults underwent ERCP at our tertiary care academic center from Jan 2011 to Jun 2017 EP03C-026 with suspected choledocholithiasis. The patients were divided into three groups based on predictability of chol- LOCAL INFILTRATION VERSUS edocholithiasis according ASGE guidelines. LAPAROSCOPIC e GUIDED Results: A total of 198 ERCPs were performed in 125 pa- TRANSVERSE ABDOMINIS PLANE tients. The mean age was 47Æ18.6 years. There were female BLOCK IN LAPAROSCOPIC majority forming 66% of the cases with a length of hospital CHOLECYSTECTOMY e DOUBLE stay of 6Æ10.4 days. Table (1) shoe the division of patients fi BLINDED RANDOMIZED CONTROL according to the risk group de ned by ASGE practice guidelines. 35 (18.8%) patients underwent a negative ERCP, TRIAL 94% were patients categorized in the intermediate-risk R. C. Siriwardana, S. K. Kumarage, group. 44% of repeated ERCP were due to retained stones, M. B. Gunathilake and S. B. Thilakarathne 39% to remove a stent, 11% due to procedure failure and 4% Department of Surgery, University of Kelaniya, Faculty of due to complications during the first procedure. The total Medicine, Sri Lanka potentially avoided cost was $533,470.

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Conclusion: There are still clear weaknesses in the current Results: The best results were in the group C: laparo- guidelines for the treatment of choledocholithiasis with scopic approach in 92% of cases, no mortality, better many intermediate-risk patients that can avoid an unnec- morbidity and shorter hospital stay with significant dif- essarily ERCP. Adherence to evidence-based practice even ferences with the others two groups. On the contrary, no for common pathology is still an issue even in academic significant differences were observed between group A centers. and B: LC 66% vs 67%, morbidity Clavien-Dindo III-IV 7% vs 7%, mortality 2% vs 1%, hospital stay 6 days vs 5. Table 1 Division of patients according to the risk Conversion rate was 11% in GroupA, 17% in GroupB and ASGE Positive Negative 3% in GroupC. guidelines ERCPs n (%) ERCPs n (%) Conclusion: Our study showed that performing LC after 6 High-risk patients 105 (56%) 66 (35.5%) 39 (21%) weeks (GroupC) should be the best option, when it is fi Intermediate-risk 80 (43%) 47 (25.3%) 33 (17.8%) possible. However, because there were not signi cant dif- patients ferences between GroupA and GroupB, our policy is to Low risk patients 1 (0.5%) 0 (0%) 1 (0.5%) treat conservatively AC.

EP03C-029 EP03C-028 EARLY CHOLECYSTECTOMY CAN BE EVALUATING THE TIMING OF PERFORMED IN A SAFE AND TIMELY LAPAROSCOPIC CHOLECYSTCTOMY MANNER AT A DISTRICT GENERAL FOR ACUTE CHOLECYSTITIS (AC) IN HOSPITAL IN ACCORDANCE WITH TWO ITALIAN CENTERS: EARLY OR NICE GUIDELINES DELAYED APPROACH? J. Yee, N. Pore, D. Raje and H. Sheth S. Vaccari1, A. Lauro1, N. De Siena1, M. Cervellera1, Upper GI Surgery, London North West University V. D’Andrea2, A. Santoro2, A. Panarese2, R. Cirocchi3, Healthcare, Ealing Hospital, United Kingdom M. Brighi1 and V. Tonini1 Introduction: NICE guidelines on the management of 1U.O. Chirurgia d’Urgenza, Policlinico Sant’Orsola, acute gallstone disease recommend that cholecystectomy Università degli Studi di Bologna, 2Policlinico Umberto I, should be offered within one week of diagnosis. Our aim Università La Sapienza, and 3Ospedale Santa Maria, was to assess whether this was safe and feasible in a district Università degli Studi di Terni, Italy general hospital. Background: Laparoscopic cholecystectomy (LC) is the Methods: Retrospective data of patients undergoing gold standard for acute cholecystitis (AC), but timing of emergency laparoscopic cholecystectomy was collated for surgery remains controversial. This study evaluates the a 4.5 year period at a London district general hospital. outcomes of patients who underwent surgery after emer- Surgery was performed at index admission by experienced gency admission at St. Orsola University Hospital of upper GI consultant surgeons. The primary end points Bologna and Umberto 1 Hospital La Sapienza University of included procedure type, time to operation, length of stay, Rome. 30-day morbidity and mortality. Methods: We performed a retrospective study on 464 pa- Results: 192 patients underwent emergency cholecys- tients who underwent cholecystectomy for AC. Three tectomy (65 male:127 female) with a mean age of 53 groups were identified according to the timing of chole- years. The indications for surgery included cholecystitis, cystectomy: Group A within 72 hours, group B between 72 gallstone pancreatitis, biliary colic, gallbladder empyema, hours and 6 weeks and group C after 6 weeks. The patients’ gallbladder perforation, and choledocholithiasis. Proced- characteristics are listed in Table 1. SPSS was used for ures undertaken were laparoscopic cholecystectomy (66; statistics; significance was defined as p < 0.05. 33.9%), laparoscopic cholecystectomy with intraoperative

EP03C-028 Table Group A Group B Group C P-value (§ AvsB;¶ BvsC;¥ AvsC) Number of Patients 95 196 173 - Age (years) 62.9±17.8 61.4±17.8 55.0±16.2 ns Male sex 46 108 77 0.05 ¶ Asa score (I–II/III–IV) 59/36 122/74 146/27 <0.01 ¶,¥ Classification of acute cholecystitis 64/30/1 101/83/12 141/31/1 <0.01 §,¶,¥ / <0.01 ¶,¥ / <0.01 ¶ [TG13] (Mild/Moderate/Severe) Operation (Open/Laparoscopic/Conversion to open) 22/63/10 30/132/334 8/160/7 0.01§/ 0.01§/ <0.01 ¶,¥ Operative time (min) 89.4±40.4 99.1±43.9 77.7±38.8 ns Complication [Clavien-Dindo] (I-II/III-IV/V) 6/7/2 27/13/2 11/4/0 < 0.01 ¶ / ns Hospital stay (days) 6.6±9.8 5.6±8.5 2.3±3.4 ns

HPB 2018, 20 (S2), S685eS764 S722 Electronic Poster (EP03A-EP03F) e Biliary cholangiogram (IOC) (119; 62.5%), and laparoscopic Introduction: Laparoscopic cholecystectomy is consid- converted to open cholecystectomy (7; 3.5%). 173 ered since long time as gold standard treatment for chol- (90.1%) patients underwent surgery within 7 days of ecystolithiasis. Preoperatively surgeon can anticipate admission and the mean length of stay was 7.6 days. 22 difficulty of the procedure and prepare a plan how to deal (11.5%) patients had an ERCP during admission for CBD with it. Sometimes the surgeon can be faced with a surprise stones detected on preoperative imaging or on IOC. The intra-operatively. 30-day readmission rate was 6.2%. In this cohort, there Methods: We collected retrospectively a series of cases were two incidences of bile leak (1.0%), managed with subjected to laparoscopic cholecystectomy in Alexandria ERCP and radiological drainage or radiological drainage university from 2014 to 2017, in which there were technical only. There were no bile duct injuries and no mortalities or anatomical difficulties, intra-operative surprises, and how in this study. was the procedure completed safely. From 350 cases of Conclusion: Our results demonstrate that definitive treat- laparoscopic cholecystectomy, 23 cases considered difficult ment of acute gallstone disease with early cholecystectomy or with intra-operative challenge. we had one case of acute can be performed safely by an experienced team, with low cholecystitis in a child with situs invertus totalis, one case of readmission and complication rates. left sided gall bladder, one case of gall stones after left donor hepatectomy, one case of heamangioma adherent to the gall bladder, one case diagnosed a huge liver cyst, one case child EP03C-030 4 years with acute cholecystitis and pancreatitis, five cases APPROPRIATENESS OF LIVER BIOPSY with previous big abdominal surgeries, one case with mul- tiple whitish spots all over the liver, one case of accessory FOR NONALCOHOLIC FATTY LIVER bile duct, three cases of caterpiller hump, two cases of stump DISEASE IN OBESE PATIENTS DURING cholecystectomy, and 4 cases of laparoscopic cholecystec- LAPAROSCOPIC CHOLECYSTECTOMY tomy after failed open cholecystectomy. FOR GALLSTONE DISEASE Conclusion: Laparoscopic cholecystectomy is a frequently performed surgery with expected difficulties and challenges K. S. Kim1, S. -H. Han1, J. H. Nahm2, D. Y. Kim3, to the surgeons. S. W. Park3 and Y. N. Park2 1Surgery, 2Pathology, and 3Medicine, Yonsei University College of Medicine, Republic of Korea Background and aims: Obesity is well known as a risk EP03C-032 factor for gallstone disease and is also a risk factor for fatty A RARE CASE OF CALCULUOS liver. Before laparoscopic cholecystectomy, it is not easy to BILIARY OBSTRUCTION FROM detect fatty liver, except for severe fatty liver. Liver biopsy PENTASTOSOMISASIS IN A SNAKE- is invasive and is not recommended except in special cases, but is not a relatively risky procedure during laparoscopic EATING NIGERIAN cholecystectomy. Therefore, we validated the efficacy of A. Adeyeye1,2, T. Adenuga1, S. Larri2, J. Agbonoga2 and liver biopsy in obese patients during laparoscopic chole- R. Adeyeye2 cystectomy for gallstone disease. 1Surgery, University of Ilorin Teaching Hospital, and Materials and methods: We retrospectively reviewed med- 2Lifefount International Hospital, Nigeria ical records in obese patients with gallstone disease who un- Introduction: Pentastomiasis is a rare zoonotic parasitic derwent laparoscopic cholecystectomy with liver biopsy. The infection caused by members of the Armillifer armillatus definition of obesity was based on the Asian obesity criteria. species. It is mainly observed in Africa and Asia. Humans (overweight :23w24.9, obese class I :>25, & obese class II are usually infected by eating contaminated undercooked >30). Total 74 patients were included, and 30 patients were snake meat or open contact with snake droppings. It is diagnosed as fatty liver (A) and compared with patients frequently asymptomatic and biliary obstruction from the without fatty liver disease (B) using various parameters. disease is extremely rare. This is the first documented case Results: There were 9 male and 21 female in fatty liver report from Nigeria, sub-Saharan Africa. group and 18 male and 26 female without fatty liver. In the Method: We report a case of 64 year old male Nigerian fatty liver group, 6 overweight, 19 obese class I, & 5 obese with clinical features and laboratory parameters suggestive class II, but in the group without fatty liver, 21 overweight, of obstructive jaundice. He had admitted to ingesting snake 19 obese class I, & 4 obese class II. The degree of obesity in meat on a regular basis for over 20 years. Abdominal CT the fatty liver group was more severe(p=.022). Except level scan revealed grossly dilated bile ducts, multiple large of aminotransferase, all biochemical parameters were not common bile ducts stones as well as multiple crescentic, different between two groups. comma-shaped, parasitic calcifications in the liver and Conclusion: The liver biopsy could be recommended in obese peritoneal cavity. There was associated eosinophilia. He I & II patients with abnormal levels of aminotransferase. subsequently had open cholecystectomy, common bile duct exploration, stone extraction and T-tube drainage. An adjacent peritoneal lymph node contained a nymph of A. EP03C-031 armillatus with reactive histocytosis. He had routine post LAPAROSCOPIC CHOLECYSTECTOMY operative care in addition to long term praziquantel and DIFFICULTIES, CHALLENGES AND mebendazole therapy. Results: His post operative course was satisfactory and T- SURPRISES tube cholangiogram on the 10th post operative day revealed M. Sharaan a patent biliary system with no retained stones. He has Hepatobiliary Surgery, Alexandria, Egypt remained symptom free for over 3 months after surgery.

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Conclusion: Biliary obstruction from common bile duct incision, a large amount of yellowish and purulent stones can occur in patients with hepatic visceral Penta- discharge was obtained from the abscess. CT-scan showed stosomiasis. It should be considered as a possible cause of a communication between the gallbladder and a subcu- obstructive jaundice in an African or Asian with multiple taneous collection of the right anterior chest wall containing crescentic, comma-shaped parasitic calcifications. a 5 x 2 cm gallstone. Under general anesthesia, the large stone was retrieved from the chest wall and the fistulous tract was tutorized with a Foley catheter ending into the EP03C-033 gallbladder as confirmed by intraoperative fistulogram. An ACALCULOUS CHOLECYSTITIS obstructive CBD stone was also visualized and therefore the patient underwent an ERCP. ASSOCIATED WITH HANTAAN VIRUS: Reults: The patient was discharged the percutaneous foley A CASE REPORT catheter in place and 6 weeks later received a laparoscopic S. H. Kim, J. Kwak, S. Park and J. Choi cholecystectomy. The postoperative course was uneventful. Surgery, Armed Forces Capital Hospital, Republic of Histology of the gall bladder did not show malignancy. Korea Conclusions: SCCF is a rare entity and extrabdominal Introduction: Acute acalculous cholecystitis (AAC) still cutaneous tract is even rarer. If a good drainage can be remains one of the most elusive diagnoses. It occurs in achieved, delayed laparoscopic cholecystectomy can be various conditions. Although AACs caused by viral in- safely performed. Presence of gallstones along the common fections are rare, various viruses have been revealed to bile duct should always be ruled out. cause AAC. Here we present a case in which a man suffered from AAC caused by a hantaan virus infection. Case report: A 37-year-old man was referred to the EP03C-035 emergency room for myalgia and fever that began 4 days LAPARASCOPIC SURGERY OF ago. He suffered oliguria and abdominal pain for 2 days. At CHOLEDOCHOLITHIASIS. the time of his visit to the emergency room, he experienced  COMPARISON OF CURATIVE AND a fever spiking up to 38.3 C. An initial blood sample objectified the following pathologic results: white blood CONSERVATIVE APPROACHES cell - 11610/ul; C-reactive protein - 10.65 mg/dL; total C. Maulat1, A. Pinto1, B. Charrière1, A. Hantoush Al Ali1, bilirubin - 2.22 mg/dL; direct bilirubin - 1.83 mg/dL; ALT - A. Culetto2, E. Cuellar1, B. Bournet2, L. Buscail2, 157IU/L; Alkaline Phosphatase - 591IU/L. In the computed B. Suc1 and F. Muscari1 tomography, bilateral perirenal fluid collections and bilat- 1Chirurgie Digestive et de Transplantation, and 2Gastro- eral flexural effusion were shown and acute hepatopathy Entérologie et Pancréatologie, CHU Toulouse - Hôpital and cholecystopathy were also shown. Because there was Rangueil, France no definite tenderness around the patient’s right upper Introduction: Two curative treatments can be proposed to quadrant from physical examination and his cholecystop- manage choledocholithiasis : an “all-surgical” approach or a athy looked like it was from secondary change according to combined approach (with endoscopic sphincterotomy (ES)). acute hepatopathy, we decided to perform conservative care Conservative surgical treatment (transcystic drain) seems to without surgical treatment. The following day, in viral be effective in the management of choledocholithiasis with antibody test, Hantaan virus antibody was detected. After narrow CBD. This study evaluates the all-surgical treatment conservative management, the patient’s condition by curative (choledochotomy) or conservative treatment, improved. The patient was discharged on day of hospital based on CBD size and local conditions. stay #10 without any symptoms. Methods: Every patient presenting choledocholithiasis Conclusion: Hantaan virus infection should be suspected discoverded during laparoscopic cholecystectomy between as a causative agent of AAC, particularly when there is 2009 and 2016 were included in one center. The primary abnormal liver function tests and abdominal pain. outcome was CBD clearance. Three groups were analyzed: Group 1 with dilated CBD (10 mm) and no pedicle inflammation was treated by curative treatment, Group 2 EP03C-034 with narrow CBD (<10 mm), and Group 3 with dilated CHOLECYSTOCUTANEOUS FISTULA CBD (10 mm) and pedicle inflammation. Groups 2 and 3 THROUGH THE INTERCOSTAL AREA: were treated with conservative treatment. Results: 109 patients had choledocholithiasis on the chol- A RARE AND FORGOTTEN ENTITY angiography during cholecystectomy. 55 patients had P. Senra, R. Melendez and F. Ausania curative treatment (Group 1), while 54 had a conservative HPB Unit, Hospital Alvaro Cunqueiro de Vigo, Spain treatment (41 cases in Group 2 and 13 cases in Group 3). Introduction: Spontaneous cholecystocutaneous fistula The CBD clearance was obtained in 96.5% in Group 1, in (SCCF) is nowadays a very rare entity in developed 80 % in Group 2 and in 54% in Group 3. 85% of the pa- countries. It usually occurs through the abdominal wall. tients did not need an ES to ensure the CBD clearance, after The treatment consist in broad spectrum antibiotics, surgical treatment. The overall morbidity and mortality drainage of subcutaneous abscess if present and cholecys- rates were 3,7% and 1.8% respectively. tectomy in fit patients Conclusion: For any patient with choledocholithiasis, there Methods: A 68 year-old female patient was referred to our is a benefit to perform all-surgical treatment, avoiding emergency unit with a right anterior chest wall abscess. The systematic ES. CBD clearance can be obtained even if patient had a history of obesity and schizophrenia. She also the choledochotomy is impossible, through spontaneous was diagnosed with diabetes mellitus. Following skin migration of the stone.

HPB 2018, 20 (S2), S685eS764 S724 Electronic Poster (EP03A-EP03F) e Biliary fi EP03C-036 strati ed in three groups: GroupI - transcystic chol- edochoscopy, GroupII - transductal choledochoscopy and IMPROVED CONTACT GALLSTONE- GroupIII - transductal LCBDE without choledochoscopy. DISSOLVING POTENTIAL AND SAFETY Laparoscopic ultrasound was performed in all patients to BEYOND METHYL TERTIARY BUTYL diagnose common bile duct (CBD) stones. ETHER Results: 193 patients with the median age of 63 years (IQR =73e47) underwent LCBDE. The most common com- K. H. Kim1,2, S. H. Lee1 and S. J. Kim2 plications of gall stone disease were pancreatitis (21.2%), 1Department of Surgery, Uijeongbu St. Mary’s Hospital, cholangitis (51.3%) and jaundice (61.7%). Preoperative College of Medicine, The Catholic University of Korea, radiologic imaging confirmed CBD stones in 58 patients. and 2Department of Surgery, Seoul St. Mary’s Hospital, Median time from admission till surgery was 4 days and College of Medicine, The Catholic University of Korea, 73.6% were stratified as ASAII or ASAIII. Median opera- Seoul, Republic of Korea tive time in GroupI was 75 (IQR=111e64), GroupII 120 Introduction: Currently, methyl tertiary butyl ether (IQR = 140e90) and GroupIII 95 (IQR = 125e83) mi- (MTBE) is the only clinically applicable topical agent for nutes. CBD clearance rate in GroupI was 91.6%, 90.7% in gallstone dissolution after having been proven its effec- GroupII and 95.3% in GroupIII. In 34 patients chol- tiveness and safety through the world-wide studies. edochoduodenostomy was performed and T-tubes were Although generally safe, the widespread use of MTBE is used only in 16%. The overall conversion rate to open limited by the drawbacks of MTBE, most which is attrib- surgery was 2.6%. Postoperative ERCP was performed in uted to relatively low boiling point of MTBE and resulting 11 (5.7%) patients. Median postoperative stay was 4 (IQR higher evaporation. =6e2) days. Readmission and ERCP for retained stones Method: 2-Methoxy-6-methylpyridine (MMP) is a com- was needed in 14 patients (7.3%). pound wherein the bulky aliphatic tert-butyl group of Conclusion: One-stage LCBDE is a feasible and safe MTBE is replaced with an aromatic group, thereby having  procedure that can be provided in urgently admitted pa- higher boiling point (156 C). In this study, we were tients with choledocholithiasis. intended to determine the safety and gallstone-dissolving potential of MMP. Results: In the in vitro dissolution test, MMP showed significantly better gallstone-dissolving potential than EP03C-038 MTBE, especially at 8 h and 24 h after reaction, respec- EVALUATION OF TOKYO GUIDELINE tively (P< 0.05). 24-h incubation with MMP has resulted in 2013 EFFICACY BY AGGRESSIVE 88.2%, 61.5%, and 39.3% dissolubility of cholesterol, URGENT CHOLECYSTECTOMY FOR mixed, and pigmented gallstones, respectively. The treat- ment with MTBE did not reduce the viability of human ACUTE CHOLECYSTITIS gallbladder epithelial cells nor did increase or decrease the T. Bekki, T. Abe, H. Amano, T. Yano, N. Fujikuni, expression of pro-apoptotic marker (Mcl-1) or proliferation H. Okuda, T. Sasada, M. Yamki, T. Noriyuki and marker (PCNA), respectively. In the in vivo dissolution M. Nakahara test, MMP exhibited the significantly higher gallstone- Onomichi General Hospital, Japan dissolving potential than MTBE in the both hamster models Aim: This study investigated that the efficacy of delayed of cholesterol and pigmented gallstones (P< 0.05). cholecystectomy in patients with acute cholecystitis (AC), Compared to MTBE. the optimal timing and usefulness of early cholecystectomy Conclusions: If a clinical trial supports these conclusion, for AC in patients with comorbid acute cholangitis. contact litholysis by MMP is expected to be an attractive Methods: Between 2011 and 2016, 252 patients underwent alternative to laparoscopic cholecystectomy in managing a early cholecystectomy for AC. Patients underwent opera- proportion of patient population with gallstones. tion with early phase operation group (EO group) and late phase operation group (LO) group. Surgical outcomes were analyzed for these two groups with propensity score anal- EP03C-037 ysis. Outcomes were compared between patients with and LAPAROSCOPIC COMMON BILE DUCT without comorbid acute cholangitis. In the subgroup anal- EXPLORATION FOR BILE DUCT ysis, outcomes of patients with comorbid acute cholangitis STONES: A 6-YEAR EXPERIENCE IN A who underwent urgent cholecystectomy and semi-urgent were compared. SINGLE INSTITUTION Results: A total of 164 patients with G1 and 2 cholecystitis 1,2 1 1 1,2 H. Plaudis , E. Saukane , K. Atstupens , V. Fokin and were underwent emergency cholecystectomy. The rate of 1,2 G. Pupelis conversion to open procedure, operation time, intra- 1 2 Surgery, and Rigas Stradins University, Latvia operative bleeding, and complications were equivalent in Introduction: Laparoscopic common bile duct exploration these two groups. After one to two propensity score (LCBDE) in experienced hands is an effective method for matched analysis outcomes of LO group were not inferior one-stage management of a complicated gallstone disease. to those of EO group. Patients had comorbid acute chol- The aim of the study is to share our experience in the angitis or non-acute cholangitis. There were no significant application of urgent one-stage LCBDE in patients with differences in postoperative complication rate, operation choledocholithiasis. time, or intraoperative blood loss between these groups. In Methods: Urgently admitted surgical patients with chol- the acute cholangitis subgroup analysis, urgent and semi- edocholithiasis were prospectively included in the study urgent cholecystectomy had comparable intra- and post- between January 2012 and October 2017. Patients were operative outcomes.

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Conclusion: Our study demonstrated the feasibility and Conclusion: Early removal of PTC catheter after resolution of safety of performing cholecystectomy within 4-7 days from acute calculous cholecystitis is safe and may reduce re-ad- symptom onset, as the 72-h limit is not necessarily required missions for PTC catheter-related and gallstone complications. for experienced laparoscopic surgeons and institutions. Early cholecystectomy within 14 days after symptom onset was safely performed for patients with after successful AC EP03C-040 treatment. LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: ARE EP03C-039 THE INTENDED OPERATIVE REMOVAL OF PERCUTANEOUS APPROACH, TIMING AND OUTCOME CHOLECYSTOSTOMY (PTC) AFFECTED BY BMI? A MULTICENTER CATHETER AFTER RESOLUTION OF RETROSPECTIVE STUDY 1 1 1 1 ACUTE CALCULOUS CHOLECYSTITIS A. Lauro , S. Vaccari , N. De Siena , M. Cervellera , ’ 2 2 2 3 IN HIGH-SURGICAL-RISK PATIENTS V. D Andrea , A. Santoro , A. Panarese , R. Cirocchi , A. Romano1 and V. Tonini1 H. T. Lok, K. Y. A. Fung, K. W. A. Fong, C. N. Chong, 1U.O. Chirurgia d’Urgenza, Policlinico Sant’Orsola, Y. S. Cheung, J. Wong, K. F. Lee and B. S. P. Lai Università degli studi di Bologna, 2Policlinico Umberto I, Department of Surgery, The Chinese University of Hong Università La Sapienza, Roma, and 3Ospedale Santa Kong, Hong Kong Maria, Università degli studi di Terni, Terni Introduction: Percutaneous cholecystostomy (PTC) was Introduction: Laparoscopy is the gold-standard for cho- an established treatment for acute calculous cholecystitis in lecystectomy after acute cholecystitis , but the issue is patients with high surgical risk. Removal of PTC catheters controversial in obese patients. may result in recurrent acute cholecystitis while keeping Method: We operated 464 patients for acute cholecystitis PTC catheters is associated with morbidities. This study to (59 open and 405 laparoscopic) at St Orsola University review outcomes of patients after PTC catheter removal. Hospital Bologna and La Sapienza University Rome, Method: This is a retrospective analysis of patients who comparing retrospectively 1) BMI < 30 (397 patients) and underwent percutaneous cholecystostomy for acute calcu- BMI =/> 30 (67 patients) and moreover 2) BMI < 25 (207 lous cholecystitis. Patients underwent interval cholecys- patients) and BMI =/> 25 (257 patients). tectomy were excluded. Outcomes including recurrent Result: In the first comparison obese patients showed higher acute cholecystitis and re-admissions for PTC catheter- cardiovascular co-morbidity (61.2% vs 44.6%, p = 0.0167), related and gallstone complications were compared be- worse symptoms (Murphy’s sign positive in 52.2% vs tween patients with early removal of PTC catheters (< 4 26.2%, p = 0.0001 ; fever >37.5C in 46.3% vs 16.4%, p = months) and those who had catheters removed beyond 4 0.0001) and more significant imaging (62.7% vs 31.7%, p = months. 0.0001) of acute cholecystitis . Laparoscopic approach was Results: From Jan 2011 to Oct 2012, 39 high-surgical-risk used in 83.6% of obese patients vs 87.9% without any dif- patients (mean age: 82.4) underwent percutaneous chol- ference , and operative time or conversion rate were similar . ecystostomy for acute calculous cholecystitis. Clinical According to Tokyo Guidelines 2013, the number of patients resolution was observed in 36 patients (92.3%) whereas 3 who underwent surgery within 3 days or after 6 weeks was patients were diseased. PTC catheters were removed in 35 similar without statistical difference between the two groups. patients (Dislodgement, n = 21; catheter malfunction, n = 3; Hospital stay, morbidity and mortality were similar. Com- planned removal, n = 11). With a median follow-up dura- plications were seen in 25.4% of obese patients vs 15.9% (p = tion of 61 months, recurrent acute cholecystitis was 0.0384). Most of the complications were mainly represented observed in 9 patients (25.7%), which were successfully by wound infections. The second comparison did show no treated with antibiotics alone (n = 2) and PTC insertion (n = difference between two groups BMI =/>25 and BMI < 25. 7). Re-admission rate is significantly lower in patients with Conclusion: Our multicenter study showed no difference early PTC catheter removal, 3.1 vs 1.2, p = 0.016, whereas related to intended operative approach, timing and outcome risk of recurrent acute cholecystitis is similar between both in higher BMI versus lower BMI in patients with acute groups, 26.3% vs 20%, p = 0.75. cholecystitis.

EP03C-040 Table BMI‡25 BMI<25 P-value Number of Patients 257 207 - Age (years) 59.1 ± 16.8 59.6 ± 18.4 0.98 Male sex 134 97 0.26 ASA class (I-II/III-IV) 182/75 145/62 0.92 Comorbidity (Cardio-Vascular/Diabetes/COPD/CRF) 128/29/27/13 90/20/18/9 0.19/0.64/0.37/0.83 Operation (Open/Lparoscopic/Conversion) 28/201/28 30/154/23 0.26/0.26/0.88 Operative timing (Within 72h/3 days or bayound/6 weeks) 52/119/86 42/78/87 1.00/0.07/0.62 Complication according clavien-dindo classification (I-II/III-IV/V) 22/11/3 22/13/1 0.62/0.80/0.80 Hospital stay (days) 4.9±7.8 5.0±7.5 0.99

HPB 2018, 20 (S2), S685eS764 S726 Electronic Poster (EP03A-EP03F) e Biliary  EP03C-041 Methods: Retrospective analysis of patients 85 years of age admitted to a Hospital Centre between May 2013 and ROBOT-ASSISTED SINGLE-SITE May 2016 with the diagnosis of AC. COMPARED WITH LAPAROSCOPIC Results: Patients with  85 years of age constituted about SINGLE-INCISION 12% (53 patients) of the patients admitted with the diag- CHOLECYSTECTOMY FOR BENIGN nosis of AC. Median age was 87 years. Approximately 59% fi GALLBLADDER DISEASE: RESULTS OF of patients were classi ed as ASA III. Nine patients (17%) were submitted to surgery with a mean hospital stay of 7.5 A SINGLE-BLINDED RANDOMIZED days. There was one case of morbidity and there were no CONTROLLED TRIAL cases of mortality. Conservative treatment was performed L. F. Grochola, C. Soll, A. Zehnder, R. Wyss, in 44 patients (83%) and percutaneous cholecystostomy P. Herzog and S. Breitenstein was required in 9 of them. Nineteen of these patients (43%) Surgery, Cantonal Hospital Winterthur, Switzerland had complications during hospitalization. Mean hospital Background: Recent advances in robotic technology stay was 12.5 days and the mortality rate was 7%. suggest that da Vinci Single-Site cholecystectomy Conclusions: According to our series, cholecystectomy (dVSSC) is safe, feasible and reduces the stress load of the seems to be a safe procedure in selected patients  85 years surgeon compared to single-incision laparoscopic chole- of age and conservative treatment seems to be associated cystectomy (SILC). However, evidence needed to objec- with higher rates of therapeutic failure and morbimortality. tively assess differences based on high-quality comparative The definition of the best therapeutic strategy in this data is lacking to date. particular subgroup of elderly patients requires the devel- Methods: This single centre, single-blinded controlled trial opment of prospective studies specifically designed to included 60 patients with benign gallbladder disease clarify this controversy. randomly assigned to dVSSC (n=30) or SILC (n=30). The primary endpoint surgeon’s physical and mental stress load was assessed using the validated Local Experienced EP03C-043 Discomfort (LED) and Subjective Mental Effort Ques- MANAGEMENT OF GALLSTONE tionnaires (SMEQ). Secondary endpoints included oper- DISEASE DURING AN ECONOMIC ating time, conversion rates, additional trocar placement, intra-operative blood loss, length of hospital stay, proced- CRISIS ure costs, health-related quality of life, cosmesis and A. Tooulias, I. Kentarhos, D. Athanasiadis, I. A. Ziogas, complications. Patients and ward staff were blinded until 12 A. Prionas, G. Tsoulfas and V. N. Papadopoulos months postoperatively. 1st Surgical Department, Aristotle University of Thessa- Results: The dVSSC-group showed a significant reduction loniki, Greece of mental stress load of the surgeon compared to SILC Introduction: The objective of this study is to assess the (SMEQ: median 25.0 vs. 42.5 points; p=0.002) and a trend surgical management of patients with gallstone disease that toward reduced physical stress load (LED: median 8 vs. 12 were treated at a university hospital during the financial points; p=0.088). The rate of postoperative complications crisis in Greece. that required a re-intervention (Dindo-Clavien gradeIIIa) Methods: Retrospective study of patients (N = 626) be- was similar in both groups (SILC n=2 vs dVSSC n=0, tween 2011 until 2017. Patients undergoing elective or p=0.492). The length of stay was longer in the SILC group emergency laparoscopic or open cholecystectomy were (3.06 vs 1.9 days, p=0.034) but overall hospital costs were included. Demographics, risk factors, clinical, radiologic higher for dVSSC (9831 vs. 6900 CHF; p=0.001). and laboratory examinations, type of operation (laparo- Conclusions: dVSSC provides significant benefits over scopic /open /conversion) and outcomes were analyzed. SILC in terms of surgeon’s stress load, matches the stan- Results: There were 626 patients aged 57 Æ 15,6 years old, dards of the laparoscopic single-incision approach with with 65% females. 41 patients (7,8%) had asymptomatic regard to patients’ outcomes but increases overall expenses. gallstone disease, 367 patients (58,6%) had mild symp- Clinicaltrials.gov trial-no: NCT02485392. toms, and 200 patients (31,9%) had severe symptoms including cholecystitis and pancreatitis. In this group 530 patients (84.6%) underwent laparoscopic cholecystectomy EP03C-042 with a conversion rate of17.7% (94/530), whereas 96 pa- ACUTE CHOLECYSTITIS IN THE tients (15.3%) underwent an open procedure from the O OPERATE beginning because of prior surgical history or disease pa- ELDERLY: T OR NOT? thology. The statistic analysis revealed that as the age of the 1 1 1 A. Ribeiro , C. Soares , T. M. Rocha , patient increases, so did the severity of the disease, 2 1 J. Pinto-de-Sousa and M. Oliveira accompanied by an increased possibility of open chole- 1 2 Tâmega e Sousa Hospital Centre, and Northeast Hos- cystectomy or conversion to one. pital Centre, Portugal Conclusion: During the current financial crisis the pro- Introduction: The increase in life expectancy has raised portion of patients presenting with complicated or severely new challenges on the management of acute cholecystitis symptomatic cholelithiasis has increased. This leads to the (AC). The purpose of this study was to evaluate the observed high conversion rate of laparoscopic to open morbidity and mortality associated to the treatment of AC procedures, to prolonged hospitalization and therefore to an in patients aged 85 years or older ( 85 years). increase of the associated healthcare costs.

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EP03C-044 Results: Overall LUS was done in 381 patients. The pro- cedure was technically successful in all cases. The median SURGICAL (OPEN AND LAPAROSCOPIC) age of patients was 59 years (IQR 71-45) and median time MANAGEMENT OF LARGE DIFFICULT to complete LUS was 2 minutes (IQR 4-2). Chol- CBD STONES AFTER DIFFERENT edocholithiasis was detected in 228 patients (60.5%), SESSIONS OF ENDOSCOPIC FAILURE significantly more frequently due to cholangitis (134 pa- tients, p < 0.001) and mechanical jaundice (137 patients, p E. H. Gad, Emad Hamdy Gad, Hazem Zakaria, = 0.018) compared with negative group (153 patients). Yasmin Kamel, Talat Zakaria, Mohamed Abbasy, Patients with CBD stones were significantly older, 63 vs 57 Ali Nada and Mohamed Housseni years, p=0.003. Biliary pancreatitis was more evident in National Liver Institute, Menoufiya University, Egypt negative group, p=0.002. One LUS was considered as false fi Objectives: For dif cult CBD stones that cannot be negative (sensitivity and specificity of 99.6% and 100%). extracted by ERCP, patients can be managed CBD explo- Conclusion: According to our experience LUS is highly ration. The aim of this study was to assess these surgical effective primary intraoperative imaging modality for bile procedures after endoscopic failure. ducts. It permitted to detect CBD stones with a high Methods: We retrospectively analyzed 85 patients under- specificity and sensitivity. went surgical management of difficult CBD stones after ERCP failure, in the period from mid 2013 to mid 2018. Results: There was significant correlation between number of ERCP sessions and post ERCP complications (P = 0.001). EP03C-047 Impacted large stone was the most frequent cause of ERCP KOSTI MISSION BY ALBAHA MEDICAL failure (60%). LCBDE and OCBDE were 29.4% (n = 25) GROUP and 70.6% (n = 60) respectively. Primary CBD repair, T- tube insertion, HJ and TDS were done in 45.9%, 40%, 8.3% B. Mohammed and 5.9% respectively. By comparing LCBDE and OCBDE General Surgery, Dallah Hospital, Saudi Arabia groups, patient age and hospital stay were significantly lower Introduction: Albaha medical group is a unique cluster of in laparoscopic group, while, T-tube insertion, choledoco- doctors who decided to embrace charity work with Kosti scope use, operative time and post operative bile leak were hospital in Sudan. Kosti is one of the major cities in Sudan significantly higher. Furthermore, patients underwent chol- in which the health care provided is less than optimum. In edocoscope had significant direction to primary CBD repair February 2018, the 6th mission will be launched enrolling and lower missed stones rate. While, on comparing T-tube around 18 doctors. with primary closure of CBD groups, there was significant Methods: The main specialty included in the mission was lower operative time and hospital stay in the later. laparoscopic surgery. The laparoscopic services in Kosti Conclusion: Difficult CBD stones can be managed either hospital were established from scratch. The mission is by open surgery or laparoscopically with acceptable com- funded by the members themselves. Its duration is for one parable outcomes with no need for multiple ERCP sessions week, during which the group provides free health services. due to their related morbidities; furthermore, choledoco- These include outpatient clinics, operations, rounds, lec- scope has a good impact on stone clearance rate with di- tures and workshops. rection towards doing primary repair that is better than T- Results: The last mission, February 2017, was accom- tube regarding operative time and hospital stay. plished by 15 doctors. The number of operations performed was around 108, in which 28 were laparoscopic cholecys- tectomies. There were five clinics in general surgery, reviewing over 30-50 patients per clinic. This was in EP03C-045 addition to the lectures and workshops. Two years previ- UTILITY OF LAPAROSCOPIC ously the group managed to establish a basic laparoscopic ULTRASOUND IN ONE-STEP skills laboratory. The group also managed to bring a lapa- MANAGEMENT OF SUSPECTED roscopic tower to the hospital from the Federal Ministry of Health in Khartoum. Now the four surgeons resident in CHOLEDOCHOLITHIASIS. LEARNING Kosti hospital are capable of performing laparoscopic sur- CURVE BASED ON 4 YEARS gery with minimum supervision. EXPERIENCE Conclusion: Charity work is crucial especially for col- K. Atstupens and G. Pupelis leagues who are less privileged. The help that we can Riga East Clinical University Hospital, Latvia provide is to share our expertise with those who need Introduction: Intraoperative detection of common bile improvement in their surgical skills. duct (CBD) stones currently provided by intraoperative cholangiography is optimal method of choice in many in- stitutions, however obviously safer and more useful is EP03C-048 laparoscopic ultrasound (LUS) that become the primary CLINICAL IMPACT OF ABNORMAL imaging method for intraoperative CBD evaluation in LIVER FUNTION TESTS IN PATIENTS specialized centers. The aim of this study was to evaluate the role of LUS in cases of suspected choledocholithiasis. WITH ACUTE CHOLECYSTITIS Materials and methods: Data analysis of LUS during P. Fernández Veiga1, P. Senra Del Rio2, laparoscopic cholecystectomy was undertaken of the pa- R. Meléndez Villar2, I. Otero Martínez2 and F. Ausania2 tients with suspected choledocholithiasis in time period from 1Servicio de Cirugía General y Digestiva, and 2Hospital 2012 to 2016. Alvaro Cunqueiro de Vigo, Spain

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Introduction: Acute cholecystitis (AC) is one the most Conclusion: The major morbidity of GC is higher than the common reason for performing urgent abdominal surgery other CAL of grade II, but it seems to be due to distant in patients aged over 55 years. Abnormal liver function infections linked to patients comorbidities. tests (LFTs) in these patients is usually associated with bile duct stones or chronic liver disease. The aim of this study is to assess the clinical impact of abnormal LFTs in absence EP03C-050 of any other biliary or hepatic disease. REMNANT CHOLECYSTECTOMY: IS IT Methods: This is a retrospective study including of patients with a diagnosis of AC treated at our Hospital from April WORTHWHILE DOING? 2016 to February 2017. Data were collected from a pro- S. Aroori1 and K. Bowling2 spectively held database. Patients with any other biliary or 1Peninsula HPB unit, and 2Derriford Hospital, United liver disease were excluded. Demographic and clinico- Kingdom pathological factors were analysed to investigate any Background: Post cholecystectomy syndrome (PCS) is a possible association with abnormal LFTs. significant problem following subtotal or total cholecys- Results: Out of 67 included patients, 25 (37%) had tectomy. The underlying reason for PCS could be recurrent abnormal LFTs. Median age was 66.8 years, 13 (19,4%) stone formation or infection of an obstructed remnant patients had diabetes mellitus and 17 (25.4) had history of gallbladder. The aim of this study is to review the outcomes cardiac disease. Sepsis was observed in 42 (62.7%) pa- of remnant cholecystectomy (RC) from the tertiary hepa- tients. All patients were received either US or CT scan. tobiliary unit. Acalcolus cholecistytis was observed in 6 (9%). patients. Material and methods: We reviewed the outcomes of all The only factor associated with abnormal LFTs was history patients that underwent RC between April 2005 and April of cardiac disease (p = 0.001). However, these patients did 2017. not show a different perioperative outcome. Results: During the study period, 38 patients (26 females, Conclusions: Once biliary and liver disease have been median age 64.9 years (range: 24.9e83.7) underwent RC. The ruled out, abnormal LFTs do not seem to have any clinical mean BMI was 30 (range: 19e42). The presenting symptoms impact and therefore treatment plan should not be modified. were recurrent biliary colic: n = 17, 48%, cholecystitis: n = 10, 26.3%, cholangitis: n = 4, 10.5%, pancreatitis: n = 3, 7.8%, and non-specific abdominal pain: n = 4, 10.5%. In 21 (55.5%) EP03C-049 patients the initial operation was performed laparoscopically. MORBIDITY OF PATIENTS OPERATED The index operation was subtotal cholecystectomy in 16 ON GANGRENOUS CHOLECYSTITIS IS (42%), total cholecystectomy in 14 (36.8%), and details were unavailable in eight patients. The median time from initial NOT RELATED TO INFECTION OF THE operationtopresentationwas1.22years(range:3monthsto30 OPERATIVE SITE years). Out of 38, 22 patients had laparoscopic RC. Three N. Ammar-Khodja1, C. Sabbagh1, E. Dumange1 and patients (8%) required biliary reconstruction. The overall post- J. -M. Regimbeau1 operative morbidity was 18.4%. All except one patient was 1Digestive and Metabolic Surgery, Universitary Hospital completely cured of their symptoms. of Amiens, France Conclusions: Majority of patients following remnant Introduction: The Tokyo Guidelines has, since 2007, cholecystectomy had symptomatic relief with no recurrence fi homogenised the surgical management of acute calculous of symptoms. However, RC is associated with signi cant cholecystitis (CAL) by defining 3 grades of severity. post-operative morbidity. Despite high morbidity, we Gangrenous cholecystitis (GC) is a specific form of grade II believe that patients with persistent symptoms should be CAL and a few specific data are available concerning GC. referred to hepatobiliary surgeons for further investigations The purpose of the study was to determine the post- and management. operative particularities of patients operated for GC. Method: From January 2007 to Decembre 2016, all pa- tients presenting a CAL grade II were included in this EP03C-051 single-centre retrospective study. The primary endpoint INCREASING BMI AND URBANISATION was to compare, after propensity matching, morbi-mortality HAS RESULTED IN HIGH RATES OF between GC and the other grade II CAL by using classi- GALLSTONE DISEASE IN SUB fication of Clavien-Dindo. Results: During the study period, 299 patients underwent SAHARAN AFRICA cholecystectomy for CAL grade II, including 122 GC Z. A. Khan1, M. U. Khan1 and M. Brand2 (40,8%). After propensity score matching using risks fac- 1Surgery, University of Witwatersrand, and 2Surgery, tors found in our study, there was no difference for post- University of Pretoria, South Africa operative mortality between the two groups ( p=0,996), but Epidemiological studies suggest the incidence of gall- there was more major morbidity (Clavien-Dindo >2OR= stones in sub Saharan Africa is low. Studies from 1980’s 3,049 p = 0,022, IC95% [1,178;7,888]) in the GC group. suggested the rate of gallstones was increasing mainly due The risk to develop local complications like deep operative to dietary changes. site infection does not increase (OR = 0,502 p = 0,602 Hypothesis - Gallstone disease is no longer uncommon IC95% [0,038; 6,699]). We observe more medical com- in South Africa (SA) and is due to increasing BMI brought plications in GC group causing major morbidity (7,4% in about by urbanization and dietary changes. GC group vs 1,6% p = 0,017). There was no significant Methods: Data was collected from a nationwide histology difference about reintervention or readmission. database of the South African National Health Laboratory

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Service for the period 2003 to 2015. 34294 cholecystec- EP03C-053 tomy specimens were analysed and divided into periods 1 (2003e2008) and 2 (2009e2015). Data regarding trends in INFORMED CONSENT IN ELECTIVE body mass index in the SA population were derived from 3 AND EMERGENCY LAPAROSCOPIC previously published studies. Urbanization ratios were CHOLECYSTECTOMY: IS PATIENTS’ obtained from Statistics South Africa. KNOWLEDGE A COMPLICATION? Results: In SA, the number of cholecystectomies increased E. Iaculli1, S. Di Carlo2, A. Burls3 and M. Silva4 by 37% in period 2 and was consistent among 7 of 8 1HPB Surgery, University Hospitals Plymouth, United provinces. Cois et. al found a significant year on year in- Kingdom, 2Aurelia Hospital, Italy, 3Department of Pri- crease in BMI which correlates with our year on year in- mary Care Health Sciences University of Oxford, and crease in cholecystectomy rates. They showed lower 4Oxford University Hospitals NHS Trust, United Kingdom obesity rates in rural communities. The Northern Cape was the only province with a decrease in cholecystectomy rates Laparoscopic cholecystectomy (LC) amongst the most in period 2 (À28.3% (p = 0.0014)). This province also was commonly performed elective procedure. Similarly surgery the only one to demonstrate more urban to rural migration, for acute cholecystitis is increasingly advocated. Although with all other provinces showing the opposite. publicly considered routine operation, LC is associated Conclusion: Increases in BMI in the SA population cor- with number of complications and high risk of litigations, relates with increases in cholecystectomy rates suggesting especially in the acute setting. an increase in gallstone disease. Residing in a rural area An appropriate consent process is part of high quality appears to be protective from obesity with a likely decrease surgical care and reduces rate of litigations. Nonetheless in gallstone disease and hence fewer cholecystectomies. informed consent (IC) is often underestimated by surgeons especially for such “routine” procedures and in the emer- gency wards. Aim of this study is to investigate appropriateness of IC and EP03C-052 possible differences between acute and elective scenarios. PRE-OPERATIVE RISK FACTORS FOR 164 consecutive patients undergoing either elective (n CONVERSION FROM LAPAROSCOPIC 108) or urgent LC (n 56) were asked to fill an anonymous TO OPEN CHOLECYSTECTOMY: A 10- questionnaire survey to analyze qualitative aspects of IC YEAR RETROSPECTIVE STUDY IN A offered, patients’ personal perceptions of the process and their level of understanding of LC possible complications TERTIARY HOSPITAL IN METRO after the IC took place. MANILA, PHILIPPINES Almost all patients (98%) were either very satisfied or J. Lee, C. Alfonso and A. M. Torio satisfied with the IC process. The level of knowledge of Department of Surgery, The Medical City, Philippines complications was associated with a higher level of satis- Introduction: Laparoscopic cholecystectomy is the gold faction. Emergency patients were more likely to experience standard procedure for symptomatic calculous cholecys- perioperative complications compared to patients under- titis. Some of the advantages it offers include less post- going elective surgery (p < 0.05), whereas patients who operative pain, shorter length of stay, earlier return to had elective surgery were marginally better informed. function, and more aesthetically acceptable scars. Conver- Elective LC, reading written booklet, age and higher edu- sion to open cholecystectomy however still happens in 5% cation are positive factors for level of complications to 25% of patients. It is then potentially beneficial to be able awareness. to predict the probability of conversion to open cholecys- We showed an overall good patients’ satisfaction of the tectomy. If classification by the risk of conversion is made, IC in LC for both for emergency and elective procedures, patients can be better allocated in terms of timing of pro- although this doesn’treflect the real level of knowledge of cedure, venue, and surgeon expertise. This study aims to complications especially in the acute setting. identify which factors may be associated with a higher risk for conversion to open cholecystectomy. Methods: A retrospective chart review included all lapa- EP03C-054 roscopic cholecystectomy cases in The Medical City in a METHODS AND CRITERIA FOR 10-year period from 2007 to 2016. From this set of sub- DIAGNOSIS OF GALLSTONE DISEASE jects, patient, disease, laboratory, and imaging variables were determined. Univariate analysis Kendall’s Tau test AND ITS COMPLICATIONS. and Chi square test are used to compare conversion rates DIFFERENTIAL DIAGNOSIS among clinical and ancillary variables. Multivariate anal- D. Stoykov1, P. Marinova1, I. Lalev2 and G. Sarafiloski2 ysis with logistic regression is used to identify significant 1Hepato-pancreato-Biliary Surgery, and 2Invasive independent predictors of conversion. Gastroenterology, Medical University of Pleven, Bulgaria Results and conclusion: Some clinical and ancillary pa- Introduction: Gallbladder inflammation and biliary tract rameters may be used as potential predictors for conversion infection are the most common complications of choleli- of laparoscopic to open cholecystectomy. It is recom- thiasis. The early diagnosis of the disease and its severity mended to do a prospective randomized trial which may are prerequisite for timely treatment and prevention of fi establish the speci c predictors of conversion, and further complications. develop a score or a predictive formula which can be used Aim: Tre purpose of the investigation is to evaluate clinical for assignation of cases to the appropriate technique of and iimaging criteria for diagnosis of acute calculouse therapy. cholecystitis and to improve early diagnosis and treatment.

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Materials and methods: We performed a retrospective performed, multiple bacteria culture positive was more research for 9298 patients, treated at First surgical depart- likely to be found. ment of University hospital Pleven for the period 2011e 2016. Results: With acute calculous cholecystitis were diagnosed EP03D-002 1208 patients (13%), and 619 (51,24%) were surgically MINIMALLY INVASIVE BILIARY treated. We had 91% matched in primary and final diagnosis and we apply Tokyo guideline criteria for acute cholecys- DECOMPRESSION METHODS IN titis management- 2007. With mild gallstone cholecystitis MANAGEMENT OF OBSTRUCTIVE were 589 patients and we treated them conservatively. The JAUNDICE OF MALIGNANT ETIOLOGY laparoscopic treatment was performed 96 hours after diag- S. Lukmonov nosis of moderate cholecystitis with conversion rate of 1,2 Faculty Surgery, Tashkent Medical Academy, Uzbekistan % , the patients with severe cholecystitis with perforation The aim of our study was to explore the possibility of and perivesical abscess were treated only by open emer- minimally invasive decompression methods of the biliary gency cholecystectomy. tract on obstructive jaundice of malignant etiology. Conclusion: Diagnosis of acute calculouse cholecystitis is Material and methods: During the period from 2016 to usually not a problem for experienced clinicians. It is more present time in the surgical department of the Republican difficult to stage the inflammatory process, becouse that Clinical Hospital N 1 MH of Uzbekistan were treated 38 determines the therapeutic approach. The most commonly patients with obstructive jaundice of malignant etiology. used imaging method is echography. The main reasons for There were male -16, female - 22. Ages were from 40 to 85 this are: high diagnostic capabilities, harmlessness, low years. financial value without trouble tracking. The results of the study: Step cares were performed to the Keywords: Gallstone disease, acute cholecyastitis patients. The first step was the decompression of the biliary tract in the next 6-24 hours after diagnosis and preoperative preparation. To do this, we used the following methods: EP03D - Electronic Poster: 3D - Biliary Surgical percutaneous transhepatic biliary drainage (PTBD) under Outcomes ultrasound guidance - 12 cases, laparoscopic chol- EP03D-001 ecystostomy - 1 case, PTBD under X-ray guidance with CLINICAL ASPECTS OF BILE CULTURE previous percutaneous transhepatic cholangiography-16 cases, ERCP with endoscopic papillosphincterotomy IN PATIENTS UNDERGOING (EPST) - 4 cases, transpapillary common bile duct drainage LAPAROSCOPIC CHOLECYSTECTOMY (Endoprosthesis) - 1 case. In 2 cases were performed PTBD S. P. Yun, H. I. Seo and M. H. Yoon and endoscopic retrograde decompression. If unsuccessful Pusan National University Hospital, Republic of Korea outcome of retrograde drainage we performed PTBD. For Aim: We identify the incidence of biliary microflora, most tumors of the proximal hepaticocholedochus (cancer of common biliary microflora and resistance of antibiotics, common hepatic duct, gallbladder, metastatic cancer of the and determine predictors of bile infection and infectious porta of hepar) it were carried out PTBD with the stage complication following laparoscopic cholecystectomy. probing of tumor and stent placement. Thus, staged treat- Methods: Bile samples were taken for culture according to ment of biliary decompression, in the earliest time after a standard routine during all cholecystectomies performed diagnosis with obstructive jaundice is depending on the from January 2015 to December 2015 in the department of location of tumor growth. Preferences were given to PTBD surgery, Pusan National University Hospital. 366 laparo- as universal method that provides the most adequate scopic cholecystectomy were performed during the study decompression of the biliary tract. period. In 215 patients, the bile culture was performed and the culture positive was found in 54 cases. According to the results of bile culture, culture negative and positive groups EP03D-003 were divided into two groups, two groups were compared CAN A SURGEON PERFORM A according to preoperative, intraoperative and postoperative MACROSCOPIC INSPECTION OF A factors. GALLBLADDER? Results: The mean age of the 54 patients was 65.46 Æ 1 1 2 10.85, male and female ratio was 26:28, and mean BMI was B. J. G. A. Corten , S. Alexander , P. van Zwam , 1 1 1 23.79 Æ 3.07. ERCP was performed in 26 cases and R. M. H. Roumen , W. K. Leclercq and G. D. Slooter 1 PTGBD in 11 cases before operation. The culture positive Department of Surgery, Máxima Medical Center, and 2 group is older. (p = 0.000) The portion of patients with Foundation PAMM Laboratories for Pathology and performance of ERCP, performance of PTGBD, presence Medical Microbiology, Netherlands of symptoms, presence of operative complication and Introduction: Routine histopathologic gallbladder exami- hospital day is significantly higher in the culture positive nation after cholecystectomy has been a point of discussion group. In the mutivariate analysis of factors associated with for several decades. Recent changes in national guidelines positive culture, age, ERCP, and symptom were indepen- suggest a selective histopathologic examination gallblad- dent factor on positive bile culture. ders. The aim of this study was to evaluate the macroscopic Conclusion: The bile of patients with laparoscopic chole- examination by the surgeon in relation to the final histology cystectomy may have microorganisms, particularly in outcome. elderly patients, those with symptoms, and those who un- Method: A prospective study was conducted in a Dutch dergo preoperative ERCP. And when ERCP was teaching hospital to investigate the practice of macroscopic

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S731 gallbladder examination by a surgeon compared to routine No patients underwent LR in the absence of PD. Recur- histopathology by a pathologist. All consecutive cholecys- rence rate was 50.0% and 41.7% respectively. tectomies were included between November 2009 and Liver resection is associated with a lower recurrence rate February 2011. Patient characteristics, operative procedure, in RPC patients with PD. In the absence of PD, BB has a conversions to laparotomy, macroscopic examination of the lower recurrence rate than CBDE, however, its absolute gallbladder mucosa, alleged necessity for microscopic anal- number remains significantly high. ysis and final histopathology of the gallbladder were analyzed. Results: A total of 319 consecutive cholecystectomies were performed. Twenty-nine patients were treated for EP03D-006 acute cholecystitis. Of all macroscopic examinations the COMPARISON OF SINGLE INCISION surgeon identified 62 gallbladders with macroscopic ab- normalities, ranging from polyps to wallthickening or VERSUS MULTIPLE INCISION ulcers. Including acute cholecystitis a total of 55 (17,2%) LAPAROSCOPIC could have had reasons for further microscopic evaluation CHOLECYSTECTOMY: A META by the pathologist. Macroscopic examination agreement ANALYSIS between surgeon and the pathologist was rated as “strong I. B. Dabu, B. J. Antolin, J. De Jesus, F. J. Yap, agreement” (k = 0,822). The surgeon and the pathologist R. I. Ngo and F. P. Battung had disagreement on the macroscopic examination of 18 Chinese General Hospital & Medical Center, Philippines gallbladders. In these gallbladders, however, the additional histology was not relevant to clinical outcome. Introduction: Laparoscopic cholecystectomy is the gold Conclusions: The present prospective study shows that the standard in the management of symptomatic gallbladder surgeon is capable of adequate macroscopic gallbladder stones. Single incision laparoscopic cholecystectomy examination postoperatively. We suggest to only perform (SILC) has emerged to achieve fewer complications and fi selective microscopic gallbladder examination, which can better cosmesis. This meta-analysis aims to nd a reliable, result in about 80% reduction of this kind of routine risk-free, or at least of comparative risk versus the standard histology. surgical procedure. This study aims to compare SILC with multiple incision laparoscopic cholecystectomy (MILC) in terms of mean operative time, various post-operative complications and aesthesis. EP03D-005 Methodology: Articles included were obtained using SURGICAL TREATMENT OF PUBMED databases. The studies evaluated were restricted RECURRENT PYOGENIC to only those with human subjects and those studies that are CHOLANGITIS: A COMPARISON OF in English. All articles included in this study met the in- OUTCOMES clusion criteria: the study was an RCT, SILC was compared 1 1 2 1 to MILC, features at least one year follow-up and the K. S. Sim ,Y.X.Koh, Y. X. Liew , S. Y. Lee , population were all adults. Exclusion criteria included: B. K. P. Goh1, S. S. Tan3,A.K.H.Chiow3 and C. Y. Chan1 1 patients with cholecystitis, suspicion or proved persistence Department of Hepatopancreatobiliary and Transplant of a choledocholithiasis, necrotic pancreatitis, BMI higher Surgery, 2Department of Pharmacy, Singapore General 3 than 30 or a history of liver disease or upper abdominal Hospital, Singapore, and Department of Hepatopancrea- surgery, published more than 5 years, non-human trials and tobiliary Surgery, Changi General Hospital, Singapore studies with incomplete data. Recurrent pyogenic cholangitis (RPC) is broadly defined Results: Mean operative time of surgery is significantly as a clinical syndrome characterized by the presence of longer for the SILC group. In terms of cosmesis and patient intra-hepatic stones and recurrent biliary infections. Sur- satisfaction rates, SILC showed optimum results. Although gical treatment has been shown to decrease the recurrence most complications were equal with both techniques, rate in RPC, though associated with significant post-oper- presence of incisional hernia was higher in the SILC group. ative morbidity. We present our experience with RPC and Conclusion: This study concludes that SILC is a feasible, our results with the surgical treatment of this recurrent safe and adaptable technique. The benefits of SILC in terms condition. of cosmetic and patient satisfaction will spearhead the use We performed a retrospective review of surgically- of this technique in the future generations. managed patients with RPC between January 1990 and November 2017. Patients with liver atrophy, abscess and/or evidence of severely dilated intra-hepatic ducts with EP03D-007 impacted stones/strictures were deemed to have paren- chymal disease (PD). Patients underwent either common CHOLEDOCHOLITHIASIS (CD): ROLE bile duct exploration (CBDE), biliary bypass (BB) or liver OF OPEN COMMON BILE DUCT resection (LR). EXPLORATION (OCBDE) IN THE ERA A total of 101 patients underwent surgery for the treat- OF ENDOSCOPIC RETROGRADE ment of RPC, of which 59 (58.4%) had evidence of PD and CHOLANIOPANCREATOGRAPHY 42 (41.6%) without. Overall recurrence of disease was observed in 42 patients (41.6%). In the group with PD, 2 (ERCP) AND LAPAROSCOPIC COMMON (3.4%) underwent CBDE, 6 (10.2%) underwent BB and 51 BILE DUCT EXPLORATION (LCBDE) (86.4%) underwent LR. Recurrence rate was 100%, 66.7% N. Vashistha1, D. Singhal1, V. Raj1 and R. Tandon2 and 33.3% respectively. In the group with no PD, 18 1Department of Surgical Gastroenterology, Max Super (42.9%) underwent CBDE and 24 (57.1%) underwent BB. Specialty Hospital, and 2Department of Gastroenterology,

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Pushpawati Singhania Research Institute and Hospital, posttraumatic pancreatic necrosis, which hampers the for- India mation of hepatoconenteroanastomosis. After operations, 1 Introduction: ERCP has emerged as overwhelmingly (2.8%) died. The change of transpedical drainage was dominant option for management of CD. LCBDE is relegated carried out every 2 months, the final removal - after 2 years. as distant second & OCBDE is considered only when ERCP Of the 34 patients who underwent surgery, one patient has or LCBDE are unavailable. A recent study (JAMA Surgery now died from a disease not associated with surgery. 2016;151:1125-30) has expressed concerns that CBDE may Conclusion: The results of treatment of 30 patients after be at risk of disappearing from surgical armamentarium. We drainage removal are good, there are no phenomena of report our experience with OCBDE in complex CD where restenosis, 3 patients continue treatment and follow-up. ERCP failed and LCBDE was not feasible. Methods: 10 year observational study of 27 consecutive patients (15 males, 12 females; median age 55 years) of EP03D-009 OCBDE (1.7% of 1600 ERCPs for CD) with holmium laser QUALITY OF LIFE AFTER HEPATICO- lithotripsy was performed. Peroperative choledochoscopy JEJUNOSTOMY ROUX-EN-Y FOR BILE was preferred method to confirm stone clearance. In group A (n = 18) choledochotomy was primarily closed over DUCT INJURY endoscopic biliary stent. Group B (n = 9) patients under- POSTCHOLECYSTECTOMY went choledochojejunostomy for benign strictures / multi- Z. Zuhdi1, F. Fahmy Jaafar1, A. Azman1, H. Othman1, ple stones / previous cholecystojejunostomy / Mirizzi’s R. Jarmin1 and C. Ian2 syndrome type III. Outcome measures included post- 1Hepatobiliary Unit, Surgical Department, UKM Medical operative morbidity and 30 day mortality. Centre, and 2Pusat Perubatan UKM, Malaysia Results: OCBDE indications included failed ERCP &/or Introduction: Iatrogenic bile duct injury following chole-  large ( 2 cm) / multiple / impacted stones (n = 17), cystectomy is a debilitating complications, especially in ’ Mirizzi s syndrome type II & III (n = 4) or benign biliary Strasberg classification type E. However long term effect of strictures with stones (n = 6). Most common complication quality of life following hepaticojejunostomy has not been was wound infection 3 (11 %). Median length of stay was 6 well established. e (range 4 10) days. In group A, two patients (11%) each Methodology: This is a prospective cross sectional study had transient bile leak and retained stones which were using SF36 Version 2 questionaire in assessing quality of life endoscopically removed. One (3.7 %) patient died due to following surgical intervention. 84 cases recruited for the massive bleeding. study from Jan 1999 till June 2015. All patient were Conclusion: In the current era, indications for OCBDE are contacted via phone and mail over the questionnaire but only limited. However OCBDE is the only treatment for complex 20 cases were responded. The score from the questionaire CD and shall remain integral part of surgical armamentarium. were analyzed using software Health Outcomes Scoring Software 4.5 created by Quality Metric Incorporated. Result: From 20 cases, 2 patients had high type of bile duct EP03D-008 injury and 18 patients had low type of bile duct injury The SYSTEMIC APPROACH IN RENDERING median time of assessment on quality of life is 5.04 years HELP TO PATIENTS WITH INJURY AND postsurgical repair. The high type injury had better quality of < STRUCTURES OF EXTRAHEPATIC life in term of General Health (P 0.05) and Vitality component (P < 0.05). 5 patients had more than 10 follow up BILIARY DUCTS after surgical repair gave a positive feedback in Mental Score S. Lukmonov1, K. Madatov1, M. Ismailov2, U. Allazarov1, Component ( P = 0.023) Vitality (P = 0.05) and Social Func- A. Sharopov1, A. Ismatov1, M. Rozikova1, I. Ramatov1, tion (P = 0.023). 14 patients had readmission after surgical J. Toshnazarov1 and O. Usmanov1 repair give a negative impact on Role Emotional component as 1Faculty Surgery, Tashkent Medical Academy, and 2Sur- compared to group of patient without readmission (66.66 gical Diseases, Tashkent State Pediatric Institute, (Readmission) vs 100 (No Readmission) P = 0.014. Uzbekistan Conclusion: Management after surgical repair in bile duct Purpose: To improve the results of treatment of patients injury postcholecystectomy has a significant impact in with trauma and strictures of extrahepatic bile ducts quality of life. Patient with more reassurance and follow up (EHBD) by systematization of surgical interventions taking tend to have better quality of life. into account the nature of the performed primary surgery. Materials and methods: The analysis of treatment of 20 patients with trauma and 15 with strictures of choledochus EP03D-010 on the basis of faculty surgery of Tashkent Medical Acad- THE ADHERENCE OF TO emy was carried out. There were 25 women and 10 men. CHOLECYSTECTOMY TIMING The age of the patients ranged from 19 years to 81 years. Results: According to E.I. Galperin damage and stricture of GUIDELINES AND ITS EFFECT ON EHBD were: of 1 type in 1 patient, 0 type - in 16, type +1 - HEALTHCARE & PATIENT CENTERED in 2, +2 type - in 13, +3 type - in 3. As in the treatment of OUTCOMES injuries and strictures of choledoch , the operation of choice M. Hassanain1, A. Afrah2, N. Al Beeshi3, was hepatoconterostomy at the interchangeable trans- S. Al Bqami3 and R. Al Ohali3 hepatic drainage on the Goetz. In technical terms, the most 1HPB and Transplant Surgery, Department of Surgery, fi dif cult were the trauma of the ducts during gastrectomy, College of Medicine, 2King Saud University, and 3College as they were accompanied by the development of of Medicine, King Saud University, Saudi Arabia

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Background: Laparoscopic cholecystectomy is a was done. Post operative minor bile leak was noted which commonly performed surgical procedure. Early inter- was managed conservatively. vention has been proven to lower complication rate and Discussion: Diagnosis and surgical approach for Mirizzi reduces hospital stay. The purpose of this study was to syndrome are still a challenge. Surgical approaches for it assess our institutional adherence to the timing guidelines differs depending on its type. For type 3 Mirizzi syndrome - and its effect on clinical and patient’s centered outcomes Cholecystectomy with Roux-en-Y Hepaticojejunostomy and the associated cost in patients with symptomatic has been described in the literature. But in our case, in view gallstones. of non dilated duct not amenable for Hepaticojejunostomy, Methods: Data was collected from the EMR of Roux-en-Y jejunal serosal patch choledochoplasty was symptomatic gallstones patients over a year period. done. Predefined definitions used to divide patients into: Conclusion: Mirizzi syndrome type 3 presents a unique biliary colic, persistent biliary colic, early cholecys- challenge to manage in non dilated ducts. Roux-en-Y je- tectomy acute cholecystitis and delayed cholecystec- junal serosal patch choledochoplasty can be a safe and tomy. A random group of patients were interviewed viable approach in such a scenario. It presents an alternative using the RAND 36-Item Health Survey 1.0 following to hepaticojejunostomy in non dilated ducts. the procedure. Results: 534 patients were identified; 79.9% were females. 76.8% patients had biliary colic, 13% had persistent biliary EP03D-012 colic, 5.9% with early cholecystectomy and 3.2% with EFFECTS OF PREOPERATIVE ORAL delayed cholecystectomy. Persistent biliary colic had a significant delay from diagnosis to surgery (p < 0.05), CARBOHYDRATES ON QUALITY OF more length of hospital stay (p< 0.0001), and more pa- RECOVERY IN LAPAROSCOPIC tients’ productivity loss (p < 0.02) when compared to CHOLECYSTECTOMY: A biliary colic with a median $266.65/patient cost increase. RANDOMIZED, DOUBLE BLIND, Delayed cholecystectomy for acute cholecystitis patients < PLACEBO-CONTROLLED TRIAL had more delay from diagnosis to surgery (p 0.0001) 1 1 1 2 more re-admission rates (p < 0.0001) when compared to J. S. Lee , Y. Song , J. Y. Kim , J. S. Park and D. S. Yoon2 the early group with a median $533.29/patient cost in- 1 fi Department of Anesthesiology and Pain Medicine, and crease. There was no statistical signi cance in complica- 2 tions or in quality of life parameters. Department of Surgery, Yonsei University College of Conclusion: Despite being in an academic center, adher- Medicine, Republic of Korea ence to the treatment guidelines of symptomatic gallstones While carbohydrate loading is an important component of is low. The increased cost is worth investment in measures enhanced patient recovery after surgery, no study has to reduce such burden on patients and healthcare system. evaluated the effects of preoperative carbohydrate loading after laparoscopic cholecystectomy on patient satisfaction and overall recovery. Thus, we aimed to investigate the EP03D-011 impact of preoperative oral carbohydrates on the quality of patient recovery after laparoscopic cholecystectomy A ROUX EN Y JEJUNAL PATCH total of 153 adult patients who underwent laparoscopic CHOLEDOCHOPLASTY FOR MIRIZZI cholecystectomy were randomized into three study SYNDROME TYPE-3: UNIQUE groups. Patients in group MN-NPO were fasted from SURGICAL APPROACH midnight until surgery. Patients in group No-NPO received 400 mL of a clear carbohydrate beverage on the N. Shivathirthan1, S. Saraf1 and Y. Kumar2 evening before surgery, and a morning dose of 400 mL 1Dept of Gastro Surgery, and 2Apollo BGS Hospital, Dept was ingested at least 2 hours before surgery . Patients in of Gastro Surgery, India group Placebo received the same quantity of flavored Introduction: Mirizzi syndrome is a rare complication of water at the same times as for group No-NPO. The gallstones with an incidence of less than 1% per year. quality of recovery was evaluated pre and postoperatively Obstructive jaundice, due to extrinsic compression of the using the QoR-40 questionnaire. Intraoperative hemody- ’ common bile duct by gallstone impacted at Hartman s namic changes were also evaluated. There were no sig- fi and formation of cholecysto-choledochal stula due to nificant differences among the groups in terms of the pre- pressure necrosis caused by compression of large gall- and postoperative global QoR-40 scores (P = 0.25). stone in Hartman’s are major presentations. If the fistula rd Group MN-NPO had an elevated heart rate compared to involves upto 2/3 circumference of CBD, entity is patients who ingested a preoperative beverage (groups labeled as type 3 Mirizzi syndrome. We hereby present a No-NPO and Placebo; P = 0.041). The preoperative car- case managed with unique surgical approach for Mirizzi bohydrate beverage did not improve quality of recovery syndrome type 3- ROUX EN Y JEJUNAL PATCH using the QoR-40 compared to placebo or conventional CHOLEDOCHOPLASTY. fasting. However, the preoperative fasting group had a Case report: 86 yr male presented with obstructive jaun- consistently increased heart rate during changes in body dice, underwent ERCP+CBD STENTING, submitted for position that induced hypotension which is likely a result cholecystectomy. Intraoperative cholecysto-choledochal of depletion of effective intravascular volume caused by fi rd stula involving 2/3 circumference of CBD was noted for traditional fasting over 8 hours. which Roux-en-Y jejunal serosal patch choledochoplasty

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EP03D-013 Methods: Patients with curative-intent surgery for PHC between 1996 and 2011 (period 1; 102 patients) were PREOPERATIVE PERCUTANEOUS retrospectively compared with those resected between 2012 TRANSHEPATIC BILIARY DRAINAGE and 2017 (period 2; 48 patients). The assessment was made HAS DETRIMENTAL EFFECT ON for the surgical approach and outcomes. Complications POSTOPERATIVE SURVIVAL IN were graded according to Dindo-Clavien classification. fi PATIENTS UNDERGOING Results: During period 2 signi cantly more liver resections (100% vs. 71.6%, p < 0.001), caudate lobectomies (87.5% PANCREATODUODENECTOMY FOR vs. 53.9%, p < 0.001) and major hepatectomies (95.8% vs. DISTAL CHOLANGIOCARCINOMA: A 63.7%, p < 0.001) were performed. However, severe PROPENSITY SCORE MATCHING morbidity rates were significantly reduced in period 2 ANALYSIS (6.3% vs. 22.5%, p = 0.019), including the subgroup of S. Mori, T. Aoki, T. Shimizu, K. Tani, K. H. Park, patients with major hepatectomies (6.5% vs. 27.7%, p = T. Matsumoto, T. Shiraki, Y. Iso, M. Kato and K. Kubota 0.006). Trends towards reduced 90-day mortality rates for Department of Gastroenterological Surgery, Dokkyo major hepatectomies were observed in period 2 (4.4% vs. fi Medical University, Japan 10.8%) albeit statistical signi cance was not reached (p = 0.301). Furthermore, the median disease-free (40 vs. 16 Background: The optimal approach for preoperative biliary months, p = 0.026) and overall survivals (54 vs. 26 months, drainage (PBD) in patients with distal cholangiocarcinoma p = 0.016) times significantly improved in period 2. (DCC) remains controversial. We compared the prognostic Conclusion: Improved experience allowed the use of major impact of endoscopic biliary drainage (EBD) with that of hepatectomies as standard of care in curative-intent surgery percutaneous transhepatic biliary drainage (PTBD) in pa- for PHC at high-volume centers from Eastern Europe, with tients undergoing pancreatoduodenectomy (PD) for DCC. significantly better disease-free and overall survivals. Methods: A total of 84 patients with DCC who underwent Despite more complex surgical procedures, severe PD following either EBD (n = 60) or PTBD (n = 24) be- morbidity rates have decreased, with no increased mortality. tween 2000 and 2016 were retrospectively reviewed. Results: The 5-year overall survival (OS) rate in the PTBD group were significantly shorter than that in the EBD group (16.7% vs. 52.3%, P = 0.007). However, the 5-year cancer- EP03D-015 specific survival (CSS) rate did not differ significantly (27% COMPARISON OF LAPAROSCOPIC vs. 57%, P = 0.072). After adjustment for propensity score VERSUS OPEN LEFT LATERAL matching, the 5-year OS and CSS rates were worse in the HEPATECTOMY FOR PTBD group (n = 22) than in the EBD group (n = 22) (13.6% HEPATOLITHIASIS IN CHINA vs. 61.2%, P = 0.003 and 23.7% vs. 64.1%, P = 0.036, respectively). Multivariate analysis showed that lymphatic W. Chen, J. Lou and T. Liang invasion, PTBD, and R1 resection were independent risk Department of Hepatobiliary and Pancreatic Surgery, The fi factors for poor OS (P = 0.027, P = 0.028, and P = 0.032, Second Af liated Hospital, Zhejiang University School of respectively); moreover, a carcinoembryonic antigen level Medicine, China of >5 ng/ml on admission and PTBD were associated with Background: Primary hepatolithiasis is prevalent in peritoneal recurrence (P = 0.010 and P = 0.018). Eastern Asia. Partial hepatectomy is the most effective and Conclusion: PTBD should not be recommended as the definitive treatment for hepatolithiasis. Laparoscopic sur- optimal approach for PBD in patients undergoing PD for gery has been used in the treatment of hepatolithiasis but DCC, as PTBD is correlated with both an increased incidence remains controversial due to the technical challenge. The of peritoneal recurrence and shorter postoperative survival. objective of this study was to evaluate outcomes of lapa- roscopic left lateral hepatectomy (LLLH) for treatment of primary hepatolithiasis. EP03D-014 Method: From June 2014 to June 2017, 105 consecutive patients with left intrahepatic duct stones who underwent IMPROVEMENT OF SURGICAL LLLH (n = 35) or open left lateral hepatectomy (OLLH) (n RESULTS FOR PERIHILAR = 70) were evaluated. We retrospectively reviewed the CHOLANGIOCARCINOMAS IN clinical outcomes and the stone clearance rates of the 2 EASTERN EUROPE. AN groups in this study. INSTITUTIONAL EXPERIENCE Result: The volume of intraoperative blood loss was less in the LLLH than OLLH group (153 ml versus 204 ml; P = T. Dumitrascu1, V. Brasoveanu2, C. Stroescu1, 0.140), but there was no significant difference. The post- M. Ionescu1 and I. Popescu2 operative hospitalization time was significantly shorter in the 1General Surgery and Liver Transplant, Carol Davila LLLH group than in the OLLH group (6.8 d versus 11.8 d; P< University of Medicine and Pharmacy/Fundeni Clinical 0.001). The postoperative complication rate was significantly Institute, and 2General Surgery and Liver Transplant, Titu lower in the LLLH group (32.9% versus 8.6%; P = 0.007). Maiorescu University/Fundeni Clinical Institute, Romania There were no differences between the LLLH and OLLH Introduction: The outcomes after surgery for perihilar groups in operation time, hepatic portal occlusion, blood cholangiocarcinoma (PHC) are poorly known in Eastern transfusion, residual stone rate, and recurrent stone rate. Europe. The study aims to investigate the evolution and Conclusion: In experienced hands, total LLLH provides outcomes of curative-intent surgery for PHC in an Eastern clinical benefits and is a safe and effective procedure for European institutional experience. selected patients with hepatolithiasis.

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EP03D-015 Operative and postoperative outcomes in two groups Operative and postoperative characteristics OLLH (n[70) LLLH (n[35) P value Operation time （min） 206 ± 70 225 ± 77 0.180 Blood loss（ml） 204 ± 208 153 ± 126 0.140 ICU stay (n,%） 7 (10.0） 2 (5.7） 0.462 Secondary surgery unplanned, n (%) 5 (7.1） 2 (5.7） 0.783 Postoperative hospital stay（d） 11.8 ± 6.5 6.8 ± 2.7 <0.001 Overall complication,n (%) 23 (32.9） 3 (8.6） 0.007 Residual stone, n(%) 7 (10.0） 6 (17.1） 0.297 Final clearance, n (%) 70 (100) 35 (100) 1 Recurrence after surgery, n(%) 1 (1.4） 0 0.480

EP03D-016 EP03D-017 STEP-UP STRATEGY WITH LIMITED MANAGEMENT AND OUTCOMES OF RESECTION FOR EARLY STAGE RIGHT SECTORAL BILE DUCT INJURY NEOPLASMS OF THE AMPULLA OF FOLLOWING LAPAROSCOPIC VATER CHOLECYSTECTOMY M. Koizumi, M. Taguchi, Y. Kaneda, A. Miki, K. Endo, N. Vashistha and D. Singhal H. Sasanuma, Y. Sakuma, A. Lefor and N. Sata Department of Surgical Gastroenterology, Max Super Surgery, Jichi Medical University, Japan Specialty Hospital, India Introduction: We have emphasized the complications and Background: Post laparoscopic cholecystectomy bile uncertain pathological evaluation of the margins after duct injuries (LC - BDI) occur in 0.4 -1.3 % patients. Of endoscopic papillectomy, and reported the usefulness of these the management of right sectoral duct (RSD) injury limited surgical resection, such as transduodenal papil- is particularly challenging as diagnosis is often delayed lectomy (TDP), or extraduodenal papillectomy (ExDP). and surgical reconstruction difficult. We present our The aim of this study is to determine the indications for experience in management of postcholecystectomy RSD limited resection of ampullary neoplasms (NAV). injury. Methods: From 1992 to 2017, 121 patients with NAV Methods: Five years observational study of 23 patients of underwent resection. 22 patients (18%, 15 males, mean age LC - BDI revealed 4 patients with RSD injury. In- 66.4y) underwent limited resection (15 TDP and 7 ExDP). vestigations, treatment and outcomes were analyzed. Results: Endoscopic ultrasonography (EUS) and/or intra- Results: Of the 4 patients, three had right posterior ductal ultrasonography (IDUS) were performed preopera- sectoral duct (RPSD) and 1 had isolated right anterior tively in all patients and no pancreatic, duodenal or biliary sectoral duct (RASD) injury. Initial ERCP (3) did not invasion was detected. Pathologically, 10 adenomas and 12 diagnose any of the RSD injuries. Percutaneous trans- adenocarcinomas including nine mucosal carcinomas, two hepatic cholangiography (PTC) in one patient was od-carcinomas (limited to the sphincter of Oddi) and one initially misinterpreted as type III injury [Figure A,B]. T2 carcinoma (duodenal invasion) were confirmed. All The diagnosis was arrived at MRCP in 3 and drain tube adenomas had negative surgical margins. Two mucosal cholangiogram (DTC) [Figure C] in 1 patient. One pa- carcinomas had positive margins at the bile duct and py- tient each with RASD and RPSD fistula healed with lorus preserving pancreatoduodenectomy (PpPD) was ERCP & biliary stenting and sequential drain shortening performed. One od-carcinoma underwent PpPD, as 24% of & clamping after 3 & 7 months respectively. Two pa- od-carcinomas had nodal metastases in our previous series. tients with RPSD stricture underwent hepaticojejunos- The one T2 carcinoma underwent PpPD. Pathological tomy [Figure D] following failed endoscopic & evaluation showed residual carcinoma in two of four percutaneous management. All patients are asymptom- additional PpPD cases, but no nodal metastases. All pa- atic at median follow up of 2.5 years. tients are alive without recurrence. Conclusion: ERCP and PTC have limitations for Conclusion: NAVs often have mucosal spread into the diagnosis of suspected RSD injury; MRC thus is the biliary or pancreatic ducts, which cannot be detected by investigation of choice. DTC is a valuable adjunct in preoperative EUS or IDUS. Limited resection for NAV patients with biliary fistula. Patients with fistula may be allows precise pathological evaluation especially for early managed nonoperatively. In symptomatic patients with stage lesions. A “step-up” strategy with limited resection as RSD stricture, management options include endoscopic the primary procedure followed by PpPD after pathological or percutaneous biliary stenting or biliary enteric evaluation is feasible for the treatment of early-stage anastomosis. NAVs.

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EP03D-019 OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY: EXPERIENCE OF A UNIVERSITY GROUP PRACTICE IN A DEVELOPING COUNTRY K. A. Delos Santos-Belen1, A. R. Perez1,2 and M. C. Mendoza1 1Department of Surgery, Asian Hospital and Medical Center, and 2Department of Surgery, University of the Philippines, Philippine General Hospital, Philippines Introduction: In developed countries, efforts to improve outcome and minimize costs prompted the performance of laparoscopic cholecystectomy as an outpatient procedure. In the Philippines and in most developing countries, most laparoscopic cholecystectomies are still performed on admitted patients who are discharged one or more days Figure A,B,C,D after the surgery. No local experience has been published in the Philippines demonstrating the safety and feasibility of outpatient laparoscopic cholecystectomy. Methods: This study is a retrospective study investigating EP03D-018 the outcome of outpatient performed laparoscopic chole- OUTCOMES OF HEPATOPANCREATO cystectomy in the University of the Philippines, Philippine DUODENECTOMY IN PATIENTS WITH General Hospital Faculty Medical Arts Building (UP-PGH BILIARY DISEASE FMAB), an ambulatory surgical facility within UP-PGH. The patients were admitted to the ambulatory facility on the K. Okamura, S. Hirano, T. Noji, Y. Nakanishi, day of surgery, underwent laparoscopic cholecystectomy T. Nakamura, T. Asano, T. Tsuchikawa and T. Shichinohe under general anesthesia and discharged on the same day. Department of Gastroenterological Surgery II, Graduate Results: From June 2012 to June 2016, 122 patients un- School of Medicine, Hokkaido University, Japan derwent laparoscopic cholecystectomy at the UP-PGH Introduction: Hepatopancreatoduodenectomy with exten- FMAB. There were 80 women (85%) and 42 men (15%) sive hepatic resection (M-HPD) remains a difficult and with a mean age of 46 years. The mean operating time was complex surgery. We sought to evaluate our procedures of 58 minutes. The unplanned admission rate was 2.4% (two M-HPD in patients with biliary diseases. patients), one for conversion to open and two for unrelieved Method: We reviewed data from 52 patients who under- postoperative nausea and vomiting. went M-HPD between 2001 to 2017. The postoperative Conclusion: Outpatient laparoscopic cholecystectomy is course and overall survival (OS) were investigated.The safe and technically feasible even in developing countries. indocyanine green clearance test value (ICG15 min), and It has potential for much economical and social benefit the size of future remnant liver volume (FRLV) were used when employed judiciously. Prospective, randomized trials to determine patient tolerance for undergoing each type of must be conducted in the local setting to refine technique, hepatectomy. Portal vein embolization (PE) was performed standardize patient selection and address system de- in cases of right hepatectomy or bilateral trisectionectomy 2 ficiencies to allow safe performance of outpatient laparo- or 3 weeks before HPD. scopic cholecystectomy in the Philippines. Results: The numbers of patients who underwent right hepatectomy, left hepatectomy, left trisectionectomy, and right trisectionectomy were 36, 12, 2, and 2, respectively. EP03D-020 fi Forty- ve patients had bile duct cancer and 6 had gall- OUTCOME OF 164 PATIENTS WITH bladder cancer. One patient was diagnosed with chol- angitis based on pathological investigation. Median IATROGENIC BILIARY STRICTURE [range] values for operative time and blood loss were SUBMITTED TO SURGICAL REPAIR IN 722 [552e989] min and 1855 [840-6180] ml, respec- A SPECIALIZED CENTER tively. PTPE was performed in 41 (79%) patients. Post- E. R. R. Figueira1, T. Bacchella1, Y. R. Shinkado2, operative complications with Clavien-Dindo (CD) grade S. G. Casagrande1, E. E. Abdo1, T. N. Costa1, G. N. Namur1, IIIa or higher developed in 33 (63%) patients. The mean R. Jureidini1, T. C. Ribeiro1 and I. Cecconello1 operative time in patients with CD grade IIIa or higher 1Gastroenterology/Division of Digestive Surgery, Hospital fi was signi cantlylongerthanthatinpatientswithCD das Clinicas of University of Sao Paulo School of Medicine, grade II or lower (p = 0.0103). Median survival time, and and 2University of Sao Paulo School of Medicine, Brazil 3- and 5-year OS for the entire cohort were 33 months, Iatrogenic bile duct injury affects 0.5% of patients sub- 48%, and 25%, respectively. mitted to cholecystectomy. Major injury is a life-threat- Conclusions: Candidates for M-HPD should be selected ening condition requiring early recognition and specialized strictly based on future remnant hepatic function. Compli- treatment for achievement of good results. We aimed to cated procedures requiring prolonged operative time should evaluate long-term outcome of surgical repair of iatrogenic be avoided. biliary injury at our institution.

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Methods: We retrospectively evaluated 164 patients with survival. Multivariate analysis revealed that tumor differ- bile duct stricture(BDS) or bilioenteric anastomosis entiation was an independent prognostic factor for stricture(BEAS). survival. Results: Age was 45.5 Æ 19.43y, 81% women. Etiologies Conclusions: Pancreaticoduodenectomy is a safe surgical were open cholecystectomy (72.5%), laparoscopic (23.5%) procedure with acceptable long-term survival for ampulla and primary bilioenteric anastomosis (4%). Diagnosis was of Vater cancer. Pattients with LNR greater than 0.2 and BDS in 95(57.9%) and BEAS in 69 (42.1%). Follow-up positive lymph node metastasis 2 or more had a poorer was 3.05(0.01e27.14)y, in-hospital mortality was 1.22% survival. and overall mortality, 5.49%. BDS showed increased inci- dence of open cholecystectomy (77%Â60%), decreased Bismuth(B)-3/4 injury-type (40.9%Â65.6%), cases with EP03D-022 Â hepatic cirrhosis (17% 31), postoperative hospitalization (9 DOES SINGLE INCISION Â 11d), bilirubin (1.12 Æ 2.03 x 2.78 Æ 6.67) and AST (33 Æ 29 Â 55 Æ 61) compared to BEAS. In both, BDS and BEAS, LAPAROSCOPIC CHOLECYSTECTOMY postoperative bilirubin, AST, ALT and GGT were decreased INCREASES THE BILE DUCT INJURY? compared to preoperative. Patients with fibrosis (84.3%) I. S. Choi, J. I. Mon and J. S. Lee showed increased postoperative bilirubin and AST. Recur- General Surgery, Konyang University Hospital, Republic rence was 4.21%(4) in BDS and 11.69%(8) in BEAS, 2 and 3 of Korea patients, respectively, had reoperations; 2 from each group, Purpose: Single-incision laparoscopic cholecystectomy endoscopic dilatation; and 3 from BEAS referred to liver (SILC) is relative safe. But it is difficult to proceed safely in transplantation; 1-year and 10-year survival was 98.95% and all cases. There is concern about the bile duct injury. So the 91.93% in BDS, and 98.46% and 94.16% in BEAS. purpose of this study was to evaluate that SILC actually Conclusions: Surgical repair of complex biliary stricture increases the bile duct injury. can achieve long-term success with decreased recurrence Method: A total of 2080 cases were performed laparo- when performed by experienced surgeons. Referral for scopic cholecystectomy between Mar. 2010 and Dec. 2016 initial treatment seems more appropriate than after unsuc- Konyang University Hospital. We divided two group based cessful bilioenteric anastomosis. In this cases injury can on whether there was injury to the bile duct. (no injury become more complex. group; n = 2065, 99.3% vs. injury group; n = 15, 0.7%). Result: This study includes 2080 cases with 1015 male (48.8%) and 165 female (51.2%) patients. Age was signif- EP03D-021 icantly higher the injury group than no injury group (70.1 Æ PROGSNOTIC VALUE OF THE LYMPH 11.7 vs. 56.6 Æ 16.0, p = 0.001). Operative time was NODE METASTASIS IN PATIENTS WITH significantly longer in the injury group (54.8 Æ 22.9 min vs. Æ < Æ AMPULLA OF VATER CANCER 88.3 41.7min, p 0.001). Bleeding loss (21.8 43.7 ml vs. 70.8 Æ 94.9 ml, p = 0.001), hospital stay days (3.0 Æ 2.8 FOLLOWING SURGICAL RESECTION days vs. 12.0 Æ 7.4 days, p < 0.001) and hemovac insertion S. B. Choi, T. W. Limi, W. J. Kim, P. Park and W. B. Kim (171(8.3%) vs. 9(60.0%), p < 0.001 ) were higher in the Surgery, Korea Univesrity Guro Hospital, Republic of injury group than no injury group. However there was no Korea pathologic difference between pathologic results (p = Background and aims: The aim of the present study is to 1.000). Also in operation type, both CLC and SILC were no determine the prognostic impact of lymph node metastasis difference between the two groups, (p = 0.121). In multi- on survival in patients with ampulla of Vater cancer variate analysis, operation type was no significant risk following surgical resection. The impact of metastatic factor (p=0.291 OR 1.924). lymph node ratio (LNR) and number of lymph node Conclusion: According to the our results, SILC does not metastasis on survival was investigated. actually involve bile duct injury in selected patiets. Material and methods: From 1991 to 2016, we identified and reviewed 128 patients with ampulla of Vater cancer retrospectively. Clinicopathologic factors and LNR, EP03D-023 number of metastatic lymph nodes influencing survival TREATMENT STRATEGY FOR TUMORS were statistically analyzed. OF THE AMPULLA OF VATER. LOCAL Results: There were 51 female and 77 male. Pancreati- coduodenectomy was performed in 112 patients. The 5- EXCISION AS A MINIMUM INVASIVE year survival rates following resection were 57.8%. Mean SURGERY, COMPARISON WITH number of retrieved lymph nodes was 13. Mean number of PANCREATODUODENECTOMY metastatic lymph nodes was 0.95. In patients with lymph (PD/PPPD) AND ENDOSCOPIC node metastasis(N1), median number of metastatic lymph PAPILLECTOMY node was 1. And mean number of LNR was 0.18. LNR 1 1 1 2 greater than 0.2 was a significant prognostic factors for M. Hamano , T. Araida , S. Katagiri , K. Takasaki , M. Yamamoto2, R. Higuchi2, T. Yazawa2 and S. Uemura2 overall survival. The survival of patients with number 1 of metastatic lymph node 0 or 1 demonstrated better sur- Department of Surgery, Institute of Gastroenterology, ’ vival than patients with metastatic lymph node 2 or more. Tokyo Women s Medical University Yachiyo Medical 2 ’ Univariate analysis for overall survival revealed that dif- Center, and Tokyo Women s Medical University, Japan ferentiation, and pancreatic invasion, lymph node metas- Introduction: Recently endoscopic Papillectomy and tasis, T stage were significant prognostic factors for overall Local excision have been performed for early papillary

HPB 2018, 20 (S2), S685eS764 S738 Electronic Poster (EP03A-EP03F) e Biliary carcinoma. In the present study, the adequacy of treatment (Autologous-group; mean 3.7 mg/dl vs Homologous- results of it were examined by attempting to compare be- group; 6.4 mg/dl) and the incidence of postoperative liver tween PancreatoDuodenectomy (PD/PPPD) performed for failure (Grade B/C; ISGLS, 23% vs 41%) was significantly early papillary carcinoma and Local excision of the higher in Homologous-group (P < 0.001, respectively). Ampulla of Vate and endoscopic Papillectomy of Tumor of After propensity score matching (69 patients in each the Ampulla of Vater. group), the above baseline characteristics of both groups Results: 21 patients underwent PD/PPPD (StageⅠ), 20pa- were similar. Although postoperative maximum T-Bil level tients underwent Local excision, and 12 patients were given were significantly higher in Homologous-group (mean 3.4 endoscopic Papillectomy. Curative resection was entirely mg/dl vs 5.7 mg/dl, P = 0.002), the incidence of post- obtained in surgical cases. Resection stumps in 3 patients operative liver failure was comparable between two groups who were given endoscopic Papillectomy were partially (41% vs 30%, P = 0.213). unclear, but there was 1 patient with positive surgical Conclusion: Autologous blood transfusion may minimize margins. The average length of a hospital stay after surgery postoperative liver dysfunction. However, further studies was 36.2 days in PD/PPPD, 18.5 days in Local excision and are needed to clarify the clinical value of preoperative 11.6 days in endoscopic Papillectomy. The number of pa- blood donation. tients who suffered complications after surgery in PD/ PPPD was 10 patient (50%), in Local excision was 1 patient with pancreatitis, and that in endoscopic Papillectomy was EP03D-025 fl 5 patients with bleeding, 3 patients with in ammation of PROGNOSTIC SIGNIFICANCE OF the gall bladder and the bile duct, and 2 patients with pancreatitis. 1 patient had a prognosis of stump recurrence TUMOR BUDDING IN PATIENTS WITH (adenoma) in endoscopic Papillectomy, but others were RESECTED PERIHILAR alive without evidence of any cancer. CHOLANGIOCARCINOMA Conclusions: Patients had neither severe complication nor N. Kuriyama1, T. Ito1, A. Tanemura1, Y. Azumi1, cancer recurrence in both Local excision of the Ampulla of M. Kishiwada1, S. Mizuno1, M. Usui1, H. Sakurai1, Vater and Endoscopic papillectomy; therefore, a decision Y. Kozuka2 and S. Isaji1 regarding the adequacy of borderline lesions in our hospital 1Department of Hepatobiliary Pancreatic and Transplant was thought to be responsible. Surgery, and 2Division of Pathology, Mie University School of Medicine, Japan Introduction: Tumor budding (TB), a type of diffusely EP03D-024 infiltrative growth observed in many gastrointestinal can- COMPARISON BETWEEN cers, is a well-established adverse prognostic factor. To the AUTOLOGOUS AND HOMOLOGOUS best of our knowledge, prognostic significance of TB in BLOOD TRANSFUSION IN LIVER perihilar cholangiocarcinoma (PHC) have not been re- fi RESECTION FOR BILIARY TRACT ported. We aimed to assess the prognostic signi cance of TB in PHC, and determine its relationship with other CANCER: A PROPENSITY SCORE clinicopathologic features. MATCHING ANALYSIS Methods: Between January 2004 and December 2017, 81 S. Onoe, T. Ebata, Y. Yokoyama, T. Igami, T. Mizuno, patients with PHC underwent surgical resection and in J. Yamaguchi and M. Nagino these patients various prognostic factors were examined. Division of Surgical Oncology, Department of Surgery, TB was defined as tumor cells or clusters composed of less Nagoya University Graduate School of Medicine, Japan than 5 cells at the invasive tumor front per field using 20 Background: Homologous blood transfusion is associated times objective lens in specimen stained with H&E. TB was fi < fi with a potential risk of adverse events. However, it remains classi ed into two groups: low-TB( 5/ eld) and high-  fi unclear whether preoperative blood donation is truly TB( 5/ eld), and compared with clinicopathological beneficial in liver surgery. The aim of this retrospective features. study was to evaluate surgical outcomes comparing autol- Results: A multivariate analysis revealed that LN metas- ogous and homologous transfusion in liver resection for tasis (HR3.894, p = 0.048) residual tumor (9.533, p = fi biliary tract cancer. 0.002), and high-TB (HR11.147, p = 0.001) were identi ed Methods: A retrospective review of patients who under- as independent poor prognostic factors. Eighty-one patients Æ fi went hepatectomy for biliary tract cancer was performed were divided into low-TB(n = 57, 2.0 1.5/ eld) and high- Æ fi (2006e2017, n = 646). Preoperative blood donation was TB groups(n = 24, 9.5 3.5/ eld). By comparing low-TB fi performed in 425 patients (66%), of which 359 patients vs. high-TB groups, the following rates were signi cantly underwent hepatectomy without homologous blood trans- higher in high-TB groups: combined PV resection (38.6% fusion (Autologous-group, n = 359). Among the remaining vs. 66.7%, p = 0.028), tumor-stage III or more (42.1% vs. 221 patients, 105 patients needed homologous transfusion 70.8%, p = 0.028), LN metastasis (40.4% vs. 70.8%, p = during hepatectomy (Homologous-group, n = 105). These 0.016), intrahepatic metastasis (1.8% vs. 20.8%, p = 0.008), two groups were compared, and propensity score matching and poor differentiation (5.3% vs. 25.0%, p = 0.019). fi analyses were performed to adjust the data for the baseline Disease speci c 5-year survival rate was 44.2% characteristics of both groups. (MST:52.4M) in Low-TB group and 9.5% (MST:19.4M) in Results: Between-group differences were observed in age, high-TB group, as shown in Figure. sex, BMI, preoperative Hb and Alb level, operative time, Conclusion: High-TB at the invasive front of tumors could and blood loss. Postoperative maximum T-Bil level be a novel prognostic factor in resected PHC.

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EP03D-026 metastasis and cytogenetic evidence of acquired clonal chromosomal abnormalities. We hereby report a case series ENDOSCOPIC RETROGRADE of three patients with inflammatory myofibroblastic tumour CHOLANGIO PANCREATOGRAPHY involving gallbladder, liver. (ERCP) e A NOVEL RISK FACTOR FOR Inflammatory myofibroblastic tumor (IMT) occurs more CONVERSION OF LAPAROSCOPIC frequently in childhood and the most common involvement fl fi CHOLECYSTECTOMY is seen in the lungs. Primary in ammatory myo broblastic tumors of the gallbladder are rather infrequent. The present M. Nandasena1, C. Lakmal2, A. Pathirana1 and 1 knowledge is based on case reports. Initiating factors such B. Gamage as reactive, infections, autoimmune and neoplastic pro- 1Department of Surgery, University of Sri Jayawardene- 2 cesses, has been proposed but the etiology of most remains pura, and Department of Surgery, Colombo South unknown. The most frequently involved organ in the Teaching Hospital, Sri Lanka abdomen is the liver, while primary gallbladder involve- Introduction: Laparoscopic cholecystectomy is the stan- ment is quite rare. Present knowledge about this entity is dard care for symptomatic gall stone disease. Although based on case reports in the literature (9). The clinical open cholecystectomy has a longer convalescence, it is picture in cases with IMT depends on the organ of considered a safe approach when difficulties are encoun- involvement and site of the organ; abdominal pain, jaun- tered during laparoscopic surgery. Though Studies have dice and ascites might be the presenting symptoms, ac- shown many risk factors for conversion the effect of pre- cording to the localisation in the liver involvement. operative ERCP is scarce worldwide. In our cases symptoms were abdominal pain and Methods: Two hundred and two consecutive lapa- dyspepsia. CT demonstrated involvement of liver, gall- roscopic(LC) and laparoscopy converted to open(LCOC) bladder, which is rare. Hence, decision of extended cho- cholecystectomies performed on patients attending a ter- lecystectomy taken to do in these cases. tiary referral centre from 2014 to 2016 were analysed using SPSS version 20.0 Results: One hundred and thirty three LC and 69 LCOC were done with a conversion rate of 34.1%. Majority were EP03D-028 e females(76%). Mean age was 46.35 years(range 16 80). MANAGEMENT STRATEGY OF BILE Demographic data and surgical factors are comparable in both groups. All patients with choledocholithiasis under- DUCT INJURY: EXPERIENCE IN went ERCP prior to cholecystectomy. Fifty two percent and DHAKA MEDICAL COLLEGE 6% had ERCP pre operatively in LCOC and LC groups HOSPITAL, BANGLADESH respectively(OR - 13.9, 95% CI 5.8-32.9). Eighty one H. A. Nazmul Hakim, T. K. Saha, A. Nure Azam, percent of the patients who underwent ERCP had a T. Talukdar and S. Haque < conversion(p 0.001). ERCP with common bile duct Surgery, Dhaka Medical College Hospital, Bangladesh stenting(11%) had no significant correlation with the con- Background: Bile duct injury presents with significant version. There is no significant association between number symptoms and causes serious complications that are life of ERCP and conversion(Median - 2, Range 1-5).Mean threatening both in short and long term. Management duration after ERCP to surgery was 20.3 weeks(range-2-48 strategy has considerable surgical challenge. weeks) in LCOC group. No bile duct injuries were reported Materials and methods: This prospective observational in both groups. study includes 160 patients of bile duct injury surgically Conclusion: High conversion rate of our case series could treated from January 2010 to December 2017. Patients were be due to the complexity of the referrals. ERCP is a sig- selected randomly irrespective of age, sex and presentation. nificant risk factor for conversion according to our data. Aim of this study was to evaluate the mode of presentation Post ERCP patients should be informed about the higher and outcome of surgery. The patients were followed up for risk of conversion. 2 to 24 months. Results: In the study 60% patients presented with obstructive jaundice. 62.5% injuries occurred during lapa- EP03D-027 roscopic cholecystectomy . 60% patients presented within 2 INFLAMMATORY MYOFIBROBLASTIC weeks of initial surgery. 45% cases were Bismuth grade 3 TUMOUR OF GALL BLADDER AND injury . Primary Roux-en-Y hepaticojejunostomy was done fi LIVER: A CASE SERIES & REVIEW OF in 18.75% patients, controlled biliary stula done in 75% patients, late (6 to 12 weeks) Hepaticojejunostomy and LITERATURE cholangiojejunostomy done in 75% patients. Anastomotic M. Kumar, L. Sinha and R. Gupta leak(10%) in primary repair and wound infection(25%) in General Surgery, All India Institute of Medical Sciences, delayed repair were most common post operative compli- India cations. After follow up 18.75% patients with primary Inflammatory myofibroblastic tumors are rare benign repair and 8.33% patients with delayed repair complained tumors that can mimic malignancy of unknown aetiology. of recurrent cholangitis. It has spectrum of myofibroblastic proliferation along with Conclusion: Control of intra abdominal sepsis by varying amount of inflammatory infiltrate. Recently, the controlled biliary fistula followed by delayed definite concept of this lesion being reactive has been challenged reconstruction results in better outcome of patients with bile based on the clinical demonstration of recurrences and duct injury.

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EP03D-029 Discusion: Hospital readmissions represent an important component of the associated costs of a disease and are an NINETY-DAY READMISSIONS AFTER indicator of the quality of care. The use of a 30 day cutoff CHOLECYSTECTOMY: A 6-YEAR point may underestimate the true incidence of complica- ANALYSIS ACCORDING TO PREVIOUS tions. The tendency is to use 90 days as a limit to measure ERCP PERFORMANCE complications associated with any procedure. Prospective studies are needed to analyze the role of ERCP on the A. Manuel, R. Latorre Fragua, A. Lopez Marcano, readmission after cholecystectomy. A. Medina Velasco, C. Garcia Amador, C. Ramiro Perez, L. Diego Garcia, V. Arteaga Peralta, R. de la Plaza Llamas and J. M. Ramia Angel General and Digestive Surgery, University Hospital of EP03D-030 Guadalajara, Spain BILE DUCT INJURIES DURING Introduction: Early cholecystectomy decreases biliary LAPAROSCOPIC CHOLECYSTECTOMY. events comparing with delayed cholecystectomy after LONG TERM RESULTS. A ERCP. Some authors have reported a relationship between MONOINSTITUTIONAL EXPERIENCE ERCP previous surgery and the intraoperative difficulty to K. Tsalis1, N. Antoniou2, D. Konstantaras2, perform surgery. There are no data about readmission after 2 2 cholecystectomy according to the ERCP before surgery. S. Simeonidis and I. Mantzoros 1 ’ Methods: We retrospectively reviewed all patients under- D Surgical Department, Aristotle University, Greece, 2 ’ going cholecystectomy at University Hospital of Guada- and D Surgical Department, Aristotle University of lajara (Spain) between 2011-2016 and included all patients Thessaloniki, Greece undergoing cholecystectomy for biliary pathology who Introduction: Bile duct injury(BDI) is perhaps the most were readmitted to hospital within 90 days (readmission to feared complication of laparoscopic chol- any hospital service as cholecystectomy related complica- ecystectomy(LC).Proper management of BDI is mandatory tions). We analyze age, ASA, cholecystectomy indication, to avoid immediate or later life -threatening sequelae. postoperative morbidity, cause and time for readmission, Methods: We analyzed our prospectively established bile according to previous ERCP before surgery or not. duct injury(BDI) after laparoscopic cholecystectomy(LC) Results: We analyzed 1714 cholecystectomies during database. From 1996 to 2017 we treated 47 patients with BDI 2011e2016. There were 80 readmissions in the 90 days after LC. The BDIs were graded according to the classifi- after discharge (rate 4.67%). 15 patients had ERCP before cation of Strasberg. After treatment the follow-up evaluation surgery. was focused on clinical outcome and biochemical analysis. Results are included in Figure 1. Results: Ten patients had minor BDIs(6 patients had Type A injury and 4 patients had Type D injury). In all of these cases the BDI was recognized postoperatively. Three pa- tients were managed with stents, six patients required lap- arotomy and bile duct ligation, and one patient underwent laparoscopy and ligation of a duct of Luschka. Thirty seven patients had major bile duct injuries. Three had E1, 9 had E2, 12 had E3, 12 had E4, and 1 patient had type E5 injury. Seven patients had biliary peritonitis lasting from 1 to 6 days, one of them died 20 days postoperatively because of sepsis. Among the patients with a major BDI, a Roux -en-Y hepaticojejunostomy was performed. No postoperative complications have been observed in 43 patients. One pa- tient had four episodes of small bowel obstruction due to adhesions. The final outcome has been graded as excellent in 43 patients and good in 3. Conclusion: Laparoscopic BDI has a significant morbidity and considerable mortality rate. Early recognition and proper management of the patients diminishes the consequences.

EP03D-031 SURGICAL OUTCOME OF LIVER RESECTION FOR TREATMENT OF Figure 1 Readmissions POST-CHOLECYSTECTOMY BILE DUCT INJURIES A. Abdelrafee Previos ERCP performance before surgery have more General Surgey, Mansoura University, Gastrointestinal postoperative morbidity after cholecystectomy (40% vs Surgery Center, Egypt 21.54%) and decreases biliary events in 90 days after sur- gery, but delays median time for readmission (22 days with Introduction: Post-cholecystectomy bile duct injuries (BDI) ERCP vs 7 days without ERCP). represents a major challenge to the surgeons especially when associated with vascular injuries. liver resection is indicated

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S741 in some patients with complex BDI. We present our expe- Results: A total of 152 emergency cholecystectomies were rience in liver resection due to BDI, highlighting indications, performed during the study period. 57 (37.5%) were postoperative complications, and long-term outcomes. gangrenous and 95 (62.5%) were non-gangrenous chol- Methods: From january 1992 to June 2017, 360 patients ecystitis(NGC). Patients with GC were older (mean age with post-cholecystectomy BDI were treated by hepatico- 59.1 vs 49.6, p< = 0.002), and more likely to be male jejunostomy Roux-en-Y in our centre . Seven patients (56.1% vs 33.7%, p = 0.011). Patients with GC had thicker (1.9%) of this group underwent liver resection. Prospective gallbladder wall on ultrasound(0.583 cm vs 0.464 cm), database of these patients including patient charecteristics, higher white cell count (16.84 x 109/L vs 8.2 x 109/L, preoperative management, indication of liver resection, p=0.0001), and higher C-reactive protein(154 mg/L vs 59 short & long-term outcomes were retrospectively studied. mg/L. p = 0.0002). There was no difference in time from Results: Five patients presented with hilar stricture Stras- presentation to surgery (GC vs NGC 64.5 hours vs 73.5 berg (E3/E4). Three patients presented with vascular hours, p = 0.49). Duration of surgery was longer for GC involvement. Right hepatectomy was performed in one (120 vs 89 minutes, p < 0.0001). There was one death in patient due to presence of right liver lobe abscess associated the GC group and no conversions to open surgery or bile with injury of right portal pedicle, left hepatectomy in one duct injuries. Post-operative length of hospital stay was patient due to failure to reach the left hepatic duct and longer for the GC group (Median of 3 days vs 1 day, p < partial resection of segment IVb in 5 patients to get a 0.001). proximal biliary stump. Postoperative bile leak was found Conclusion: GC represents over a third of emergency in 3 cases (42.9 %). There was one case of early mortality in cholecystectomies performed at our institution. Patients our study. The median follow-up was 28 months. One with GC are more likely to be male, older, have patient presented with recurrent cholangitis and was suc- thicker gallbladder wall on ultrasound, higher white cessfully treated with medical treatment. cell count, and C-reactive protein. Patients with GC Conclusion: In our series, liver resection for treatment of had longer operative times and longer post-operative post-cholecystectomy BDI was a feasible treatment with length of stay. high rates of postoperative morbidity and excellent long- term outcomes. It requires a multidisciplinary team in specialized referral centers.

EP03D-031 perioperative data of liver resection Variable Number (total no[7) % Sex: a- Male b- Female 2 5 28.6% 71.4% Age (y) (mean ± SD ) 40 ± 12.2 — Cholecystectomy: a- Open b- Lap c- Failed lap 4 1 2 57.1% 14.3% 28.6 Level of injury: a- E2 b- E3 c- E4 2 1 4 28.6% 14.3% 57.1% Preoperative management: a- USTD b- PTD c- ERCP 214221 28.6% 14.3% 57.1% 28.6% d- Peritoneal toilet e- CBD exploration over 28.6% 14.3% T-tube f- 1ry repair of CBD Vascular injury: a- RHA b- RPV 2 1 28.6% 14.3% Stent use 4 57.1% Long-term outcome: a- Good b- poor 5 2 71.4% 28.6%

EP03D-032 EP03D-033 GANGRENOUS CHOLECYSTITIS INFLUENCE OF DIAGNOSTIC AND REPRESENTS OVER A THIRD OF REFERRAL DELAY ON TIMING OF EMERGENCY CHOLECYSTECTOMIES SURGICAL REPAIR AND OUTCOMES IN A TERTIARY AUSTRALIAN AFTER BILE DUCT INJURY IN HOSPITAL LAPAROSCOPIC CHOLECYSTECTOMY, T. Y. Chin1,2, A. Mimery1, J. Hartono1, H. Iswariah1, A SINGLE CENTER OBSERVATIONAL 1 1 1 A. Hughes , I. Shaw , R. Franz and STUDY M. Chandrasegaram1,2 J. Lindemann1,2, J. E. J. Krige1, U. Kotze1, S. Burmeister1, 1Department of General Surgery, The Prince Charles M. Bernon1, C. Kloppers1 and E. Jonas1 Hospital, Australia, and 2Faculty of Medicine, The Uni- 1Department of Surgery, University of Cape Town Health versity of Queensland, Australia Sciences Faculty, South Africa, and 2Department of Surgery, Introduction: Gangrenous cholecystitis(GC) is reported to Washington University School of Medicine, United States occur in 10-40% of acute cholecystitis. The current litera- Timing of bile duct repair after laparoscopic cholecys- ture reports a higher rate of conversion to open surgery, bile tectomy (LC) is influenced by time to diagnosis, referral duct injury, morbidity, and mortality with GC. and planned delays in subsequent repair. This study aimed Methods: A retrospective review of emergency cholecys- to determine the individual contribution of delay on timing tectomies over a three-year period at The Prince Charles of BDI repair and the effect on outcome in patients referred Hospital in Brisbane. to a tertiary center.

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Review of a prospective database for BDI after LC was Surgery, Washington University School of Medicine, performed. Timing of repair in relation to time of injury United States was divided into immediate, early, intermediate and late. The health care system in South Africa consists of an Contribution of time to diagnosis, referral and repair were understaffed and under-financed public sector where most assessed separately for each time category and presented as of the population are treated, and a private sector better medians and interquartile ranges. Morbidity was recorded staffed and resourced, serving a small fraction of the pop- using the Accordion classification system. ulation. The purpose of this study was to compare patients From 1991 to 2017, 125 patients (median age 46 years, with bile duct injury (BDI) after laparoscopic cholecys- range 17e80), 82% female, underwent immediate (3days, tectomy originating from either public or private facilities, n=18),early(>3, 14 days, n = 33), intermediate (>14, and then referred to and treated at a single tertiary center, in 90 days, n = 49) or late repair (>90 days, n = 25). Compared terms of diagnosis, referral pattern, management, and to the contribution of diagnostic and referral delay, surgeon outcome. delay was most marked in the late repair group. In this group, Patients who underwent hepaticojejunostomy (HJ) in delay resulted in the lowest percentage of complications and the Hepatobiliary Pancreatic (HPB) unit at the University more significantly, the complications were of a minor nature. of Cape Town were retrieved from a prospectively main- Timing of bile duct repair is complex and influenced by tained BDI database. Time of diagnosis of injury and factors beyond the control of the surgeon, such as delays in referral as related to time of injury, classification of injury diagnosis and referral. However, the time from injury to (Strasberg-Bismuth classification), pre-repair in- repair was also influenced by surgeon delay, mostly so in terventions, time of surgery, complications (Accordion the late repair group, which in this study had a beneficial classification) and need for re-intervention were compared outcome with the least number of complications. for the two groups.

EP03D-033 Outcomes for delays in diagnosis, referral, repair Time Categories (n) Time - LC to HJ Time - Diagnosis Time - Diagnosis to Time - Referral to Median (IQR) Median (IQR) Referral Median (IQR) HJ Median (IQR) Immediate Repair (18) 0 (0-1.5) 0 (0) 0 (0-0.5) 0 (0-1) Early Repair (33) 9 (7-13) 2 (0-4) 1 (0-3) 4 (2-6) Intermediate Repair (49) 34 (25-57) 7 (3-10) 12 (6-21) 8 (5-23) Late Repair (25) 168 (118-203) 13 (4-24) 15 (5-59) 78 (51-128) Complications by Accordion Grading Scale (1/6, increase left to right, final column h total) n (%) Immediate Repair n=18 3 (16.7) 2 (11.1) 1 (5.6) 1 (5.6) 3 (16.7) 2 (10.5) 12 (67.7) Early Repair n=33 4 (12.1) 14 (42.2) 0 1 (3) 0 0 19 (57.6) Intermediate Repair n=49 2 (4.1) 15 (30.6) 5 (10.2) 0 1(2) 0 23 (46.9) Late Repair n=25 2 (8) 7 (28) 5 (20) 0 0 0 14 (56)

EP03D-034 A total of 125 patients, 64 originating from the public A COMPARISON OF THE SURGICAL and 61 from the private sectors were included. Severity of BDI and timing of diagnosis, referral or repair were similar MANAGEMENT AND TREATMENT between the two groups. Patients in the public sector were OUTCOME OF BILE DUCT INJURIES IN more likely to receive a percutaneous drain and ERCP. PRIVATE AND PUBLIC SECTOR There was no statistically significant difference in post- PATIENTS IN SOUTH AFRICA operative re-interventions or complications between the two groups. J. Lindemann1,2, E. Jonas1, U. Kotze1, M. Bernon1, Despite differences in public and private health care C. Kloppers1, S. Burmeister1 and J. E. J. Krige1 system resources, in this study patients were referred early 1Department of Surgery, University of Cape Town Health and appropriately from both sectors, and had similar post- Sciences Faculty, South Africa, and 2Department of operative outcomes when treated in a specialized HPB unit.

EP03D-034 Bile duct repair at tertiary center Public Referral Private Referral p-value Public Referral Private p-value n[64 n[61 n[64 Referral n[61 Median (IQR) Median (IQR) Time - Injury to Repair 23.5 (7.75–77.5) 20 (9–54) 0.776 Pre-repair Interventions n (%) Time to Diagnosis 4 (0–9) 3 (0–8) 0.298 ERCP 41 (64.1) 24 (39) 0.005 Time to Referral 2.5 (0–12.5) 6 (1–15) 0.067 PTC 48 (75) 47 (77) 0.791 Time to Repair 8 (3–32.5) 5 (2–12) 0.151 Percutaneous Drain 17 (26.6) 7 (11.5) 0.032 Complications by Accordion Grade n (%) Laparotomy 21 (32.8) 19 (31.1) 0.843 Mild 5 (7.8) 6 (9.8) 0.693 Laparoscopy 1 (1.6) 5 (8.2) 0.084 Moderate 19 (29.7) 19 (31.1) 0.952 Post-repair Interventions n (%) Severe 10 (15.6) 7 (11.5) 0.503 Percutaneous 2 (3.1) 5 (8.2) 0.221 Death 2 (3.1) - 0.167 Operative 2 (3.1) 2 (3.3) 0.961

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S743 EP03D-036 The surgical procedure was PD in 11 patients, PPPD in 22 and CAUSES AND MANAGEMENT OF SSPPD in 15. The overall and disease-free 1-, 3-, 5-, 10-year survival rates were 84.2%, 66.7%, 45.9%, 42.1%, and 82.7%, PLEUROBILIARY AND 54.5%, 41.0%, 41.0%, respectively. Patients were grouped BRONCHOBILIARY FISTULAS according to TNM-staging as Stage 0 (n = 4, 8.3%), Stage IA (n M. Morawski, W. Patkowski, M. Grat, N. Gołuchowska, = 6, 12.5%), Stage IB (n = 13, 27.0%), Stage IIA (n = 6, 12.5%), P. Rzepniewski, M. Terkiewicz and K.Î Zieniewicz Stage IIB (n = 14, 29.2%), Stage III (n = 5, 10.4%). Log Rank Department of General, Transplant and Liver Surgery, test revealed significant differences only in curability. Medical University of Warsaw, Poland Conclusions: Curability is the key of long-survival, fi Introduction: Pleurobiliary (PBF) and bronchobiliary therefore, radical surgery seems to con rm long-term sur- (BBF) fistula is a rare complication seen in patients treated vival in patients with ampulla of Vater carcinoma. at hepatobiliary units with very scarce literature data. The aim of this study was to evaluate causes and management of EP03D-038 patients with PBF and BBF. TRANSDUODENAL AMPULLECTOMY Methods: Clinical data of all patients hospitalized in the FOR AMPULLARY MASS: ONE Department of General, Transplant and Liver Surgery (Med- ’ ical University of Warsaw) between years 2008 and 2017 were SURGEON S EXPERIENCE retrospectively reviewed in order to identify patients with PBF Y. K. Jung, D. Choi and K. G. Lee or BBF. Data concerning primary disease, cause of fistula, Department of Surgery, Hanyang University Hospital, treatment approach and clinical outcomes were collected. Republic of Korea Results: Nine individuals with suspected PBF and BBF Introduction: Ampulla of Vater (AOV) mass, especially were identified. Further analysis revealed 7 patients with benign lesion, has been treated with endoscopic ampullec- confirmed PBF or BBF. Two patients were excluded tomy in many centers. However, surgical resection for AOV because both liver abscess and pleural empyema showed no mass is the treatment of choice. Traditionally, pancreatico- radiologic signs of communication. Four out of 7 patients duodenectomy (PD) has been performed for AOV mass. were diagnosed with BBF and 3 out of 7 patients had PBF. However, due to the high risk of postoperative complica- In 5 and 2 patients fistula occurred after percutaneous tions, transduodenal ampullectomy (TDA) has recently transhepatic biliary drainage and liver resection, respec- received attention as a method of treatment for AOV mass. tively. Initial endoscopic management with biliary stenting Methods: We reviewed the medical records of 25 patients was sufficient in 3 patients, while remaining 4 patients diagnosed as AOV mass and underwent TDA from March required pleurocentesis. One patient required mechanical 2013 to June 2017. ventilation following endoscopy. In addition, 2 patients Results: All 25 patients underwent TDA, and 3 of them with BBF underwent partial pneumonectomy. converted to PPPD due to intraoperative frozen biopsy re- Conclusions: Pleurobiliary and bronchobiliary fistulas most sults. (2 for presence of cancer in margin, 1 for regional commonly occur after percutaneous transhepatic biliary lymph node metastasis) Of the 25 patients, 10 were diag- drainage. Majority of cases can be successfully treated nosed with malignancy and 15 were diagnosed with benign applying endoscopic treatment and percutaneous drainage, yet lesions. Of the 10 patients who were diagnosed as malig- BBF is often associated with the need of surgical management. nancy in postoperative biopsy, only 2 patients (20%) were diagnosed with malignancy on preoperative endoscopic biopsy. In 7 patients who underwent TDA for malignancy, EP03D-037 there was no recurrence during the follow-up period. PROGNOSTIC FACTORS OF (mean: 44.7 months, range: 5e133) AMPULLARY CARCINOMA: ANALYSIS Conclusion: TDA is treatment of choice for patients who are unsuitable AOV mass for endoscopic ampullectomy and OF 49 RESECTED CASES may be considered as an alternative operation in highly se- T. Ochiai, S. Iida, K. Saito, Y. Ohata, R. Matsumoto, lective patients -histologic well diffentiation, polypoid lesion H. Yamana, T. Igaki, K. Nihei, M. Sakano and S. Yamazaki and high risk group of operation- with early ampullary cancer Surgery, Ohta Nishinouchi General Hospital, Japan (Tis and T1). Further studies on consensus of TDA indication Introduction: The prognosis after curative resection for for early ampullary cancer will be needed in the future. patients with carcinoma of the papilla of Vater is relatively better than that for the other periampullar cancer. However, prognostic factors after resection of ampullary carcinoma EP03D-039 fi have not been identi ed. PREDICTION ON SURGICAL Methodology: From January 2000 to December 2016, consecutive 49 patients with carcinoma of the papilla of OUTCOMES OF VIDEOLAPAROSCOPIC Vater underwent pancreatoduodenectomy (PD), pylorus COLECISTECTOMY IN ELDERLY preserving pancreatoduodenectomy (PPPD) or subtotal PATIENTS USING COMORBIDITY stomach preserving pancreatoduodenectomy (SSPPD) with COMBINED SCORE dissection of regional lymph nodes in Ohta Nishinouchi J. A. Rocha-Filho1, E. R. R. Figueira2, V. C. Romano3, General Hospital. We retrospectively analyzed surgical T. Bacchella2, M. D. S. Vilas-Boas3, I. S. L. Sacramento3, procedures, macroscopic and microscopic curability, clin- S. G. Casagrande2, T. N. Costa2, M. J. C. Carmona1 and icopathologic variables and survivals. I. Cecconello2 Results: A total of 49 patients underwent PD, PPPD or SSPPD 1Surgery/ Division of Anesthesiology, 2Gastroenterology/ aged 44 to 88 years and consisted of 28 males and 21 females. Division of Digestive Surgery, Hospital das Clinicas of

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University of Sao Paulo School of Medicine, and 3Uni- occurred in 28 (22.0%), 80 (63.0%), and 25 (19,7%) pa- versity of Sao Paulo School of Medicine, Brazil tients, respectively. Univariate analysis disclosed that Laparoscopic cholecystectomy is the gold standard cancer-positive margin was the only predicting factor for treatment of cholelithiasis. Elderly patients are more sus- biloma (odds ratio (OR) = 3.13, p = 0.023) and infectious ceptible to gallbladder disease and acute cholecystitis. complications (OR = 3.12, P = 0.044). On the other hand, Nevertheless they appear to be undertreated compared to male (P = 0.019), cancer-positive margin (P = 0.006), right younger patients, mainly due to the fear of postoperative side hepatectomy (P = 0.016), preoperative jaundice (P = complications. We aimed to evaluate outcome of laparo- 0.031), operative blood loss >1500 mL (P = 0.033), and scopic cholecystectomy (LC) in elderly patients according blood transfusion (P = 0.007) were predicting factors for to the preoperative Comorbidity Combined Score (CCS). hepatic insufficiency in univariate analysis, while, cancer- Methods: We retrospectively evaluated 537 patients over positive margin (OR = 3.29, P = 0.033) and blood trans- 60 years of age submitted to LC from 2008 to 2015. Pa- fusion (OR = 3.06, P = 0.047) were independent risk fac- tients were divided in low CCS, CCS  0, and high CCS tors in multivariate analysis. groups. CCS was calculated according to Gagne JJ et al. (J Conclusions: This study indicated that cancer-positive Clin Epidemiol, 2011). surgical margins influenced not only poor prognosis but Results: Age was 67.93 Æ 6.75y, 65.92% women. Patients also severe complications after extensive hepatobiliary of Low-CCS group (n = 344) showed increased number of resection. Incomplete surgical resection in addition to women (70.93% vs. 57.49%), decreased age (67.38 Æ 6.17 excessive surgical stress, such as extensive hepatobiliary vs. 68.90 Æ 7.35 y), Karnofsky score [90(50e100) vs. resection, may cause hypercytokinemia and result in worse 90(40e100)], ASA score [2(1e3) vs. 2(1e4)], length of postoperative condition. hospital [4(0e48) vs. 6 (1e50) days] and ICU [3 (1e7) vs. 3(2e20)days] stay, patients admitted to ICU (5.8% vs. 21.2%), and patients with postoperative complications (25.8% vs. 35.9%) compared to High-CCS group (n = 193). EP03D-041 There was no difference in incidence of major complica- OUTCOME OF SURGICAL tions according to Clavien-Dindo Classification in Low- MANAGEMENT OF LAPAROSCOPIC CCS compared to High-CCS group, but early postoperative CHOLECYSTECTOMY (LC) e RELATED death was significantly higher in High-CCS group (2.59% MAJOR BILE DUCT INJURIES vs. 0.29%). Conclusions: CCS score can predict higher risk of E. H. Gad, Eslam Ayoup, Yasmin Kamel, Talat Zakaria, morbimortality of elderly patients submitted to LC. Patients Mohamed Abbasy, Ali Nada and Mohamed Housseni fi with high CCS must have careful preoperative evaluation National Liver Institute, Menou ya University, Egypt and greater flexibility for indication of ICU admission. Objectives: Laparoscopic cholecystectomy (LC) - associ- ated bile duct injury (BDI) has poor outcome. The study analyzed the outcome of surgical management of these EP03D-040 injuries. Patients and methods: We retrospectively analyzed 69 CANCER-POSITIVE SURGICAL patients underwent surgical management of these injuries, MARGINS AS A RISK FACTOR FOR in the period from mid 2013 to mid 2018. BILOMA, INFECTIOUS Results: The Strasberg classification of injury was as COMPLICATIONS, AND HEPATIC follow: E1 = 25, E2 = 32, E3 = 8, and E4=4. The definitive INSUFFICIENCY AFTER EXTENSIVE procedures were as follow: End to end biliary anastomosis with stent, hepaticojejunostomy (HJ) with or without HEPATOBILIARY RESECTION stenting, and RT hepatectomy plus biliary reconstruction N. Kimura, K. Ishido, D. Kudo, S. Sakuraba, with stenting in 4.3%, 87%, and 8.7% of patients respec- Y. Wakasa and K. Hakamada tively. According to time of definitive procedure from Gastroenterological Surgery, Hirosaki University, Japan injury; the immediate (before 72 h), intermediate (between Introduction: Extensive hepatobiliary resection for hepa- 72 h and1.5months), and late (after1.5 months) manage- tobiliary malignancies is known to be the most effective ment were 13 %, 14.5 %, and 72.5 % respectively. The treatment for acquiring negative margins and improved overall mortality was 2.9%. On univariate analysis, the long-term survival. However, this complex procedure is following factors were significant predictors of early more difficult to perform and can lead to severe post- morbidity; Sepsis at referral, higher Strasberg grade, asso- operative complications. The aim of this study was to ciated vascular injury, RT hepatectomy with biliary evaluate the short-term outcomes after this complex surgery reconstruction, intra-operative bleeding, liver cirrhosis and for hepatobiliary disease. longer operative times. However, the following factors Methods: Total of 127 consecutive patients who under- were significantly associated with late biliary morbidity: went major hepatectomy with biliary reconstruction be- Sepsis at referral, end to end anastomosis with stenting, tween January 2001 and December 2017 were enrolled in Reconstruction without stenting, liver cirrhosis, operative this study. Risk factors for postoperative complications, bleeding and early morbidity. such as biloma, infectious complications, and hepatic Conclusion: Sepsis at referral, liver cirrhosis and operative insufficiency were assessed. bleeding were significantly associated with both early and Results: Major morbidity (Grade 3) and mortality were late morbidities after definitive management of LC related 52.0% (n = 66) and 2.4% (n = 3), respectively. Biloma, MBDIs, so it is crucial to avoid these catastrophes when infectious complications, and hepatic insufficiency doing those major procedures.

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EP03D-042 laparoscopic completion cholecystectomy.This was after thorough evaluation for the cause of pain and pancreatitis POST-OPERATIVE BILOMA CAUSED BY did not yield any other cause. UNUSUAL DETECTION OF LUSCHKA Results: 52 patients underwent lap completion chole.Two DUCT: DEMONSTRATION WITH MRCP patients required open procedure,one due to dense adhe- D. Paramythiotis1, P. Bangeas1, P. Goulas2, V. Rafailidis3, sions and other patient requiring biliary bypass. Rest 50/52 A. Kalogera3, T. Papavramidis1, S. Apostolidis1 and patients were completed laparoscopically. Average time A. Michalopoulos1 taken was 75 minutes with minimal blood loss. Energy 11st Propedeutic Surgical Department, 2Aristotle Univer- source was required in 30 patients. 46/52 had preoperative sity of Thessaloniki, and 3Ahepa Radiology Department, mrcp or ercp. Average postoperative stay was 3 days.Gb Aristotle University of Thessaloniki, Greece stump was ranging from 2.2 -4.6 cms. All patients had uneventful recovery. At average followup of 48 months 50/ Introduction: Laparoscopic cholecystectomy is currently 52 patients had symptomatic relief. 2 patients continued to regarded as the optimal treatment method for cholelithiasis. have pain. No mortality. Five patients required suturing of Normal anatomy of the biliary tree is reported to be found the CBD. in only 58% of the population. Duct of Luschka represents Conclusion: Laparoscopic completion cholecystectomy a well-known and widely reported anatomic variation of the should be the treatement of choice for patients with biliary tree which may lead to bile leakage if injured during symptomatic gall bladder stump.It is feasable, safe and hepatobiliary surgery. curative of the symptoms. Methods: We report a case of 71 years old man presented to our department with choledocholithiasis and lap-chole- cystectomy was performed. Purpose of this case report is to focus on the clinical significance of Luschka duct injury EP03D-044 and its potential to be successfully management with THE SURGICAL OUTCOMES OF EARLY endoscopic ERCP. TRANSECTION AT MID POINT OF Results: During laparoscopic cholecystectomy, an ectopic CHOLEDOCHAL CYST DURING luschka duct alongside inferior border of liver in the VI segment was accidentally injured. We decide to convert to EXCISION OF CHOLEDOCHAL CYST open cholecystectomy and luschka duct ligation was S. R. V. Gunturi, J. R. Bathalapalli, V. Thumma, performed. In the 5th PO day, bile content was detected in N. Kunduru, N. R. Rakesh, K. K. Bishnoi, G. Gondu, the patient drainage. MRCP revealed a Full-thickness D. Sarma, R. Kamineni and B. Nagari maximum intensity projection showing the Luschka ducts Surgical Gastroenterology, Nizams Institute of Medical feeding a biloma. ERCP was performed in the 6th PO day Sciences, India and immediate, patient have no signs of bile content in his Introduction: The surgery for Choledochal cysts in HPB drainage. Patient was discharged on the 9th PO day. units is not very rare even in adult patients.There is a slight Conclusion: Clinical significance of Luschka ducts, lies on but potential risk of developing complications like their risk for injury during cholecystectomy. Clinical pre- pancreatic fistula in an attempt to excise the distal extent of sentation of patient with po bile leakages varies from choledochal cyst adequately. Most of the times these su asymptomatic to biliary peritonitis. PO identification is rgeries were performed by fellows in HPB units. In our unit feasible with MRCP imaging and can be treated with less we adopted the safe technique described by Steven M. invasive techniques such as ERCP. Strasberg group. Method: The technique is early transaction of the chol- edochal cyst near its mid point.this provides improved EP03D-043 access to the posterior part of cyst and slitting sides of the LAPAROSCOPIC COMPLETION cyst allows clear visibility from with in the cyst the pancreatic duct below and confluence of the hepatic ducts CHOLECYSTECTOMY IS GENERALLY above. FEASABLE, SAFE AND ALLAYS THE Results: Sixteen cases were performed by this techni- SYMPTOMS IN POST que(Type I and Type IV). All these patients were CHOLECYSTECTOMY PATIENTS WITH discharged with out any complications.In one patient GALLBLADDER AND CYSTIC DUCT pancreatic duct opening to distal cyst with a small calculi in it and is retrieved with out any morbidity.in one patient REMNANTS lower end of choledochal cyst there is small suspicious R. Dama, P. Rebala and G. Rao lesion and whipples pancreaticoduodenectomy was done Surgical Gastroenterology, Asian Institute of Gastroen- ,final histopathology confirmed malignancy.in three pa- terology, India tients there is right accessory hepatic artery and in one it is Introduction: Laparoscopic cholecystectomy is the gold difficult to identify before anterior transaction due to dense standard for symptomatic gallstone disease.However in pericholedochitis. cases with difficult calots anatomy it is safer to do a subtotal Conclusions: Early transection at mid point of Chol- cholecystectomy rather than injure the common bile duct. edochal cyst is a very safe technique.Though ours is a study Methods: Between 2006 to 2017, 52 post chole(12 were with small numbers there is a definite reduction of com- post open chole) patients symptomatic with recurrent plications and morbdiity when we compared with our pain(45) and episodes of pancreatitis(7), who on evaluation regular technique.Its benefit will be more applicable for had a gallbladder or cytic duct remnant were taken up for training centres.

HPB 2018, 20 (S2), S685eS764 S746 Electronic Poster (EP03A-EP03F) e Biliary fi EP03D-045 scores to predetermined operative ndings, as described in a new scoring system developed by Sugrue M et al. Scores were IMPACT OF MEDICAL OR SURGICAL assigned to five predetermined, defined, operative findings ADMISSION ON OUTCOMES OF (a) Appearance of the Gall Bladder PATIENTS WITH ACUTE CALCULOUS (b) Distension/Contraction of the Gall Bladder CHOLECYSTITIS IN A TERTIARY (c) Difficulty in access HEALTH CARE FACILITY IN THE (d) Pericholecystic sepsis/complications and (e) Time for completion of the procedure. PHILIPPINES Based on the calculated total score, operative difficulty 1 2 M. K. Doratan and C. Alfonso was graded as Mild, Moderate, Severe and Extreme. Total 1 Department of Surgery, The Medical City, Philippines, scores and difficulty grades were analysed for co-relation 2 and Section of Hepatopancreatobiliary Surgery, Depart- with postoperative complications, morbidity, length of ment of Surgery, The Medical City, Philippines hospital stay and conversion rates to open cholecystectomy. Introduction: Acute cholecystitis occurs most commonly Results: Patients with higher operative scores and higher because of an obstruction of the cystic duct by gallstones. This grade of operative difficulty had higher complication rates, surgical disease warrants prompt cholecystectomy. Delays in morbidity rates, had longer hospital stays, and higher the definitive surgical management result to more complica- conversion rates. Statistically significant correlation was tions, longer hospital stays, and overall higher medical ex- noted between higher scores and postoperative complica- penses. This study shows the disparity between the medical tions, morbidity and conversion rates. service and the surgical service in the management of acute Conclusion: Objective assessment and scoring of the five calculous cholecystitis prior to its definitive intervention. defined operative parameters using this new scoring system Methods: Sixty-four patients (aged 18 to 74) presented to is useful in predicting postoperative recovery and outcomes the emergency room, from January 2011 - December 2013, following Laparoscopic Cholecystectomy. This scoring with acute calculous cholecystitis and underwent chole- system is thus also useful in postoperative counselling of cystectomy during the same admission. Gallbladder disease patients regarding length of hospital stay as well as antic- severity, hospital length of stay, time to surgical evaluation, ipated postoperative issues. and time to cholecystectomy were compared between pa- tients admitted to medical service and surgical service. Results: Thirty-three patients (51.6%) admitted under EP03E - Electronic Poster: 3E - Biliary Technical medicine service had more severe gallbladder disease found Surgery 2 during cholecystectomy as compared to surgery service (Х EP03E-001 < = 7.5147, p 0.001). Patients admitted under surgery ser- COMPARISON OF POSTOPERATIVE vice had shorter hospital length of stay (4.06 days vs. 5.03 days, p = 0.059), waiting time to surgical consultation (3.14 PAIN IN VARIOUS PRESSURE hours vs. 16.10 hours, p < 0.001), and time to cholecys- PNEUMOPERITONEUM OF tectomy (26.16 hours vs. 43.58 hours, p = 0.012). LAPAROSCOPIC CHOLECYSTECTOMY: Conclusion: Patients presenting to the emergency room A DOUBLE BLIND RANDOMIZED fi with acute calculous cholecystitis bene t from being CONTROLLED STUDY admitted to a surgical rather than to a medical team irre- spective of age and comorbidities. T. Yoo and W. T. Cho Department of Surgery, Hallym University College of Medicine, Republic of Korea EP03D-046 Introduction: Even though laparoscopic cholecystectomy (LC) is the gold standard procedure for cholelithiasis, pa- PREDICTING POSTOPERATIVE tients are still suffering from various causes of pain. one of OUTCOMES UTILIZING A SCORING main causes is high pressure by pneumoperitoneum which SYSTEM BASED ON OPERATIVE makes peritoneal stretching and diaphragmatic irritation. FINDINGS DURING LAPAROSCOPIC However, there are few well-designed studies for evalu- CHOLECYSTECTOMY: A ating pneumoperitoneum. Therefore, we conducted a study PROSPECTIVE STUDY to compare the postoperative pain after LC at serial different pressure methods. 1 2 2 R. Mohan , S. Siraj and G. Anantharaju Method: A prospective randomised double blind study was 1 Department of Surgery, K.S. Hegde Medical Academy, done in 147 patients with benign gallbladder disease. They 2 and Department of Surgery, SDM College of Medical were divided into 3 groups. Each 49 patients underwent LC Sciences & Hospital, India with different pneumoperitoneum method; Group A: far- Introduction: Laparoscopic Cholecystectomy is the low (6e8 mmHg), group B: low (9e11 mmhg) and group accepted surgical procedure for the treatment of symp- C: standard pressure (12e14 mmHg). Three groups were tomatic Gall Bladder disease. However, recovery and out- compared for pain intensity, duration, analgesic require- comes vary according to operative situations, making ment and complications. decisions on postoperative care and discharge sometimes Results: Post-operative pain score was significantly least in very subjective. We have attempted to utilize a scoring far-low pressure group as compared to low or standard system based on operative findings to objectively predict pressure group during late periods (12, 24 hours). But, there postoperative morbidity and complications. were no pain score difference between far-low and low Method: We prospectively enrolled 308 consecutive patients groups during early period (1, 2, 4, 8 hours) even though undergoing Laparoscopic Cholecystectomy, and assigned scores of standard group were significant higher than those

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S747 of low group. Number of patients requiring rescue anal- and sequential upsizing of Silastic transanasmototic stents gesic doses and intraoperative complications were not (STS) for benign HJ strictures. significantly different among 3 groups. Material and methods: A total of 146 patients with HJ Conclusion: This study demonstrates reducing the pressure stricture (59 male, 87 female; age range, 6e71 y; mean age of pneumoperitoneum results in reduction in intensity of 42 y), recruited for study between 2007e2016. PBBD was post-operative pain. This study also shows that low pressure performed under Ultrasound and fluroscopy guidance, technique is safe with comparable rate of intraoperative followed by placement of STS from multiple ducts. These complications. However, in immediate postoperative period, catheters wee fashioned as transanastomotic stents and there is limitaton of pain relief after low pressure surgery. were upsized sequentially over a period of one year at 3 Therefore, there may need new alternatives for pain. months interval. Hepatolithiasis without obvious stricture (n = 28) were managed after balloon sweeping of calculi. Mean maximum diameter achieved at the end of one year EP03E-002 34.5 F. Mean procedure time and mean Fluroscopy time NEW PORTS PLACEMENT FOR were 49.5 minutes (31e64 minutes) and 15.33 minutes ROBOTIC CHOLECYSTECTOMY (13.6e18.2 minutes).Whitaker Manometric Perfusion tests 1 2 and cholangiograms were done before removal of STS T. Yoo and W. T. Cho 1Hallym University College of Medicine, Republic of ensuring adequate decompression of strictures. The pri- Korea, and 2Department of Surgery, Hallym University mary outcome measure was the absence of clinical biliary College of Medicine, Republic of Korea obstruction symptoms at 24 months. Results: The overall technical and clinical success rates Introduction: Since advantages of robotic surgery is being were 98.5 and 97.7 %, respectively. The primary outcome more emphasized, robotic cholecystectomy (RC) cases are measure was achieved in 97.7 % of patients. The mean increasing. Ajou group had introduced a method called which follow-up period was 43.6 months. Mean primary patency technique places the trocars transversally on the bikini line and durations was 42.5 months. Procedure-related mortality fi it makes cosmesis and pain bene cial. However, RC with low and major morbidity rates were 0% and 3.8%, respectively. incision port has several limitations. Therefore, we changed Conclusions: PBBD and sequential upsizing of STS of port placement which may be a one of safe tehniques for RC. benign HJ strictures is a safe and effective procedure with Method: This study retrospectively reviewed data for patients excellent outcomes. who received RC with port changing method (RCPC, n = 33) and RC with low incision port (RCLI, n = 81) from February 2016 to February 2017 and surgical variables were analyzed. Results: Patients in both groups had similar demographic EP03E-005 features and indications for surgery. The RCPC group SYNCHRONOUS LAPAROSCOPIC required no conversions to conventional robotic surgery and CHOLECYSTECTOMY AND INTRA- no additional operation, whereas the RCLI group had one OPERATIVE ENDOSCOPIC incisional hernia (1.2%) and two bowel perforation (2.4%) RETROGRADE CHOLANGIO- cases. Length of stay (4.29 Æ 0.72 vs. 5.13 Æ 0.93 days, respectively; p = 0.123) did not significantly differ between PANCREATOGRAPHY: SHOULD IT BE the RCPC and SCLI groups. However, the RCPC group had THE STANDARD OF CARE? shorter operative time (71.30 Æ 48.88 vs. 74.70 Æ 30.16 M. El Sorogy1 and A. El Nakeeb2 minutes; p = 0.772) than the RCLI group, although the pa- 1General Surgery, Gastrointestinal Surgery Center, rameters mentioned above were not statistically significant. Mansoura University, and 2Mansoura University, Conclusion: Robotic cholecystectomy with bikini line Gastrointestinal Surgery Center, Egypt incision has some limitations even though it has cosmetic Introduction: Up to 20 % of patients diagnosed with chronic fi bene ts. Whereas robotic surgery with changing port calcular cholecystitis have concomitant CBD stones. Man- method is one of safe and feasible procedures for agement included open and laparoscopic CBD exploration, performing robotic cholecystectomy. Also nothing more to endoscopic approach; pre-operative or intra-operative ERCP. say that it gains cosmesis effect and escapes complications. Methods: This is a retrospective analysis of 120 patients who underwent laparoscopic cholecystectomy (LC) and intra- operative ERCP at Gastrointestinal surgery center, Mansoura EP03E-003 university between 2012 and 2017. LC was done first. Intra- PERCUTANEOUS BILIARY BALLOON operative cholangiography (IOC) was attempted in all cases. DILATATION AND SEQUENTIAL Results: Median age was 32 years. Median CBD stone size UPSIZING OF SILASTIC was 8 mm. Median number of stones was 1 (1e3). The TRANSANASTOMOTIC STENTS FOR median operative time for both LC and ERCP was 75 mi- BENIGN HEPATICOJEJUNOSTOMY nutes. Transcystic IOC was successful in 97.5% of cases where passed CBD stone was confirmed in 9 patients STRICTURES: LONG-TERM RESULTS therefore avoiding unnecessary ERCP. We had 4 cases of Y. Bang, S. Patil, J. Singh, P. Rabella and G. V. Rao failed endoscopic cannulation (3.6%), 2 of them underwent Surgical Gastroenterology, Asian Institute of Gastroen- laparoscopic CBD exploration and the other 2 underwent terology, India open CBD exploration. We failed to completely clear the Introduction: Stricture at HJ anastomostic site are common CBD endoscopically in 3 cases. (12.5%) and presents a difficult problem in management. Conclusion: LC with intra-operative ERCP is safe and Purpose: To determine the safety, efficacy, and long-term feasible where combining laparoscopy and endoscopy en- results of percutaneous biliary balloon dilatation (PBBD) hances the outcomes of both.

HPB 2018, 20 (S2), S685eS764 S748 Electronic Poster (EP03A-EP03F) e Biliary EP03E-006 EP03E-007 DEFINITIVE MANAGEMENT OF EFFECTIVENESS OF BILE SORBTION POSTCHOLECYSTECTOMY IN MALIGNANT OBSTRUCTIVE CONTROLLED BILIARY FISTULA (CBF) JAUNDICE BASED SOLELY ON ABDOMINAL S. Lukmonov1, M. Kurbanbay1, A. Sharopov1, DRAIN TUBE CHOLANGIOGRAM (DTC) U. Allazarov1, A. Ismatov1, M. Rozikova1 and 2 N. Vashistha1, B. Aggarwal2 and D. Singhal1 M. Ismailov 1 2 1Department of Surgical Gastroenterology, and 2Depart- Faculty Surgery, Tashkent Medical Academy, and Sur- ment of Radiology, Max Super Specialty Hospital, India gical Diseases, Tashkent State Pediatric Institute, Uzbekistan Background: MRCP is the investigation of choice for fl cholangiographic delineation of biliary tree in patients with Purpose: The study of the in uence of choleretic (CS) on postcholecystectomy CBF. Many centers prefer ERCP due the level of SM in serum and bile in patients with me- to its additional therapeutic potential. DTC is seldom chanical jaundice (MJ) of tumor origin. fi performed and regarded as complementary investigation. We Materials and methods: For the objecti cation of the evaluated outcomes of postcholecystectomy CBF patients results, we isolated two groups of patients: one group managed with DTC as sole cholangiographic investigation. comprised 34 patients, after the imposition of percuta- Methods: Retrospective analysis of 17 consecutive post- neous transhepatic cholangiostomy (PTCS) without cholecystectomy CBF patients managed over 5 years. All cholerocorticosis, the second group-32 patients after patients were referred with drain placed at cholecystec- PTCS with CS with enterosorbent activated charcoal- fi tomy. Following abdominal ultrasonography, DTC (07) stone (AC-S), t .e. after puri cation of bile from toxic was performed by injecting Gastrograffin through abdom- substances with the help of sorbent. The study was inal drain. Other investigations included MRCP (05), conducted on the basis of faculty surgery of the Tash- ERCP (03), one percutaneous transhepatic cholangiog- kent Medical Academy. raphy (PTC) and multiple investigations (01). Result: The initial concentration of SM in serum and fi Æ Results: DTC was performed at median of 19 (range 12e bile in the rst group of patients averaged 0.493 0.03 Æ 267) days postcholecystectomy and accurately diagnosed and 0.334 0.06 units. respectively (the norm of 0.250 Æ the level / nature of leak in all patients - complete tran- 0.02 units).In the second group of patients, the initial section (06) and posterior sectoral duct injury (01) [Figure SM concentration in blood plasma and bile was, on Æ Æ A,B,C]. The type of drain had no bearing on quality of average, 0.498 0.06 and 0.337 0.08 units. respec- cholangiogram; details obtained were comparable to PTC tively. On day 3 with cholerocorbtion there was a and MRCP. The mean cost for DTC was US $ 77. Com- decrease in SM in serum and an increase in its concen- parable costs for MRCP, ERCP and PTC were $ 154, $307 tration in bile by 14.5%. At the end of the observation, and $ 615 respectively. All patients with common duct the concentration of SM in the blood serum decreased by transection underwent biliary enteric bypass. The post- 42.9%, and in bile there was an increase of 64.0% from operative T -tube cholangiogram did not reveal any the baseline level. excluded segments (Figure D). Conclusion: Thus, the use of CS with the help of AC-S in Conclusion: DTC may be the sole cholangiographic patients with MJ of tumor genesis promotes the accelera- investigation for postcholecystectomy CBF where it de- tion of elimination of SM with bile as a factor of lineates entire proximal biliary tree. DTC is technically endotoxicosis. simple, low cost and useful for centers with no access to high end imaging to plan definitive management for CBF. EP03E-009 A COST ANALYSIS STUDY ON EARLY VERSUS ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS Z. Zuhdi, S. Ghani, A. Azman, C. Ian, H. Othman and R. Jarmin Hepatobiliary Unit, Surgical Department, UKM Medical Centre, Malaysia Introduction: Laparoscopic cholecystectomy (LC) is the gold standard in the treatment of acute cholecystitis. Early LC has become more common and have proven similar safety profile compared to the elective LC. This study was to compare the length of stay and cost analysis of early LC versus elective LC in patients with acute cholecystitis. Methodology: There were a total of 48 patients, with 26 patients in early LC group and 22 patients in elective LC group. This was a cross-sectional study from January 2015 Figure A,B,C,D until March 2017 in the Department of Surgery, Universiti Kebangsaan Malaysia Medical centre, Malaysia.

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Results: Shorter length of stay was observed in the EP03E-012 early LC group (4.0 days versus 4.5 days. The mean total provider cost for early LC was RM 2532, and RM LAPAROSCOPIC END TO END BILIARY 2751 for elective LC. This difference was mostly seen RECONSTRUCTION WITH T-TUBE FOR in the consumable cost (i.e investigations and operating TRANSECTED BILE DUCT INJURY equipment) with p < 0.05. Operative outcome was DURING LAPAROSCOPIC statistically similar in each group in terms of conversion CHOLECYSTECTOMY rate (23.1% vs. 18%), post-operative complications (11.5% vs 4.5%) and readmission rate ( 7.7% vs. 4.5%) B. J. Kwak, T. H. Hong, D. G. Kim, Y. K. You, H. J. Choi, with p > 0.05. However the operative time was statis- J. H. Han and Y. M. Kim tically longer in the early LC group (134.2 + 48.5 mi- Division of Hepatobiliary-Pancreas Surgery and Liver ’ nutes) versus elective group (105.9 + 40.1 minutes)(p = Transplantation, Department of Surgery, Seoul St. Mary s 0.032). Hospital, College of Medicine, The Catholic University of Conclusion: The average provider’s cost for early LC Korea, Seoul, Republic of Korea was statistically similar when compared to elective LC Introduction: Roux-en-Y choledocho-jejunostomy are with comparable safety profile. Early LC should still be most common reconstruction procedure for transected bile the preferred treatment option for patients with acute duct injuries during laparoscopic cholecystectomy. How- cholecystitis if adequate facilities and expertise is ever, end to end reconstruction can be performed in selected available. patients. This report describes eight cases of laparoscopic end to end biliary reconstruction with T-tube for transected bile duct injury during laparoscopic cholecystectomy. EP03E-010 Methods: A retrospective descriptive analysis was performed for all patients with transected bile duct injury at a TRANS-T-TUBE BILIARY DRAINAGE; single institution between January 2014 and December 2017. AN ALTERNATIVE TREATMENT Details of injury site and type, reconstruction methods, OPTION FOR INTRACTABLE conversion rate and outcomes were collected and analyzed. POSTOPERATIVE BILIARY FISTULA Results: Between January 2014 and December 2017, 2901 AFTER CHOLEDOCHOTOMY patients underwent laparoscopic cholecystectomy at a single institution. Among them, eight patients had trans- C. K. Cho and H. J. Kim ected bile duct injury during laparoscopic cholecystectomy. Surgery, Chonnam National University Medical School, They underwent laparoscopic end to end biliary recon- Republic of Korea struction with T-tube. The reported series consisted of 6 Introduction: Persistent biliary fistula after biliary opera- women (75%) and 2 men (25%) with a mean age of 48.3 tion is not common, but sometimes it is very difficult years (range 29e77 years). Two cases were converted to problem, especially in case of friable common bile duct open surgery. The most common injured type classified (CBD). Herein, we report a case of intractable post- according to Bismuth’s classification was type I (3/8, operative biliary leakage treated with trans-T-tube biliary 37.5%). The mean operating time was 136.8 min (range 0e drainage (TTBD). 180.0 min). The mean hospital stay was 7.0 days (range Methods: A 65-years-old man visited because of CBD 3.0e21.0 days). The mean follow-up was 29.0 months stone and multiple left intrahepatic bile duct (IHBD) stones. (range 0e57.0 months). We have observed one post- After the left hemihepatectomy and choledocholithotomy, operative complication during follow-up period, anasto- primary closure of CBD was performed because there was mosis site leakage cured by re-operation. endoscopic retrograde biliary drainage (ERBD) catheter Conclusion: Laparoscopic end to end biliary reconstruction inserted already. On postoperative day 7, covered stent with T-tube for transected bile duct injury during laparo- insertion in right hepatic artery was performed due to scopic cholecystectomy can be safe and feasible in selected th bleeding from hepatic artery branch. On the 5 day after the patients, operated on by expert laparoscopic surgeon. intervention, bile leakage was observed from drain and re- operation was performed. There was necrosis of CBD wall around choledochotomy site and debridement and T-tube EP03E-014 insertion was performed. Persistent bile leakage was observed with average amount of 500ml/day even though ROBOTIC APPROACH SIMPLIFIES THE well-functioning T-tube until 30 days after re-operation. REOPERATION OF INCIDENTAL And two times of ERBD tries were failed. T-tube cholan- GALLBLADDER CANCER giography revealed bile leakage from CBD more proximal R. L. C. Araujo, M. A. Sanctis, F. Felippe, D. Burgardt and portion to T-tube insertion site. A drainage catheter through D. Wohnrath T-tube was inserted with positioning the catheter tip in right Department of Upper GI and HPB Surgery, Barretos IHBD. Cancer Hospital, Brazil Results: Two days after the procedure of TTBD, the Introduction: Although laparoscopy is the gold standard amount of bile from drain was dramatically decreased and to cholecystectomy, its use to approach incidental gall- the drain was removed after 6 days after TTBD. Four weeks bladder cancer (IGBC) is uncommon. The laparoscopic after the TTBD, T-tube and TTBD catheter were removed bisegmentectomy IVb/V (either anatomical or not) plus without any problem. hilar lymphadenectomy represents a challenging procedure. Conclusion: For intractable persistent biliary fistula after We report our initial experience with robotic approach to choledochotomy, TTBD could be considered for useful IGBC as an option to improve feasibility of this procedure. alternative treatment option.

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Methods: Three consecutive patients undergone robotic Post cholecystectomy ERCPs(suspecting IBDI) were reoperation by daVinciÒ SI, and by the same team were analysed and categorized into Bismuth-Strasberg classi- reported. Patients were positioned in reverse Trendelen- fication(A-E). E(1e5) were considered as major injuries. burg. For all patients, five trocars were used (3 of 8 mm and The stented patients were evaluated for symptom 2 of 12 mm), and surgical specimens were removed through improvement, need of repeat endoscopy and complications. Pfannestiel incisions. Eighty seven IBDI was detected during ERCP(2007e Results: From November 2016 to December 2017, three 2016, 70% following Laparoscopic cholecystectomy). cases of IGBC were performed. Clinicopathological, Male:female was 1:3 and mean age was 38.6 years(range operative and postoperative data are summarized in the 28e70). 53% had minor injuries(Bismuth-Strasburg A-D). table. Briefly, all patients underwent bisegmentectomy IVb/ Cystic stump leak was the commonest single injury(36%). V (1 anatomical and 2 non-anatomical) plus hilar All the minor injuries(n = 46) were stented with 7Fr or 10 Fr lymphadenectomy; they were pT1b, and neither presented plastic stents. All stented patients needed repeat ERCP(two residual liver disease nor positive node at final pathology. monthly in most cases) with a median number of 5(range 2e Neither Pringle maneuver nor blood transfusions were 11) and 81% underwent serial dilatation and multiple necessary. All discharges from ICU and hospital were on stenting. All the patients had symptom improvement within second and third postoperative days, respectively. No three months of the initial intervention. In stented group 5 complications at 30-days were recorded. patients(10%) needed surgery as they developed chronic Conclusion: Our initial experience suggests that robotic CBD stricture which were not improved with at least 6 at- reoperation seems to be safe, and simplifies both hilar tempts of serial dilatation(after 3 years of initial surgery). lymphadenectomy as well as intrahepatic control of pedi- Zero mortality was reported in stented group. cles allowing anatomic resections. The putative benefits of Minor IBDI can be effectively managed with ERCP and its approach are the articulate arms facilitating traction and stenting according to our data. Serial dilatation with dissection of hilar structures with precise movements and repeated ERCP is needed in most of the cases but avoiding tridimensional view. Both articulate mono and bipolar a major surgery would be an advantage. The number of scalpels helped to work bi-axially on the liver wedge serial dilations attempts before deciding on reconstructive necessary to remove segments IVb/V with their pedicles. surgery should be evaluated further as many patients improved after multiple attempts of dilatation.

Clinic, operative and postoperative data Characteristic Overall 1st 2nd 3rd case case case EP03E-016 Age 45 ± 11 53 33 49 SAFETY AND FEASIBILITY OF SOLO Gender (Female) 2 (66.7%) Fem Male Fem SINGLE-INCISION LAPAROSCOPIC Body mass index 30.9 ± 1 29.9 31.8 30.9 CHOLECYSTECTOMY COMPARED TO ASA score II (66.7%) II I II CONVENTIONAL THREE-INCISION Iwate criteria 4(4–7) 4 4 7 LAPAROSCOPIC CHOLECYSTECTOMY: (difficult score) A MULTICENTER COHORT STUDY Anatomical resection 1 (33.3%) No No Yes S. -W. Suh1, Y. Choi2, J. Jeong3, H. -S. Han4, Node Harvesting (range) 4 (3–6) 6 3 4 Y. -S. Yoon4, J. Y. Cho4, Y. S. Choi1 and S. E. Lee1 1 Operative time (min) 392 ± 16 380 410 385 College of Medicine, Chung-Ang University, Republic of 2 Estimated 186 ± 126 50 200 300 Korea, Seoul National University Bundang Hospital, Blood Loss (ml) Seoul National University College of Medicine, Seongnam, Republic of Korea, 3Soonchunhyang University College of Medicine, Republic of Korea, and 4Seoul National Uni- EP03E-015 versity Bundang Hospital, Seoul National University Col- HOW EFFECTIVE IS ENDOSCOPIC lege of Medicine, Seongnam, Republic of Korea STENTING IN MANAGEMENT OF POST- Introduction: A shortage of experienced surgical assis- tants makes difficulties in performing laparoscopic chole- CHOLECYSTECTOMY BILE DUCT e cystectomy (LC) that we introduced solo surgery by using a INJURIES EXPERIENCE OF A laparoscopic scope holder to maintain a stable surgical TERTIARY CARE HEPATOBILIARY view. The aim of this study was to investigate the safety and CENTER IN A DEVELOPING COUNTRY feasibility of solo LC compared with conventional LC C. Lakmal1, M. Nandasena2, B. Gamage2, assisted by an experienced scopist. T. Wijerathne2 and A. Pathirana2 Methods: A retrospective comparison of solo single-incision 1Department of Surgery, University Surgical Unit, LC (group A, n = 566) and conventional three-incision LC Colombo SouthTeaching Hospital, Sri Lanka, and (group B, n = 874) from January, 2013 to December, 2016 at 2Department of Surgery, Faculty of Medical Sciences, multicenter was performed. Baseline characteristics, operative University of Sri Jayawardenapura, Sri Lanka outcomes, and postoperative complications were compared. Results: No significant differences in baseline characteris- Iatrogenic bile duct injury(IBDI) is the most serious tics were found between the two groups. Operative time was complication of cholecystectomy. Endoscopic stenting is similar in two groups (53.1 Æ 15.4 vs. 50.1 Æ 15.1, mins, P = an alternative to surgery in managing IBDI and data on this 0.176), however there was significant higher intraoperative aspect is scarce in our setting. gallbladder perforation in group A, compared with group B

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(17.0% vs. 2.3%, P = 0.000). There was no significant dif- Introduction: Choledochal cysts are rare congenital ference of postoperative complications (10.6% vs. 10.4%, P cystic lesions of the biliary tree. They are associated with = 0.909) and major complications requiring radiologic recurrent cholangitis, stone disease, and malignant intervention or reoperation (1.2% vs. 1.3%, P = 0.971) be- change. Total cyst excision is recommended with good tween two groups. The length of postoperative hospital stay long term outcomes. We are reporting a rare complica- was significantly shorter in group A compared with group B tion of a gastric outlet obstruction caused by cystic (1.9 Æ 2.7 vs. 3.3 Æ 2.3, days, P = 0.000). dilatation of the remnant intra-pancreatic choledochal Conclusion: Solo LC had comparable operative safety and cyst after an open total choledochectomy and Roux-en-Y feasibility compared with conventional LC. Frequent hepaticojejunostomy reconstruction, which was drained intraoperative gallbladder perforation might be considered endoscopically. when selection of surgical candidates. Methods: A 57 year old male was referred for an asymptomatic choledochal cyst. Pre-operative imaging showed a Todani Type 1 choledochal cyst. He under- EP03E-017 went an open total choledochectomy and Roux-en-Y SHOULD WE STENT BILIOENTERIC hepaticojejunostomy reconstruction. The proximal extent was taken just distal to the bifurcation of the ANASTOMOSIS AFTER COMPLEX common hepatic duct, while the distal extent which was IATROGENIC BILE DUCT INJURY? taken at the superior border of the pancreas and over- P. Senra, R. Melendez and F. Ausania sewn. Post-operatively, the patient complained of HPB Unit, Hospital Alvaro Cunqueiro de Vigo, Spain persistent vomiting with a high nasogastic aspirate. A Introduction: Iatrogenic bile duct injuries after cholecys- contrast study showed gastric outlet obstruction, and a tectomy are challenging complications that often require computered tomography showed compression of D2 multidisciplinary approach. Placement of an anastomotic from the cystic dilatation of the remnant cyst in the stent is a matter of debate especially when a vascular injury head of pancreas. is associated. Results: An endoscopic approach was taken to aspirate Methods: We report two cases referred to our HPB Unit and drain the cyst with insertion of internal stents. presenting with sepsis secondary to biliary peritonitis The symptoms completely resolved after this following laparoscopic cholecystectomy. Both cases consis- procedure. tedoncomplexbileductinjury(Strasberg E4) associated to Conclusion: Gastric outlet obstruction from cystic dilata- vascular injury (right hepatic artery). The first patient was tion of the remnant intra-pancreatic distal choledochal cyst initially treated with percutaneous drainage of multiple is a rare complication following surgery for choledochal intraabdominal collections and bilobar percutaneous trans- cyst. Successful management via endoscopic means is hepatic biliary drainage (PTBD). Intraoperatively, no viable feasible, although the risk of subsequent malignant change bile ducts could be identified. Following source control of is uncertain. This has to be balanced with the risks of a sepsis, the patient underwent a portoenterostomy and PTBDs more radical surgery. were utilized to stent the anastomosis. In the second patient, no PTBD were placed preoperatively because an urgent lap- arotomy was needed due to biliary peritonitis. Intra- EP03E-020 operatively, three small ischemic ducts could be identified RESULTS OF LAPAROSCOPIC (right, segment 4 and segment 2-3 bile ducts). The portoen- CHOLEDOCOJEJUNOSTOMY USING terostomy was stented with three transjejunal tubes. CONTINUOUS SUTURE Results: In both cases, the catheters were removed three months after surgery following a cholangiography Y. Oguri, G. Honda, J. Yamamoto, Y. Honma, Y. Ome, demonstrating absence of leak or strictures. At 12-month M. Doi and H. Ishida follow-up, no biliary complications were detected. Surgery, Tokyo Metropolitan Cancer and Infectious Dis- Conclusion: In case of hilar bile duct injuries associated eases Center Komagome Hospital, Japan with vascular injury, stenting of bilioenteric anastomosis Objectives: For choledocojejunostomy (CJ), we have used can be helpful to avoid postoperative bile leak and late continuous suture when using the laparoscopic approach biliary complications. and have standardized it, while we have used interrupted sutures when using the open approach. The aim of this study was to evaluate the results of laparoscopic CJ using EP03E-018 continuous suture. AN ENDOSCOPIC APPROACH FOR Methods: Between April 2011 and March 2017, 224 pa- tients underwent CJ after pancreaticoduodenectomy in 205, DRAINAGE OF A REMNANT INTRA- extrahepatic bile duct resection in 18, and simple transec- PANCREATIC CHOLEDOCHAL CYST e tion of the common hepatic duct in 1. Of the 224 patients, 3 A RARE COMPLICATION FOLLOWING who had a choledochal cyst, 2 who underwent interrupted CHOLEDOCHAL CYST EXCISION suture via a laparoscopic approach, and 1 who underwent CAUSING GASTRIC OUTLET continuous suture via an open approach were excluded. Clinical characteristics, surgical findings, and the incidence OBSTRUCTION of biliary complications were compared between the M. Y. Tan and K. K. Madhavan “laparoscopic CJ using continuous suture (LCJ)” group (n Hepatobiliary & Pancreatic Surgery, National University = 59) and the “open CJ using interrupted suture (OCJ)” Hospital, Singapore group (n = 159).

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Results: The mean observation period was longer for the EP03E-022 LCJ group than for the OCJ group (31.6 vs. 25.3 months, p = 0.03). The incidence of postoperative UTILITY OF PORTAL VEIN cholangitis tended to be higher (16.9% vs. 8.2%, p = EMBOLIZATION IN SURGICAL 0.061) and the incidence of intrahepatic stone was MANAGEMENT OF LOCALLY significantly higher in the LCJ group (8.4% vs. 1.9%, p ADVANCED GALLBLADDER CANCER = 0.035). The proportion of patients who required V. Mohapatra1, S. H. S. Reddy1, K. S. Madhusudan2, invasive intervention for anastomotic stenosis, such as N. R. Dash1, S. Shalimar3, S. Pal1, P. Sahni1 and endoscopic or percutaneous stenting or surgical rean- D. N. Srivastava2 astomosis, was significantly higher in the LCJ group 1GI Surgery and Liver Transplantation, 2Radio- (11.7% vs. 1.9%, p = 0.005). diagnostics, and 3Gastroenterology and Human Nutrition, Conclusions: Although LCJ using continuous suture had AIIMS Delhi, India been standardized within the study period, it is more likely to cause anastomotic stenosis than OCJ using interrupted Introduction: Portal vein embolization (PVE) enables suture. surgical resection of hepatobiliary tumours which would otherwise be unresectable due to insufficient future liver remnant (FLR). Here, we evaluated the outcomes after PVE for carcinoma gallbladder (CaGB) cases necessitating EP03E-021 major hepatectomy. ANTEGRADE SPYGLASS AND Methods: Between August 2015 to July 2016, seventeen LITHORIPSY AS TREATMENT patients with CaGB needing extended right hepatectomy MODALITY FOR RETAINED but having insufficient FLR on CT volumetry were offered INTRAHEPATIC DUCT STONE AFTER PVE. Preoperative biliary drainage (PBD) was done to decrease bilirubin to <5mg/dL. Right PVE was done by BILIARY RECONSTRUCTION ipsilateral approach using glue and lipiodal. Volumes were 1 2 2 2 J. Razman , S. M. Ikhwan , M. F. Azem , O. Iqtidaar and reassessed after 4 weeks before considering for surgery. 3 V. M. Leow Results: All the 17 cases were jaundiced and therefore 1 Department of Surgery, Universiti Kebangsaan Malaysia, required PBD. 2 patients had received neo-adjuvant 2 3 Department of Surgery, and Advance Medical and chemo-radiotherapy. Technical success was achieved in Dental Institute, Universiti Sains Malaysia, Malaysia all and there were no procedure related complications. Bile duct resection and reconstruction is performed for Mean baseline segment 2+3 volume was 16.46 Æ 5.07 % variety of indications, including benign and malignant which increased to 25.34 Æ 7.01% post embolization. tumors; congenital anomalies as well as complications Only 2 patients could undergo curative surgery despite from biliary and gallbladder diseases or surgery. The increase in FLR, one of whom required ALPPS proced- procedure still carries small risk of complications ure due to inadequate FLR on intra-operative assessment. including anastomotic leak, anastomotic stricture, disease 8 cases had tumour progression, 2 developed main portal recurrence and not to forget possibility of retained stone vein thrombosis, 1 developed portal hypertension, 3 had in certain cases. persistent sepsis or poor performance status and 1 We presented a case of a 26-year-old gentleman with defaulted. There was no post operative liver failure in the known history of choledochalithiasis secondary to operated patients. extrahepatic fusiform choledochal cyst who underwent Conclusions: FLR increase after PVE doesn’t translate into excision of choledochal cyst, extraction of stone and improved resectabilty in locally advanced but resectable Hepatico Jejunostomy (HJ) due to episodes of recurrent CaGB cases due to further disease progression. Hence, cholangitis. He was well for a month post operatively alternative approaches should be considered in these subset until he presented again with another episode of chol- of patients. angitis. Computed Tomography (CT) Scan revealed dilated intrahepatic ducts above the HJ anastomosis due to retained stone. Percutaneus Transhepatic Biliary EP03F - Electronic Poster: 3F - Biliary Drainage (PTBD) was performed and he improved Miscellaneous clinically. He subsequently underwent 3 sessions of EP03F-001 PTBD tract dilatation until the size of 14 Fr PTBD tube. The Spyglass scope was introduced from the entry point IS THE 8-MM ROBOTIC PORT SAFE? A of PTBD tract until the HJ anastomosis showed presence CASE OF TROCAR SITE HERNIA AFTER of 2 stones. There was no stricture at the anastomosis ROBOTIC CHOLECYSTECTOMY USING siteanditshowedgoodflow of contrast during chol- THE DA VINCI XI SYSTEM angiogram. Due to failure of stone extraction using T. Yoo and W. T. Cho dormia basket and balloon, laser lithotriptor was intro- Department of Surgery, Hallym University College of duced and the the stones were successfully broke into Medicine, Republic of Korea fragments. The stones were evacuated with dormia basket and some were pushed beyond the HJ anasto- Introduction: Recently, robotic surgical technology has fi mosis. The post procedure cholangiogram showed revolutionized the eld of minimally invasive surgery. complete stone clearance and the PTBD tube was However, as the number of surgical cases increase, so does removed after a month. the number of complications, especially the trocar site

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S753 hernia (TSH), which rarely occurs on the 8-mm port site EP03F-003 after robotic cholecystectomy using the da Vinci Xi system. Method and result: A 37-year-old woman was diagnosed IS ENDOSCOPIC MANAGEMENT OF with calculous cholecystitis with the aid of an abdominal OESOPHAGEAL VARICES IN sonography. She underwent a robotic cholecystectomy EXTRAHEPATIC PORTAL VENOUS using the bikini-line incision technique where ports were OBSTRUCTION (EHPVO) A RISK placed in 8-mm port sites at the right, middle and left lower FACTOR FOR PORTAL BILIOPATHY? quadrant abdominal areas. The patient was discharged after 1 2 3 2 2 an uneventful recovery, two days postoperatively. On the J. George , S. Pal , V. Mangla , N. R. Dash , P. Sahni , G. K. Pande4, S. K. Acharya5, T. K. Chattopadhyay6 and day of discharge; however, the patient presented to the 3 emergency room with small bowel obstruction secondary to S. Nundy 1Dept of GI and HPB Surgery, Rajagiri Hospital, 2Dept of dilated bowel herniated loop through abdominal fascial and 3 peritoneal defects at the left 8-mm port site. After 5-day GI Surgery and Liver Transplantation, AIIMS Delhi, Dept failure to resolve the mechanical ileus, the patient under- of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India, 4Launceston General went emergency diagnostic laparoscopy where bowel 5 6 resection and anastomosis of the ischemic area were Hospital, Australia, Fortis Vasant Kunj, and Institute of performed. After surgery, the patient was discharged Liver and Biliary Sciences, India without any complications. Although, robotic cholecys- Introduction: There are no data on the risk factors for tectomy with 8-mm robotic ports in non-midline sites has development of portal biliopathy (PB). We did a case- lower chances of occurrence. control study to ascertain the risk factors for occurrence of Conclusion: We recommend that surgeons carefully close PB in patients with EHPVO. the trocar sites, especially in cases of large fascial defect or Methods: The records extracted from a prospectively high possibility of herniation. maintained database of all patients with portal hyper- tension due to EHPVO presenting to the department of GI surgery AIIMS, New Delhi , between January 1976 EP03F-002 and January 2013, were screened for the presence of PB. A group of sex-matched controls who did not have ev- THE REALITY OF TOKYO GUIDELINES idence of PB at the time of presentation were selected FOR ACUTE CHOLECYSTITIS IN from the EHPVO database for comparison, in order to INDONESIA: AN ONLINE SURVEY identify the factors associated with the development of AMONG SURGEONS PB. Results: Between January 1976 and January 2013, 1027 A. Nugroho and R. Saunar patients were diagnosed to have EHPVO and underwent Digestive Surgery, Fatmawati General Hospital, a surgical procedure for portal hypertension at our Indonesia centre. PB was diagnosed in 134 (13%) patients, of There is a wide variability in the management of acute whom 74 (55.2%) were symptomatic.Incidence of PB fi cholecystitis. Currently there are no of cial national data was 36 patients over a five year period from 2003 to regarding this issue. This study was designed to assess the 2007 but doubled to 72 over the next five years. On current clinical practice in the management of acute logistic regression between the group of 134 sex- cholecystitis, with regards to Tokyo Guidelines, among matched controls who did not have evidence of PB, ’ Indonesian s surgeons. absence of gastrointestinal bleeding, incidence of Methods: We did a cross-sectional study using a descrip- endoscopic therapy for oesophageal varices and absence tive questionnaire. General surgeons and Digestive Sur- of high grade oesophageal varices at the time of diag- geons practicing in Indonesia were contacted and asked to nosis were found to be associated with PB (p < 0.001; complete a short Internet-based questionnaire (using http:// Table I). www.surveymonkey.com) on the management of acute cholecystitis. There were 10 questions, consist of 4 back- ground questions and 6 specific questions addressing the management of acute cholecystitis. Table 1 Results: Sixty surgeons have participated in this survey, Risk Factors PB Controls P value Odds ratio from which 47% were digestive surgeons. Critical view of n[134(%) n[134(%) (95% CI) safety was the preferred method among digestive surgeon, fi Gastrointestinal 100 (74.6) 123 (91.8) <0.001 0.14 while general surgeon mostly answered no speci c method bleed (0.06–0.33) for cholecystectomy. Early cholecystectomy based on im- Endotherapy 83 (61.9) 48 (35.8) <0.001 3.3 aging ultrasound by radiologist was the most common (1.75–6.3) approach in treating acute cholecystectomy. While some High grade 39/128 94/132 <0.001 0.24 surgeons (58%) still preferred fundus down technique for varices (30.5) (71.2) (0.13–0.42) difficult gallbladder, there were 26% of surgeons who already familiarized with subtotal cholecystectomy. Conclusion: Despite its basic nature and prone to bias, this survey gave us a glimpse understanding on how Indonesian Conclusion: Endoscopic Obliteration of varices or absence surgeons dealt with acute cholecystitis, with regards to of high grade varices may be a predisposing risk factor for Tokyo Guidelines. Further in depth assessment is necessary development of PB in patients with EHPVO. for more widespread usage.

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EP03F-004 disease recurrence were analyzed using univariate and multivariable tests. COMPREHENSIVE ANALYSIS FOR Results: The 5-year disease-free and overall actuarial ACUTE CHOLECYSTITIS USING survival rates were 39.3% and 51.3%, respectively. METAGENOMIC APPROACH Moderate or poor differentiation, preoperative ERCP, M. Kujiraoka1, M. Kuroda2, K. Asai1, M. Watanabe1, advanced T stage, lymph node metastases, advanced H. Matsukiyo1, T. Saito1, H. Moriyama1, Y. Saida1 and stage and lymphovascular invasion were associated with S. Kusachi1 disease-free survival in univariate analyses. The prog- 1Surgery, Toho University Ohashi Medical Center, and nosis was worse in patients who underwent ERBD than 2Laboratory of Bacterial Genomics, Pathogen Genomics in patients who underwent PTBD or no biliary drainage. Center, National Institute of Infectious Diseases, Japan Multivariable analysis showed that advanced AJCC stage and preoperative ERCP were independent risk factors for Background: The rapid comprehensive diagnosis of acute recurrence. Patient who underwent preoperative ERCP cholecystitis (AC) enables appropriate treatment and the had a significantly higher rate of early distant metastasis determination of new findings. Here we performed a within 1 year, especially in patients with early stage comprehensive analysis of AC using the metagenome AOV cancer. approach. Conclusions: Preoperative ERCP was an independent risk Methods: Between May 2015 and August 2016, fifty-five factor for postoperative recurrence in patients with AOV patients who underwent cholecystectomy for AC at cancer, and is characterized by early distant metastasis in the Department of Surgery, Toho University Ohashi early stage cancer. Therefore, unnecessary ERCP should be Medical Center, were enrolled in this study. Bile was avoided in patients with AOV cancer. If biliary drainage is collected intraoperatively, and metagenome analysis were necessary, PTBD may be preferred to ERBD in AOV performed. The comprehensive condition of the AC pa- cancer. tients was statistically analyzed in terms of detected caus- ative agents, pathological findings, and clinical findings. Results: Causative agents were rapidly identified from each detection ratio (within 72 h). Regarding the patho- EP03F-007 logical findings, the homo sapiens DNA reads ratio derived ETHANOL ABLATION FOR from the gall bladder (GB) mucous membrane significantly REFRACTORY BILE LEAKAGE AFTER differed between cases that were negative or positive for COMPLEX HEPATECTOMY bleeding, fibrosis, and necrosis (p = 0.031, 0.027, and 0.018, respectively). Regarding the clinical findings, homo A. Ito, T. Ebata, Y. Yokoyama, T. Igami, T. Mizuno, sapiens and bacterial DNA reads ratio was also analyzed for J. Yamaguchi, S. Onoe and M. Nagino the factors of body temperature, serum white blood cell Division of Surgical Oncology, Department of Surgery, counts, and serum C-reactive protein (CRP) levels. The Nagoya University Graduate School of Medicine, Japan amount of homo sapiens and bacterial DNA reads signifi- Introduction: Only a few reports exist on the use of cantly differed between cases with low and high levels of ethanol ablation for posthepatectomy bile leakage. The aim CRP (p = 0.001 and 0.001, respectively). of this study was to assess the value of ethanol ablation in Conclusions: Metagenome analysis enables rapid deter- refractory bile leakage. mination of bacterial type, GB condition, and clinical Methods: Medical records of consecutive patients who severity. It is a next-generation examination for AC underwent a first hepatobiliary resection with bilioen- patients. teric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International EP03F-005 Study Group of Liver Surgery definition. Absolute PREOPERATIVE ENDOSCOPIC ethanol was injected into the target bile duct during CHOLANGIOGRAPHY IN AMPULLA OF fistulography. VATER CANCER IS INDEPENDENT Results: Of the 609 study patients, 237 (38.9%) had bile leakage, including grade A in 33, grade B1 in 18 and POOR SURVIVAL FACTOR grade B2 in 186. Left trisectionectomy was more often Y. H. Kim, K. S. Ahn, J. W. Lee, T. S. Kim and K. J. Kang associated with grade B2 bile leakage than other types of Surgery, Keimyung University Dongsan Medical Center, hepatectomy (P < 0.001). Of 186 patients with grade B2 Republic of Korea bile leakage, 31 underwent ethanol ablation therapy. Background: The aims of this study were to determine the Ethanol ablation was started a median of 34 (range 15e clinicopathologic factors associated with survival and dis- 122) days after hepatectomy. The median number of ease recurrence in patients with AOV cancer, focusing on treatments was 3 (1e7), and the total amount of ethanol the impact of preoperative endoscopic retrograde chol- used was 15 (3e71) ml. Complications related to ethanol angiopancreatography (ERCP) and type of biliary drainage ablation included transient fever (27 patients), and mild (endoscopic retrograde biliary drainage [ERBD] or percu- pain (13). Following ethanol ablation, bile leakage taneous transhepatic biliary drainage [PTBD]). resolved in all patients and drains were removed. The Methods: We retrospectively reviewed the medical records median interval between the first ablation and drain of 80 patients who underwent curative resection for AOV removal was 28 (1-154) days. cancer at a single institution between 1995 and 2015. The Conclusions: Ethanol ablation is safe and effective, and clinicopathologic factors associated with survival and may be a treatment option for refractory bile leakage.

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EP03F-008 EP03F-009 CASE SERIES OF COMPLEX CASES OF RADICAL RESECTIONS IN CHOLEDOCHAL CYSTS XANTHOGRANULOMATOUS J. De Vinatea1,2, G. Reaño2, F. Revoredo2, P. Polanco3, CHOLECYSTITIS (XGC) e OVERKILL L. Villanueva2, F. Kometter2, J. Arenas4, J. Tang2 and OR NECESSITY? M. Uribe2 1 N. Shivathirthan, Y. Kumar and K. Patel Surgery, Universidad Nacional Mayor de San Marcos, Dept of Gastro Surgery, India 2Surgery, Guillermo Almenara Hospital, Peru, 3Surgery, Introduction: Xanthogranulomatous cholecystitis (XGC) UT Southwestern Medical Center, United States, and is a destructive inflammatory disease of the gallbladder, 4Pathology, Guillermo Almenara Hospital, Peru rarely involving adjacent organs and often mistaken for Introduction: Choledochal cyst (CC) is a rare disease in gallbladder carcinoma (GB Ca). The diagnosis is usually western countries that presents in adults and is considered a possible only after histopathological examination. This premalignant lesion. A series of unusual presentations and study reviews the management and outcome of all XGC complex management and some very infrequent situations cases at our institute during past 2 years. are presented. Methods: From January 2015 to December 2017, a total of Methods: We performed a case review of CC cases operated 197 cholecystectomies were performed in Apollo BGS at Guillermo Almenara Hospital, Lima, Peru from 2008 to Hospital, Mysore. Of these, 7 patients were diagnosed on 2017. Cases of complex management due to their rare pre- histopathology to have XGC. These patients were retro- sentation were included. Ten cases of CC are described. spectively assessed for symptoms, radiological findings, Results: surgery performed and outcomes in terms of morbidity. The Case #1: CC associated with hepatic hydatid cyst. main study outcomes were incidence, diagnostic dilemma Case #2: CC associated with intracystic fasciola with GB Ca and management protocol of patients with hepatica. XGC. Case #3: CC associated with a medusa-shaped arterial Results: Our study revealed incidence of XGC to be malformation at the cyst. 3.55%, as compared to global incidence of 1.3% -1.9%. In Case #4: Jaundice after laparoscopic cholecystectomy. 3(42.85%) cases preoperative evaluation and intraoperative Video was reviewed and it is noticed that cholecystectomy findings were suggestive of GB Ca which resulted in and a resection of a CC, mistaken for the infundibulum, was additional diagnostic tests like PETCT and EUS-FNA. performed. These 3 patients underwent Radical Cholecystectomy with Case #5 and #6: Very distal resections of CC a few 2 of them undergoing additional Sleeve Gastrectomy and millimeters from the ampulla. Distal Gastrectomy to achieve R0 resection. Case #7: Same as cases #5 and #6 but presented in Conclusion: XGC is a rare inflammatory disease of GB pancreas divisum. with higher incidence in India. Differentiating XGC from Case #8: Previously treated CC with a cysto-duodenal GB Ca preoperatively is a conundrum. Every attempt anastomosis underwent resection of the cyst and Roux-en- should be made to preoperatively diagnose XGC. Since Y anastomosis. PETCT can not accurately differentiate between XGC and Case #9: Previously CC case treated with cysto-jejunal GB Ca, radical resection including adjacent organ resection Roux-en-Y anastomosis. A complete resection of the cyst whenever feasible is a necessity if malignancy can not be was performed laparoscopically. completely ruled out. Case #10: Previously resected CC presented with abnormal pancreas head. Pancreaticoduodenectomy is performed. Conclusion: Choledochal cysts can have complex pre- EP03F-010 sentations and surgical management should be tailored for EMERGENCY ERCP IN ACUTE each individual case. CHOLANGITIS: IMPLEMENTATION OF NEW SCORING SYSTEM Z. Zuhdi1, W. Azfaruddin2, A. Azman3, H. Othman3, I. S. Muhammad2, A. C. Ariffin2, R. Jarmin3 and C. Ian4 1Hepatobiliary Unit, Surgical Department, 2UKM Medical Centre, Malaysia, 3Hepatobiliary, Surgery, UKM Medical Centre, and 4Pusat Perubatan UKM, Malaysia Introduction: Acute cholangitis is a spectrum of disease with a wide range of severity. It is defined as bacterial infection of the biliary tract, which occurs in an obstructed system and eventually leads to the systemic signs and symptoms of infection. We performed this study to identify the indication for urgent Endoscopic Retrograde Cholangio Pancreatography (ERCP) in acute cholangitis patients, based on the new prognostic scoring system. Methodology: This was a prospective cross sectional study Choledochal cysts analysis of 112 patients who was admitted with the diag- nosis of acute cholangitis from January 2015 till May 2015.

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The patient was scored using the proposed new scoring EP03F-012 system and base on the score they were divide into urgent- ERCP group and elective-ERCP group. COMMON BILE DUCT OBSTRUCTION Results: From 112 patients there were 39 patients who AND ELONGATION ACROSS THE have a score of equal and more than 2 and requires an MIDLINE CAUSED BY DUODENAL urgent ERCP within 24 hours of admission. The receiver INTUSSUSCEPTION SECONDARY TO operator characteristics (ROC) curve of the proposed new AN AMPULLARY ADENOMA IN A scoring system showed a good test performance for predicting the need for an urgent ERCP and the areas under PATIENT WITH PANCREAS DIVISUM 1 2 1 concentration curves (AUCs) was 0.96. A. Torices Dardon , P. F. Saldinger and A. Dakwar 1 2 Conclusion: We found that this new proposed scoring General Surgery, and Surgery, New York Presbyterian system which base on Tokyo guideline and inclusive of Queens, United States CRP score good screening tool to identify the indication for Introduction: Small bowel intussusception is an uncom- urgent ERCP in patient diagnosed with moderate acute mon condition with cases of duodenoduodenal intussus- cholangitis. ception (DDI) being exceptionally rare. DDI is very unusual due to the fixed position of the duodenum within the retroperitoneum. In this case, the presence of an EP03F-011 ampullary mass caused DDI with submucosal elongation of IS EXTENDED SURGICAL RESECTION the common bile duct and obstructive jaundice in a patient with pancreas divisum. JUSTIFIED FOR Methods: A 65 year old female presented with obstructive XANTHOGRANULOMATOUS jaundice. She underwent attempted ERCP and was found to CHOLECYSTITIS IN A HIGH have an ampullary mass causing intussusception. The PD PREVALENCE REGION FOR GALL was cannulated but the common duct could not be cannu- BLADDER CANCER? lated. CT scan and MRI revealed intussusception, with the 1 2 2 2 2 elongated common bile duct entering the duodenum to the P. Joshi , R. Yadav , S. Kumar , V. Gupta , V. Gupta and left of the midline (Fig. 1) A. Chandra2 1Surgical Gastroenterology, King George Medical Uni- versity, and 2King George Medical University, India Introduction: Xanthogranulomatous cholecystitis (XGC) malingers malignancy, both clinically and radiologically. This study aimed to determine the incidence of XGC with Gallbladder cancer and discuss the surgical approach. Material and methods: Retrospective data collection and analysis of patients with pathologically confirmed XGC, was done from 2010 to 2017. Chi square test and logistic regression analysis was performed for dichotomous data, t test and linear regression analysis was performed for Fig. 1 Dilated, elongated CBD crossing the midline continuous data. Results: Pathologically confirmed XGC patients(n = 70) were enrolled in the study. Mean age was 49.7 years(range Results: The tumor was palpated close to the Ligament of =22e70 years) with male to female ratio of 1:2 for XGC. Treitz at exploration. The adenoma was excised after Abdominal pain (n = 67), fever (n = 16) and jaundice (n = reducing the intususception to the right, with reimplanta- 17) were most common symptoms. Gall stones (n = 67), tion of common bile duct. Due to the presence of pancreas wall thickening(n = 45), liver infiltration(n = 15) and divisum, no pancreatic duct was encountered within the adjacent organ infiltration(n = 15) were most common ampulla. radiological findings. Patients with carcinoma presented Conclusion: This is the first description of duodenal intu- with palpable abdominal mass having an Odds ratio (OR) susception causing a submucosal elongation of the of 5.2 (p = 0.03, 95%CI = 1.11-24.3). Operative findings in common bile duct and translocation of the ampulla to the patients with carcinoma were palpable mass (OR=10; p < left of the midline. 0.01, 95%CI = 2.7-36.7) and enlarged lymph nodes(OR = 10.2; p < 0.01, 95%CI = 1.86e56.7). Extended chole- cystectomy was done in nine patients, among which four EP03F-013 patients turned out to be carcinoma gall bladder and five patients XGC. Gall bladder carcinoma coexist with 11.43% TIMING OF LAPAROSCOPIC (n = 8) of XGC patients. Postoperative hospital stay was 6.9 CHOLECYSTECTOMY FOR ACUTE days (range 2e21 days). Surgical site infection(31.4%, n = CHOLECYSTITIS USING PROPENSITY 22) and bile leak(2.9%, n = 2) were most common post- SCORE MATCHING operative complication without any mortality. H. Moriyama, K. Asai, M. Watanabe, T. Saito, Conclusions: Since gallbladder carcinoma and XGC may M. Kujiraoka, Y. Saida and S. Kusachi coexist, extended surgical resection is justified especially in Toho University Ohashi Medical Center, Japan high prevalence areas for carcinoma gall bladder, whenever diagnosis is in doubt. Introduction: This study evaluates the therapeutic out- comes for laparoscopic cholecystectomy for acute

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S757 cholecystitis based on the duration from symptom onset to We have to be careful with empirical treatment because we surgery. also reported an increase in the resistances especially in Methods: A total of 224 patients were enrolled in this quinolones, tetracyclines and 3rd and 4th generation study. Patients’ characteristics and operative outcomes cephalosporines. were compared between patient groups based on the timing of laparoscopic cholecystectomy from symptom onset: within 72 h versus more than 72 h, and within 7 days versus EP03F-015 more than 8 days. Then, we performed propensity score GRAM-NEGATIVE BLOOD-STREAM matching of 13 relevant variables, including patient de- mographics, examination findings, and therapeutic factors. INFECTIONS IN PATIENS WITH Results: Among the groups, the early surgery group HEPATOBLIOPANCREATIC TUMORS (within 72 h and within 7 days) had significant younger E. Laviano1, T. González-Nicolas1, M. Sanchez1, patients with less comorbidity and shorter duration from S. Genzor1, T. Gimenez1, M. D. P. Palacian1, symptom onset to presentation before performed pro- M. C. Villuendas2, A. Serrablo1,3 and A. Rezusta2,4 pensity score matching, as well as shorter duration of sur- 1Cirugia General y Digestiva, 2Microbiología, Hospital gery, postoperative and total length of stay. Other operative Miguel Servet de Zaragoza, 3Cirugia, and 4Microbiología, outcomes, including blood loss, conversion to open sur- Universidad de Zaragoza, Spain gery, bile duct injury, and postoperative complications Introduction: Bloodstream infections represent a major fi showed no signi cant difference among the groups. After complication in cancer patients and the third cause of performed propensity score matching, all therapeutic out- nosocomial infection following surgery after pneumonia fi comes, including duration of surgery, showed no signi - and wound infection. Cancer patients are predisposed to cant differences in both analyses. developing infections, with gram-negative blood stream Conclusions: Performance of laparoscopic cholecystec- infections being more common in hepatobiliar cancer pa- tomy at the earliest possible time after presentation was a tients. The most common source of these bacteria is chol- safe therapeutic strategy for acute cholecystitis, regardless angitis, followed by other abdominal sites and the urinary of the time from symptom onset. tract. Material and methods: We analized all the blood cultures obtained between 2010 to 2017 from hospitalized patients EP03F-014 with hepatobiliopancreatic tumors in the Hepatobiliar Unit GRAM-NEGATIVE BACTERIEMIA IN of a third level Hospital in Spain. We reported gram- negative isolation and bacterial resistance. AN HEPATOBILIARY UNIT FROM A Results: We reported 30 positive cultures from 27 operated THIRD LEVEL HOSPITAL cancer patients with gram-negative bacteriemia. 14 of them E. Laviano1, M. Sanchez1, T. Gonzalez-Nicolas1, suffered from pancreas cancer and the rest had liver me- T. Giménez1, S. Genzor1, M. P. Palacian2, tastases from colon adenocarcinoma. Escherichia coli was M. C. Villuendas2, A. Rezusta2,3 and A. Serrablo1,4 isolated in all pancreatic cancer patients and in 39% of the 1Cirugia General y Digestiva, 2Microbiología, Hospital liver metastases patients we isolated E.coli, a further 30% Miguel Servet de Zaragoza, 3Microbiología, and 4Cirugia, showed Enterobacter cloacae complex, Bacteroides fragi- Universidad de Zaragoza, Spain lis in 15.3% and Campylobacter in 7%. Isolations and re- Introduction: Bloodstream infections constitute one of the sistances have increased over the years. E.coli bacteria most severe forms of bacterial infection. Over the last two have became more resistant to penicilines (20-40%), decades gram positive microorganisms predominated, but tetraciclines(32%) and they are also starting to be resistant nowadays are almost equal as gram-negative ones. Central to 3rd and 4th generation cephalosporines(4%) and venous catheter and surgical site are the main origins of quinolones(16%). these bacteriemias in surgical patients. Conclusions: Patients with solid tumors should be Material and methods: We analized all the blood cultures considered a distinctive population as they are predisposed obtained from 2010 to 2017 from hospitalized patients in to infections, specially bloodstream infections due to a the Hepatobiliar Unit of a third level Hospital in Spain. We variety of different mechanisms. Escherichia coli was the reported gram-negative isolation and bacterial resistance. most frequent isolated bacteria in our patients and we re- Results: We documented 126 episodes of gram negative ported an increase in the resistances to penicilines and bacteriemia in 126 patients. Escherichia coli was recovered cephalosporines. in 55.5% of cases, Bacteroides fragilis in 8.8%, Entero- bacter cloacae complex in 8.8%, Klebsiella oxytoca in 8.8%, Klebsiella pneumoniae in 4.4% and Pseudomonas EP03F-016 aeruginosa in 4.4%. The incidence of the episodes incresed SCHWANNOMA OF THE progressively from 3 isolations per year to 13. E.coli bac- HEPATODUODENAL LIGAMENT: teria have progressively become more resistant to quino- lones, tetracyclines and some of them even to 3rd and 4th A RARE CLINICAL CASE generation cephalosporines. We are also starting to report E. Nikou cases of E.coli able to produce extended-spectrum B- Army Share Fund Hospital, Greece lactamases (ESBLS). Introduction: Schwannomas are usually benign nerve Conclusions: The incidence of Gram-negative bacteriemia sheath tumors, typically found in the head, neck, spinal in the Hepatobiliary Unit has increased in the last seven cord and extremities. Schwannoma of the hepatobilliary years and E.coli was the most frequent isolated bacteria. tract is extremely rare.

HPB 2018, 20 (S2), S685eS764 S758 Electronic Poster (EP03A-EP03F) e Biliary

Methods: A female patient, 56 years old presented, in EP03F-018 2013, to a district hospital claiming headache and soreness of upper abdomen. Pathological exam revealed slight A CASE OF DUODENAL elevation of the liver function tests. Radiology tests GANGLIOCYTIC PARAGANGLIOMA evidenced a right upper quadrant mass. She was admitted to WITH REGIONAL LYMPH NODE ward for further treatment-investigation. The CT and MRI METASTASIS scan failed to provide further information regarding the S. B. Choi, T. W. Lim, W. J. Kim, P. Park and W. B. Kim origin of the mass. Surgery, Korea Univesrity Guro Hospital, Republic of Results: The patient underwent exploratory laparotomy Korea with local excision of the tumor, measured 9cm, and a triple biliary-intestinal anastomosis was performed. One month Introduction: Gangliocytic paraganglioma derived from later she was discharged from the hospital in a really good neural crest is an unusual neuroendocrine tumor having a shape, with regular follow-ups. Five years later, she devel- characteristic triphasic microscopic appearance with oped a thrombosis of the right portal vein with a concom- epitheloid cells, spindle cells, and ganglion cells. It is ittant atrophy of the right lobe, for which she received generally considered to be a benign. Here, we report a case anticoagulative therapy. of gangliocytic paraganglioma with regional lymph node Conclusion: Schwannomas are uncommon tumors. metastasis. Exlporative laparotomy is the only method to establish the Case: A 41-year-old man was admitted due to hematemesis. diagnosis and treatment. Upon arrival, he was evaluated and underwent an esoph- agogastroduodenoscopy that revealed a large submucosal tumor at second portion of duodenum near ampulla of Vater. Surgical resection was planned. On exploration, EP03F-017 there was an 1.5 cm-sized lymph node in the paraduodenal LAPAROSCOPIC CHOLECYSTECTOMY area. The lymph node was proven to be a metastatic ma- IN A SITUS INVERSUS TOTALIS lignant lesion in the frozen biopsy. Therefore we decided to PATIENT WITH ACUTE CALCULOUS perform pancreaticoduodenectomy. Grossly, the mass was CHOLECYSTITIS: A CASE REPORT soft, 2.5 Â 1.7 Â 0.9 cm in size, well demarcated, located near the ampulla of Vater. Pathologically, the duodenal W. Y. Kim and Y. N. Lee mass was a gangliocytic paragangliomoa. The tumor was HBP Surgery, Presbyterian Mecical Center, Republic of positive cellular reaction for chromogranin, synaptophysin, Korea neurofilament by immunohistochemistry. There was one Background: Situs inversus is a rare and silent autosomal metastatic lymph node among 11 retrieved lymph nodes. He recessive disorder occurring in 1:5,000 to 1:20,000 in- was recovered without complication and discharged at dividuals. Laparoscopic cholecystectomy, a standard postoperative day 9. After 7 year after operation, he was treatment for gallbladder disease in the general population, alive without recurrence. is very challenging in patients with situs inversus totalis and Conclusion: Radical surgery was necessary in a patient acute cholecystitis, especially for right-handed surgeons. with lymph node metastasis. Close follow-up was advo- We herein report a case involving our modified laparo- cated because gangliocytic paraganglioma with lymph scopic cholecystectomy technique for right-handed sur- node metastasis was considered as tumors with uncertain geons in a Korean female patient with situs inversus totalis malignant potential. who developed a acute diffuse suppurative calculous cholecystitis. Case presentation: An 83-year-old female patient with EP03F-019 dextrocardia presented with a two days history of epigastric and left upper quadrant abdominal pain. Vital signs were DOUBLE CYSTIC DUCT MIMIC CBD stable. White blood cell showed 18,400/uL. C reactive INJURY DURING OPERATION AND protein was 22.57 mg/dL. Abdominal commputerized to- SUCCESSFULLY TREATED WITH mography revealed a left-sided gallbladder with volumetric LAPAROSCOPIC increase of the gallbladder and even enhancing thickness- CHOLECYSTECTOMY: A CASE REPORT severe of the gallbladder wall suggesting acute calculous cholecystitis. We performed emergent laparoscopic chole- G. Yang, S. Lee and S. Joo cystectomy with our modified technique including port Department of Surgery, KyungHee University Hospital at relocation. The operation went well, and our patient Gangdong, Republic of Korea recovered satisfactorily. Cystic duct variation is quite common, but a single Conclusion: Laparoscopic cholecystectomy in a patient gallbladder with double cystic duct is an extremely rare with a left-sided gallbladder is not often confidently variant. These variations increase risks of duck injury or performed by right-handed surgeons. However, some bile leakage unless it was diagnosed preoperatively or modifications of “mirror image” ports are the keys to suc- intraoperatively. cessful completion of this operation. The patient will thus We report a case of choledocholithiasis in a patient with a still obtain benefits from this standard minimally invasive cholangitis and cholecystitis who was intraoperatively technique. diagnosed double cystic duct and successfully treated with Keywords: Laparoscopic cholecystectomy, Situs inversus laparoscopic cholecystectomy. totalis and Acute cholecystitis. A 72-year old man was admitted to our hospital due to epigastric pain and fever. He presented with right upper

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S759 quadrant tenderness and positive Murphy’s sign. Total surgeons and residents are unable to correctly discern the bilirubin, direct bilirubin, liver function test was elevated essential steps of CVS from actions not part of the tech- with leukocytosis. Cholangitis with distal common bile nique and even potentially harmful. Residents’ current duct stone and gallbladder stone was diagnosed by knowledge regarding CVS is superior to those of surgeons. computed tomography. Endoscopic retrograde chol- angiopancreatography and endoscopic sphincterotomy was performed with removal of CBD stone and sludges. ERCP EP03F-021 revealed normal bile duct anatomy. Under general anes- EARLY RECURRENCE FOLLOWING thesia, four ports elective laparoscopic cholecystectomy was done and double cystic duct was found. During oper- PANCREATICODUODENECTOMY IN ation we ligated cystic duct and cystic artery, more PATIENTS WITH AMPULLARY dissection was done for removal pericholecystic connective CANCER tissue from hilum. Non pulsatile tubular structure was H. M. Park, S. -J. Park, S. D. Lee, J. H. Lee, S. M. Woo, observed from liver hilum to gallbladder. It was ligated and S. -S. Han, Y. H. Ko, S. H. Kim, S. -A. Lee and E. K. Hong divided after fully dissected. Postoperatively magnetic National Cancer Center, Republic of Korea resonance cholangiopancreatography revealed that CBD Introduction: We aimed to identify the factors of patients was not injured neither leaked. with early recurrence (within 6months) following curative Double cystic duct with single gallbladder is a very rare resection for ampullary cancer and to compare the immu- anomaly. Although preoperatively image does not reveal nohistochemistry (IHC) expression rate between the two this variation, laparoscopic cholecystectomy could be done main histological subtypes of ampullary adenocarcinoma. safely and intraoperative cholangiogram should be Methods: In this retrospective study, the postoperative considered to prevent ductal injury. outcomes and clinicopathologic factors for early recurrence that occurred in 14 of a total of 93 patients who underwent the pancreaticoduodenectomy (PD) for ampullary adeno- EP03F-020 carcinoma between January 2002 and August 2014 were LACUNAR IMPLEMENTATION OF THE analyzed. CRITICAL VIEW OF SAFETY Results: The patients who underwent PD for ampullary TECHNIQUE FOR LAPAROSCOPIC cancer were divided into two groups: early recurrence and late recurrence. 14 patients (32.6%) showed the early CHOLECYSTECTOMY. RESULTS OF A recurrence and they showed the shorter median DFS and NATIONWIDE SURVEY median OS than those of patients with late recurrence F. W. van de Graaf1, J. van den Bos2, L. P. S. Stassen2 and (DFS, 4.2 Vs. 49.7 months, p = 0.001; OS, 18.2 Vs. 113.7 J. F. Lange1 months, p < 0.001). Large tumor, LN metastasis, and 1Department of surgery, Erasmus MC - University Medi- pancreatico-biliary type were independently associated cal Center Rotterdam, and 2Department of surgery, with early recurrence in patients with ampullary cancer Maastricht University Medical Center (MUMC), following PD. When we compared two histologic types of Netherlands ampullary cancer through IHC staining, CK7, MUC1, and Background: Bile Duct Injury (BDI) remains a substantial S100P were dominantly stained in pancreato-biliary type. complication after laparoscopic cholecystectomy (LC), In intestinal type, CK20 and CDX2 staining appeared more fi with an incidence still higher than in conventional chole- frequently and signi cantly. cystectomy. The Critical View of Safety technique (CVS) Conclusions: Ampullary cancer patients with large tumor, has been appraised as the optimal operating technique to LN metastasis, and pancreatico-biliary type should be reduce BDI incidence. The objective of this study was to considered to have aggressive adjuvant treatment and determine current practices in LC and the use of CVS follow-up more frequently postoperatively. In addition, among surgeons and residents in surgical training. different strategies of adjuvant therapy may be helpful to Methods: We conducted an electronic survey among all improve the outcomes of different histologic type tumors. affiliated members of the Association of Surgeons of the Netherlands containing questions regarding the current practice of LC, essential steps of CVS, reasons for con- EP03F-022 version to open cholecystectomy and the use of other safety DIAGNOSIS AND MANAGEMENT OF techniques. BENIGN BILIARY STRICTURES - Results: The response rate was 37% (766/2055). 610 DISEASE BENIGN BUT HOSTILE TO completed surveys were analyzed. Of the respondents, 410 (67.2%) were surgeons and 200 (32.8%) were residents in THE PATIENT AND THE SURGEON surgical training. 98.2% of respondents indicate to incor- H. S. Pranav, A. Amudhan, S. Rajendran and porate CVS in current practice. However, only 72% of O. L. Naganath Babu respondents perform the essential steps of CVS frequently. Institute of Surgical Gastroenterology, Rajiv Gandhi Half of respondents were able to identify the corresponding Government General Hospital and Madras Medical Col- steps of CVS and only 16.9% were able to adequately lege, India distinguish these from possible harmful steps. Furthermore, Introduction: With laparoscopic cholecystectomy, 74.9% incorrectly selected one or more possible harmful Common bile duct (CBD) exploration and liver trans- steps as part of this technique. plantation being increasingly performed, and the wide- Conclusion: Responses indicate that practically all Dutch spread use of quality imaging, the presentation of patients surgeons and residents claim to use CVS. The majority of with benign biliary strictures (BBS) has increased

HPB 2018, 20 (S2), S685eS764 S760 Electronic Poster (EP03A-EP03F) e Biliary

Management decisions are very crucial in these conditions management. How long to keep the patients on follow up since the etiology is benign and the patients are young with surveillance is a question that needs to be answered. good life expectancy in contrast to malignancies where usually the aim of treatment is palliation. These strictures are ideally managed by an experienced hepatobiliary team EP03F-025 which greatly improves patient outcomes. XANTHOGRANULOMATOUS Objectives: To evaluate treatment modalities available for the management of BBS and to find the best possible CHOLECYSTITIS: STILL A approach. DIAGNOSTIC DILEMMA-OUR Methods: Clinical data of 38 patients who underwent EXPERIENCE e treatment at our institute between 2012 017 were analysed A. Pandey1, D. Kumar1, S. Masood1, S. Chauhan1, retrospectively from a prospectively maintained database. S. Kumar1 and K. Noman1 All the patients had been managed in our institute which 1Surgical Gastroenterology, RMLIMS, India specializes in the management of hepatobiliary diseases. Introduction: Aims of our study -To assess whether Results: 3 patients underwent Endoscopic chol- xanthogranulomatous cholecystitis can be diagnosed based angiopancreatography and stent placement (ERCP), and the on clinical presentation and radiological findings –Is intra rest underwent surgical biliary tract reconstruction with 9 operative frozen section enough to label xanthogranulom- patients doing so after failed ERCP. Patients who were atous cholecystitis vis a vis co existing carcinoma referred early had better outcomes when compared to pa- Materials and methods: A retrospective review of clinical tients who were referred late. record of 732 consecutive patients who underwent laparo- Conclusion: Early referral to a specialist hepatobiliary scopic/open cholecystectomy during the period of 4 years centre along with scrupulous use of imaging with surgical from October 2013 to November 2017. modality as the choice of management were related to Result and discussion: Out of 732 procedures performed better outcomes. Specialist management is recommended there were 34 cases of xanthogranulomatous cholecystitis. for the management of this condition. There were 2 cases of simultaneous gall bladder cancer with XGC. In one case of XGC reported on frozen section the final histopathology revealed carcinoma gallbladder EP03F-023 with presence of XGC. The other case revealed carcinoma ADULT BILIARY CYSTS e HURDLES gallbladder on frozen section and on final histopathology, FACED IN DIAGNOSIS AND there was presence of XGC with carcinoma gallbladder. The incidence of XGC was 4.5%. The mean age of pre- TREATMENT sentation was 52.1 years with a female to male ratio 1.6:1. H. S. Pranav, U. P. Srinivasan, S. Rajendran and Most common symptom was abdominal pain (96%) O. L. Naganath Babu followed by jaundice (15%) and fever (15%), weight loss, Institute of Surgical Gastroenterology, Rajiv Gandhi anorexia present and palpable RUQ mass present in 3.12% Government General Hospital and Madras Medical Col- of patients.Abdominal CECT revealed focal wall thickness lege, India in 16% and diffuse wall thickness in 60% of patients. He- Introduction: Biliary cysts, also known as choledochal patic and pericholecystic infiltration was present in 12% of cysts are benign dilatations of the biliary tract with malig- patients with 84% had associated cholelithiasis. nant potential. They usually are a disease of childhood but Conclusions: The diagnosis of xanthogranulomatous adult biliary cysts are now increasingly reported probably cholecystitis is only confirmed on histopathology. The because of better diagnostic modalities and increased clinical presentation is unequivocal in most cases. The awareness of the condition. They have varied modes of intraoperative frozen section may help in planning the presentation often puzzling the caregiver. Prompt recog- radical surgery but the final histopathology may reveal a co nition and treatment of this spectrum of conditions is existing cancer. important since they are known to result in recurrent cholangitis and progress to malignancy. Methods: Clinical data of 22 patients who underwent EP03F-026 various forms of treatment at our institute between 2012- REMNANT CHOLEDOCHAL CYST 2017 were analysed retrospectively from a prospectively WITH SYMPTOMATIC maintained database. Our department is a specialized hepa- tobiliary unit routinely managing liver and biliary diseases. CYSTOLITHIASIS Results: Symptoms were varied with pain and jaundice K. Muthalampet being the most common symptoms. Few patients presented Surgical Gastroenterology, Rajiv Gandhi Government with cholangitis and 1 patient with pancreatitis resulting in General Hospital and Madras Medical College, India a diagnostic dilemma. 81.8 % patients were female patients. Introduction: This case is a rare presentation owing to Majority of the cases were type 1 cysts, with 1 patient each stone formation in remnant intrapancreatic choledochal in type 2, 3, 4a, 4b and 5. Most of the patients underwent cyst, causing an episode of acute pancreatitis. excision of the cyst with a hepaticojejunostomy whereas Case report: A 23 year old female who underwent bile the patient with type 5 disease underwent left hepatectomy duct excision with roux en y hepaticojejunostomy for type as the disease was more severe in that lobe. 4a choledochal cyst in 2003 at presented with recurrent Conclusion: Choledochal cysts are recognised more episodes of abdominal pain, which Increased in severity commonly than before in adults. A high index of suspicion, over the last 3 months.she was diagnosed with mild acute prompt diagnosis and excision forms the mainstay of pancreatitis with elevated lipase level (1988 IU/l) and no

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S761 local complications secondary to pancreatitis. Mrcp scan at there are limitations to this study that can be considered in our center showed an impacted calculus in the remnant future studies. intrapancreatic choledochal cyst. Since it was a distal cal- culus, ercp with stone extraction was attempted twice but the ampulla could not be visualized. On exploration, the EP03F-028 blind end of the roux limb was adherent to the remnant cyst ADENOSQUAMOUS CARCINOMA IN and the stone was impacted in the intrapancreatic remnant choledochal cyst. The adherent blind end was taken down THE EXTRAHEPATIC BILE DUCTS: from remnant cyst and stone was extracted. The jejunal end TWO CASE REPORTS was reinforced in two layers and remnant cyst was closed I. Y. Park1,G.H.Na1 and H. J. Choi2 with vicryl. 1Surgery, Bucheon St. Mary Hospital, and 2Seoul St. Mary Conclusion: While complete excision of remnant chol- Hospital, Catholic University of Korea, Republic of Korea edochal cyst offers best curative option in terms of symp- Adenosquamous carcinoma in the extrahepatic bile duct tomatic relief and risk reduction for malignancy, complete is a rare disease. We report two adenosquamous carcinoma excision is not always feasible particularly in isolated patients that underwent radical operation. The first case was intrapancreatic remnant choledochal cyst. While there are a 74-year-old male patient was admitted due to swallowing case reports of stone extraction by ercp for such stones, the difficulties without jaundice. During the evaluation, CT and same failed in our patient on two occasions. Hence this case MRCP showed that there was a mass in the distal common is being presented for the novel approach of stone extrac- bile duct and multiple intrahepatic stones in the left lateral tion via cystolithotomy without dismantling the patent segment of the liver. The biopsy revealed an adenosqu- hepaticojejunostomy. amous carcinoma. He underwent Whipple’s operation and left lateral sectionectomy of the liver. He survived 87 months after the operation without chemotherapy. The EP03F-027 second patient was a 77-year-old patient who was admitted A PROSPECTIVE STUDY ON due to persistent jaundice and pruritus for 1 month. MEASUREMENT OF COMMON BILE Abdominal CT and ERCP showed multiple polypoid le- DUCT, CYSTIC DUCT AND ITS sions in the distal CBD and a polyp with stone in the gallbladder. She underwent pylorus preserving pancreato- ANATOMICAL VARIATIONS IN THE duodenctomy. Pathology showed combined adenosqumous MELANESIAN POPULATION OF PAPUA carcinoma and papillary carcinoma with lymph node in- NEW GUINEA vasion. Two months later, CT scan showed multiple liver A. Waine1, B. Korowaro1, I. Kevau2, F. Bannick3 and metastasis. She refused to receive chemotherapy. She sur- D. Lenturut4 vived 22months after surgery with liver metastasis. 1University of Papua New Guinea, 2Surgery, University of Adenosquamous carcinoma is a rare and aggressive fi Papua New Guinea, 3Pathology, and 4Radiology, Port disease. Their characteristics are variable. It is dif cult to Moresby General Hospital, Papua New Guinea diagnose the tumor preoperatively. Curative resection, however, can offer the chance of long-term survival. Introduction: The biliary system is involved in the pro- duction, transportation, concentration and storage of bile. At present, there is increasing incidence of Gall Bladder and Biliary tree diseases. Understanding the anatomy and EP03F-029 its variance helps in the diagnosis and provides best treat- TYPE IV-A CHOLEDOCHAL CYSTS ment option in under resource countries. DURING PREGNANCY Methodology: A prospective study over one year (October 2015 - October 2016) at a tertiary national referral hospital H. J. Jang and C. S. Park was done. Three different methods were used: Intra- Surgery, University of Ulsan College of Medicine, Gang- operative measurement, ultrasonographic studies and by neung Asan Hospital, Republic of Korea performing autopsy. All study population were adult and Purpose: Choledochal cysts in pregnant women represent a included both sexes. Data was recorded and analysed using diagnostic and therapeutic challenge to a broad spectrum of the Microsoft excel. the medical profession. As a result, diagnosis is often Results: Eighteen females (51.4%) and seventeen males delayed until patients present with life-threatening com- (48.6%) had surgery. The mean common bile duct and plications. We reported our experiences in managing one cystic duct diameter was 6.17 Æ 1.42mm and 5.71 Æ case of choledochal cyst in pregnant patient 2.07mm respectively. 36.9% male and 63.1% female had Case report: A 28-year-old primigravida at 36-wk gesta- ultrasound scan. The mean common bile duct diameter was tion presented with jaundice, upper abdominal pain during 6.31Æ3.85mm. Two - third of Seventy- three autopsies the past three months and was admitted. Ultrasound & MRI done were male. The mean common bile duct and cystic examination showed a cystic lesion, 12 cm  9cm 10 cm duct diameter were 4.96 Æ 1.10mm and 3.81 Æ 1.02mm at the right upper quadrant with a dilated intrahepatic ducts respectively. Common anatomical variants found were, in left lobes of liver. Diagnosis was gestation with a type insertion of cystic duct to the left border of common bile IV-A choledochal cyst. Percutaneous transhepatic biliary duct, cystic duct arising from right hepatic duct, and drainage was performed. She delivered C/S 2 weeks later. invariably an absent cystic duct. As choledochal cyst was attached to the surrounding tis- Conclusion: Despite anatomical changes observed during sues, it was dissected using Left lobectomy & cyst Excision the diseased biliary system, the nominal dimension and and hepaticojejunostomy 3 weeks after delivery. The pa- variation is consistent in the study population. However, tient was discharged 10 d postoperation.

HPB 2018, 20 (S2), S685eS764 S762 Electronic Poster (EP03A-EP03F) e Biliary

Conclusion: More conservative approaches such as Background: We analyzed patients initially diagnosed as external drainage of choledochal cyst should be considered gallbladder cancer but resulting in postoperative patho- for pregnant patients with high risk, complete excision of logical diagnosis as benign lesions. choledochal cyst during hepaticojejunostomy is recom- Patients: This study included 110 patients undergoing mended at the optimal time. Excision of only the extrahe- operation with preoperative diagnosis of gallbladder cancer patic part of the cyst has become the accepted form of in our institution from 1994 to 2017. Among them, 4 cases treatment for type-IV-A cysts. Hepatic resection for a type (3.6%) were diagnosed as benign as a result of post- IV-A choledochal cyst should be considered when the operative pathological diagnosis. intrahepatic dilatation is confined to one part of the liver Results: The breakdown of the subjects was 3 males and 1 We think that lt. lobectomy may be indicated in type IV-A female, and the average age of the cases was 67.3 years. All choledochal cyst pts. with an intrahepatic stricture that exist cases were diagnosed as advanced gallbladder cancer with deep in the liver parenchyma. varying organ invasions, such as the liver, duodenum or transverse colon. Three patients underwent intraoperative rapid pathologic diagnosis of bile duct or cystic duct stump, and no malignant finding was observed. Two patients un- EP03F-030 derwent surgery with hepatectomy + extrahepatic bile duct A RARE CASE OF SPONTANEOUS resection, one patient underwent pancreaticoduodenectomy COMMON BILE DUCT PERFORATION + right hemi-colectomy, one patient underwent extended N. Thiruchelvam, L. S. Lee, A. K. H. Chiow and S. S. Tan cholecystectomy and extrahepatic bile duct resection. In fi General Surgery, Changi General Hospital, Singapore postoperative pathologic ndings, they were diagnosed as Xanthogranulomatous cholecystitis (XGC). Spontaneous perforation of the common bile duct (CBD) Conclusion: Each of the 4 cases could have avoided in adults is an extremely rare complication of gallstones. It excessive surgery if we had diagnosed as XGC preopera- is challenging to establish the diagnosis pre-operatively tively or intraoperatively. In all cases, intraoperative rapid however with increasing utility of computer tomography, pathologic diagnosis of the excised specimen was not there may be subtle features visualized. We describe a case performed, with a possibility that excessive surgery may of a 35 year old Indian male who presented with an acute have been prevented of it had been performed. Even in the abdomen and was found to have biliary peritonitis sec- case of gallbladder cancer with invasion into surrounding ondary to a spontaneous CBD perforation. organs, it is better to consider performing careful preoper- Mr JJ presented with sudden onset of abdominal pain ative examination, and intraoperative rapid pathological associated with vomiting and diarrhea. He had generalized diagnosis of the excised specimen, keeping in mind of the abdominal peritonitis. Initial erect chest x-ray was unre- possibility of a benign lesion hiding in XGC. markable for free air under the diaphragm, hence a CT was performed which revealed moderate amounts of free fluid around the 2nd part of the duodenum extending along the anterior para-renal space into the pelvis, with a 4mm distal EP03F-033 CBD stone resulting in mild upstream dilatation. The PROGNOSTIC RELEVANCE OF THE gallbladder was decompressed and the CBD wall was not MODEL FOR END-STAGE LIVER well visualized in the mid-portion, raising the possibility of DISEASE (MELD) IN PATIENTS WITH perforation. POST-CHOLECYSTECTOMY BILE An exploratory laparotomy revealed generalized biliary peritonitis secondary to a 2 cm CBD perforation just distal to DUCT INJURY: A TERTIARY HOSPITAL the cystic duct junction. Choledochoscopy confirmed the EXPERIENCE small 4mm distal CBD stone which was advanced success- R. J. Romero, R. Ong-Abrantes, A. Canones, E. Domingo, fully through the ampulla into the duodenum. He underwent A. David, R. R. Barroso, R. Fernandez, E. Tan and abdominal lavage, cholecystectomy, choledochectomy and a R. Sarmiento roux-en-Y hepatico-jejunostomy reconstruction. His recovery Department of Surgery, Section of Hepatopancreatobiliary was uneventful. Histology confirmed focal transmural necro- Surgery, Rizal Medical Center, Philippines fi sis of the bile duct with brosis and micro-abscess formation. Background: Bile duct injury during cholecystectomy, Clinicians should be aware that whilst spontaneous though uncommon, results in a vast spectrum of compli- extrahepatic bile duct perforations are rare, it is important cations that may greatly impact the quality of life of the as timely diagnosis can be life-saving. patient. Prognostication in these patients is important to determine the appropriate endoscopic or surgical manage- ment. Model for End-Stage Liver Disease (MELD) is a EP03F-031 laboratory-based prognostic tool that is mainly used in liver ANALYSIS OF BENIGN GALLBLADDER transplantation, but has also been proposed for critically ill LESION SURGICALLY RESECTED BY patients with compromised liver function. The study aims PREOPERATIVE DIAGNOSIS OF to evaluate MELD as a prognostic tool in patients with post-cholecystectomy bile duct injuries. GALLBLADDER CANCER Methods: 25 patients diagnosed with post-cholecystec- Y. Wakasa, N. Kimura, K. Ishido, D. Kudo and tomy bile duct injury were included and retrospectively K. Hakamada reviewed from 2016 to 2017. Types of injury was docu- Gastroenterological Surgery, Hirosaki University Grad- mented via endoscopic retrograde cholangiography or uate School of Medicine, Japan transhepatic cholangiography and classified according to

HPB 2018, 20 (S2), S685eS764 Electronic Poster (EP03A-EP03F) e Biliary S763 the Hannover classification. The pre-operative MELD Introduction: Biliary dyskinesia is a motility disorder of score was obtained and correlated with the following: pa- the gallbladder in the absence of gallstones or cystic duct tient characteristics, perioperative variables and post- obstruction. Typically these patients present with right operative outcomes, including mortality rates. upper abdominal pain, bloating, eructation, vomiting and Results: Out of 25 patients, 13 (52%) had open and 12 nausea. When the diagnosis is confirmed, laparoscopic (48%) had laparoscopic cholecystectomy. 17 patients cholecystectomy is indicated. (68%) were referred to our center within 6 weeks from the Method: The authors present two clinical case reports. time of injury. 14 (56%) were managed by endoscopic Twenty five-year-old and 41-year-old ladies, without stenting, while 7 (28%) had definitive surgical reconstruc- comorbidities, with repeated episodes of right upper tion. There were no mortalities for patients with MELD abdominal pain and nausea. They had an ultrasonography score < 20. However, for those patients with MELD scores and an MRI which did not show any changes. We ordered of 20-29 and 30, the mortality rate was 50% and 100%, an Hydroxyiminodiacetic acid (HIDA) scan that confirmed respectively. the diagnosis of biliary dyskinesia by showing an ejection Conclusion: MELD score is a potential prognostic tool for fraction of 12% and 15% respectively. Surgical interven- patients with iatrogenic bile duct injury sustained during tion was proposed. cholecystectomy. Results: Laparoscopic cholecystectomy was performed without complications. The pathology report reveals lesions of chronic cholecystitis without evidence of gallstones. In EP03F-034 the follow-up visits the patients are asymptomatic. RUPTURED CHOLEDOCHAL CYST IN Conclusion: Biliary dyskinesia is a rare disorder. With clinical suspicion in the absence of gallstones a functional ADULTS radionuclide study to investigate gallbladder ejection frac- S. R. V. Gunturi1, G. R. Gondu1, V. Thumma1, tion is mandatory. An ejection fraction of less than 35% is J. R. Bathalapalli1, N. Kunduru1, D. Sarma1, C. V. Vishnu1, considered abnormal and patients should undergo chole- B. Nagari1 and M. Nambada2 cystectomy as literature reports clinical improvement in 1Surgical Gastroenterology, Nizams Institute of Medical 98% of patients. Sciences, and 2Nizams institute of medical sciences, India Introduction: Rupture of Choledochal cyst is very rare.- when compared with paediatric patients it is even rare in EP03F-036 adults. CLINICAL COMPARISON BETWEEN Method and results: We present two cases of Ruptured EXTERNAL VERSUS INTERNAL- choledochal cyst. In First case a young gentleman presented with features of generalized peritonitis .laparotomy EXTERNAL PERCUTANEOUS confirmed choledochal cyst perforation.Damage control TRANSHEPATIC BILIARY DRAINAGE surgery was done in the form of T-tube placement after FOR MALIGNANT peritonel lavage.He recovered well and was planned for PANCREATICOBILIARY second stage surgery of choledochal cyst excision. In OBSTRUCTION second case a young lady presented with right upper 1 2 1 abdominal pain and evaluation revealed Choledochal D. A. Awang Dahlan , H. Othman , N. A. Nik Abdullah , 3 4 cyst.she was planned for NBD(Naso biliary drainage) and A. F. Mohamad Ali and A. Azman 1 2 percutaneous drainage for the clinical suspicion of Surgery, Sarawak General Hospital, Surgery, Universiti 3 contained rupture but she developed signs of generalized Kebangsaan Malaysia, Interventional Radiology & 4 peritonitis and emergency surgery was performed and Diagnostic Imaging, National Cancer Institute, and Sur- recovered well. gery, Universiti Kebangsaan Malaysia Medical Centre, Conclusions: The rupture of choledochal cyst can occur Malaysia without any prior episodes of pain abdomen as was seen in Objectives: The ideal intervention for patients with ma- both of our patients. With Availability and Advances in lignant pancreaticobiliary obstruction has not been estab- imaging along with clinical suspicion it is possible to di- lished and still depends on favoured local policy. We agnose rupture preoperatively.After Rupture the patients design this study to compare the clinical outcome between may have a generalized peritonitis as seen in first case or external versus internal-external percutaneous transhepatic they may have a initial localized symptoms due to biliary drainage. contained rupture as seen in second.A staged surgery may Methods: This is a retrospective study recruiting patient be a safe option in patients with generalized peritonitis. with malignant pancreaticobiliary obstruction who presented to Sarawak General Hospital between 2011 until 2016. Patient who required percutaneous intervention, EP03F-035 either external percutaneous transhepatic biliary drainage e (EPTBD) or internal-external percutaneous transhepatic BILIARY DYSKINESIA IS IT STILL biliary drainage (IEPTBD) is included based on selection A REALITY AND AN INDICATION FOR eligibility. Data was extracted from medical records and CHOLECYSTECTOMY? radiological imagings and entered into a standardized form. M. Sá, J. Constantino, C. Prudente, C. Daniel, Results: 93 patients with malignant pancreaticobiliary J. Pereira and C. Casimiro obstruction were included. 49 male and 44 female patients Serviço de Cirurgia Geral, Unidade de Cirurgia HBP, with the mean age of 63 years. 52 patients underwent Centro Hospitalar Tondela-Viseu, Portugal EPTBD and 41 patients underwent IEPTBD. There was no

HPB 2018, 20 (S2), S685eS764 S764 Electronic Poster (EP03A-EP03F) e Biliary difference in the baseline demographics, type of primary Introduction: Laparoscopic cholecystectomy is one of the tumour, level of obstruction and pre-procedural laboratory most frequently performed surgical procedures. The most data between the two groups. Comparison between EPTBD feared complication is iatrogenic bile duct or vascular and IEPTBD showed no significant difference in effec- injury.Misperception of intraoperative anatomy is one of tiveness of biliary drainage and post-procedural cholangitis the most important causes of these injuries. To decrease the and sepsis. However, IEPTBD has significantly higher incidence of bile duct injuries, Strasberg introduced the post-procedural complications at 39% compared to EPTBD “critical view of safety” technique in 1995. The use of at 17% (p value = 0.02). complimentary methods to avoid iatrogenic bile duct in- Conclusions: EPTBD is recommended as the preferred juries, such as intraoperative cholangiography (IOC), is intervention for patients with malignant pancreaticobiliary recommended to define unclear anatomy. obstruction requiring percutaneous intervention. EPTBD Methods: The authors present thecase of a 32 year old may be less deleterious to certain high risk group, namely, patient admitted for elective laparoscopic cholecystectomy the elderly, patients with proximal obstruction and those due to symptomatic cholelithiasis. During dissection of with pre-procedural cholangitis and sepsis. However, Calot’s Triangle in order to obtain the critical view of selected palliative cases may benefit from the more physi- safety, we’ve identified more than two structures. ological drainage of IEPTBD. Results: IOC revealed anomalous drainage of the right posterior segmental duct to the cystic duct. The cystic duct was divided above the insertion of this segmental duct. EP03F-037 Postoperative period was uneventful. A RARE CASE OF ATYPICAL Conclusion: Biliary anatomy and its common and uncom- mon variations are of considerable clinical significance. BRANCHING PATTERN OF AN Normal biliary anatomy is thought to be present in 58% of the INTRAHEPATIC BILE DUCT population and atypical branching patterns of intrahepatic bile C. Afonso1, J. Pereira2, C. Daniel1, C. Prudente1, ducts were found up to 37% of cases. Anomalous drainage of J. Constantino1, M. Sá1 and C. Casimiro1 the right posterior segmental can be subdivided into types 3A, 1Centro Hospitalar Tondela-Viseu, and 2General Surgery, 3B, and 3C, according to the literature. This case represents a Centro Hospitalar Tondela-Viseu, Portugal type 3C because it drains into the cystic duct.

HPB 2018, 20 (S2), S685eS764