Poster
Biliary 		  
Friday 27 November 15:00 – 15:30   Poster Library
PB04 Biliary: Surgical Outcomes (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PB04-04  Early Laparoscopic Cholecystectomy Using the Bailout Procedure for Acute Cholecystitis with Severe Local Inflammation
Koji Asai, Japan

K. Asai, M. Watanabe, M. Kujiraoka, H. Moriyama, R. Watanabe, N. Kakizaki, S. Teraoka, Y. Saida
Surgery, Toho University Ohashi Medical Center, Japan

Introduction: The Tokyo Guidelines 2018 have proposed a bailout procedure that includes the fundus first technique and subtotal cholecystectomy to prevent bile duct injury and vasculo-biliary injury in acute cholecystitis (AC) with severe local inflammation, especially at Calot's triangle. The study aim was to assess the influence of laparoscopic cholecystectomy (LC) using the bailout procedure for AC with severe local inflammation.
Patients and methods: A total of 362 patients were enrolled during 15-year study period. The median preoperative length of hospitalization was 1 day (range, 0-30 days). The patient's characteristics, therapeutic strategies, and operative results were compared between the former period (n = 260) and a recent 3-year period (n = 102).
Results: In both groups, approximately 20% of the patients with taking antithrombotic agents, and approximately 30% of the patients had severe local inflammation, including gangrenous cholecystitis. Early LC within 4 days after admission was predominantly performed in the recent period (100 cases, 98.0%, p < 0.001). Conversion to open surgery decreased from 6.5% to 1.0%, and postoperative complication was decreased from 4.2% to 2.0%. The postoperative and total length of hospitalization were significantly shorter in the recent period than in the earlier period
(3 days and 5 days, respectively).
Conclusions: Active performance of the bailout procedure and technical modification were associated with fewer conversion to open surgery and postoperative complications, leading to significant decreases in the postoperative and total length of hospitalization for AC patients with severe local inflammation.
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PB04-08  Outcome of Post Cholecystectomy Bile Duct Injury Management in a High Volume Referral Center in Iran
Nasir Fakhar, Iran, Islamic Republic of

N. Fakhar1,2, S.Y. Zarghami2, A. Jafarian2, S.H. Dashti2
1Surgery, Tehran University of Medical Sciences, Iran, Islamic Republic of, 2Hepatobiliary and Visceral Transplant Research Center, Tehran University of Medical Sciences, Iran, Islamic Republic of

Introduction: However more than a century pass from first cholecystectomy and iatrogenic bile duct injury, still this is a big problem, here we report our experience in a high volume referral center in Iran about handling of this complication.
Methods: We collect data of 59 patient who referred us , suspected to post-cholecystectomy bile duct injury for 3 years since may 2016 both retrospectively through review of charts and calling them and prospectively by regular out-patient visit.
Results: In this period 59 patients with age range of 20 to 74y/o referred our center, 15 male and 44 female. 21 patients underwent definite repair in 2 weeks from injury,17 patient after 2 weeks and before 6 weeks and 21 patients after 6 weeks. The most common presenting feature was bilious drain discharge, MRCP and ERCP was falsely negateive in 23.07% and 11.53% repsctively and the most reliable point was primary surgeon think of “something is wrong during surgery”.17% of patients had failed repair in original hospital and 33.9% had exploration ,irrigation and drainage.laboratory abnormality just in 66% of patients detected, most injuries was in Bismuth classII(18%),III(16%)and IV(16%),and Rt hepatic artery injury detected in 27(45.8%)patients.hepatectomy did in two patients and two patients died. No significant deference found when interval from injury to definite surgery compared between groups.
Conclusion: Best decision for patients suspected to bile duct injury is referring to a high volume center at any time before exploration and with any interval from injury, HPB surgeon can go for repair.
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PB04-09  Surgery for Recurrent Biliary Carcinoma: Results for 5 Recurrent Cases
Shojiro Hata, Japan

S. Hata, A. Kuroda, M. Hayasaka, K. Yamaguchi, M. Teruya, M. Kaminishi
Department of Gastrointestinal Surgery, Showa General Hospital, Japan

Introduction: Typically chemotherapy has been used as standard treatment and surgeries were rarely performed for recurrent extrahepatic biliary carcinoma (RBC). Thus whether surgery for RBC is feasible has remained unclear.
Methods: From 2013 to 2019, 5 patients underwent radical resection for RBC at our institution. We retrospectively reviewed the medical data.
Results: Recurrence sites were liver metastasis in 3 patients (LM group) and local or bile duct recurrence in 2 patients (BD group). In the LM group, the underlying pathology was distal bile duct carcinoma, gallbladder carcinoma and ampullary carcinoma. Limited resections of the liver were performed for all 3 patients in the LM group. There was no morbidity nor mortality. 1 patient with liver metastasis of gallbladder carcinoma survived 6 years after surgery for RBC. The other 2 patients had recurrence at 9 and 14 months after surgery. In the BD group, the underlying pathology was distal bile duct carcinoma and proximal bile duct carcinoma. 1 patient underwent pancreaticoduodenectomy in the primary surgery and extended right hemihepatectomy for RBC. The other underwent central bisegmentectomy of the liver in the primary surgery and right lateral sectionectomy of the liver for RBC. There was morbidity in 1 patient but no mortality. Both patients could achieve curative resection and survive without recurrence for 9 and 2 months after surgery for RBC.
Conclusion: Surgery for RBC is technically demanding procedure but appears feasible and have a possibility of offering longer survival for selected patients but we should be cautious of indication.
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PB04-10  Incidence and Impact of Concomitant Vascular Injuries in Post-Cholecystectomy Bile Duct Stricture: A Prospective Study with MR Angiography
Saurabh Galodha, India

S. Galodha1,2, R. Saxena2, S. G2, R. Singh2, A. Behari2, V.K. Kapoor2
1G I Surgery & Liver Transplantation, AIIMS, India, 2Surgical Gastroenterology, SGPGIMS, India

Introduction: Impact of concomitant vascular biliary injury (VBI) on post- cholecystectomy benign biliary stricture (BBS) repair is still debatable with studies both in favor and against. In our study we look for incidence of VBI and impact on long-term outcomes.
Methods: Consecutive patients with BBS during the period December 2010 to May 2012 were included. Magnetic resonance angiography (MRA) with MRCP was done prior to repair. Long-term outcomes were analyzed as per McDonald grading.
Results: 36 patients were included in the study. Median age was 36 (15-70) years and 28 (78%) were females. 10 patients (28%) had prior failed repair. 23 (64%) patients had high strictures (Bismuth Type ≥3). VBI was present in 22 (61%) involving right hepatic artery (RHA). Of these, laparoscopic cholecystectomy was performed in 18 patients (82%). Additionally right portal vein injury was present in one patient. In patients with prior failed repair 5 (50%) had RHA injury. 34 patients underwent Roux en Y hepaticojejunostomy (RYHJ). Median blood loss was 300ml (range 50-950). Median duration of surgery was 5 hours (range 2-9). Complications were present in 13 (36%) patients. At median follow up of 48 months (24 - 60), there were 8 failures (Success= 76%) requiring re-intervention. Two patients required right hepatectomy. Failed previous repair and secondary biliary cirrhosis were significantly associated with failure.
Conclusion: Concomitant VBI has significant impact on long-term outcomes of BBS repair. It will be prudent to do MRA with MRCP during workup of BBS patients for better management planning
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PB04-11  Does Concomitant Vascular Injury Have an Impact on the Outcome after Surgical Repair of Iatrogenic Bile Duct Injuries
Sarun Mahasupachai, Thailand

S. Mahasupachai1, S. Asavakarn2, S. Limsrichamrern3
1General Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand, 2Surgery, Bangkok General Hospital, Thailand, 3Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand

Introduction: Effect of concomitant vasculobiliary injury (VBI) and timing for surgical repair remains debatable in case of iatrogenic bile duct injuries (IBDI). Result from previous studies are difficult to compare because difference in definition of patency. This study evaluates outcome of surgical repair for IBDI with or without VBI using standards for reporting outcome proposed by Starberg et al. in 2018.
Method: A retrospective study of 78 patients with IBDI treated with surgical repair from 2010-2019 was conducted to compare the patency between VBI and non-VBI patients. We also analyzed patency in VBI patients with immediate, early and late repair.
Results: Twenty-four and 54 patients were categorized into VBI and non-VBI groups respectively.The most common vascular injury was right hepatic artery (22/24). Follow-up ranged from 7-120 months (median 36 months). Hepaticojejunostomy is the most common procedure, which was performed in 90% of the patients. Primary repair with T-tube was performed in 10%. There was no difference in the patency grading after the primary treatment between VBI and non-VBI patients (p=1.00). Both methods of repair result in similar patency grading. In VBI group, subgroup analysis of the timing of repair showed no difference in patency rate [Immediate vs. early vs. late repair (p=0.338)]
Conclusion: Our study results indicate that VBI and timing of the repair are not associated with poor long-term treatment outcome. Based on our findings, an attempt to repair concomitant vascular injury is not necessary and the primary surgical treatment does not need to be delayed.
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PB04-12  Single Incision Laparoscopic Cholecystectomy: Lessons Learned from 1300 Consecutive Patients in a Single Center
Seung Jae Lee, Korea, Republic of

S.J. Lee, I.S. Choi, J.I. Moon
Surgery, Konyang University, Korea, Republic of

Introduction: Single incision laparoscopic cholecystectomy (SILC) is a considerable option in benign gallbladder surgery. We have developed Konyang Standard Method(KSM) for SILC and gradually innovated KSM. We report the outcomes of our high volume data of SILC.
Methods: We retrospectively reviewed the preoperative characteristics and surgical outcomes of 1313 consecutive patients who underwent SILC at a single institution between April 2010 and July 2019. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM(mKSM). After that, we have used a commercial 4-channel (Glove) port for simplicity(C-mKSM).
Results: The patients included 745 women and 568 men (mean age, 51.4 years). The most common preoperative diagnosis was chronic cholecystitis (n=458, 34.9%). The mean operative time and postoperative hospital stay were 51.83 minutes and 2.55 days, respectively. Overall complication rate was 4.0%. Conversion rate to conventional laparoscopic cholecystectomy and open cholecystectomy were 1.7% and 0.1%, respectively. The proportion of acute cholecystitis was highest in phase 2 (37.0%) and lowest in phase 3 (19.9%). The surgical outcomes were significantly improved in phase 3 period (C-mKSM). On multivariable analysis, acute cholecystitis was risk factor for major complication, conversion, and prolonged operative time.
Conclusion: In our experience, SILC can be a safe and feasible treatment for benign gallbladder disease and the use of the mKSM with a commercial 4-channel port was most effective. However, in case of acute cholecystitis, SILC should be selected carefully.
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PB04-13  The Safety and Feasibility of Single Incision Laparoscopic Cholecystectomy for Acute Cholecystitis: Comparison with Conventional Laparoscopic Cholecystectomy
Seung Jae Lee, Korea, Republic of

S.J. Lee, I.S. Choi, J.I. Moon
Surgery, Konyang University, Korea, Republic of

Introduction: Single incision laparoscopic cholecystectomy (SILC) is a considerable option in benign gallbladder surgery. However, the safety and feasibility of SILC in acute cholecystitis has not been confirmed. We report our surgical outcomes of SILC in acute cholecystitis compared with conventional laparoscopic cholecystectomy (CLC).
Methods: 386 patients who underwent SILC and 592 patients who underwent CLC for acute cholecystitis between April 2010 and December 2018 in single institution were retrospectively reviewed the preoperative characteristics and surgical outcomes.
Results: The patients in CLC group were older (55.1 vs 65.0 years, p< 0.001), higher ASA score (12.7 vs 35.5% in over III, p< 0.001), and higher incidence of preoperative percutaneous transhepatic gallbladder drainage (PTGBD) than the patients in SILC group. According to Tokyo guideline 18, the patients above grade 2 were more common in the CLC group (15.8 VS 24.3%, p=0.001). There is no statistical significance in operative time, Blood loss, intra-operative transfusion, adjacent organ injury, open conversion, postoperative complication, incisional hernia, and mortality. The length of postoperative hospital stay was significantly shorter in SILC group. On multivariable analysis, grade II or III acute cholecystitis according to Tokyo guideline 18 (TG18), was risk factor for major complication and prolonged operative time.
Conclusion: In our experience, SILC can be a safe and feasible treatment for acute cholecystitis, if appropriate experience and when expertise is available. However, in case of grade II or III acute cholecystitis according to TG18, SILC should be selected carefully.
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PB04-14  Cholecystectomy Outcomes in Pancreas-kidney Transplant Recipients Compared to Kidney or Pancreas Transplant Alone Recipients
Lauren Weaver, United States

L. Weaver1, A. Parsikia2, J. Colvin3, E. Siskind4, T. Clark5, J. Ortiz4
1Department of Surgery, University of Minnesota, United States, 2University of Pennsylvania, United States, 3Urology, University of Toledo Medical Center, United States, 4Albany Medical Center, United States, 5University of Toledo College of Medicine, United States

Introduction: Previous studies have demonstrated that kidney transplant recipients have greater risk for all cause morbidity and mortality when undergoing cholecystectomy. However, cholecystectomy following pancreas transplantation has not been previously studied.
Methods: In a total 3738229 cholecystectomies performed in the United States between 2005-2014. There were 600 cholecystectomies performed in pancreas transplant recipients. There were 57.1 White patients and 36.2% male patients. There were 58.5% male pancreas transplant patients and 72.2% White pancreas transplant patients. 75% of pancreas transplant patients received their cholecystectomy at a transplant center.
Results: Pancreas transplant alone was associated with a significantly higher odds ratio for developing any complication (3.158, p< 0.001). Simultaneous kidney pancreas transplant was not significantly different compared with the general population. (P 0.787). At transplant centers, odds ratio for complications for PTA was significantly higher than at non transplant centers (OR 1.748 P 0.025).
Discussion/Conclusion: The results of this study differs from previously published materials. While the PTA results are consistent with previously published data showing that transplant recipients are at higher risk for morbidity and mortality when undergoing cholecystectomies, the SPK results showing no difference are unique. This may indicate that factors beyond obligate immunosuppression are causative and require further investigation. Higher rates of complications at transplant centers may be reflective of common practice patterns where patients with greater disease severity and complexity are transferred to specialized quaternary care transplant centers, rather than treated in the community setting.
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PB04-15  Outcomes of Common HPB Cases in Rural Australia: Identifying Predictors of Tertiary Care Management
Olukunle Onasanya, Australia

O. Onasanya, H. Azher, M. Rouse, V. Usatoff
Upper GI/HPB Unit, Department of Surgery, Western Health, Australia

Introduction: Hepato-Pancreatico-Biliary (HPB) surgery remains an important sub-speciality of General Surgery due to the complexity and the multidisciplinary approach required for the management of these cases. The rural general surgeon is often in a position to either manage or transfer these often-complex cases. Resource availability and remote location pose significant obstacles to the timely and specialised treatment of these conditions. Our primary endpoint was to identify predictors of tertiary referral for common HPB emergencies presenting to a rural general surgery service.
Methods: After obtaining relevant ethics approvals, we conducted a review of common HPB cases in two main hospitals in central Victoria over a 2-year period. Both centres have an elective ERCP service.
Results: Age was not a predictor for requiring tertiary care whilst cholangitis was; with 60% of transfers due to this. 106 ERCPs were performed with 55% for emergency presentations. Patients requiring ICU care were transferred pre-operatively. Three patients had bile leaks post cholecystectomy. Overall, about 10% of the HPB cases presenting to these centres were transferred to tertiary facilities.
Conclusion: Regional centres are an integral part of the management of common HPB emergencies with most cases handled successfully locally; we however advocate the need for a regular on-call roster to manage cholangitis or the establishment of a transfer algorithm to improve the care delivered to this subset of patients.
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PB04-18  On-table Hepato-pancreatico-biliary Surgical Consults for Difficult Cholecystectomies Have Inferior Outcomes
Ailica Lee, Singapore

A. Lee, K.S. Chan, E. Hwang, J.K. Low, T. Ju Cheong Wei, V. G. Shelat
General Surgery, Hepato-Biliary Team, Tan Tock Seng Hospital, Singapore

Introduction: Laparoscopic cholecystectomy is a general surgical operation. “Call for help" is an acceptable standard for intra-operative difficulties. Locally, “call for help” is attended by hepato-pancreatico-biliary (HPB) specialists. We audit referral patterns and outcomes for on-table referrals for difficult cholecystectomy.
Methods: During the seven-year period from 2011-2017, 87 on-table HPB consults were attended. Patients who required HPB referral for oncologic clearance or multivisceral resection were excluded. 50 patients with on-table cholecystectomy consults were included. Patient demographics, reason for referral, perioperative and postoperative outcomes were studied.
Results: There is a male predominance (n=33/50, 66.0%) with median age of 62.5 years. No patient had previous HPB pathology. Majority of the surgery were started laparoscopic (n=48/50, 96.0%). Median operating time and blood loss was 165 (IQR 124 - 209) minutes and 100 (IQR 50 - 200) mL respectively. 17 (34.0%) were emergency cholecystectomies. Gallbladder median thickness was 5 (IQR 4 - 7) mm. Majority of the consults were reactive (n=49, 98.0%). The reason for consult was: anatomical difficulties (n=24/49, 49.0%), pathological difficulties (n=22/49, 44.9%) including gangrenous/emphysematous cholecystitis or empyema, and surgical complications (n=14/49, 28.6%) including bile duct injury (n=3, 6.0%), cystic duct injury (n=3, 6.0%) and cystic artery injury (n=1, 2.0%). Open conversion was 31.3% (n=15). Median length of stay was 5 (IQR 3 - 7) days. There was no 30-day or 90-day mortality.
Conclusion: Outcomes of cholecystectomy patients who needed on-table consult are inferior to expectations. It remains to be shown if a proactive approach to engage HPB specialists may improve outcomes.
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PB04-19  Incomplete Surgical Resection Can Cause Severe Complications after Extensive Hepatobiliary Resection for Hepatobiliary Disease
Norihisa Kimura, Japan

N. Kimura, K. Ishido, T. Wakiya, H. Nagase, K. Hakamada
Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan

Introduction: The aim of this study was to identify the predictors for fatal complication (FC) and 3 severe complications: biloma (BL); infectious complication (IC); hepatic insufficiency (HI) after extensive hepatobiliary resection for hepatobiliary disease.
Methods: One hundred forty patients who underwent major hepatectomy with biliary reconstruction between January 1999 and December 2019 were identified. FC was defined as ≥ Clavien-Dindo classification (C-D) grade IVa. BL was defined as ≥ C-D grade IIIa. IC included all surgical site infections. HI was defined as total bilirubin >7.0 mg/dL postoperatively or within 50-50 criteria (total bilirubin of >3.0 mg/dL and prothrombin time < 50% on postoperative day 5).
Results: FC, BL, IC, and HI occurred in 8 (5.7%), 23 (21.1%), 47 (43.1%), and 22 (20.2%) patients, respectively. In univariate analysis, the significant predictors for FC were right side hepatectomy (p=0.041) and cancer-positive margin (p=0.034) which was also independently associated with FC (odds ratio (OR)=4.44, p=0.049) in multivariate analysis. Cancer-positive margin was the only risk factor for BL (p=0.005) and IC (p=0.011) in univariate analysis. Regarding HI, male (p=0.034), cancer-positive margin (p=0.027), right side hepatectomy (p=0.007), preoperative portal vein embolization (p=0.044), blood loss >2000 mL (p=0.033), and blood transfusion (p=0.013) were found to be risk factors in univariate analysis, while blood transfusion (OR=4.46, p=0.035) was the only independent factor and cancer-positive margin was close to significance (OR=2.55, p=0.076) in multivariate analysis.
Conclusions: Incomplete surgical resection in addition to excessive surgical stress caused by extensive hepatobiliary resection can trigger hypercytokinemia and worsen postoperative condition.
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PB04-20  Management of Iatrogenic Bile Duct Injuries Following Cholecystectomy in Cipto Mangunkusumo General Hospital Indonesia
Lam Sihardo, Indonesia

L. Sihardo, T. Lalisang
Digestive Division, Surgery Departement, University of Indonesia, Cipto Mangunkusumo Hospital, Indonesia

Introduction: Iatrogenic bile duct injuries (IBDI) were most common caused by cholecystectomy during laparoscopy than laparotomy. The aim of this study was to evaluate the management of IBDI following cholecystectomy procedure in Cipto Mangunkusumo General Hospital, Jakarta as a tertiary hospital.
Methods: The cross-sectional design was used. We collected patient who undergo IBDI repair since January 2015 until December 2019. We retrospectively analyzed the repair technique, and follow up post-operative.
Results: There were 13 patients, who undergo IBDI repair. The median age of the patient was 48 years with composition were 6 male and 7 female. There was 3 patients who proceded laparoscopy cholecystectomy. The whole patients referred from secondary hospital. We performed hepaticojejunostomy Roux-en-Y to the 11 patients who experiences IBDI and performed drainage in patients due to bile leakage. There were 6 patients which classified as Strasberg E3 type and the rest of it were classified as E1 type. No mortalities were detected post-operatively. Median length of stay of the patient was 27 days and no jaundice recur reported after long-term follow up.
Conclusion: Hepaticojejunostomy Roux-en-Y procedure already becomes the first choice in the management of IBDI in our hospital. The prognosis after the procedure tented to be good.
Key words: Iatrogenic bile duct injury, Cholecystectomy
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PB04-21  Clinical Significance of Intraoperative Bile Culture in Surgery Including Bile Duct Resection
Youngju Ryu, Korea, Republic of

Y. Ryu, N. Kim, Y.H. You, I.W. Han, J.S. Heo, D.W. Choi, S.H. Shin
Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of

It is widely accepted that intraoperative bacterial infection may potentially result in a worse postoperative outcomes. The purpose of this study is to analyze the microbiology of intraoperative bile smear culture test and the correlation between the results of culture and postoperative outcomes in bile duct resection operation.
Methods: The data was prospectively collected from 235 patients who underwent bile duct resection at Samsung Medical Center for one year from October 2018 to September 2019. The diseases included in the data are periampullary cancer, gallbladder cancer, hilar cholangiocarcionoma, and intrahepatic cholangiocarcinoma. Intraoperative bile smear test was performed in operation, and the included operation was pancreaticoduodenectomy and liver resection surgery with bile duct resection. Specimens were obtained from culture swab of bile drained during bile duct resection.
Results: Of the 235 patients, microorganism was isolated in 141 patients (60%). The predominant microorganisms grown from the intraoperative bile cultures were Enterococcus faecalis (38 cultures, 27.0%), Enterococcus faecium (32 cultures, 22.7%), Klebsiella pneumoniae and Enterobacter cloacae (28 cultures, 19.9%). In postoperative complication, the positive results of intraoperative bile cultures was related with Clavien-Dindo Classification≥Ⅲ (OR3.117, 95%CI:1.498-6.485, p=0.002). Also, it was a risk factors for occurrence of surgical site infection (OR3.266, 95%CI:1.237-8.621, p=0.013) and intra-abdominal abscess (OR1.145, 95%CI:1.057-1.240, p=0.003). In addition, the incidence of postoperative pancreatic fistula was increased in patients with microorganisms grown in bile (OR1.974, 95%CI:1.098-3.549, p=0.022).
Conclusions: Smear positivity of intraoperative bile fluid is associated with occurrence of major complication. It was risk factor for surgical site infection and intra-abdominal abscess.
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PB04-22  Adverse Effect of Sarcopenic Obesity on Postoperative Complications after Major Hepatectomy in Patients with Hilar Cholangiocarcinoma
Youngju Ryu, Korea, Republic of

Y. Ryu1, C.-S. Lim2, Y.C. Shin3, N. Kim4, Y.H. You4, S.H. Shin4, J.S. Heo4, D.W. Choi4, I.W. Han4
1Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of, 2Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Kosovo, Republic of, 3Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Kosovo, Republic of, 4Division of Hepatobiliary-pancreatic surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of

Recently, it is well known that sarcopenia is one of the risk factors on post-hepatectomy outcomes in patients with hepatocellular carcinoma. However, there were seldom reports for effect of sarcopenia or sarcopenic obesity (SO) on postoperative outcomes in patients with perihilar cholangiocarcinoma (CCC). The purpose of this study is to evaluate the effect of preoperative sarcopenia or SO on postoperative outcomes in patients with hilar CCC following major heptectomy.
Preoperative sarcopenia and SO was assessed in 328 patients undergoing hepatectomy for hilar CCC at three institution between 2006 and 2016, retrospectively. The sarcopenia was calculated from cross-sectional visceral fat and muscle area on preoperative CT imaging (muscle area/height2 = skeletal muscle index, SMI). SO was defined by visceral fat area/SMI.
Preoperative sarcopenia and SO was present in 97 (29.6%) and 98 (29.9%) of the patients. Preoperative sarcopenia itself was not associated with postoperative outcomes. However, the rate of major complication in patients with SO was higher than in those without SO (54.1 vs. 37.0%, p=0.004). Also, postoperative hospital stay was prolonged in patients with SO (18.5 vs. 16.5 days, p=0.038). After multivariable analysis, male sex (OR1.937, 95%CI:1.182-3.174, p=0.009) and SO (OR1.866, 95%CI:1.148-3.034, p=0.012) were independent risk factors for occurrence of major complication. There was no statistically significant in overall survival with sarcopenia or SO.
SO was an independent risk factor of major complication after hepatectomy in hilar CCC. As a result, careful postoperative management would be needed after major hepatectomy in patients with hilar CCC in case of SO.
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PB04-23  Surgical Management of Sectoral Bile Duct Injury after Cholecystectomy - A Case Series
Harjeet Singh, India

H. Singh1, M. Avudaiappan2, T.D. Yadav1
1Department of Surgery, Post Graduate Institute of Medical Education and Research, India, 2Post Graduate Institute of Medical Education and Research, India

Introduction: Injuries to segmental or sectoral bile ducts are encountered less commonly than main bile duct injuries and present a unique diagnostic and therapeutic challenge.
Methods: This retrospective study was conducted and data of patients who underwent surgery for sectoral bile duct injury were retrieved from January 2014 to December 2019.
Results: Four patients were analyzed. All four were females with mean age of 36.5 years. Two of the four patients had undergone an open cholecystectomy, whereas the remaining two patients had undergone a laparoscopic cholecystectomy. The clinical presentation was external biliary fistula in two and another two patients presented with Pain and fever. Two patients without biliary fistula had late presentation at 2 year and 6 year respectively after index surgery. Two patients had undergone endoscopic retrograde cholangiography (ERCP), the result of ERCP had been interpreted as normal with no leak in one patient, and cystic stump leak in one patient. All patient had undergone magnetic resonance cholangiopancreatography (MRCP). Two of the four patient had right posterior sectoral duct injury and one patient had right anterior sectoral duct injury, one patient had stricture involving right hepatic duct leading to disconnection from common hepatic duct. All patients underwent Roux- en -Y cholangiojejunostomy. At mean follow up of 27 months (range 4 to 68 months) all patients are asymptomatic.
Conclusion: Segmental/sectoral bile duct injury should always be suspected and looked for if a biliary leak following cholecystectomy persists. Surgical treatment for this type of lesions, generally results in a favorable outcome.
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PB04-24  Optimal Time Interval for Revision Surgery in Incidental Gallbladder Cancer(iGBC)
Swapnil Patel, India

S. Patel, S. Patkar, A. Gupta, A. Parray, M. Goel
Surgical Oncology, Tata Memorial Hospital, India

Introduction: Management of iGBC involves Revision surgery either upfront or after neoadjuvant treatment. There is no evidence in literature on the impact of time interval between index surgery and revision surgery on survival.
Material and method: Retrospective analysis of the prospectively maintained database of all operated patients of iGBC at our centre from 2009 till 2019 was performed. Total number of iGBC operated were 359 of which 275 patients underwent upfront revision surgery and were analysed to study the impact of time interval on the final outcome.
Results: 74.9% patients were females with mean age being 50.8yrs. Stagewise distribution of the initial cholecystectomy specimen included 16.9% T1, 75.2% T2 & 6.9% T3 cancers, which had statistically significant association with the 3yr OS & DFS. Median time to revision surgery was 10.4 weeks. Cox Hazard Regression Model was used to identify the association between OS and the time interval between index and revision surgery, which was not found to be statistically significant with HR 0.99(95%CI,0.96 - 1.04) (p=0.896). Patients with residual disease in the liver wedge &/or the periportal nodes in the post-operative specimen had inferior OS & DFS (p< 0.0001).
Conclusion: Time interval to Revision Surgery for iGBC doesn't impact the survival outcomes especially when patients do not have any residual disease in the postoperative specimen, possibly reflection of the good disease biology. It may be prudent to give neoadjuvant treatment to patients of iGBC who have residual disease at presentation.
Number of iGBC patientsMedian Follow up(Months)3yr OS (%)3yr DFS (%)
Operated upfront (275)29.469.758.2
After Neoadjuvant treatment(84)2466.547.2
[Overall Survival Statistics]
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PB04-25  Management of Type E Bile Duct Injuries over a 10 Year Period at a HPB Referral Unit
Izhar-Ul Haque, Australia

I.-U. Haque1, C. Apostolou1, A. Das2, N. Merrett2
1HepatoPancreaticoBiliary Surgery, Bankstown Hospital, Australia, 2HepatoPancreaticoBiliary Surgery, Bankstown Hospital, Australia

Introduction: Common Bile Duct Transection is an unfortunate rare complication of Laparoscopic Cholecystectomy. We reviewed management of Common Bile Duct transections (Type E injuries) during Laparoscopic Cholecystectomy over 10 year period at our Hospital, which is a HepatoPancreaticoBiliary referral centre for the area.
Methods: Retrospective review of Bankstown Hospital Medical records from 2010 to 2019 was performed to identify any patients who had operative management of bile leak post cholecystectomy.
Results: After extensive search, only 5 Type E Common Bile Duct Injuries were found in our database from January 2010 to December 2019. Other bile leaks (Types A,B,C,D), from peripheral ducts or Cystic Duct stump leaks or subtotal cholecystectomy leaks were excluded from the analysis. Of the 5 cases, only 1 primary cholecystectomy was performed at Bankstown Hospital; the other 4 were referred from other hospitals. 4 were recognised intraoperatively as either CBD injuries or difficult anatomy and advice sought. 1 was recognised 24 hrs later due to bile leak. 3 were E2 and 2 were E1 according to Strasberg classification. They were all managed with Roux-en-Y hepatojejunostomy with Jejunal access limb using Infant Feeding catheter for cholangiography/stenting. Strictures ensued in 4 of the 5, requiring ERCP or Percutaneous Drainage and Dilatation including 1 patient requiring Redo-Hepatojejunostomy.
Conclusions: Hepatojejunostomy for Type E CBD injuries should be managed in a tertiary referral centre and advice sought early. Stricturing and proximal dilatation are long-term sequalae requiring further intervention.
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PB04-27  Long and Short Term Outcomes of Biliary Surgery for Portal Biliopathy at a Tertiary Care Centre in India
Nihar Ranjan Dash, India

N.R. Dash, V. Moond, S. Pal, P. Sahni
Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, India

Background: Portal biliopathy (PB) with extrahepatic portal venous obstruction (EHPVO) is usually managed with decompressive shunt surgery and endoscopic drainage. Bilioenteric drainage is rarely indicated (persistent symptoms/shunt not feasible). We report our experience of biliary surgery for PB over 30 years.
Methods: Prospectively collected data for PB patients was analysed for clinical, surgical, and long-term followup information. Surgical, postoperative and long-term outcome of patients who underwent bilioenteric drainage was analysed.
Results: Thirty-four patients (M:F::1.2:1; mean age 29.2 years) with symptomatic PB who required biliary surgery were included. Jaundice was the initial presentation in 11 patients. 47% of patients had a prior shunt surgery, while 53% underwent direct biliary surgery. The most common bilioenteric procedure done was a side-to-side Roux-en-Y hepaticojejunostomy (25 patients) followed by choledochoduodenostomy (n=3) and CBD exploration and stone clearance (n=1). The planned procedure was executed successfully in 29 (85%) patients. In 5 patients the procedure was abandoned due to intraoperative bleeding and haemodynamic instability. Mean blood loss was 1200 ml (range 100-4000 ml) and the mean number of blood transfusions was 1.25 (range 0-5). Postoperative morbidity was 29% ( wound infection, bile leak and cholangitis). One patient developed severe cholangitis and succumbed to MODS. Mean postoperative stay was 12 days. Over a mean follow-up of 62.2 months, 32 (94%) patients were asymptomatic. 2 patients developed anastomotic strictures and were managed by percutaneous dilatation.
Conclusion: Bilioenteric bypass in patients with EHPVO and PB is feasible, with low mortality and good long-term control of cholangitis in most patients.
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PB04-28  Analysis of Preoperative Ultrasonography to Predict Intraoperative Findings during Laparoscopic Cholecystectomy of Cholecystolithiasis
Wendy Primadhani, Indonesia

D.W. Primadhani1, D.S. Singh2
1Division of Digestive Surgery, Department of Surgery Siti Fatimah General Hospital, Indonesia, 2Division of Digestive Surgery, Mohammad Hoesin General Hospital, Department of Surgery, Faculty of Medicine, Universitas Sriwidjadja, Indonesia

Introduction: Management of cholecystolithiasis and its complications has evolved dramatically and outcomes from surgery is a major challenge and defining surgical findings may help set the benchmark. Abdominal ultrasonography often preceds this operation and can prove diagnosis, as well as helps in showing possible complications during the perioperative period.
Methods: Patients aged 18 years and over were included in the study. Data from 2017 until now including demographic , clinical data, comorbidity, laboratory, radiological and findings during intraoperative and surgery technique selection were collected retrospectively and prospectively until now with diagnose cholecystolithiasis.
Results: Preoperative USG findings such as gall bladder wall thickness and size, impacted and size of gall stones, presence of pericholecystic fluid collection were significantly associated with difficult laparoscopic cholecystectomy.
Conclusion: This study show that analysis of preoperative ultrasonography helping to predict intraoperative laparoscopic cholecystectomy helping to figure out the successful of the operation and outcomes in patients.
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