Abstracts

Plenary Papers

PL 1.01

BLUE LIVER SYNDROME INCREASES MORBIDITY AFTER MAJOR HEPATECTOMY IN PATIENTS WITH COLORECTAL LIVER METASTASES RECEIVING PREOPERATIVE CHEMOTHERAPY

Nakano, Hiroshi¹; Oussoutzoglou, Elie²; Rosso, Edoardo²; Giraudo, Giorgio²; Otsubo, Takehito³; Bachellier, Philippe²; Jaeck, Daniel²

¹Hopital de Hautepierre, Chirurgie Viscerale et de Transplantation, Universite Louis Pasteur, Strasbourg, France; ²Hopital de Hautepierre, Chirurgie Viscerale et de transplantation, Strasbourg, France; ³St Marianna Univer sity Hospital, Gastroenterological Surgery, Kawasaki, Japan

Background. Sinusoidal obstruction & congestion, i.e., blue liver syndrome (BLS), is shown to be associated with oxaliplatin-based chemotherapy (OBC) before hepatectomy in patients with colorectal cancer liver metastases (CRCLM). However, it is still unclear whether BLS Results in a worse outcome after hepatectomy in patients with CRCLM.

Patients and Methods. Between 2003 and 2005, 90 patients with CRLM who underwent an elective hepatectomy following preoperative chemotherapies were included. Diagnosis of BLS was established pathologically in the non-tumoral liver parenchyma of the resected specimens, and perioperative data were assessed in these patients.

Results. Preoperative indocyanine green retention rate at 15 minutes (ICG-R15) and postoperative value of total bilirubin were significantly higher, and hospital stay was significantly longer in patients presenting with BLS. Multivariate analysis showed that female gender, administration of 6 cycles or more of OBC, abnormal value of preoperative aspartate aminotransferase (AST > 36 IU/L), or abnormal value of preoperative ICG-R15 (more than 10%) were preoperative factors significantly associated with BLS. Among patients undergoing a major hepatectomy, BLS was significantly associated with higher morbidity (Dindo & Clavien: Grade III and IV) and longer hospital stay.

Conclusion. Blue liver syndrome resulted in a poorer liver functional reserve and in a higher complication rate after major hepatectomy. Therefore, female patients who received 6 cycles or more of OBC, or presenting with abnormal preoperative AST and ICG-R15 values should be carefully selected before deciding to undertake a major hepatectomy.

PL 1.02

LAPAROSCOPIC RADIOFREQUENCY ABLATION OF UNRESECTABLE HEPATOCELLULAR CARCINOMA: LONG-TERM FOLLOW UP

Siperstein, Allan; Berber, Eren; Ballem, Naveen

Cleveland Clinic, Department of Surgery, Cleveland, United States

Background. Hepatocellular Carcinoma(HCC) has seen a dramatic rise in the United States over the last 30 years. Unresectable disease is present in 80–90% of patients, for which Laparoscopic Radiofrequency Ablation(LRFA) is a proven option. The aim of this study is to report the long term survival after LRFA.

Methods. This is a prospective analysis of 104 patients undergoing LRFA from April 1997 to October 2006. Overall survival(OS) and Disease Free Survival(DFS) were estimated using Kaplan-Meier analysis. Univariate and Multivariate Cox Proportional Hazard Models were used to evaluate various demographic and clinical parameters with respect to survival. Patients were classified according to the Barcelona Clinic Liver Cancer(BCLC) staging system and subgroup analysis of OS and DFS were evaluated.

Results. Median(range)data:age 63 yrs (41–81), lesion size 3.5 cm(1–10), number of lesions 1(1–5), AFP 26.45(3.7–43588.5) and time from diagnosis to RFA 2 months (mos) (1–42). The median Kaplan-Meier survival for all patients was 26 mos (OS) while DFS was 14 mos. Univariate analysis demonstrated improved OS for the absence vs presence of ascites(28 vs 6 mos, p = 0.003), Bilirubin <2 vs >2(27 vs 19 mos, p = 0.01), AFP <400 vs >400(34 vs 11 mos, p < 0.0001) and Child-Pugh Grade(A = 28, B = 15, C = 5 mos, p = 0.01). Significant factors for improved DFS:absence vs presence of ascites(16 vs 5 mos, p = 0.02), Bilirubin <2 vs >2(14 vs 5 mos, p = 0.0278), AFP <400 vs >400(15 vs. 4 mos, p = 0.0025) and Child-Pugh Grade(A = 38, B = 12, C = 3 mos, p = 0.03). Patient age, tumor size, number of lesions, INR and albumin did not reach clinical significance. All other clinical variables evaluated did not reach statistical significance. BCLC staging was not found to have prognostic significance for OS or DFS(OS, p = 0.11 and DFS, p = 0.07). 3 and 5 yr actual survival rates are 21% and 8.3% respectively.

Conclusions. Our study suggests that LRFA may have a positive impact on survival for unresectable HCC. It also determines which patients fare best after LRFA, by determining predictive factors that improve survival.

PL 1.03

HEME OXYGENASE-1 GENOTYPE OF THE DONOR IS ASSOCIATED WITH GRAFT SURVIVAL AFTER LIVER TRANSPLANTATION

Buis, Carlijn I¹; van der Steege, Gerrit²; Visser, Dorien S³; Nolte, Ilja M²; Hepkema, Bouke G⁴; Nijsten, Maarten⁵; Slooff, Maarten JH¹; Porte, Robert J¹

¹University Medical Center Groningen, Hepatobiliary Surgery and Liver Transplantation, Groningen, Netherlands; ²University Medical Center Groningen, Medical Biology, Groningen, Netherlands; ³University Medical Center Groningen, Surgical Research Laboratory, Groningen, Netherlands; ⁴University Medical Center Groningen, Transplantation Immunology, Groningen, Netherlands; ⁵University Medical Center Groningen, Surgical Intensive Care Unit, Groningen, Netherlands

The heme oxygenase 1 (HO-1)/carbon monoxide (CO) pathway has been shown to provide cytoprotection during liver ischemia and reperfusion. Inducibility of HO-1 is modulated by a (GT)n polymorphism and a single nucleotide polymorphism (SNP) A(-413)T in the promoter. Both a short (GT)n allele and the A-allele are associated with increased HO-1 promoter activity, compared to the long (GT)n repeat and the T-allele. In 308 liver transplantations we performed HO-1 genotyping in donor genomic DNA. For (GT)n genotype, livers were divided into two classes: short alleles (<25 repeats; class-S) and long alleles (¡Ý 25 repeats; class-L). [For the SNP A(-413)T, recipients of livers with at least one A-allele (A-receivers) were compared with the TT-variant.] In a subset of patients, HO-1 mRNA expression was correlated with genotype and haplotypes. Graft survival at 1 year was significantly better for A-receivers compared to TT-receivers (84% versus 63%, p = 0.004). Graft loss due to primary dysfunction was observed more frequently in TT-receivers compared to A-receivers (p = 0.03). Recipients of a liver with TT genotype had significantly higher serum levels of alanine aminotransferase and aspartate aminotransferase in the first two weeks after liver transplantation. HO-1 mRNA in liver biopsies, retrieved at the end of the cold storage period, was significantly lower in TT genotype livers compared to the A-allele livers (p = 0.03). Haplotype association suggested a greater importance of the A(-413)T SNP over the (GT)n polymorphism. No differences were found between class S-receivers and LL-receivers. In conclusion, HO-1 genotype is associated with graft survival after liver transplantation. This is at least partially explained by a higher rate of primary dysfunction in TT-genotype livers. The functional relevance of the A(-413)T SNP was confirmed by differences in HO-1 mRNA expression. These findings provide additional evidence that the HO-1/CO pathway mediates graft survival after clinical liver transplantation

PL 1.04

EFFICACY OF HUMAN UMBILICAL CORD-DERIVED MULTIPOTENT STEM CELL IN LIVER CIRRHOSIS OF RATS AND HUMAN

Park, Hwon Kyum¹; Lee, Kwang Soo²; Lim, Sung Vin³; Han, Hoon⁴; Han, Hoon⁴

¹Hanyang University Guri Hospital, Department of Surgery, College of Medicine, Hanyang University, Guri-Si, Korea, Republic of; ²College of Medicine, Hanyang University, Department of Surgery, Seoul, Korea, Republic of; ³College of Medicine, Kyung Hee University; ⁴Seoul Cord Bank, Histostem, Seoul, Korea, Republic of

Background. Liver transplantation is the accepted method of treatment for end stage liver disease. Development of various immunosuppressive drugs and advances in the surgical techniques have led to the improvement in patient and graft survival. However, cell-based therapies are emerging as an alternative to whole-organ transplantation because whole liver transplantations in human beings far outweighs the supply.

Aims. We want to find out the efficacy of human umbilical cord-blood derived multipotent stem cells(HUCB MSCs) in the liver cirrhosis of rats induced with CCl4 and 6 patients.

Methods. We already demonstrated in vitro differentiation of HUCB MSCs into hepatocyte-like cells. We made the animal model of cirrhosis with CCl4 in Sprague-Dawley rats for 8 weeks. We transplanted HUCB MSCs into the cirrhotic rats at 8 weeks in amount of one million cells labled with CM-Dil, a fluorescent lipophilic probe. We had clinical trial of 6 cirrhotic patients, 3 hepatitis B, 1 hepatitis C, 1 biliary cirrhosis and 1 ¥á1-antitrypsin deficiency. We transplanted HUCB MSCs more than one million cells under the laparoscopy.

Results. HUCB MSCs infusion ameliorated various biochemical markers related with liver function. In immunohistochemistry, RT-PCR, and Western blot, fibrosis markers, such as TGF-¥â1, collagen type I, and a-SMA, were also decreased by HUCB-derived MSCs infusion. Early results of 6 cases of HUCB MSCs transplantation in Liver Cirrhosis were very promising.

Conclusion. These results suggest that HUCB MSCs infusion could not only inhibit the fibrosis formation but also halt the progression of CCl4-induced liver cirrhosis in rats. There has not been any side effect in these patients. HUCB MSCs transplantation in Liver Cirrhosis is not the only curative Treatment method at present but can be one of effective Treatment modalities in patients with acute & chronic liver disease.

PL 1.05

CARBON DIOXIDE ENHANCED VIRTUAL CHOLANGIO-PANCREATOGRAPHY: THE CLINICAL BENEFITS IN 100 CONSECUTIVE PERFORMANCES WITHOUT COMPLICATIONS

Sugimoto, Maki; Yasuda, Hideki; Koda, Keiji; Yamazaki, Masato; Tezuka, Tohru; Kosugi, Chhiro; Higuchi, Ryota; Yagawa, Yousuke; Suzuki, Masato

Teikyo University Chiba Medical Center, Department of surgery, 3426-3 Anesaki Ichihara Chiba, Japan

Background/Aim. The recent imaging of cholangio-pancreatography has dramatically advanced, requiring accurate diagnosis and selection of appropriate surgical procedures. We evaluate the clinical benefits of our new technique of carbon dioxide enhanced virtual MDCT cholangio-pancreatography (CMCP) in surgical strategy for HPB surgery.

Methods. One hundred cases were performed MDCT under trans-papillary infusion of carbon dioxide, synchronously intravenous contrast material were applied for virtual angiography, 3-D reconstructions were incorporated using OsiriX (CMCPA). Feasibility of as an operative virtual navigation for surgical procedure in HPB surgery was evaluated.

Results/Discussions. One hundred consecutive performances were applied without any complications including pancreatitis, cholangitis, or hepatic dysfunction. This procedure enabled to facilitate the detection of multiple small cystic lesions of the IPMN preoperatively and provided feasible surgical procedure, to evaluate distal additional segments of the occluded bile duct in bile duct cancer patient and post stenting patency, and to visualize detailed gallbladder mucosa without intervention into the gallbladder. Virtual endoscopy using CMCP revealed excellent endoluminal visualization to detect stenosis, obstruction, protruding, and cystic lesions. CMCPA enabled synchronous visualization of HPB and abdominal vessels to provide accurate information for localizing HPB malignancies with its relationship to the vessels. It was feasible for planning operation and image-guided navigated surgery in resection the tumors, dissection lymph nodes, and preserving organic function.

Conclusions. Our results indicate that CMCPA provided accurate visualization of HPB disorder and detailed preoperative reconstruction of HPB anatomy in safety. Newer software developments may further enhance its accuracy, so that CMCP might challenge or replace more invasive diagnostic measures in the near future.

PL 1.06

GLUTATHIONE-PRODUCING PROBIOTICS AMELIORATE OXIDATIVE STRESS AND THE SEVERITY OF EXPERIMENTAL ACUTE PANCREATITIS

Lutgendorff, Femke¹; Sandström, Per A¹; Trulsson, Lena¹; Timmerman, Harro M²; van Minnen, Leo P²; Rijkers, Ger T²; Gooszen, Hein G²; Akkermans, Louis MA²; Söderholm, Johan D¹

¹University Hospital Linköping, Surgery, Linköping, Sweden; ²University Medical Center Utrecht, Surgery, Utrecht, Netherlands

Background. During acute pancreatitis (AP) oxidative stress contributes to the severity of the disease.

Aim. We tested the effects of multispecies probiotics on oxidative stress and markers of severity in experimental AP.

Material and Methods. 53 Male Spraque-Dawley rats were randomly allocated into five groups: 1) controls, non-operated, 2) sham-operated, 3) AP, 4) AP + probiotic mixture of six strains and 5) AP + placebo. AP was induced by intraductal glycodeoxycholate infusion and intravenous cerulein (6 h). Probiotics or placebo were administered intragastrically on a daily basis, starting five days prior to induction of AP. After cerulein infusion, ileal mucosa was collected for permeability measurements in Ussing chambers, and tight junctions (TJs) were assessed by immunofluorescence. Histological damage and inflammatory markers were determined in pancreas and liver samples. In all tissues oxidative status was assessed and intracellular glutathione contents of the administered probiotic strains were determined.

Results. Probiotics reduced AP-induced increase in ileal permeability to E.coli K12 and ⁵¹Cr-EDTA. Disruption of the TJ proteins occludin and claudin-1 and upregulation of the pore-forming protein claudin-2 was prevented by probiotics. Moreover, probiotics ameliorated AP-induced tissue damage and reduced the activity of IL-1β-converting-enzyme (ICE) and NF-?B in pancreas and liver. In all tissues, lipid peroxidation was attenuated by probiotics. The AP-induced decrease in glutathione was prevented in the probiotics group, and probiotics increased the intestinal, pancreatic and liver glutathione contents, even compared with sham operated rats. Of the administered strains B. bifidum, B. infantis and L. acidophilus contained high levels of glutathione.

Conclusion. Multispecies probiotics reduced AP-induced intestinal barrier dysfunction and disruption of TJ proteins and decreased the tissue damage and activation of inflammatory markers in liver and pancreas. These effects may be mediated by enhancement of intestinal, pancreatic and liver glutathione content.

Award Papers

AP 1.01

IMPACT OF TUMOR EXTENT AND LYMPH NODE INVOLVEMENT ON SURVIVAL IN GALLBLADDER ADENOCARCINOMA

Zaydfudim, Victor¹; Feurer, Irene D.²; Pinson, C. Wright²

¹Vanderbilt University Medical Center, Hepatobiliary Surgery and Liver Transplantation, 801 Oxford House, Nashville, TN, United States; ²Vanderbilt University Medical Center, Hepatobiliary Surgery and Liver Transplantation, Nashville, TN, United States

Background. Gallbladder adenocarcinoma is an aggressive malignancy with surgical resection as the primary treatment option. The combination of tumor extent (T stage) and lymph node involvement (N stage) significantly impacts survival in patients with gallbladder adenocarcinoma.

Objectives. We investigated whether T stage and N stage are independent predictors of survival in patients with gallbladder adenocarcinoma.

Methods. We conducted a retrospective, population-based cohort analysis of the Surveillance Epidemiology and End Results (SEER) database for patients who underwent surgical resection for gallbladder adenocarcinoma between 1988 and 2004. Kaplan-Meier and Cox proportional hazard regression methods were used to test univariate effects of demographic and clinical covariates and develop multivariate models of survival. Summary data are presented as mean±SD or percentages.

Results. 3824 patients with complete staging data who survived the immediate perioperative period (age = 70.9±12.5, 26.0% male, 81.2% Caucasian) were identified. Age, gender, race, radiation treatment, tumor grade, tumor extent and lymph node status had significant independent effects on survival (all p < 0.05). Overall survival differed by stage (p < 0.001). Patient survival (1- and 5- year rates indicated) was better for: T1N0-Stage IA (74% & 37%), T2N0-Stage IB (67% & 28%), T1N1-Stage IIB (60% & 19%), and T2N1-Stage IIB (68% & 21%) disease; than for: T3N0-Stage IIA (43% & 10%), T3N1-Stage IIB (45% & 7%), Stage III (24% & 0%) and Stage IV (14% & 0%) disease (all Log-rank p < 0.05). SEER defined extent of surgical resection did not affect survival in the multivariate model (p = 0.69), or in patients with T3 disease (all Log-rank p ≥ 0.10).

Conclusions. Presence of T3 and N1 disease confers independent increased risk of death in patients with gallbladder adenocarcinoma. Survival in patients with node positive disease is significantly improved if their tumor does not violate the serosal layer.

AP 1.02

HMOX-1 promoter polymorphism is associated with neuroendocrine pancreatic carcinomas and correlates with recurrence and poor outcome

Vashist, Yogesh; Schurr, Paulus; Uzunoglu, Guentac; Bogoevski, Dean; Mann, Oliver; Gawad, Karim; Liebl, Lena; Izbicki, Jackob R.; Yekebas, Emre F.

University Clinic Hamburg-Eppendorf, General, Visceral- and Thoracic Surgery, Hamburg, Germany

There is a paucity of molecular markers to distinguish between benign and malignant neuroendocrine pancreatic tumors (NEPT) and /or predict outcome. Heme oxygenase-1 promoter polymorphism has been reported to correlate with clinicopathological parameters and be associated with outcome in several malignancies. The polymorphism is characterized by short (<25) and long (>/ = 25) GT repeats in the promoter. The aim of the following study was to analyze the role of HMOX-1 promoter polymorphism in NEPT. Tumor, corresponding healthy tissue and also lymph node metastasis DNA of 46 patients that underwent surgical resection of NEPT was analyzed for HMOX-1 promoter polymorphism by PCR, capillary electrophoresis and DNA-sequencing. The findings were correlated with clinicopathological characteristics and outcome. No difference in repeat pattern was found between tumor, healthy tissue and lymph node DNA. Higher frequency of short allele carriers was found in carcinoma and poorly-differentiated carcinoma patients. HMOX-1 polymorphism strongly correlated in the univariate analysis with sex, tumor grading, tumor recurrence and WHO classification of NEPT (p < 0.05, ANOVA). Furthermore disease-free and overall survival were also strongly associated with HMOX-1 polymorphism with short allele carriers having a highly significant shorter disease-free and overall survival compared to long allele carriers (p < 0.005, log rank test). However in the multivariate analysis HMOX-1 was not identified as an independent prognostic marker. WHO classification was the only prognostic independent marker for survival. These findings suggest that the repeat pattern distinguishes between benign and malignant NEPT. Short repeat of HMOX-1 gene promoter is associated with higher frequency of carcinomas and strongly correlates with tumor recurrence, disease-free and overall survival in NEPT patients. Studies with larger number of patients are required to evaluate the prognostic value of HMOX-1 promoter polymorphism in NEPT.

AP 1.03

THE DONOR RISK INDEX INDEPENDENTLY PREDICTS PRIMARY NON-FUNCTION: AN ANALYSIS OF OVER 600 LIVER TRANPLANTS

Bonney, Glenn K¹; Kalyanaraman, Aarti²; Aldersley, Mark A²; Toogood, Giles J²; Pollard, Stephen G²; Lodge, J Peter A²; Prasad, K Rajendra²

¹St James' University Hospital, Department of Hepatobiliary and Tranpslantation, Beckett Street, Leeds, United Kingdom; ²St James' University Hospital, Department of Hepatobiliary and Tranpslantation, Leeds, United Kingdom

Background. Primary non-function remains the most adverse outcome in liver transplantation. Pretransplant factors that can predict its occurrence may prove crucial to organ allocation and utilisation. Here we assess donor and recipient factors that may result in primary non-function

Methods. A prospectively collected database of 660 liver transplant recipients at one centre between 1998–2005 was analysed. The Donor Risk Index was used to score donor variables and calculated using the published formula. Recipient variables included age, gender, ethnicity, diagnosis, ABO incompatibility, intra-operative cardiac arrest, hypotension, hypoxia, chronic renal failure, ALT on Day 1–3 and MELD score at transplantation. IPF was defined as ALT > 1500 within the first three days of transplantation

Results. The PNF rate in this cohort was 2.9%. None of the recipient factors including demographics, MELD at transplantation, ABO incompatibility, hypotension and chronic renal failure predicted the occurrence of PNF. Furthermore, the day 1 to 3 ALT as well as the occurrence of IPF was not associated with PNF. The Donor Risk Index was the only significant predictor of PNF (p < 0.0001).

Conclusion. Donor variables, as evaluated here by the Donor Risk Index independently predict primary non-function following liver transplantation.

AP 1.04

EFFECT OF S-NITROSO-N-ACETYLCYSTEINE ON ISCHEMIA/REPERFUSION LESION IN STEATOTIC LIVERS OF RATS

Andraus, Wellington; Haddad, Luciana B P; Coelho, Ana Maria M; Sampietre, Sandra N; Oliveira, Marcelo G; Machado, Marcel C C; Bachella, Telésforo

University of São Paulo School of Medicine, Department of Gastroenterology, São Paulo, Brazil

Background. Steatosis is the most frequent chronic liver disease in general population. Steatosis can make ischemia/reperfusion (I/R) lesions worse in liver transplants and hepatic surgeries. Several antioxidant drugs have been already used in steatotic and I/R experimental models, and showed better outcome in treated groups. The S-nitroso-N-acetylcysteine (SNAC) releases NAC and NO. It ameliorated oxidative stress in experimental models of steatosis and skeletal muscle I/R. In contrast, this drug has never been used in steatotic liver I/R.

Objective. evaluate the effect of SNAC on I/R lesion on steatotic livers of rats.

Methods. thirty four male Wistar rats were studied and divided in four groups: group I (n = 8) – without steatosis and treated with saline solution; group II (n = 8) – without steatosis and treated with SNAC; group III (n = 9) – with steatosis and treated with saline solution; group IV (n = 9) – with steatosis treated with SNAC. Aproteic diet was used for steatosis induction. The animals underwent a partial hepatic ischemia (70%) for 1 hour and reperfusion for 4 hours.

Results. There were no difference between groups I and II in all parameters evaluated (histology, mithocondrial function (RCR and ADPO), transaminasis (AST and ALT), pulmonary Evans blue extravasation and mieloperoxidasis), and it showed only tendency of less oxidative stress (MDA) (p = 0,07) in ischemic liver of treated group (group II). Groups III and IV didn't show any difference in transaminasis (AST and ALT), pulmonary Evans blue and mieloperoxidasis. Group IV (steatosis and SNAC) showed in the ischemic liver lower intraparenchymatous hemorrhage (p = 0,02), better mitochondrial function (RCR (p = 0,01) and ADPO (p = 0,01)), and less oxidative stress (MDA (p = 0,007) when compared with untreated group (group III).

Conclusions. SNAC treatment shows no benefit in non steatotic I/R lesion, however, in steatotic rats, SNAC ameliorates hepatic lesions post I/R.

AP 1.05

SINUSOIDAL SHEAR STRESS IS NOT A SUFFICIENT STIMULUS FOR LIVER GROWTH

Mortensen, Kim Erlend¹; Conley, Lene²; Bendixen, Christian²; Sorensen, Peter²; Nygaard, Ingvild¹; Revhaug, Arthur¹

¹University Hospital of Northern Norway, Gastrointestinal Surgery, Tromsø, Norway; ²Research Centre Foulum, University of Aarhus, Department of Genetics and Biotechnology, Aarhus, Denmark

Background. Increased sinusoidal flow and shear stress following partial hepatectomy has been suggested to be a primary stimulus in triggering liver regeneration. Shear stress results in the production of Nitric Oxide (NO) and liver regeneration is inhibited by administration of NO synthase antagonists and restored by NO donors. Portal vein branch ligation results in atrophy of the segments supplied by the ligated vein and compensatory hyperplasia within the residual segments. The same hemodynamic condition is created upon hepatectomy. We hypothesized that it is the increased sinusoidal flow per se and hence shear-stress stimulus on the endothelial surface within the liver remnant which is the main stimulus to regeneration/hyperplasia.

Aims. To study the acute and chronic effects of selective regional portal hyperperfusion.

Methods. Segments II, III and IV in pigs were hyperperfused by creating an aortoportal shunt to the left portal vein resulting in a four fold increase in flow to these segments. The impact of this manipulation was studied in an acute model (6 animals, 9 hours) with a global porcine cDNA microarray chip and in a chronic model (8 animals, 3 weeks).

Results Gene expression profiling does not suggest that hyperperfusion per se results in activation of known cell cycle genes. Chronic regional hyperperfusion over three weeks results in the whole liver gaining a supranormal weight of 3.6% of the total body weight (versus the normal 2,5%). Contrary to our hypothesis, the weight gain was observed on the non-shunted side, an observation corroborated by histological examination showing dilated lobuli.

Conclusion. Increased sinusoidal flow of isolated liver segments does not result in the activation of cell cycle genes controlling liver regeneration nor does it result in hyperplasia over time.

AP 1.06

ANATOMICAL VARIATIONS IN ARTERIAL SUPPLY TO SEGMENT IV OF THE LIVER: AN ANALYSIS OF 116 POTENTIAL LIVER DONORS BY CT ANGIOGRAPHY

Nagpal, Anish; Kumaran, Vinay; Kakodkar, Rahul; Nundy, Samiran; Soin, Arvinder

Sir Gangaram Hospital, Surgical Gastroenterology & Liver Transplantation, DELHI, India

Background. Preservation of segment IV arterial supply is essential to ensure adequate remnant and its regeneration after right hepatectomy for tumors and transplantation. This may also be vital to prevent cut surface and bile duct stump leaks. Conventionally, segment IV receives its supply from left hepatic artery (LHA) but variations are common which may occasionally result in rejection of prospective donors or postoperative complications if ignored. There is paucity of data regarding these variations.

Aim. To study the arterial supply of segment IV in 116 consecutive potential liver donors who were evaluated by CT angiography.

Methods. Of 116 donors tested, 12 were excluded due to aberrations in venous or biliary anatomy. Segment IV arterial supply was assessed in the remaining 104 in relation to its origin, distance of its origin from the proper hepatic artery (PHA) and in case of right hepatic origin, the availability of right hepatic artery (RHA) length for anastomosis in right lobe grafts.

Results. Of 104 potential donors, segment IV arterial supply was predominantly from LHA in 74, RHA in 21, both in 4, PHA in 3, anterior RHA in 1, and superior mesenteric artery in 1. In cases with RHA origin, mean length of RHA proximal to it was 10.1 mm (range 2–25 mm). The distal length of RHA was less than 10 mm in 2 (0.5, 4.1 mm) and more in the remaining 19. The patient with anterior RHA origin and the one with 0.5 mm distal stump of RHA were excluded from right lobe donation. Two with segment IV artery separate from the LHA were excluded from left lobe donation. The remaining 100 donors uneventfully donated their right or left lobe.

Conclusion. Segment 4 artery has an anomalous origin in 30% cases that may result in exclusion of 4% of potential liver donors. In those arising close to bifurcation of the RHA, care must be taken to preserve both the segment IV artery and the RHA trunk for anastomosis. This study provides the first detailed insight into anatomical variations of the segment IV hepatic artery.

AP 2.01

LIVER TRANSPLANTATION FROM DONATION AFTER CARDIAC DEATH: A WAY TO INCREASE THE DONOR POOL.

Nezakatgoo, Nosratollah¹; Rai, Rakesh¹; Vera, Santiago¹; Vanatta, Jayson¹; Hubbard, Lynn²; Gilly, Kim³; Eason, James¹

¹Methodist University hospital, Transplant surgery, Memphis, United States; ²Transplant Institute, Memphis, United States; ³Midsouth Transplant foundation, Memphis, United States

Background. The disparity between the waiting list and available donors has contributed to the mortality of patients on the waiting list. There has been reluctance to use donation after cardiac death (DCD) grafts because of concern over viability of these grafts.

Aim. To evaluate our experience of liver transplantation using DCD livers and to maximize the donor pool by using more than 10% of DCD grafts.

Methods. From September 1,2006 to August 31, 2007 100 liver transplants were performed in our center. Twelve transplants were performed using DCD livers. All patients received steroid free immunosuppression. Review of donor and recipient characteristics and results of transplantation were evaluated.

Results. Donor age varied from 15 to 51 (mean 36.4 years). Eight were males 4 females. Cause of brain injury included 10 head injuries, 1 cerebrovascular accident and 1 drug overdose. Total warm ischaemic time in donors varied from 6 to 27 minutes (mean 14.6 minutes). Cannulation time was 1 to 2 minutes in 11 patients, 6 minutes in 1 patient procured by another team. Recipients were 40 to 73 (mean 57.25 years). Ten males and 2 females. Etiology of liver disease was Hepatitis C (HCV) (6), HCV& alcoholic liver disease (ALD)(1), HCV and hepatocellular cancer (HCC) (1), ALD(1), Nonalcoholic steatohepatitis (1), biliary cyst (1) and primary sclerosing cholangitis (1). Anastomotic time ranged 27 to 68 (mean 37.41 minutes). Cold ischaemic time 2 hrs 30 minutes to 8 hours (mean 5 hrs 26 minutes). Model for end-stage liver disease (MELD) score of recipients were 14–22 (mean 16). One patient developed biliary stricture at 3 months following transplant and was treated by endoscopic stent insertion and 1 patient died within 30 days of transplantation. Hospital stay varied from 6 days to 58 days with mean of 12.83 days. Three months actuarial survival was 91%.

Conclusion. DCD can be an excellent source of liver grafts with above average graft and patient survival and low morbidity. They can contribute to more than 10% of liver grafts.

AP 2.02

IS HEPATIC RESECTION JUSTIFIED IN PATIENTS WITH COLORECTAL LIVER METASTASES AND LYMPH NODE INVOLVEMENT?

de Haas, Robbert J; Wicherts, Dennis A; Aloia, Thomas; Delvart, Valérie; Azoulay, Daniel; Castaing, Denis; Bismuth, Henri; Adam, René

Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France

Background. For patients with colorectal liver metastases (CLM), lymph node (LN) involvement is one of the worst prognostic factors. However, only small patient series are described, which renders the role of surgery in these patients highly controversial. Furthermore, increasingly effective chemotherapy may have changed the spectrum of this metastatic disease.

Aim. To define the role of surgical treatment in patients with CLM and LN involvement treated by preoperative chemotherapy.

Methods. All consecutive patients resected at our institution for CLM and simultaneous LN involvement were included in the study. If LN involvement was diagnosed prior to hepatic resection, lymphadenectomy was only performed if LN disease responded to or was stabilized by chemotherapy. When diagnosed intraoperatively, surgery only proceeded when resection of both LN disease and CLM could be complete. Overall survival (OS) and disease-free survival (DFS) were calculated and prognostic factors were identified.

Results. Of the 775 patients resected for CLM between June 1992 and July 2006, 47 (6%), all treated by preoperative chemotherapy, were simultaneously resected for LN involvement. Five-year OS for patients with and without LN involvement were 18% and 53%, respectively (P < 0.001). Five-year DFS were 11% and 23%, respectively (P = 0.004). Localization of metastatic LN strongly influenced survival, with an OS at 5 years of 25% for pedicular, 0% for celiac, and 0% for para-aortic LN (P = 0.001). Multivariate analysis identified 2 independent poor prognostic factors: celiac LN involvement and age at surgery ≥ 40 years.

Conclusion. Liver resection combined to lymphadenectomy is justified when lymph node metastases respond to or are stabilized by preoperative chemotherapy and involve pedicular sites, especially in young patients. By contrast, this approach could not be recommended to patients with celiac and/or para-aortic LN involvement, even when responding to preoperative chemotherapy.

AP 2.03

LASER THERMOTHERAPY OF RAT LIVER CARCINOMA INCREASES ANTI-TUMOUR LYMPHOCYTE REPONSIVENESS IN TUMOUR-DRAINING AND SYSTEMIC LYMPH NODES AND IN SPLEEN

Tranberg, Karl-Göran¹; Ivarsson, Kjell¹; Sjögren, Hans Olov²; Stenram, Unne³

¹Lund University Hospital, Department of Surgery, Lund, Sweden; ²Lund University, Department of Cellular and Molecular Biology, Lund, Sweden; ³Lund University, Department of Pathology, Lund, Sweden

Introduction. We have shown that interstitial laser thermotherapy (ILT) induces an immunologic anti-tumour effect, but the mechanisms are unclear.

Aim. The aim of this study was to investigate ILT-induced effects on the anti-tumour proliferative responsiveness and the cytokine profile of lymphocytes in lymph nodes and spleen.

Methods. A dimethylhydrazine-induced adenocarcinoma (H1D2) was implanted into the liver of syngeneic rats. Intraperitoneal injection of irradiated, IL-18 transfected H1D2 tumour cells was performed 7 days later. Rats were allocated to treatment with ILT or sham ILT + resection of the tumour-bearing lobe, 9 days after tumour implantation. Spleen and lymph node anti-tumour lymphocyte proliferation and cytokine production in response to wild-type and IL-18 transfected tumour stimulator cells was studied 11, 30 and 50 days after treatment.

Results. ILT increased the proliferative lymphocyte response in tumour-draining lymph nodes at 11–50 days after treatment, as compared to sham ILT + resection. The proliferative lymphocyte response was increased also in systemic lymph nodes and spleen 30–50 days after ILT. Following ILT, tumour stimulation increased the release of IFN-γ and IL-10 from lymphocytes in tumour-draining lymph nodes and lowered the release of IL-10 from lymphocytes in the spleen. There were no differences in the lymphocyte release of IL-12 or TGF-β between ILT and sham ILT + resection. Results were similar after stimulation with wild-type and IL-18 transfected H1D2 tumour.

Conclusions. Laser thermotherapy induced an anti-tumour lymphocyte proliferative response that started in tumour-draining lymph nodes and subsequently developed in other lymph nodes and in the spleen. The main effects on lymphocyte cytokine production were an increased release of IFN-γ and IL-10 from tumour-draining lymph nodes and a decreased splenic release of IL-10.

AP 2.04

D-DIMER CAN PREDICT DEVELOPMENT OF ORGAN FAILURE IN ACUTE PANCREATITIS

Radenkovic, Dejan; Bajec, Djordje; Ivancevic, Nenad; Jeremic, Vasilije; Gregoric, Pavle; Djukic, Vladimir; Stefanovic, Branislav

Clinical Center of Serbia and School of Medicine, University of Belgrade, Serbia., Belgrade, Serbia and Montenegro

Background. Despite the fact that increasing experimental evidence suggests an important role of the coagulation system in acute pancreatitis (AP), meaningful studies on the clinical value of parameters of the coagulation system in predicting pancreatitis-associated complications are still scarce.

Aim. We aimed to address this issue in a clinically and morphologically well defined series of patients with AP.

Methods. In this prospective study 91 consecutive patients with AP were included. In all patients coagulation, anticoagulation and fibrinolysis parameters: prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin III, protein C, plasminogen activator inhibitor-1, D-dimer, and plasminogen were measured in plasma within the first 24 hours of admission and 24 hours thereafter. Two study groups comprising 24 patients with organ failure (OF) and 67 patients without organ failure (NOF) were compared.

Results. On admission, the mean d-dimer concentration was 903.5 ìg/l (sd.174.5) for OF group and 220 ìg/l (sd. 80.5) for NOF group (p < 0,001). On first day after admission respective values were 317.00 ìg/l (sd. 269.25) and 1139.50 ìg/l (sd. 672.75), p < 0,001. The sensitivity, specificity, positive predictive, and negative predictive values of the test to predict development of OF on admission (cut off >414.00 ìg/l), were 90%, 89%, 75%, and 96% respectively, and 24 h after admission (cut off >525.50 ìg/l), were 90%, 81%, 62.%, and 95%. The levels of all other measured parameters were significantly different between the compared groups, but all values were within physiological limits.

Conclusion. Prediction of development of OF is already possible on patients admission to the hospital with very high sensitivity and specificity. D-dimer as single test parameter significantly contributes to an improved stratification of patients at risk to develop most serious complications during the course of AP and deserves routine clinical application.

AP 2.05

ADDITIONAL RESECTION OF MARGIN-POSITIVE PROXIMAL BILE DUCT DOES NOT IMPROVE SURVIVAL IN PATIENTS WITH HILAR CHOLANGIOCARCINOMA.

Shingu, Yuji; Koji, Oda; Hideki, Nishio; Tomoki, Ebata; Yukihiro, Yokoyama; Tetsuya, Abe; Tsuyoshi, Igami; Masato, Nagino

Nagoya University Graduate School of Medicine, Division of Surgical Oncology, Dept. of Surgery, Nagoya, Japan

Background. The aim of the present study was to elucidate whether additional resection of margin-positive proximal bile duct can improve survival.

Methods. From January, 1977 to December, 2005, 291 patients with hilar cholangiocarcinoma underwent surgical resection with curative intent. Excluding 25 patients who died in hospital, the remaining 266 patients formed a cohort of this study. Surgical procedure performed comprised of hepatobiliary resection in 258 patients and bile duct resection in 8 patients. The proximal ductal margin status was classified into three: negative, positive with carcinoma in situ (CIS), or positive with invasive carcinoma.

Result. Five-year survival rate of 240 patients with negative margin and 26 patients with positive margin (CIS: n = 10, and invasive: n = 16) was 38% and 16%, respectively(p = 0.060). When the 26 patients were divided into CIS or invasive, the 2-year survival rate was 67% and 63%, respectively(p = 0.144). Among 108 patients whose proximal ductal margins were intraoperatively assessed with frozen section examination, positive margin was present in 21 patients, 13 of whom (61.9%) were positive with invasive carcinoma. After additional resection of the intrahepatic bile duct, 6 of the 13 patients achieved negative margin. There was not significantly different between the survival of the 6 patients whose ductal margin status became negative by additional resection and that of 16 patients whose ductal margin was positive with invasive carcinoma (p = 0.798), with 2-year survival rate of 67% and 63%, respectively. Multivariate Cox proportional hazard model identified histologic type and nodal status as independent predictors.

Conclusion. The proximal ductal margin status was not a prognostic factor in patients with hilar cholangiocarcinoma. Even when involved ductal margin was cleaned with additional resection, long-term survival was not improved. Our results may lead that routine use of frozen section examination is not necessary for confirmation of the ductal margin status.

AP 2.06

RESPONSE OF THE DIMERIC FORM OF M2-PYRUVATE KINASE TO ALTERED MICROENVIRONMENT IN PANCREATIC CANCER CELLS.

Kumar, Yogesh¹; Yang, Shiyu²; Fuller, Barry³; Davidson, Brian¹

¹Royal Free and University College Medical School, HPB and Liver Transplant Surgery, London, United Kingdom; ²Royal Free and University College Medical School, Department of Surgery, London, United Kingdom; ³Royal Free and University College Medical School, Academic Department of Surgery, London, United Kingdom

Background. Hypoxic and nutritionally deprived areas are thought to confer pancreatic cancer cells resistance to apoptosis. Tumour M2- pyruvate kinase, a tumour associated isoenzyme of pyruvate kinase, is elevated in patients with pancreatic cancer.

Aim. This study aimed to observe the effect of altered tumor microenvironment on levels of tumor M2-pyruvate kinase in relation to resistance of pancreatic cancer cell lines to apoptosis.

Materials And Methods. The dimeric form of M2-pyruvate kinase was measured in cell homogenate supernatant of Panc 1 (ductal cancer origin) and Colo357 (metastatic lymph node origin) human pancreatic cancer cell lines, exposed to acidic pH (6.5), hypoxic (1% O2) and glucose deprived culture conditions for 24, 48,72 and 96 hrs, using sandwich type ELISA (ScheBo® Tumour M2-PK™) based on monoclonal antibodies specific for it. Total M2-pruvate kinase protein expression was measured semiquantatively by western blotting. Apoptosis in these conditions was measured by FITC Annexin V and Propium Iodide FACS analysis and Active Caspase 3 and 8 assay.

Results. Tumor M2-PK level was significant ly enhanced in Colo357 cells (p < 0.05) at acidic pH compared to normal, hypoxic or glucose deprived culture condition without any change in total M2-PK protein expression. No significant difference was seen between normal and altered microenvironment condition in terms of cell viability and apoptosis in both cell lines.

Conclusion. High levels of tumor M2-pyruvate kinase levels in metastatic cancer cell lines exposed to acidic environment may indicate a survival strategy of cancer cells in altered tumor microenvironment.

AP 2.07

RENIN ANGIOTENSIN SYSTEM AND COLORECTAL LIVER METASTASES

Neo, Jaclyn H¹; Zhu, Jin¹; Herath, Chandana²; Muralidharan, Vijayaragavan¹; Angus, Peter W²; Christophi, Christopher¹

¹Austin Health, University of Melbourne, Surgery, Heidelberg, Australia; ²Austin Health, University of Melbourne, Medicine, Heidelberg, Australia

Background. The Renin Angiotensin System (RAS) appears to be an important mediator of tumour growth and metastasis in several malignancies. Pharmacological blockade of this system may, therefore, provide an alternative strategy in the management of liver metastases.

Aims. This study established the expression of components of the RAS in CRC liver metastases and after RAS blockade.

Methods. CRC liver metastasis was induced in male inbred mice by intrasplenic injection of murine colon cancer cells. Animals were killed at 5, 10, 16 and 21 days after tumour induction (spanning lag, exponential and plateau phases of tumour growth). The expression and cellular localisation of components of the RAS in normal and tumour-induced liver were assessed by quantitative RT-PCR and immunohistochemistry. The effects of blockade of the RAS on expression were also examined.

Results. Components of the RAS were expressed in normal liver, tumour-induced normal liver, and in tumours and the angiotensin converting enzyme (ACE) protein localised to the hepatic endothelial cells. ACE expression significantly increased at day 16 (p < 0.003) and Mas receptor expression increased at days 16 and 21 (p = 0.01 and p = 0.03, respectively) in tumours compared to normal liver from sham operated animals. However, expression of angiotensinogen was significantly lower in tumours (p = 0.01) compared to shams. Captopril, an ACE inhibitor, decreased ACE2 expression in tumours at day 16 compared to shams (p = 0.0294), while ACE expression increased in Captopril treated tumours at day 21 compared to shams (p = 0.0001).

Conclusion. These results provide important and novel information regarding the expression and localisation of key components of the RAS in CRC liver metastases. Elucidation of the role of the hepatic RAS in the development of liver metastases may have implications for the treatment of patients with unresectable liver metastases and may potentially provide a novel therapeutic strategy to be used alone or as an adjuvant with other conventional therapies.

AP 2.08

MODIFIED ENDOCYSTECTOMY VERSUS PERICYSTECTOMY IN ECHINOCOCCUS GRANULOSUS LIVER CYSTS: A RANDOMIZED CONTROLLED STUDY

Elsebae, Magdy¹; Elsebaie, Sameh¹; Esmat, Emad¹; Nasr, Maged¹; Kamel, Manal²

¹Theodor Bilharz Medical Research Institute, General Surgery, Cairo, Egypt; ²Theodor Bilharz Medical Research Institute, Immunology, Cairo, Egypt

The evidence based data of hydatid liver disease indicate that the level of evidence was too low to help decide between radical or conservative surgeries. So, there is a need for accurately designed randomized trials with precise goals to compare pericystectomy versus a specific modified endocystectomy technique for the treatment of hepatic hydatid cysts 8 cm or less in diameter in Egyptian patients, regarding the operative time, intra-operative blood loss, complications and long-term recurrence 60 patients with 131 liver cysts of E. granulosus fulfilling the study criteria were randomly divided to two groups. GI: 32 patients with 69 cysts treated by modified endocystectomy and GII: 28 patients with 62 cysts treated by closed total pericystectomy. Preoperative evaluation included history taking, clinical examination, blood tests, specific anti-hydatid IgG4, abdominal sonography and CT scan. The operative time for dealing with each cyst was in minutes. Operative blood loss and need for blood transfusion were estimated for each patient. Specific anti-hydatid IgG4 by ELISA was used to diagnose and to detect early recurrence. Patients were followed up clinically and by ultrasonography every 3 months and for anti-hydatid IgG4 every 6 months for 24–90 months. The mean maximum operative time was in GIIa followed by GIa, GIb, then GIIb. The operative time was significantly lower in GIIb than Ib and in GIa than IIa. Seven patients (GII) had blood transfusion. The intraoperative bleeding in GI was <500 ml/ patient, and 18 patients (GII) each bled >500 ml. No intraperitoneal seedling during the follow up. 5 of 55 patients (9%) were serologically suspected of relapse or incomplete cure. One (GII) showed early recurrence at 3 months. High IgG4 antibodies were detected in patients which decreased gradually after surgery and normal after 18 months post-operation.

AP 2.09

LONG TERM SURVIVAL AND DISEASE RECURRENCE AFTER PREOPERATIVE PORTAL VEIN EMBOLISATION PRIOR TO MAJOR HEPATECTOMY FOR COLORECTAL CANCER LIVER METASTESE

Pamecha, Viniyendra¹; Glantzounis, George¹; Biswas, Atin¹; Fusai, Kitu¹; Sharma, Dinesh¹; Davies, Niel²; Davidson, Brian¹

¹Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION; ²Royal Free Hospital, University College Medical School, Department of Radiology, LONDON, United Kingdom

Background. Portal vein embolisation (PVE) can be used to increase the remnant liver parenchyma volume before major hepatectomy. Embolisation is known to influence tumour growth yet few studies have addressed the disease progression, recurrence and long term survival in patients with PVE before major resection for colorectal cancer liver metastases.

Objective. To assess the effect of preoperative PVE on disease progression, recurrence and long term survival in patients undergoing major resection for colorectal cancer liver metastases.

Methods. Thirty six patients underwent preoperative PVE before resection of four or more liver segments. PVE was performed when the future liver remnant (FLR) assessed by MRI scan volumetry was less than 30%. Disease free and overall survival was compared with a control group of patients undergoing major resection (four or more segments) for CRC metastases without PVE.

Results. PVE was successful in all patients. PVE significantly increased the FLR volume (pre PVE 295 mls, post PVE 404 mls p < 0.0001). Liver resection was performed after PVE in 22 patients (61%), twelve patients (33%) developed disease progression. The 5 year actual survival after liver resection with PVE was 25% with a median follow up of 46 months. The 5 year survival after liver resection of the control group was 50%. The 5 year disease free survival was 30% post PVE (median 12 months) and 50% without PVE (median 22 months).

Conclusion. PVE allows patients with previously unresectable liver metastases to benefit from resection. A significant proportion of patients have disease progression post PVE. Actual long term and disease free survival is inferior to when compared with patients requiring major resection without PVE.

AP 2.10

THE ROLE OF NEO-ADJUVANT CHEMOTHERAPY FOR COLORECTAL LIVER METASTASES: A CASE CONTROLLED STUDY

Malik, Hassan; Shahid, Farid; Al-Mukhtar, Ahmed; Toogood, Giles; Lodge, Peter; Prasad, Raj

St James University Hospital, Leeds, United Kingdom

Background. The aim of this study was to analyse the outcome of patients that received neo-adjuvant chemotherapy prior to resection for colorectal liver metastases (CRLM) and compare them with a matched cohort of patients that underwent resection followed by adjuvant chemotherapy.

Methods. 687 patients have undergone curative resection between January 1993 and January 2006. In this period, 84 patients received neo-adjuvant chemotherapy and 71 of this group went on to resection. A control group was chosen, matched with these patients, made up of patients who underwent resection followed by adjuvant chemotherapy.

Results. There was no difference in clinico-pathological features between the neo-adjuvant and the control group. However patients in the control group had more extended resections and had longer hospital stays compared to those in the neo-adjuvant group, p = 0.015. Patients in the control group had an increased incidence of “early” recurrences, p < 0.001. Despite this, there was no significant difference in either the cancer-specific or the disease-free survival between the two groups of patients.

Conclusion. Neo-adjuvant chemotherapy has a role in the management of patients with disease that is considered initially unresectable as a “down sizing” technique. In patients with resectable disease, a “test of time” that neo-adjuva nt therapy offers is yet to be proven.

AP 3.01

HYPERBARIC OXYGEN THERAPY AND ISCHAEMIA PRESERVATION AND REPERFUSION INJURY IN LIVER TRANSPLANTATION

Tran, Nhut Quang; Christophi, Christopher; Muralidharan, Vijayaragavan

Austin Health, The University of Melbourne, Surgery, Heidelberg, Australia

Background. Ischaemia, preservation and reperfusion injury (IPRI) is a major cause for suboptimal donor organ function after liver transplantation. Accumulating evidence suggests that hyperbaric oxygen therapy (HBO) may improve IPRI. This study investigates the effect of HBO on a rat model of liver transplantation.

Methods. Syngeneic liver transplantation was performed on male inbred Lewis rats. Donor organs were stored for 24 hours at 4°C for severe IPRI. HBO was administered twice daily. The animals were killed and the livers were removed at 48 hours after transplantation. Effect of HBO on IPRI was assessed by quantification of hepatocyte necrosis, apoptosis and proliferation. Techniques used include histopathology, quantitative stereology and immunohistochemistry.

Results. After 48 hours of treatment, HBO therapy significantly reduced hepatic necrosis in the median (0.76±0.54% vs. 5.87±1.62%, P < 0.001) and right liver lobes (2.1± + 0.92% vs. 6.07±1.55%, P < 0.001) and neared significance (4.59±1.5% vs. 9.46±2.56%, P = 0.07) in the left lobe when compared to controls. Concurrently, HBO therapy reduced apoptosis in all liver lobes; including the left (1.32±0.16% vs. 2.78±0.37%, P < 0.001), median (1.02±0.12% vs. 2.13±0.31, P < 0.05) and right liver lobes (0.74±0.11% vs. 2.04±0.212%, P < 0.05). By day seven, recovery was near complete with minimal necrosis or apoptosis in both treatment and control groups. HBO therapy stimulated early hepatocyte proliferation in all lobes (the median: 19.67±1.18% vs. 11.3±1.13%, p < 0.0001, left: 16.51±1.55% vs. 4.94%±0.51%, P < 0.001 and the right: 19.31±1.55% vs. 9.75±0.81%, P < 0.05).

Conclusion. The application HBO therapy post transplantation significantly reduces IPRI induced necrosis and apoptosis while stimulating increased proliferation of hepatocytes leading to faster recovery.

AP 3.02

EFFECT OF PREOPERATIVE PORTAL VEIN EMBOLISATION ON TUMOUR MORPHOLOGY OF COLORECTAL CANCER LIVER METASTASES

Pamecha, Viniyendra¹; Levene, Adam²; Woodward, Nick³; Dhillon, Amarpal²; Davidson, Brian⁴

¹Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION, Pond Street, Hampstead, LONDON, United Kingdom; ²Royal Free Hospital, University College Medical School, Department of Histopathology, LONDON, United Kingdom; ³Royal Free Hospital, University College Medical School, Department of Radiology, LONDON, United Kingdom; ⁴Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION, LONDON, United Kingdom

Background. Portal vein embolisation (PVE) has now become an established technique to increase remnant liver volume prior to major liver resection for colorectal metastases. The resection rate after PVE in the published series is 60–70%. This is mainly influenced by disease progression following PVE. The effect of PVE on tumour morphology has not been previously been investigated.

Objective. To compare the morphology of resected colorectal liver metastases in patients who had undergone pre-operative PVE with matched controls who had not undergone PVE.

Methods. Tumour growth rate was calculated by change in tumour volume from the time of diagnosis (CT/MRI volumetric assessment) to volume at the time of resection in 20 patients undergone PVE and compared with 20 matched controls (non PVE). Resected histological specimens were examined for cell differentiation; percentage of necrosis, mitotic rate. Immunochemical staining with Ki-67 was performed using the MIB-1 monoclonal antibody and quantified using a Glasgow cell counting graticule. The number of tumour cells was counted in the ten bold squares over 10 fields.

Results. The groups were comparable in demographics, stage of primary disease, adjuvant chemotherapy and volume of liver metastases. The tumour growth rate was rapid in PVE group compared with controls (control −0.010¡Ó0.46, PVE 1.6¡Ó0.85, p = 0.084). In the resected specimen there was no significant difference in the resection margins (control-20.2¡Ó3.7, PVE-14.7¡Ó4.25, p = 0.3382), tumour volume (control-229¡Ó6.8, PVE-99.4¡Ó50.4, p = 0.1365), degree of differentiation, cell necrosis (control-39.50¡Ó4.9, PVE-46¡Ó5.6, p = 0.390) and mitotic index (controls-10.50¡Ó1.07, PVE -12.0¡Ó1.14, p = 0.346). The proliferation index Ki67 was significantly higher post PVE (control- 27 b10%, PVE –37, b17%, p < 0.05).

Conclusion. PVE causes increase in tumour growth and cancer cell proliferation.

AP 3.03

MODE OF HEPATIC SPREAD FROM CARCINOMA OF THE GALLBLADDER

Wakai, Toshifumi¹; Shirai, Yoshio¹; Sakata, Jun¹; Korita, Pavel¹; Ajioka, Yoichi²; Hatakeyama, Katsuyoshi¹

¹Niigata University Graduate School of Medical and Dental Sciences, Division of Digestive and General Surgery, Niigata City, Japan; ²Niigata University Graduate School of Medical and Dental Sciences, Division of Molecular and Diagnostic Pathology, Niigata City, Japan

Background. The aims of this study were to analyze the mode of hepatic spread from gallbladder carcinoma and to elucidate its prognostic value.

Methods. Of 162 consecutive patients undergoing radical cholecystectomy for gallbladder carcinoma, 40 had hepatic involvement. The mode of hepatic metastasis was examined grossly and histologically in the resected specimens. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity for D2–40 monoclonal antibody. The median follow-up time was 172 months.

Results. Twenty-four patients had evidence of microscopic angiolymphatic portal tract invasion, in whom 16 had intrahepatic lymphatic invasion and 2 had venous invasion. Nine had distant hepatic metastatic nodules and 7 had direct invasion alone. The gross depth of direct invasion of the liver showed a linear correlation with the distance of angiolymphatic spread by simple linear regression analysis (correlation coefficient [r] = 0.52361; P = 0.0086; formula, y = 1.972 + 0.137x). The mode of hepatic spread (P < 0.001) and residual tumor status (P < 0.001) were independent prognostic factors. The type of hepatectomy procedure (nonanatomic vs. anatomic) did not influence survival after resection (P = 0.9033). All 9 patients who had tumors with distant hepatic metastatic nodules expired within 11 months of undergoing surgical resection.

Conclusions. Angiolymphatic invasion within the portal tracts is the main mode of hepatic spread from gallbladder carcinoma. The correlation between the extent of angiolymphatic invasion and the gross depth of direct invasion may be useful for estimating adequate hepatectomy margins.

AP 3.04

HIGH AFFINITY PEPTIDES MODULATE CHEMOTHERAPY INDUCED DRUG-RESISTANCE IN PANCREATIC CANCER

Hoffmann, Katrin; Schmidt, Jan; Buechler, Markus W; Maerten, Angela

Ruprecht-Karls-University of Heidelberg, Department of General Surgery, Heidelberg, Germany

Background. Pancreatic cancer is highly resistant to chemotherapy. Decreased survival rates are associated with acquired over-expression and increased activity of drug extruding resistance proteins. The high affinity peptide R121 modulates the activity of drug-resistance proteins and restores the up-take of cytotoxic agents in cancer cells. An interaction of high affinity peptides and drug-resistance proteins in pancreatic cancer has not yet been investigated.

Methods R121 was tested in an orthotopic ultrasound guided pancreatic cancer mouse model. Animals were either treated with monotherapy of 5-Fluorouracil, cisplatin and gemcitabine or combination of these agents with R121. The drug-resistance proteins P-Glycoprotein, MRP1 and MRP3 were quantified by multicolor flowcytometry and protein function was evaluated in vitro and in vivo.

Results Chemotherapy significantly up-regulated the expression of drug-resistance proteins in vitro and in vivo. The cellular drug efflux activity increased significantly compared to the untreated control. Combinative treatment with 5-Fluorouracil or gemcitabine plus R121 significantly down-regulated P-Glycoprotein, MRP1 and MRP3 expression. The protein activity decreased significantly. Tumor size and prevalence of liver and lung metastases were significantly reduced by combination therapy.

Conclusion. Acquired multi-drug resistance is inducible by sta ndard chemotherapy in pancreatic cancer. The high affinity peptide R121 inhibits the activity of multi-drug resistance proteins and restores the chemosensitivity. The improved outcome after combinative therapy implicates a potential role of R121 as chemosensitizer.

AP 3.05

PROPHYLACTIC ANTIBIOTICS ARE NOT USEFUL IN PREVENTING INFECTION IN SEVERE PANCREATITIS WITH PANCREATIC NECROSIS. SINGLE CENTER, DOUBLE BLIND STUDY.

Borobia, Francisco G¹; Garcia Barrasa, Arantxa¹; Jorba, Rosa²; Busquets, Juli²; Ramos, Emilio²; Torras, Jaume²; Llado, Laura²; Rafecas, Antonio²; Poves, Ignasi³; Fabregat, Joan²

¹Hospital Universitari de Bellvitge, General Surgery, L'Hospitalet de Llobregat. Barcelona, Spain; ²Hospital Universitari de Bellvitge, Hepatobiliary and pancreatic surgery, L'Hospitalet de Llobregat. Barcelona, Spain; ³Hospital del Mar, Hepatobiliary and pancreatic surgery, L'Hospitalet de Llobregat. Barcelona, Spain

Use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial, and only two previous studies with double blind design had been published.

Methods. This is a prospective, randomized, placebo-controlled, double blind study carried out at one tertiary European Hospital during 5 years. Among 798 patients with acute pancreatitis, 229 were diagnosed of severe acute pancreatitis, and 80 of them had evidence of necrotizing pancreatitis (34 of the 80 patients were not included in the randomization protocol because of previously establish reasons). Then, 46 patients without previous antibiotic treatment and with pancreatic necrosis in a contrast-enhanced CT scan, were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study protocol (22 patients received intravenous ciprofloxacin and 19 patients received placebo). Ciprofloxacin was chosen by the infectious Committee of our Center because its broad antibacterial spectrum and safety.

Results. Comparing the 22 patients received intravenous ciprofloxacin and 19 received placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.707), and the mortality rate was 18% and 11%, respectively (p = 0.668). In addition, no significant differences between both treatment groups were observed with respect to several variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, development of organ failure, and length of hospital and IUC stays.

Conclusion. In the present double blind study, the prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection nor decrease the mortality rate. However, it should be considered the small number of patients that could be finally included.

AP 3.06

FAST TRACK MAJOR LIVER SURGERY; AN UPDATE ON AN ENHANCED RECOVERY PROGRAMME

Van Dam, Ronald M.¹; Stoot, Jan H.M.B¹; Hendry, Paul O.²; Jippes, Mariëlle¹; Bemelmans, Marc H.A.¹; Fearon, Ken C.H.²; Garden, O. James²; Dejong, Cornelis H.C.¹

¹University Hospital Maastricht, Department of Surgery, Maastricht, Netherlands; ²Royal Infirmary, Department of Surgery, Edinburgh, United Kingdom

Background. Optimising peri-operative care using a fast track programme has been shown to improve convalescence following major abdominal surgery. Recovery is accelerated through continuous thoracic epidural pain control, stimulation of gut motility, early physical re-activation and limited use of catheters, tubes and drains.

Objective. An international two centre study was conducted to assess feasibility, efficacy and safety of an enhanced recovery programme after major liver resection (MLR).

Methods. A consecutive series of 44 patients undergoing MLR from 1 march 2005, was studied (Group I). The Enhanced Recovery After Surgery (ERAS) multimodal core protocol was used perioperatively. Data on nasogastric drainage, resumption of normal food after surgery, length of postoperative hospital stay (LOS), readmissions, pre-operative chemotherapy, morbidity and mortality were collected prospectively and compared with historical data from a prospectively collected data base of all MLR in our units in 2004 (group II, n = 66).

Results. In 93% of patients de NG tube was removed and oral intake restarted within 4 hours after surgery. The median day of normal food intake after MLR was 1 (range 0–3) day in group I vs 4 (0–14) days in group II, (p < 0,001, Mann Whitney). Readmission rate was 18,2% in group I and 9,1% in group II (ns). Complication rate was 50,0% in group I and 30,3% in group II (p < 0,04, chi square). Pre-operative chemotherapy was used more widely in group I (65,9% vs 37,9%, p< 0,004). The median LOS was 6.5 (range 3–82) days in group I and 8.0 (5–55) days in group II p < 0,002. Mortality for the subgroups was 0% and 3%, group I and II respectively (ns).

Conclusion. An enhanced recovery programme after liver resection is safe and can accelerate postoperative recovery. Normal food intake can be restarted on the first day after surgery. Median length of postoperative hospital stay is reduced from 8.0 to 6.5 days.

AP 4.01

INHIBITION OF MULTI-DRUG RESISTANCE IN PANCREATIC CARCINOMA BY INTERFERON ALPHA

Hoffmann, Katrin; Schmidt, Jan; Buechler, Marcus W; Maerten, Angela

Ruprecht-Karls University of Heidelberg, Department of General Surgery, Heidelberg, Germany

Background. Recent studies indicate a correlation between Interferon alpha (IFN-alpha) based immunotherapy and improved survival in pancreatic cancer. Over-expression of multi-drug resistance proteins and consecutive response rates <15% to chemotherapy are important prognosis limiting factors. Drug-resistance modulation by IFN-alpha has not yet been examined.

Methods. Pancreatic cancer was induced orthotopically by ultra-sound guided implantation of syngenic PANC02 cells in mice. Animals were either treated with monotherapy of 5-Fluorouracil, cisplatin and gemcitabine or combination of these agents with IFN-alpha. Multicolor flowcytometry was used for quantification of drug-resistance proteins P-Glycoprotein, MRP1 and MRP3 and analysis of intratumoral immunological phenotyping, cytotoxic activity and T-cell activation status. Function of drug-resistance proteins was investigated in vitro.

Results. Expression of resistance proteins and drug efflux activity of cancer cells were significantly increased by chemotherapy in vitro and in vivo compared to the untreated control. Addition of IFN-alpha to cytotoxic regimes significantly down-regulated P-Glycoprotein, MRP1 and MRP3 as well as protein activity. Compared to single agent therapy tumor size and metastatic seeding decreased significantly and survival was prolonged. A significantly higher proportion of activated and cytotoxically active CD8+ tumor infiltrating lymphocytes was detectable after up-regulation of drug resistance proteins. Immuno-chemotherapy induced a decrease of naive T-cells and increased central as well as effector memory cells within the tumor.

Conclusion. Reconstitution of chemosensitivity and improvement of outcome by addition of IFN-alpha to chemotherapy were demonstrated in experimental pancreatic cancer for the first time. Our data support immuno-chemotherapy as a new encouraging approach and suggest clinical significance of tumor-specific immune response in pancreatic cancer.

AP 4.02

INTERACTION OF CD44 AND ITS LIGAND HYALURONAN PLAYS A CRITICAL ROLE IN THE DEVELOPMENT OF BILE DUCT PROLIFERATION IN CHOLESTATIC LIVERS

Wu, Gordon; He, Yao; Sadahiro, Tomohito; Noh, Sang-Ik; Klein, Andrew

Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, United States

Introduction. Previously we have demonstrated high levels of CD44 expression in proliferative bile ducts in cholestatic livers.

Objective. The current study was carried out to further investigate the pathophysiology of CD44 expression by biliary epithelia.

Methods. Rat cholestatic livers were induced by bile duct ligation (BDL). Histological distribution of CD44-expressing cells and disposition of extracellular hyaluronic acid (HA) were examined in cryostat sections of the livers with immunofluorescence or histochemistry. Biliary epithelial cells (BEC), hepatic stellate cells (HSC), CD31+ hepatic endothelial cells (HEC) and ED2+ Kupffer cells (KC) were isolated and examined for expression of CD44 standard (s) and variant (v) isoforms with quantitative real time PCR. The effect of CD44-HA interaction in biliary epithelial proliferation was studied in cultures.

Results. Metamorphic analysis of the liver sections stained with HA binding protein demonstrated strikingly increased HA synthesis in the portal triads of the BDL livers when compared with those of sham operated controls. Immunofluorescent staining confirmed that cell surface CD44 proteins were intensively present in intrahepatic bile ducts which exhibited vigorous proliferation. BEC isolated from BDL livers dis played high levels of CD44 mRNA expression, which was 3-fold greater than that expressed by HEC (P < 0.05), 22-fold greater than KC (P < 0.05) and 25-fold greater than HSC (P < 0.01). CD44 species expressed in the cholestatic livers were predominantly variant isoforms. In cultures, BEC significantly increased expression of CD44 and the cell proliferation maker ki-67 in responses to hyaluronan stimulation.

Conclusion. Extracellular HA accumulated in the portal triads can stimulate biliary epithelia to proliferate and to express high levels of CD44. The results suggest that the CD44-HA pathway plays a critical role in the development of bile duct proliferation in cholestatic livers.

AP 4.03

Caudate lobe involvement by colorectal metastases translates into reduced survival following hepatic resection.

Khan, Aamir Z; Wong, Vincent; Malik, Hassan; Morris-Stiff, Gareth; Prasad, Raj; Lodge, J Peter A; Toogood, Giles J

St James University Hospital, Leeds, United Kingdom

Aims. To analyze operative and oncological outcomes following hepatic resection for colorectal metastases involving the caudate lobe.

Patients and Methods. Six hundred and eighty seven consecutive patients undergoing hepatic resection for colorectal metastases from 1993 to 2006. Data were analyzed from a prospectively collected database, operative and oncological outcomes including disease free and overall survival were used as outcome measures. Patients were analyzed as those having caudate lobe involvement (CLM) or no caudate lobe involvement (NCLM).

Results. Fifty two of 687 patients had metastases involving the caudate lobe (7.5%). Patients with caudate lobe involvement were more likely to require an extended hepatic resection (75% vs 27%, P = 0.001), perioperative blood transfusion (29% vs 14%, P = 0.002), have a positive resection margin (57% vs 32%, P = 0.001) and stay longer in hospital (12 vs 8 days, P = 0.001). There was no difference in the in the proportion of patients requiring hepatic pedicle clamping (29% vs 31%, P = 0.424), complication rate (37% vs 29% P = 0.321) or 30-day mortality between the two groups (1.12% vs 1.19% P = 0.446). Thirty one percent of patients in the CLM group exhibited a raised inflammatory ratio versus 19% in the NCLM group (P = 0.049). Although the disease free survival was similar (19.9 months vs 21.2 months, P = 0.191), patients in the CLM group had a reduced overall survival compared to patients in the NCLM group (36.5 months vs 50.5 months, P = 0.036).

Conclusions. Although long term survival can be offered to these patients, caudate lobe involvement should be regarded as an independent prognostic factor for reduced survival following hepatic resection for colorectal metastases.

AP 4.04

HEAVY METALS IN GALLBLADDER CANCER TISSUES: A PRELIMINARY STUDY

Chhabra, Deepak¹; Oda, Koji²; Utsunomia, H³; Bharde, Shubhada⁴; Takekoshi, S⁵; P, Jagannath¹; Nimura, Yuji²

¹Lilavati Hospital and Research Centre, Dept. of Surgical Oncology, Mumbai, India; ²Nagoya University Graduate School of Medicine, Division of Surgical Oncology, Dept. of Surgery, Nagoya, Japan; ³Wakayama Medical College, School of Medicine, Dept. of Pathology, Wakayama, Japan; ⁴S. L. Raheja Hospital-Asian Institute of Oncology, Dept. of Pathology, Mumbai, India; ⁵Tokai University School of Medicine, Dept. of Pathology, Isehara, Japan

Background. High incidence of gallbladder cancer (GBC) is reported from North India. High concentrations of heavy metals were detected in river waters in areas of high incidence of GBC.

Aims And Objectives. To determine if there were increased levels of heavy metals in Indian GBC or non-neoplastic gallbladder (GB) tissue using spectrophotometry and electron microscopy and to compare with Japanese GBC and non-neoplastic GB tissue. To determine if human scalp hair could be a marker for wide scale epidemiological study in endemic areas in India.

Materials And Methods. Spectrophotometric assessment was done for 19 Indian gallbladder tissues (9 GBC, 10 non-neoplastic GB) and 9 Japanese gallbladder tissues (5 GBC, 4 non-neoplastic GB). Transmission electron microscopy (TEM) including thin foil element analysis was carried out in 7 Indian samples (6 GBC, 1 non-neoplastic GB) to detect tissue heavy metal concentrations. Scalp hair metal levels were evaluated using spectrophotometry in 31 samples (18 endemic, 13 non-endemic) from India.

Results. Cadmium, Chromium, Lead, Arsenic, Mercury, Iron, Zinc and Manganese were detected by spectrophotometry in Indian GBC and some non-neoplastic GB. A comparative study with Japanese specimens demonstrated that Lead, Arsenic, and Zinc were specifically highly accumulated in Indian tissues. TEM of Indian tissues demonstrated electron dense deposits in GBC; however, thin foil TEM element analysis could not localize any metals. Human scalp hair analysis of 18 endemic samples from India revealed significantly high levels of Cadmium, Arsenic, Mercury, lead and Zinc.

Conclusions. We hypothesize that heavy metals: Arsenic, Mercury, Lead and Zinc may be the potent carcinogens in Indian GBC from endemic areas. As these metals could not be localized by thin foil TEM analysis, they may be contained in the Indian gallbladders not as particles but in a soluble active form with higher carcinogenic potential. The specific cause effective relationship of these potential carcinogens needs further evaluation.

AP 4.05

FACTORS INVOLVED IN LIVER REGENERATION AND THEIR ROLE IN THE STIMULATION OF TUMOUR GROWTH

Harun, Nadia; Zhu, Jin; Muralidharan, Vijayaragavan; Christophi, Christopher

Austin Hospital, Surgery, Heidelberg, Australia

Background. Partial hepatectomy for colorectal liver metastases is associated with a 40–80% tumour recurrence rate. This recurrence may be linked to factors involved in liver regeneration which have been shown to stimulate occult tumour growth.

Objective. This project aims to determine factors of liver regeneration which may contribute to the stimulation of tumour growth in an established mouse model of colorectal liver metastases.

Methods. Male CBA mice (8 week old) were used. Five groups of animals underwent 70% resection and were compared to sham laparotomies (0%). Each group of animals was killed at various timepoints (day 2, 4, 6, 8 and 10) and livers analysed using immunohistochemistry to determine the pattern of growth factor receptor expression during regeneration. This same experiment was again performed however livers were induced with a mouse derived colon cancer cell line (MoCR) following resection. Growth factor receptor expression was assessed on tumour as well as normal liver surfaces.

Results. Significant early increases in hepatocyte growth factor receptor (c-MET), (p ≤ 0.01) and epidermal growth factor receptor (EGFR), (p < 0.05) levels were observed compared to the shams. These were also found to be highly expressed on tumour surfaces. Expression of growth factor receptors in the liver tissue of animals which underwent tumour induction were found to be higher and maintained for longer than in the liver tissue of animals which had no tumours.

Conclusion. Growth factor receptors elevated during liver regeneration are also found to have receptors on tumour surfaces which may be contributing to the stimulation of tumour recurrence following partial hepatectomy.

AP 4.06

PHASE I STUDY OF THERMODOX(THERMALLY SENSITIVE LIPOSOMES CONTAINING DOXORUBICIN)GIVEN PRIOR TO RADIOFREQUENCY ABLATION FOR UNRESECTABLE LIVER CANCERS

Poon, Ronnie¹; Ng, Kelvin¹; Yuen, Jimmy²; Hahne, William³; Prabhakar, Raj³; Eugeni, Michelle⁴; Locklin, Julia⁵; Wood, Bradford⁵; Libutti, Steven⁴

¹Queen Mary Hospital/The University of Hong Kong, Department of Surgery, Hong Kong, Hong Kong; ²Queen Mary Hospital/The University of Hong Kong, Department of Radiology, Hong Kong, Hong Kong; ³Celsion Corp, Columbia, Colombia; ⁴Surgery Branch NCI, USA, United States; ⁵NIH, Diagnostic Radiology, USA, United States

Background. Radiofrequency ablation (RFA) for liver cancers is associated with a high recurrence rate. Thermodox (TDox) liposomes are engineered to release doxorubicin locally at temperature >39.5C. High local TDox concentrations around RFA-treated area could possibly increase local tumor control.

Aims. A completed phase I study was conducted in patients with unresectable liver cancers undergoing RFA with a 30-min. IV infusion of TDox starting 15 min. before RFA. The aims were to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of TDox.

Methods. Patients with hepatocellular carcinoma (HCC) or metastatic liver cancer (MLC) eligible for RFA were recruited. Main inclusion criteria were lesions < 4 in number and < 7 cm in greatest diameter. Dose escalation was: cohorts of 3–6 pts treated with a single dose of 20, 30, 40, 50 or 60 mg/m2. RFA was performed by percutaneous or surgical approach. Contrast CT scans were done pre-, 1 and 3 months post-treatment and every 3 months thereafter. Patients were assessed for safety, pharmacokinetics, and local tumor control on CT.

Results. A total of 24 patients (9 with HCC and 15 with MLC) were treated (3, 6, 6, 6, 3 patients at 20, 30, 40, 50 and 60 mg/m2, respectively). Median tumor size was 3.7 cm (range 1.7–6.5 cm). Totally 28 tumors were treated. Twenty (83%) patients had no evidence of local tumor control failure. Three patients had local failure detected at 28 days post-treatment, and one had local failure at 9 months post-treatment. Grade 3/4 toxicity (reversible neutropenia) has been observed to be dose-dependent. Two patients at 60 mg/m2 met DLT criteria and 50 mg/m2 was considered the MTD.

Conclusions. TDox can be safely given in combination with percutaneous or surgical RFA for liver tumors, with limited and manageable toxicity. The MTD was 50 mg/m2 for singe-dose administration. The local control for RFA plus TDox in relatively large tumors appears favorable, supporting a randomized trial comparing RFA plus TDox versus RFA alone.

AP 5.01

ACUTE PANCREATITIS SEVERITY IS EXACERBATED BY INTESTINAL ISCHEMIA-REPERFUSION CONDITIONED MESENTERIC LYMPH

Phillips, Anthony¹; Flint, Richard S²; Power, Sharleen E¹; Dunbar, P. Rod¹; Brown, Caroline¹; Delahunt, Brett³; Cooper, Garth JS¹; Windsor, John A²

¹University of Auckland, School of Biological Sciences, Auckland, New Zealand; ²University of Auckland, Department of Surgery, Auckland, New Zealand; ³Wellington School of Medicine, University of Otago, Department of Pathology and Molecular Medicine, Wellington, New Zealand

Background. Intestinal ischaemia is a feature of acute pancreatitis. It is not known whether this contributes to its severity or is a consequence of it.

Aims. To determine the effect of intestinal ischaemia-reperfusion on acute pancreatitis and the role of mesenteric lymph in contributing to disease severity.

Methods. Two experiments are reported using intravital microscopy and a sodium taurocholate rodent model of mild pancreatitis. In the first study, rats underwent intestinal ischemia-reperfusion during acute pancreatitis, produced by 30 minute occlusion of the superior mesenteric artery (as 30 minutes or 3×10 minutes) followed by 2 hours of reperfusion. In the second study, rats with acute pancreatitis had an intravenous infusion of mesenteric lymph collected from donor rats that had been subjected to a similar duration intestinal ischemia-reperfusion injury. The pancreatic erythrocyte velocity, functional capillary density, leukocyte adherence, histology and edema index were measured.

Results. Intestinal ischemia-reperfusion during acute pancreatitis caused a decline in the pancreatic microcirculation beyond that of pancreatitis alone (erythrocyte velocity 42% of baseline vs. 73% of baseline with pancreatitis alone, functional capillary density 43% vs. 72%, leukocyte adherence 7-fold increase vs. 4-fold increase). This caused an increased severity in acute pancreatitis, evidenced by a 1.4 – 1.8 fold increase in severity indices over acute pancreatitis alone. A very similar exacerbation of microvascular failure and increased severity was demonstrated by the intravenous infusion of intestinal ischemia-reperfusion-conditioned mesenteric lymph.

Conclusion. Unidentified factors released into mesenteric lymph following intestinal ischemia-reperfusion injury are capable of exacerbating acute pancreatitis severity. This highlights an important role for the intestine in the pathophysiology of severe acute pancreatitis and identifies mesenteric lymph as a significant component of this pathobiology.

AP 5.02

PREDICTORS OF SURVIVAL AFTER PERCUTANEOUS ABLATION OF HEPATOCELLULAR CARCINOMA

Chen, Min-Shan¹; Peng, Zhen-Wei¹; Zhang, Yao-Jun¹; Liang, Hui-Hong¹; Li, Jin-Qing¹; Zhang, Ya-Qi¹; Lau, Wan Y²

¹Department of Hepatobiliary Surgery, Cancer Centre of Sun Yat-Sen University, Guangzhou, China; ²Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

Aims. This study aimed to determine risk factors predicting survival in patients with Hepatocellular carcinoma (HCC) under going percutaneous radiofrequency ablation (PRFA).

Patients and Methods. Between August 1999 and May 2005, 281 patients, 250 males and 31 females who were 33 to 80 years old (mean 65.3 years) had PRFA only or PRFA combined with percutaneous ethanol injection (PEI) in our center. Patients were treated with PRFA or PEI by using a percutaneous approach with ultrasound (US) guidance and were evaluated at regular intervals to determine disease recurrence and survival. The survival curves were constructed by Kaplan-Meier method and compared by log-rank test, the relative prognostic significance of the variables in predicting overall survival were assessed by multivariate Cox proportional hazards regression analysis.

Results. At the end of the study, 189 patients were alive, and 92 were dead. Median survival was 48.7 months. The overall 1-year, 3-year and 5-year survival rates were 89%, 54% and 43%, respectively for all patients. The overall 1-year, 3-year and 5-year survival rates for small tumor size (¡Ü 3 cm) were 97.8%, 65.7%, 58.6%, respectively, for medium tumor size (3.1–5 cm) were 94.1%, 57.1%, 37.1% at 1 year, 3 years, 5 years, respectively and for large tumor size (> 5 cm) were 62.8%, 40.3%, 0%, respectively. Survival of patients treated with PRFA was dependent on tumor size (p = 0.000; Risk Ratio [RR] 9.6, 95% CI 5.2–17.8), number of tumors (p = 0.003; RR 1.6, 95% CI 1.2–2.0), combination with PEI (p = 0.010; RR 0.6, 95% CI 0.4–0.9), Child-Pugh class (p = 0.002; RR 2.0, 95% CI 1.3–3.0) and safety margin (p = 0.0026; RR 0.6, 95% CI 0.4–0.9).

Conclusions. PRFA is an effective treatment for HCC. This study determined which patients with HCC do best after PRFA. Tumor size, number of tumors, combined with PEI, safety margin, and Child class are independent risk predictors of survival

AP 5.03

Disordered Pancreatic Inflammatory Responses and Inhibition of Fibrosis in CD39-null mice

Kunzli, Beat¹; Enjyoji, Keiichi²; Nuhn, Philipp¹; Berberat, Pascal¹; Friess, Helmut¹; Robson, Simon²

¹Technical University Munich, Department of Surgery, Munich, Germany; ²Harvard University, Department of Gastroenterology, Boston, United States

Background and Aims. Extracellular nucleotides are released from injured cells and bind to purinergic-type 2 receptors (P2-R) that modulate inflammatory responses. Ectonucleotidases, such as CD39/NTPDase1, hydrolyze extracellular nucleotides and integrate purinergic signaling responses. As the role of CD39 in mediating chronic inflammation and fibrosis is poorly understood, we studied the impact of gene deletion in a model of pancreatic disease.

Methods. Experimental pancreatitis was induced by cyclosporine pretreatment, followed by cerulein injections (50 µg/kg, 6 i.p. injections daily, 3 times per week) and mice were sacrificed at days 2, wk 3 and wk 6. Experimental parameters were correlated with cytokine levels in blood, mRNA and protein expression of purinergic and fibrotic parameters in tissues. Immunohistochemistry and pancreatic morphometry of fibrosis were done in wild-type and CD39-null mice. Proliferation of primary pancreatic stellate cells (PSC) and effects of CD39 deletion were investigated in vitro.

Results. Wild-type mice developed morphological features of pancreatitis with the development of parenchymal atrophy and fibrosis. CD39 and P2-R were overexpressed in both vascular and adventitious tissues in pancreatitis. CD39-null mice developed only minor degrees of pancreatic atrophy and fibrosis. Interferon-γ was significantly increased in tissues and plasma of CD39-null mice. Wild-type pancreatic stellate cells (PSC) expressed high levels of CD39 and P2-R. CD39-null PSC had impaired rates of proliferation but differentiated well in vitro although the production of procollagen-α1 was significantly impaired (P < 0.03).

Conclusions. CD39 deletion decreases fibrogenesis in experimental pancreatitis. Our data implicate CD39 as a modulator of PSC proliferation and collagen production in pancreatitis.

AP 5.04

RIGHT PORTAL VEIN LIGATION IS AS EFFICIENT AS PORTAL VEIN EMBOLIZATION TO INDUCE HYPERTROPHY OF THE LEFT LIVER REMNANT

Aussilhou, Beatrice¹; Lesurtel, Mickael¹; Dokmak, Safi¹; Kianmanesh, Reza¹; Farges, Olivier¹; Sauvanet, Alain¹; Sibert, Annie²; Vilgrain, Valérie²; Belghiti, Jacques¹

¹Beaujon Hospital, HepatoPancreatoBiliary Surgery, Clichy, France; ²Beaujon Hospital, Radiology, Clichy, France

Background. Right Portal Vein (PV) obstruction induces hypertrophy of the future left liver remnant.

Aim. To compare Portal Vein Ligation (PVL) and Portal Vein Embolization (PVE) before right hepatectomy in terms of efficacy for induction of left liver hypertrophy.

Methods. Between 1998 and 2003, 35 patients with liver metastases underwent a right portal branch obstruction before “high risk” right hepatectomy because of a future remnant liver volume less than 30% of the total liver volume or because of a postchemotherapy liver parenchyma. PVE was performed percutaneously in 18 patients, while 17 patients underwent a PVL during a first stage laparotomy for resection of the primary tumor (n = 10) and/or resection of left liver metastases (n = 16).

Results. There was no complication following PVE and postoperative hospital stay was 2±1 days. In group PVL, 6 patients had postoperative complications which were related to primary tumor resection and postoperative hospital stay was 13±6 days. After PV occlusion, the increase of the left liver volume was not significantly different between the two groups (35±38% after PVE vs. 38±26% after PVL, p = 0.7). After PVE, 6 patients were not eligible for right hepatectomy because of insufficient hypertrophy of the left liver (n = 2) or tumor progression (n = 4). After PVL, 3 patients were not eligible for resection because of tumor progression (n = 2) or death (n = 1). Technical difficulties during right hepatectomy were similar in both groups according to duration of procedure (6.4±1 hours vs. 6.7±1 hours, p = 0.7) and transfusion rates (33% vs. 28%, p = 0.7). Mortality was nil in both groups and morbidity rates were respectively 58% for the PVE group and 36% for the PVL group (p = 0.6).

Conclusion. Right PVL and PVE result in a comparable hypertrophy of the left liver. During the first laparotomy of a two-step liver resection, PVL can be efficiently and safely performed.

AP 5.05

15-YEAR EVOLUTION OF LIVER TRANSPLANTATION IN EUROPE

Adam, René¹; Karam, Vincent¹; Buckels, John²; O'grady, John³; Castaing, Denis¹; Klempnauer, Jurgen⁴; Jamieson, Neville⁵; Neuhaus, Peter⁶; Lerut, Jan⁷; Pollard, Stephen⁸; Salizzoni, Mauro⁹; Rogiers, Xavier¹⁰; Garcia-Valdecasas, Juan¹¹; Muhlbacher, Ferdinand¹²; Mir, Jose¹³; BROELSCH, Christopher¹⁴; BURRA, Patrizia¹⁵

¹Hôpital Paul Brousse, Centre Hépatobiliaire, Villejuif, France; ²The Queen Elizabeth Hospital, Queen Elisabeth Medical Center, Birmingham, United Kingdom; ³King's College, Liver Transplantation Unit, London, United Kingdom; ⁴Medizinische Hochschule Hannover, Klinik für Viszeral-und Transplantationschirurgie, Hannover, Germany; ⁵ADDENBROOKE'S Hospital, Department of Surgery, Cambridge, United Kingdom; ⁶Charité- Campus-Virchow klinikum, für Allgemein-Viszeral- und Transplantationschirur, Berlin, Germany; ⁷Catholic University of Louvain, Cliniques Universitaires St-Luc, Brussels, Belgium; ⁸St Jame's & Seacroft University Hospital, Transplantation Unit, Leeds, United Kingdom; ⁹Centro de Trapianti di Fegato, Azienda Ospedaliera S. Giovanni Battista, Torino, Italy; ¹⁰Universitatskrankenhaus Eppendorf, Dept. of Hepatobiliary Surgery, Hamburg, Germany; ¹¹Hospital Clinic I Provincial de Barcelona, Gastrointestinal Surgery Department, Barcelona, Spain; ¹²Transplantationszentrum, Klinishe Abteilung für Transplantation, Wien, Austria; ¹³Hospital Universitario LA FE, Servicio de Medicina D, Valencia, Spain; ¹⁴C. U. K. GHs Essen, Klinik für Allgemeine und Transplantationschirurgi, Essen, Germany; ¹⁵Universitat degli Studi di Padova, Department of Surgery & Gastroenterological Scienc, Padova, Italy

From May 1968 to December 2005 the ELTR has accumulated data on 68776 Liver Transplantations (LT) at 137 centers (23 countries). We analysed the evolution of main indications, surgery techniques and results during the last 15 years period comparing 3 era: (1) 1990–1995; (2) 1995–2000 and (3) 2000–2005. Evolution of indication and surgical technique

	1990–1995	1995–2000	2000–2005
	n = 11883	n = 17939	n = 26824
Indication
Fulminant hepatitis	1238 (10%)	1531 (8%)	1989 (7%)
Alcoholic cirrhosis	1841 (15%)	3561 (20%)	5402 (20%)
Virus C cirrhosis	1351 (11%)	2810 (16%)	4265 (16%)
Virus C cirrhosis	891 (7%)	1139 (6%)	1547 (6%)
Hepatocellular carcinoma	1042 (9%)	2085 (12%)	4191 (16%)
Surgical technique
Cadaveric full-size	11094 (93%)	16174 (90%)	22840 (85%)
Split liver	211 (2%)	790 (4%)	1689 (6%)
Living donor	81 (0.7%)	299 (2%)	1484 (6%)

Patient survival

	Survival	1990–1995	1995–2000	2000–2005	P value
Fulminant hepatitis	1-yr	62%	68%	75%	<0.001
	5-yr	54%	61%	65%
Alcoholic cirrhosis	1-yr	81%	86%	88%	<0.001
	5-yr	68%	73%	71%
Virus C cirrhosis	1-yr	81%	84%	87%	0.167
	5-yr	64%	67%	62%
Virus B cirrhosis	1-yr	81%	88%	91%	<0.001
	5-yr	68%	79%	80%
Hepatocellular carcinoma	1-yr	75%	84%	89%	<0.001
	5-yr	46%	57%	60%
Cadaveric full-size	1-yr	78%	84%	87%	<0.001
	5-yr	64%	71%	69%
Split liver	1-yr	64%	77%	85%	<0.001
	5-yr	55%	70%	73%
Living donor	1-yr	73%	86%	86%	0.078
	5-yr	69%	78%	67%

With regard to the indication, the results show an increase of alcoholic (ALCI) and virus C cirrhosis (VCC), as of hepatocellular carcinoma (HCC). Regarding the surgical technique, split and living donor have increased to represent currently each one 6% of all LT. Concerning the outcome, LT is increasingly providing a survival exceeding 80% at 1 year. Survival has significantly improved for all indications including HCC with however the exception of VCC. The same improvement in survival was observed in cadaveric full-size and split transplants but not for living donor transplant. In conclusion, improved patient management and surgical technique, and more effective immunosuppression still lead to significant improvements in the outcome of LT. Website: www.eltr.org

Free Paper Abstracts

FP 1.01

INTERVENTIONAL RADIOLOGY IN MANAGEMENT OF COMPLICATIONS AFTER PANCREATIC RESECTIONS: TATA MEMORIAL HOSPITAL EXPERIENCE

Nagarjan, Ganesh¹; Kulkarni, Aniruddha²; Kulkarni, Suyash²; Barreto, George¹; Shukla, Parul J¹; Shrikhande, Shailesh V¹

¹Tata Memorial Hospital, Surgical Oncology, Mumbai, India; ²Tata Memorial Hospital, Radiology, Mumbai, India

Background. Major causes of morbidity and mortality after pancreatic resections are pancreatic leaks, collections and hemorrhage. The data on interventional radiology (IR) after pancreatic resections remains sparse from the developing world.

Aims. Assess the impact of IR on complications after pancreatic resections.

Materials And Methods. Prospective data of 63 pancreatic resections (January 2006-July 2007). Type of surgery, complications, IR procedures (IRP's), reoperations, and hospital stay were evaluated.

Results. 56 and 7 underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. There were 39 males and 24 females. Mean age was 46.5 years (11–72 years). 18 had peripancreatic collections of which 13 underwent IRP's (20%). 4 patients had pancreatic fistula while 2 developed bile leaks. Remaining 7 had collections unrelated to leaks. 4/7 who underwent DP (57%), required an IRP compared to only 9/56 who underwent PD (12.5%). Of the 13 patients, two required a single aspiration, one multiple aspirations, and eight required pigtail catheter drainage. Percutaneous biliary drainage was required in the two bile leaks. One had embolization for a gastrointestinal bleed in addition to aspiration of collection. None required reoperation. Mean postoperative stay was 34.7 days in those with IRP's and 16.2 days in those without. Mortality was 1/63 (1.5%). 7 of 13 patients who underwent IRP's would have required resurgery if this facility was unavailable.

Conclusion. This is perhaps the first audit highlighting IR in pancreatic resections from the developing world. IRP's are an asset to pancreatic surgical teams since they avoid resurgery and associated morbidities.

FP 1.02

WHIPPLE VS PYLORUS PRESERVING PANCREATICODUODENECTOMY. POSTOPERATIVE Results AND SURVIVAL OF A PROSPECTIVE- RANDOMIZED STUDY IN A SINGLE INSTITUTION.

Borobia, Francisco G¹; Altet, Joan¹; Jorba, Rosa¹; Busquets, Juli¹; Torras, Jaume¹; Llado, Laura¹; Ramos, Emilio¹; Rafecas, Antonio¹; Pelaez, Nuria¹; Martin Comin, Josep²; Valls, Carlos³; Fabregat, Joan¹

¹Hospital Universitari de Bellvitge, Hepatobiliary and pancreatic surgery, L'Hospitalet de Llobregat. Barcelona, Spain; ²Hospital Universitari de Bellvitge, Nuclear Medicine, L'Hospitalet de Llobregat. Barcelona, Spain; ³Hospital Universitari de Bellvitge, Radiology, L'Hospitalet de Llobregat. Barcelona, Spain

Objective. A prospective randomized study was designed to compare operative, postoperative and survival results after performing classic Whipple pancreaticoduodenectomy (WPD) versus pilorus preserving pancreaticoduodenectomy (PPPD).

Methods. Patients with surgical diseases in the head of the pancreas and periampulary region are invited to participate. The study was approved by our Hospital ethical committee. Randomization was performed after confirming resectability by both techniques. Data concerning patients’ demographics, intraoperative, histology, as well as postoperative complications and survival were analysed. Delayed gastric emptying (DGE) was evaluated clinically and quantified by isotopic nuclear gammagraphy with oral ingestion of Tc99m pre and postoperatively. Nutritional parameters and quality of life test were also recorded pre and postoperatively. Seventy-five patients were included and randomized for a WPD (36) or a PPPD (39) resection from 2003.

Results. There were no significant differences between both groups attending demographics, histology study, blood loss and duration of surgery. Postoperative morbidity and mortality was also similar. DGE were similar in both groups, clinically (WPD, n = 10, PPPD, n = 16; p = 0,81) and measured by Tc99m (p = 0,92). No differences were found in body weigh loss and prealbumin determination. Quality of life test showed similar score. Global morbidity was 33.3%. Hospital length of stay were 17 days without differences between them (p = 0,38). Operative mortality was 6.6%.

Conclusions. Our study demonstrated that both surgical procedures are similar to treat pancreatic head diseases, attending to postoperative results and long-term survival. No differences were found in surgical parameters, postoperative morbidity and a similar incidence of DGE were recorded in two groups.

FP 1.03

A SYSTEMATIC REVIEW AND META-ANALYSIS OF PYLORUS-PRESERVING VERSUS CLASSICAL PANCREATICODUODENECTOMY FOR SURGICAL TREATMENT OF PANCREATIC CANCER

Diener, Markus K¹; Heukaufer, Christina¹; Antes, Gerd²; Seiler, Christoph M¹; Büchler, Markus W¹

¹University of Heidelberg, Department of General, Visceral and Trauma Surgery, Heidelberg, Germany; ²University of Freiburg, German Cochrane Centre, Freiburg, Germany

Objective. Comparison of effectiveness between the pylorus-preserving pancreaticoduodenectomy (“pylorus-preserving Whipple”-PPW) and the classical Whipple (CW) procedure for pancreatic and peri-ampullary carcinoma.

Methods. A systematic literature search (Medline, Embase, The Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed to identify all eligible articles. Randomized controlled trials (RCTs) comparing PPW versus CW for periampullary and pancreatic carcinoma were eligible for inclusion. The methodological quality of included studies was evaluated independently by two authors. Quantitative data on peri-operative parameters (blood loss, transfusion, operation time and length of hospital stay), mortality, morbidity and survival were extracted from included studies for meta-analysis. Pooled estimates of overall treatment effect were calculated using a random effects model.

Results. 1235 abstracts were retrieved and checked for eligibility and 6 RCTs finally included. The critical appraisal revealed varying heterogeneity with respect to methodological quality and outcome parameters. The comparison of overall in-hospital mortality (OR 0.49; 95% CI 0.17 to 1.40; P = 0.18), morbidity (OR 0.89; 95% CI 0.48 to 1.62; P = 0.69) and survival (HR 0.74; 95% CI 0.52 to 1.07; P = 0.11) showed no significant difference. However, operating time (WMD −68.26 min; 95% CI −105.70 to −30.83; P = 0.0004) and intraoperative blood loss (WMD −766 mL; 95% CI −965.25 to −566.74; P = 0.0001) were significantly reduced in the PPW group.

Conclusions. Hence, in the absence of relevant differences in mortality, morbidity and survival, the PPW seems to be as effective as the CW. Given obvious clinical and methodological interstudy heterogeneity, efforts should be intensified in the future to perform high quality RCTs of complex surgical interventions on the absis of well defined outcome parameters.

FP 1.04

COMPARISON OF SURVIVAL BETWEEN SURGICAL RESECTION AND CHEMORADIATION FOR LOCALLY ADVANCED PANCREATIC CANCER

Shinchi, Hiroyuki¹; Maemura, Kosei¹; Noma, Hidetoshi¹; Mataki, Yukou¹; Kurahara, Hiroshi¹; Maeda, Shinichi¹; Aikou, Takashi¹; Takao, Sonshin²

¹Kagoshima University Graduate School, Department of Surgical Oncology, Kagoshima, Japan; ²Kagoshima University, Frontier Science Research Center, Kagoshima, Japan

Purpose. The purpose of this study was to compare the length of survival of surgical resection with that of chemoradiation in patients with locally advanced pancreatic cancer.

Methods. Eighty-four patients with histologically proven locally advanced pancreatic cancer without distant metastases were evaluated in this retrospective study. Forty-one patients received surgical resection while 43 patients received EBRT (50.4 Gy/28/fractions) with concurrent twice-weekly gemcitabine (40 mg/m2/day). The length of survival of the two groups were analyzed and compared.

Results. The median survival and 1-year, 3-year, and 5-year survival rate was 12.6 months and 54%, 13%, and 6% in the resection group, while 11.3 months and 47%, 4%, and 0% in the chemoradiation group (P = 0.12). The R0 resection group had a significantly longer survival than the chemoradiation group. On the other hand, R1/2 group had a similar survival as compared to the chemoradiation group.

Conclusions. Locally invasive pancreatic cancer without distant metastases appears to be best treated by R0 surgical resection, while chemoradiation should be recommended rather than R1/2 resection.

FP 1.05

Comparison of Pancreatic Fistula between Closed Suction Drainage and Natural Drainage in Pancreaticoje junostomy

Lee, Seung Eun; Young-Joon, Ahn; Jang, Jin-Young; Hwang, Dae Wook; Kim, Sun-Whe

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. Leakage of the pancreaticojejunal anastomosis has been a major complication after pancreaticoduodenectomy. Over the past decades, various measures directed towards prevention of pancreatic leakage have been studied. The purpose of this study is to find better method as comparing closed suction drainage and natural drainage in pancreaticojejunostomy for preventing pancreatic fistula.

Methods. During the period 2004 to 2005, a total of 120 patients who underwent pancreaticojejunostomy was enrolled in this study and randomly classified into two groups. 65 patients was allocated to closed suction drainage group and 55 patients to natural drainage group. We inserted PVC tube into remnant pancreatic duct across the duct-to-mucosa type pancreaticojejunostomy in 2 cm depth as a totally external pancreatic stent, which was connected with aspiration bag of Jackson-Pratt drain for generating negative pressure or with bile bag for natural drainage. Pancreatic fistula was defined and graded into A, B, C by ISGPF criteria.

Results. There were no differences between the two groups in age, sex, diagnosis, texture of the pancreas, using of sandostatin and staging. Pancreatic fistula occurred in 24 patients (43.6%) among the natural drainage cases and in 15 (23.1%) among the closed suction drainage cases (P = 0.017). In the natural drainage group, grade A occurred in 18 patients (75%), grade B in 4 (16.7%), and grade C in 2 (8.3%). In the closed suction drainage group, grade A occurred in 9 patients (60%), grade B in 4 (26.7%), and grade C in 2 (13.3%) (P = 0.614).

Conclusion. In this randomized pilot study, temporary external drainage of the pancreatic duct with closed suction drainage significantly reduced the incidence of pancreatic fistula. Additional randomized prospective multicenter study based on this study is ongoing to compare closed suction drainage with natural drainage.

FP 1.06

INFLUENCE OF RECONSTRUCTION METHODS ON QUALITY OF LIFE AFTER PANCREATODUODENECTOMY IN PANCREATIC HEAD CANCER PATIENTS

Marcin, Musiewicz; Ciosek, Jakub; Pawel, Lampe; Mrowiec, Slawomir

Medical University of Silesia, Department of Gastrointestinal Surgery, Katowice, Poland

Background. The most important aspect which determine the outcome and success of the pancreatoduodenectomy (PD) procedure is pancreatic anastomosis. The quality of life (QoL) after the surgical treatment of pancreatic head carcinoma depends on the method of alimentary tract reconstruction and clinical factors. The main purpose of this research is the assessment of the QoL of patients after PD with pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) reconstruction and the influence of clinical factors on the QoL.

Material and Methods. The study involved 68 patients with pancreatic head carcinoma who had undergone radical PD between 2004 to 2006. EORTC-QLQ-C30, QLQ-PAN26 questionnaires and Beck's scale were additionally sent to patients at least six months after PD. 37 patients were included to the study and were divided into 2 groups: PJ group including 25 patients after Whipple, Traverso and Imanaga reconstruction; PG group including 12 patients after Clagett and Flautner reconstruction.

Results. In PG group, there was a statistically significant reduction in gastrointestinal symptoms (p = 0,04) and greater QoL in most functional, symptoms and single item scales. The PJ group were greater only in scales: cognitive functioning, fatigue and insomnia. No statistical differences were found in preoperative, intraoperative factors and postoperative complications. In PJ group was no depression and mild depression in PG group was found. Some strong correlations were found between clinical factors and QoL. Preoperative loss of weight and pain, duration of pancreatoduodenectomy and duration of hospitalisation had impact on the QoL in both groups.

Conclusions. The Patients who underwent PD with PG have better quality of life than patients after PJ reconstruction. Some of clinical factors could deteriorate the QoL in most patients after PD. Beck's scale can detecting depression which was masking true results of the QoL.

FP 1.07

DRAIN FLUID AMYLASE LEVELS AFTER PANCREATICODUODENECTOMY FOR CANCER: CORRELATIONS WITH OUTCOME

Ramesh, Hariharan¹; Sharma, Mohit²; Manish, Gandhi²; Manoj, Jacob²; Ambady, Venugopal²; Bedi, Manmohan²

¹Lakeshore Hospital & Research Center, GI Surgery, Cochin, India; ²Lakeshore Hospital & Research Center, Cochin, India

Background. Pancreatoenteric anastomotic leak is a major cause of morbidity and mortality after pancreaticoduodenectomy. Drain fluid amylase levels are used as markers for pancreatico-enteric anastomotic leak.

Aim. To record drain amylase levels after surgery, and to correlate them with clinically significant pancreatic leak or adverse outcome.

Patients and Methods. 100 consecutive patients with pancreatic cancer treated by pancreaticoduodenectomy (male 63, female 37, age range 17 to 74 years, mean 54.81, median 56). Anastomosis of the pancreatic remnant was carried out by pancreaticogastrostomy in 42, and pancreaticojejunostomy in 58 cases. Drain amylase levels were measured on alternate days starting Day 1, along with drain fluid amounts, type of fluid and the same was correlated with overall complication rate, postoperative fever, intra abdominal collections, bleed, overt leakage, and hospital stay. Sensitivity, specificity and ROC curves were obtained using SPSS PC (version 14).

Results. There was no mortality. Complications occurred in 48 patients, including 9 pancreaticoenteric anastomotic leaks. Hospital stay ranged between 11 and 58 days (mean 15.65, median 14) when there was no anastomotic leak and between 16 and 41 days (mean 29.22, median 33; p <0.001). Re-intervention was also higher in patients with anastomotic leak (4 out of 12; 33%) versus those who did not have leak (5 out of 88; 6% P = 0.009). High drain amylase on Day 1 was sensitive but not specific. High drain amylase on Day 5 was a sensitive and specific predictor of clinically overt pancreatic fistula and the area under the curve on the ROC curve was >95%.

Discussion. High drain amylase on Day 5 has a higher accuracy in predicting postoperative pancreatic fistula than the European Pancreatic fistula study group criterion of Day 3 values.

Conclusion. High drain fluid amylase on Day 5 is a sensitive and specific indicator of clinically significant pancreatic fistula.

FP 1.08

PROGNOSTIC ANALYSIS FOR SMALL PANCREATIC HEAD ADENOCARCINOMA: A SINGLE INSTITUTE EXPERIENCE

Hwang, Tsann-Long; Yeh, Chun-Nan; Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung University, Department of General Surgery, Taipei, Taiwan

Introduction. The prognosis of pancreatic adenocarcinoma is poor, and 5 years survival rate after resection is still around 15% to 25%. This study was designed to analyze clinicopathological and prognostic factors to differentiate between small and large pancreatic head adenocarinoma (PAD) patients undergoing resection in the past 25 years from a single center in Taiwan.

Materials And Methods. Between 1983 and 2006, the clinical features of 36 small PAD patients (tumor size less than 2 cm) undergoing resection were retrospectively reviewed and 123 large PAD patients were used for comparison.

Results. One hundred and fifty nine patients with PAD underwent resection from 1983 to 2006 were enrolled in this study. Among them, 36 patients (22.6%) with PAD had tumor small than 2 cm in size classified as small PAD. Patients with small PAD had similar clinico-pathological features to those with large PAD. The follow-up duration of 36 patients with small PAD underwent resection ranged from 1.0 to 122.7 months (median: 10.9 months). Patients with small PAD underwent resection had similar outcome to that of patients with large PAD. Overall survival rates for patients with small PAD underwent resection at 3, and 5 years were 26.4 and 6.6 per cent, respectively. Univariate log rank analysis identified good nutritional status as the only favorable influence on overall survival for resectable small PAD patients.

Conclusion. Patients with small PAD had similar clinico-pathological features and prognosis to those with large PAD. Small PAD should not be regarded as early PAD.

FP 1.09

ROLE OF STAGING LAPAROSCOPY/LAPAROSCOPIC ULTRASOUND IN RESECTABLE PANCREATIC AND PERI-AMPULLARY CANCERS

Hariharan, Deepak¹; Siddeshwarappa, Madhu²; Bhattacharya, Satyajit²; Abraham, Ajit²; Kocher, Hemant²

¹Barts & the London School of Medicine & Dentistry, Institute of Cancer, London, United Kingdom; ²The Royal London Hospital, Barts and the London HPB centre, London, United Kingdom

Background. The role of staging laparoscopy (SL) and laparoscopic ultrasound (LUS) remains controversial in the management of patients with pancreatic and peri-ampullary cancers (PAC).

Aim. To det ermine the utility of SL/LUS in detecting unresectability in patients with PAC who were otherwise resectable based on conventional staging.

Method. Publications (1995-to date) examining the role of SL/LUS in potentially resectable PAC were examined with respect to change in surgical management. Studies indirectly assessing the role of SL/LUS without actually performing laparoscopy as well as those where surgical outcome could not be determined were excluded. Operative evaluation was considered as gold standard for staging, when undertaken, while laparoscopy alone was considered as gold standard when it detected metastatic disease. Overall test characteristics and yield of SL/LUS in preventing unnecessary laparotomy were determined.

Result. A total of 20 studies with 2,040 patients satisfied our inclusion criteria. However, as the definition of resectability varied, data were re-analysed with a specific algorithm to determine resectability. The test characteristics of SL/LUS for different sets of patients were as follows:

	Sensitivity	Specificity	positive predictive value	negative predictive value	Yield
*Locally advanced disease (N = 316)	63.6	100	100	45.6	48.7
*Resectable disease (N = 1724)	63.4	98.6	97.6	75.7	29.2
Combined (resectable + locally advanced disease)	63.4	98.7	98.2	72.1	32.3

*Metastatic disease excluded, All values in%

Conclusion. SL/LUS has a potential role in preventing unnecessary laparotomy in patients with PAC without metastases and should be thoroughly evaluated in a prospective multi-centre trial with pre-determined criteria.

FP 2.01

Results of Resection and Transplantation for HCC in Cirrhosis and non-Cirrhosis

Rayya, Fadi; Bartels, Michael; Hauss, Johann; Fangmann, Josef

University Hospital Leipzig, Clinic for Abdomen- and Transplantation Surgery, Leipzig, Germany

Background. Hepatocellular carcinoma (HCC) is one of the most common cancer worldwide. Both resection and transplantation are surgical treatment options depending on the size of tumours and the presence of cirrhosis. Liver cirrhosis is the main reason for the high early postoperative mortality after resection. Even in the Child A stage, extensive resections are not recommended.

Objectives. This study presents the results of the surgical treatment (LR or LT) for HCC in cirrhotic- and non cirrhotic livers.

Patients and Methods. We analysed the data of 76 patients who underwent LR or LT for HCC from January 2001 to December 2006.

Results. In non cirrhotic livers the following resections were performed: 30 right and extended right hemihepatectomies (54,5%), 11 left hemihepatectomies ( 20%) and 14 mono- or bisegmentectomies (25,5%). In cirrhotic livers were performed in Child A stage 1 right hemihepatectomy, 1 extended right hemihepatectomy, 1 extended left hemihepatectomy and 4 mono- or bisegmentectomies and in Child B stage 3 mono- or bisegmentectomies. In 11 patients who underwent transplantation were 2 patients with tumors exceeding the Milan criteria and 5 patients of them (5/11) were treated with TACE before the transplantation.

Conclusion. Liver resection for HCC in cirrhosis should be performed with caution (no long-term survival in our data). Our study confirms that transplantation shows good long- term survival in early HCC stages. However, this may also be true for stages above the Milan criteria. For HCC in non-cirrhotic livers resection remains the treatment of choice, justifying an extensive surgical approach. This achieves favourable long term survival as demonstrated in the study presented

FP 2.02

RESOURCE UTILIZATION AND CLINICAL OUTCOMES OF PREOPERATIVE TRANSARTERIAL CHEMOEMBOLIZATION FOR RESECTABLE HEPATOCELLULAR CARCINOMA

Lee, King-Teh

Kaohsiung Medical University Hospital, Department of Surgery, Kaohsiung, Taiwan

Background. Hepatocellular carcinoma (HCC) is one of the most malignant cancers in world. Transarterial chemoembolization (TACE) is an effective treatment for HCC, although the outcome is still contradictory.

Aim. To assess the resourece utilization and clinical ouotcomes of preoperative TACE for resectable HCC, we conducted a comparative analysis in 347 HCC patients who underwent liver resections.

Methods. We retrospectively compared medical resource ultilization and clinical outcomes after liver resection between those underwent preoperative TACE (LR-TACE, n = 113) and who did not (LR, n = 234).

Results. The over-all mortality rate is 29% for LR versus 41.7% for LR-TACE (p < 0.05). The over-all recurrent rate is 51% for LR versus 48% for LR-TACE(p > 0.05). The 1,3,5 year survival rate for LR is significantly higher than that of LR-TACE (89%, 73%, 59% for LR vs. 81%, 57%, 47% for LR-TACE, p = 0.02). The difference is not statistically significant, although the dissease free survival rare is higher in LR-TACE (66%, 44%, 32% for LR vs. 60%, 49%, 40% for LR-TACE p = 0.96). The assessment of resource utilization shows that the mean length of stay is 14.69±8.94 for LR versus 16.23±13.83 days for LR-TACE (p = 0.21). The total hospital charges is USD 3807±2322 for LR versus USD 4318±3883 for LR-TACE (p = 0.23). The average re-admission days in 6-month period after discharge from liver resection is 2.24±5.11 days for LR versus 4.76±10.52 days for LR-TACE. The difference is statistical significance (p = 0.03). The average hospital charge for this period is USD 459±1080 for LR versus USD 983±2204 for LR-TACE. The difference is also statistical significance (p = 0.03).

Conclusion. Preoperatvie TACE consumes more medical resource and causes poorer long-tern survival, therefore, we suggest that preoperative TACE should not be performed for resectable HCC.

FP 2.03

LAPAROSCOPIC VERSUS OPEN MINOR LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA

Lai, Eric C.H; Tang, Chung Ngai; Yang, George P.C.; Tsui, David K.K.; Li, Michael K.W.

Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, Hong Kong

Introduction. Laparoscopic liver resection of hepatocellular carcinoma (HCC) is a new option. The advantages of laparoscopic liver resection are those of minimally invasive surgery, such as early recovery, shorter hospital stay, and better cosmetic outcome. However, it is still a matter of debate because of the uncertainty of the surgical outcome, and the fear of compromising the oncological resection. The aim of this study was to compare the surgical outcomes between laparoscopic and open approaches.

Methods. A retrospective non-randomized comparative study was performed in a single tertiary center regarding the outcomes between laparoscopic and open minor liver resection of HCC from January 2001 to June 2007.

Results. During the study period, 22 and 25 patients with HCC underwent laparoscopic minor liver resection and open minor liver resection in our surgical unit, respectively. No differences in operation time (mean, 148.3 minutes vs. 135.6 minutes, p = 0.261), blood loss (mean, 389 ml vs. 575 ml, p = 0.051), operative morbidity (18.1% vs. 20%, p = 0.083), and operative mortality (0% vs. 4%, p = 0.083) were found between laparoscopic group and open group. There was significant difference in hospital stay between laparoscopic group and open group (mean, 7 days vs. 14.5 days, p = 0.035). The 3-year disease-free survival rates of laparoscopic group and open group were 46% and 32%, respectively (p = 0.98). The 3-year overall survival rates of laparoscopic group and open group were 58% and 60%, respectively (p = 0.56).

Conclusion. This study showed that, when compared with open approach, laparoscopic minor liver resection for HCC has similar surgical outcome. In addition, laparoscopic approach had benefit of shorter hospital stay. However, this procedure should be performed by surgical team expert in hepatobiliary and laparoscopic surgery in properly selected patients. These favorable findings of laparoscopic resection for HCC certainly warranted further investigations and studies.

FP 2.04

2250 HEPATECTOMIES FOR LIVER TUMORS: AN INVERSE VOLUME-OUTCOME RELATIONSHIP

Azoulay, Daniel; Pascal, Gerard; Andreani, Paola; Andreani, Paola; Iacopinelli, Marco; Adam, René; Castaing, Denis, Aphp hopital Paul Brousse, Villejuif, France

Objective. To assess the changes in liver resectional surgery over 20-years.

Methods. From 1985 to 2005, 2250 consecutive hepatectomies were performed. Operative morbidity and mortality were analyzed. Trends over the study period were analyzed.

Results. The diagnosis were colorectal metastases (n = 1110, 49.3%), primary hepatic or biliary cancers (n = 625, 27.9%), miscellaneous malignant disease (n = 355, 15.8%), and benign disease (n = 169, 7.1%). The liver parenchyma was normal in 1756 cases (78.0%), cirrhotic in 237 cases (10%), fibrotic in 106 cases (5%), steatotic in 110 cases (5%), cholestatic in 41 cases (2%). Resections needed in 1775 cases (78.9%) some form of clamping ranging from triad clamping to total vascular exclusion. Anatomical resections were performed in 1383 cases (61.5%). The mean blood transfusion was mean = 1.7 + 4.5 blood units. Morbidity and mortality rates were 29.1% and 2.4%. With experience, indications for liver resection were enlarged to significantly more severe patients, and/or significantly more complex procedures. This was realized at the price of significantly increased morbidity and mortality rates (from 1985 to 1995 vs from 1995 to 2005, morbidity and mortality rates were 21.6% vs 34.4% (p < 0.0001) and 0.9% vs 2.9% (p = 0.01) respectively. Mortality and morbidity rates were similar when comparing patients of similar severity and/or resections of similar complexity. On multivariate analysis, presence of cirrhosis or fibrosis, preoperative bilirubin > 34 µmole/L, and transfusion were the only independent predictors of both morbidity and mortality.

Conclusion. The present series, the largest reported so far, shows it is possible to extend the indications for liver resection (most often the only chance of cure) “at the price” of increased morbidity and mortality rates, still acceptable. We consider this attitude as the responsibility of tertiary centers compared to the one using experience to favor early results by a stringent selection excluding high risk patie nts/and or procedures.

FP 2.05

The Survival Paradox Of Elderly Patients After Major Liver Resections

IJtsma, Alexander

University Medical Center Groningen, Surgery, Groningen, Netherlands

Objective. The objective of this study is to assess the short and long term outcome of liver resections in the elderly in a matched control analysis.

Methods. From a prospective single center database of 628 patients undergoing a liver resection, 132 patients were aged 60 years or over and underwent a primary major liver resection. Of these patients, 93 could be matched on a one-to-one basis with a control patient, aged less than 60 years, with the same diagnosis and the same type of liver resection.

Results. The mean age difference was 16.7 years. The matched elderly patients had a significantly higher American Society of Anesthesiologists (ASA) grade. All other demographics and operative characteristics were not different. In-hospital mortality was higher in the matched elderly patients (11 vs. 2%, p = 0.017). Morbidity rate was also higher in the matched elderly patients (47 vs. 31%, p = 0.024). One, three, and five year survival rates in the matched elderly patients were 81%, 58% and 42%, respectively compared to 90%, 59% and 42% in the control patients (p = 0.558).

Conclusion. Besides achieving radical resections, the patients’ preoperative ASA grade proved to be an independent and clinically significant predictor regarding the outcome after major liver resection. This finding does not only underline the obvious statement to strive for tumor free margins, but it also urges those involved in preoperative patient selection for major liver resections rather to consider the ASA grade than patient age as a predictive factor for long term survival.

FP 2.06

CLINICAL SIGNIFICANCE OF THE TUMOR SIZE AS A POSTOPERATIVE PROGNOSTIC FACTOR IN HEPATOCELLULAR CARCINOMA PATIENTS

Kim, Dong-Goo; Lee, Kyung Keun; Kim, Sae June

Kangnam St. Mary's hospital, Surgery, Seoul, Korea, Republic of

Introduction. In hepatocellular carcinoma, postoperative prognosis are related to the morphologic feature such as tumor size and number and biologic feature such as vascular invasion and tumor cell differentiation. In preoperative state, the morphologic features of tumor could be evaluated through the radiologic examination which is not accurate compare to pathologic findings but the pathologic characteristic could not be revealed.

Methods. From Jan., 1995 to Sep. 2006, the 287 patient with hepatocellular carcinoma who underwent the operations including surgical resection and transplantation at Catholic University of Korea were evaluated. The patients were grouped 4 categories by the tumor size and evaluated general characteristics and tumor biology including vascular invasion and tumor cell differentiation. The authors also evaluated the patient survival and disease free survival according to tumor size and operative methods (resection vs transplantation).

Results. The incidence of vascular invasion, poorly differentiation of tumor cell and serum AFP level were increased significantly according to tumor size(P < 0.05). The survival rate and disease free survival rate after surgical treatment were correlated to tumor size. (75.8% of less than 2 cm and 20.3% of more than 10 cm in 5 years survival rate, P < 0.05). In treatment method including surgical resection and transplantation, the patients with smaller tumor had more benefit by transplantation treatment in disease free survival rate (P < 0.05) but similar result in patient survival rate(P = 0.9). The patients with large tumor were increased the survival and disease free survival rate in surgical resection group.

Conclusions. The tumor sizes were closely related to tumor biology (vascular invasion and tumor cell differentiation) and major prognostic factor after surgical treatment in survival and disease free survival rate. Surgical methods including resection and transplantation in patients with hepatocellular carcinoma could be selected according to tumor size.

FP 2.07

THE NEED FOR HEPATIC VEIN RECONSTRUCTION IN PARTIAL PROXIMAL HEPATECTOMY FOR LIVER TUMOR

Wu, Cheng-Chung; Cheng, Shao-Bin; Yeh, Dah-Cherng

Taichung Veterans General Hospital, Department of Surgery, Taichung, Taiwan

Introduction. The need for hepatic vein reconstruction in partial proximal hepatectomy (Couinaud¡∣s segment II, IVa, VII and VIII) with major hepatic vein resection is controversial.

Methods. Among 1427 hepatectomies which were performed between 1991 and June 2007, 54 patients underwent partial proximal hepatectomies. Of these 54 patients, 18 patients underwent hepatic vein reconstruction (group A). During operation, the preserved distal part of the liver showed congestive discoloration in all 18 patients. Of the remaining 36 patients without undergoing hepatic vien reconstruction, the area of congestive discoloration in 9 patients (group B) was > 1 Couinaud¡∣s segment, that of the other 27 patients (Group C) was < 1 Couinaud¡∣s segment.

Results. No patients died after hepatectomies, postoperative AST, ALT and total bilirubin level was significantly higher in group B than group A and C. No differences were found between group A and C. Postoperative ascites complication occurred in all group B patients, while only 2 and 3 patients in group A and C developed this complication. The postoperative hospital stay and hospital costs in patients with morbidity is higher.

Conclusion. Hepatic vein reconstruction is needed in partial proximal hepatectomy with resection of major hepatic vein when area of congestive discoloration of distal liver is > 1 Couindaud¡us segment.

FP 2.08

Prognostic impact of anatomical and non-anatomical resection for the hepatocellular carcinoma

Kang, Koo Jeong; Kim, Yong Hoon; Lim, Tae Jin

Keimyung University Dong-San Medical Center, Surgery, Daegu, Korea, Republic of

Introduction. Anatomical resection of the liver including the tumor is reasonable treatment option for better outcome than non-anatomical resection in patients who have hepatocellular carcinoma.

Aim. We analyzed the surgically resected 147 HCC patients. Our point of view in this study stands on the prognostic impact between types of surgical resection or whether the patient factors are more important rather than the type of surgical resection or not.

Method. Of one hundred and forty seven hepatectomies performed at Keimyung University DSMC during 2000 to 2006, ruptured, laparoscopically resected, non-operatively treated patients(preoperatively) were excluded. One hundred and twenty nine patients were included in this study. Survival analysis was performed to look at two different scopes of prognostic factors, patients¡^— factors including cirrhosis, ICG R15, tumor staging, and surgical factors including anatomical or non-anatomical resection, amount of bleeding, resection margin and ischemic time etc.

Result. Eighty anatomical resections, a sectionectomy or more hemihepatectomy in 52 patients and systematic segmentectomy stained by injection of methylene bule dye in the portal tributary in 28 cases, non anatomical resection in 49 patients were performed. Significant prognostic factors in univariate analyses include cirrhotics, ICG R15, tumor size and stage, however only cirrhotics and tumor size were significant in multivariate analysis. The type of resection was not appeared in the significant prognostic factors.

Conclusion. Segmental resection is safe and allows complete resection of liver tumors with more preservation of normal liver parenchyma, but the patient and tumor factors are significantly important prognostic factors. Anatomical resection including systematic segmentectomy was no survival benefit in comparison to the non-anatomical resection.

FP 2.09

PROGNOSTIC FACTORS AFFECTING SURVIVAL AFTER RECURRENCE IN PATIENTS WHO UNDERWENT LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA

Shin, Woo Young; Suh, Kyung-Suk; Lee, Hae Won; Kim, Joohyun; Yi, Nam-Joon; Lee, Kuhn Uk

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. Liver transplantation is regarded as good treatment for early hepatocellular carcinoma (HCC). However, some patients experience recurrence and show rapid progression of disease. In present study, we investigated prognostic factors affecting survival after recurrence in patients who underwent liver transplantation for HCC.

Methods. From October 1992 to December 2005, 105 patients underwent liver transplantation for HCC. Among these 23 (21.9%) recurred patients were retrospectively reviewed. Mean age was 54.6 years. There were 18 men and 5 women. All patients had past history of hepatitis B virus infection. There were 4 deceased donor liver transplantations and 19 living donor liver transplantations. Univariate and multivariate analyses were performed to analyze factors affecting survival after recurrence.

Results. Mean recurrence time was 8.9 months. Mean survival time after recurrence was 13.1 months and 1- and 3-year survival rates afte r recurrence were 43.5% and 7.2% respectively. Initially, 4 patients showed multi-organ involvement, however in the follow up 18 patients had multi-organ involvement. On univariate analysis, preoperative AFP > 400 ng/ml, maximal size of tumor > 5 cm, beyond pathologic UCSF criteria, major vessel invasion, Edmondson-Steiner grade III and IV, 6th AJCC T3 and T4, recurrence within 4 postoperative months, AFP > 400 ng/ml at recurrence, and extrahepatic recurrences were related with shorter survival after recurrence. On Multivariate analysis, recurrence within 4 postoperative months (HR = 18.3, p = 0.004), Edmondson-Steiner grade III and IV (HR = 8.4, p = 0.001) and preoperative AFP > 400 ng/ml (HR = 3.5, p = 0.025) were identified on independent prognostic factors of survival after recurrence.

Conclusion. After transplantation, recurred HCC has a tendency to involve multi-organs, and prognosis is very poor. Hence, adjuvant treatment may be considered in patients with preoperative AFP > 400 ng/ml and/or high grade tumor.

FP 3.01

RAPID PROGRESSION OF AFP IN THE WAITING TIME OF TRANSPLANTION FOR HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENTS: A POOR PROGNOSTIC FACTOR

VIBERT, Eric¹; IACOPINELLI, Salvatore Marco²; SALLOUM, Chady²; AZOULAY, Daniel²; KARAM, Vincent²; CASTAING, Denis²; SAMUEL, Didier²; ADAM, René²

¹Paul Brousse hospital (AP/HP), Centre Hepato Biliaire, Villejuif, France; ²Paul Brousse hospital (AP/HP), Centre Hepato-Biliaire, Villejuif, France

Introduction. Despite selective criteria, liver transplantation (LT) for hepatocellular carcinoma (HCC) on cirrhosis is still associated with reduced survival in patients with poor histological features. Rather than AFP static level, AFP dynamic assessment on waiting list may be more relevant to predict patient outcome after LT in Milan Criteria.

Objective. Assessment of the prognostic value of AFP rapid progression before LT.

Methods. AFP progression was defined according to preliminary results as a slope of AFP > 15 ng/ml by month. From 1987 to 2005, among 252 cirrhotic patients transplanted for HCC, 153 primarily transplanted patients for AFP secreting HCC were analysed: 26 (16%) were transplanted with AFP progression and 126 (82%) were transplanted during a period of low increase or decline of AFP level. The two groups were compared with regards to preoperative and histological data. A uni- and multivariate analysis of prognostic factors of overall survival (OS) and disease-free survival (DFS) was made.

Results. Preoperatively, both groups were similar except for the rate of AFP higher in the progression group (p = 0.0001). After median follow-up of 45 months, 5-year OS and DFS was 72% and 69% respectively, in the total cohort. In the progression group, 5-year survival was significantly lower to those of the no progression group (OS 77% versus 54%, p = 0.02 – DFS 74% versus 47%, p = 0.01). In multivariate analysis, AFP progression was a preoperative factor independently associated with OS and DFS decrease with, respectively, a preoperative number of nodule > 3 for OS and an age > 60 years for DFS. With regard to pathological analysis, satellite nodules (p = 0.02) and vascular invasion (p = 0.01) were more frequent in the progression group.

Conclusion. As a surrogate marker of poor tumoral pathological features, AFP progression is the more relevant preoperative prognostic factor for OS and DFS after LT. Hence, a reappraisal of therapeutic strategy should be done in case of rapid progression of AFP on waiting list.

FP 3.02

LIVER TRANSPLANTATION AND MORBID OBESITY: A MULTI-CENTER STUDY

Shokouh-Amiri, Hosein¹; Santiago, Vera²; Gaber, Osama³; Mehrazin, Reza⁴; Nezakatgoo, Nostratollah⁴; McMillan, Robert⁵; Mook, Julie⁵; LaRoux, Sarah⁵; Cataldo, Doria³; Ranjan, Dinesh⁶; Zibari, Gazi⁵

¹Louisiana State University Health Sciences Center, Surgery, 1501 Kings Highway, Shreveport, United States; ²Methodist University Hospital, Surgery, Memphis, United States; ³Methodist Hospital, Surgery, Houston, United States; ⁴Methodist University Hospital Transplant Institute, Surgery, Memphis, United States; ⁵Louisiana State University Health Sciences Center, Surgery, Shreveport, United States; ⁶University of Kentucky Medical Center, Surgery, Lexington, United States

Background. Severe obesity has increased to more than 35% in the U.S. Patients with morbid obesity (BMI > 40 kg/m2) are being referred for liver transplantation. Reports have suggested increased early morbidity and mortality for obese patients undergoing liver transplantation. PURPOSE: To evaluate several centers experiences transplanting livers into patients with morbid obesity (BMI > 40 kg/m2).

Method. A retrospective, IRB approved, chart review of first transplant, deceased donor liver transplantation at four centers (1 & 2 actively transplanting, and 3 & 4 sporadically transplanting morbidly obese patients) from 1992 to 2006 was undertaken. There were a total of 633 patients in centers 1 and 2. There were 34 patients identified with BMI > 40 (Group I), 48 patients with BMI >35– < 40 (II), 123 patients with BMI > 30– < 35 (III) and 428 patients with BMI <30 (IV). Demographic data were gathered. Outcomes measured include perioperative mortality, length of stay, 1 and 5 years patient and graft survival. In centers 3 and 4, there were 8 patients with BMI >40 kg/m2 among 980 liver transplants.

Results. Demographic data were similar in all groups, as well as distribution of MELD. One perioperative mortality was encountered in Group I. Five patients from Group I died within 3 months, all with high MELD. Similar 3 month mortality was found in all groups (14.7% vs 12.5% vs 13.8% vs 14.9% respectively). Length of stay was similar in all. There was a correlation between MELD and length of stay independent of BMI. One and five year patient survival were similar in all, independent of their BMI (83% and 77% vs 81% and 73% vs 84% and 74% vs 84% and 74% respectively in Groups I, II, III and IV). In center 3 and 4, no preoperative mortality was encountered and their long term survival was similar to the rest of their patient population.

Conclusion. Outcomes of liver transplantation are not adversely affected by severe morbid obesity, therefore; morbid obesity alone should not be considered a contraindication for liver transplantation.

FP 3.03

A SYSTEMATIC REVIEW OF COST OF LIVER TRANSPLANTATION

Van der Hilst, Christian¹; IJtsma, Sander²; Slooff, Maarten²; TenVergert, Elisabeth²

¹University Medical Center Groningen, University of Groningen, Groningen, Netherlands; ²University Medical Center Groningen, University of Groningen, Hepatobiliary Surgery and Liver Transplantation, Groningen, Netherlands

Background. Studies concerning costs of liver transplantation (LTx) are heterogenous regarding included patients, methods of assessing costs, inclusion of procedural phases, health systems, and year of publication. Consequently, a large variation in costs is observed.

Aim. The aim of this study was to improve insight into the differences in cost of LTx by performing a systematic review.

Methods. Eight databases were searched without language restriction (MeSH and full text). In total, 2000 citations were identified of articles published between 1990 and 2006. Thirtyfour articles were found eligible for data extraction. Information on clinical admission for LTx until discharge were extracted and compared. All costs were expressed in US$ (pricelevel: 2005). Differences between health care systems, changes in cost for LTx over time, different methods of assessing costs, and differences between adult and pediatric recipients were assessed.

Results. In total, 6107 LTx were included in the review. The reported inflation-corrected mean cost per LTx was $159,517. Mean cost of studies varied from $18,891 to $434,129. LTx performed in the US were most expensive, followed by Japan, Europe, and South-America. The difference between the US, Japanese, European, and South-American health care systems was the most important factor explaining cost differences. Cost differences did not depend on the method of assessment. The inflation corrected mean costs were stable over time. No important differences in costs between pediatric and adult LTx were observed.

Conclusion. Important differences in costs were observed between different health care systems. Differences were independent of methods of cost assessment. The higher cost of LTx in the US was in line with the higher cost of the US health care system compared to other health care systems. Costs remained stable over time indicating that in view of the improved results of LTx and the increase in numbers of LTx perform ed over the years, cost effectiveness has improved.

FP 3.04

FINANCIAL COMPARISON OF ADULT-TO-ADULT LIVER TRANSPLANTATION FROM LIVING- VS DECEASED-DONORS

Mohanka, Ravi; Kayler, Liise; Tom, Kusum; Fontes, Paulo; Dvorchik, Igor; DeVera, Michael; Soltys, Kyle; Blisard, Deanna; Sharma, Vivek; Starzl, Thomas; Marcos, Amadeo

University of Pittsburgh Medical Center, Thomas E Starzl Transplantation Institute, Pittsburgh, United States

Background And Objective. Liver transplantation is one of the most costly surgical procedures performed today. Live-donor liver transplantation (LDLT) may be more financially advantageous over deceased-donor liver transplantation (DDLT) due to the opportunity to select patients who are less ill and to operate in an elective manner; however, few studies have addressed this issue.

Methods. Between January 2001 and December 2004, 833 consecutive adult liver transplants (LDLT 74, DDLT 758) were analyzed. Charges were recorded for the following time periods: (1) pretransplant, 90 days before transplantation, (2) the transplant hospitalization, and (3) posttransplant, 365 days after the transplant hospitalization. Charges were expressed as an arbitrary charge unit (ChU) that is a value between $5,000 and $15,000.

Results. Compared with DDLT, the average ChU for LDLT was threefold lower for pretransplant care (p < 0.0001), 22% lower for the transplant admission (p = 0.0316), and 8% lower for post-hospitalization medical care (p = 0.2113). Baseline characteristics indicated a healthier status of the LDLT group who exhibited significantly lower MELD scores ( p < 0.0001), shorter average 90-day pretransplant hospital length of stays (p = 0.0091), shorter average time on the liver transplant waiting list ( p < 0.0001), and proportionately less requirement for pretransplant mechanical ventilation (p = 0.0320], compared to DDLT recipients.

Conclusion. The magnitude of the cost advantage for living- over deceased- donor transplantation depends greatly on recipient health.

FP 3.05

LIVER TRANSPLANTATIONS WITH DONORS OVER 60 YEARS OLD COULD HAVE THE SAME OUTCOME AS WITH YOUNGER DONORS

Ravaioli, Matteo; Grazi, Gian Luca; Cescon, Matteo; Cucchetti, Alessandro; Ercolani, Giorgio; Del Gaudio, Massimo; Vetrone, Gaetano; Zanello, Matteo; Lauro, Augusto; Tuci, Francesco; Dazzi, Alessandro; La Barba, Giuliano; Zanfi, Chiara; Bertuzzo, Valentina; Di Gioia, Paolo; Vivarelli, Marco; Pinna, Antonio Daniele

S. Orsola-Malpighi Hospital; University of Bologna, Liver and Multi-organ Transplantation, Bologna, Italy

Background. according to liver transplant registries, the survival of grafts from older donors is lower than with younger donors. We sought to determine whether donor selection by liver biopsy would positively influence the outcome.

Methods. from a prospectively collected database in the period 1999–2005 we retrospectively reviewed the outcomes of 89 patients who received a liver from a donor ≥ 60 years after a histologically evaluated liver biopsy and with the shortest possible ischemia time (group D ≥ 60 + ). These outcomes were compared with the outcomes in 198 matched recipients, whose livers were not histologically evaluated. Their donors were < 60 years in 89 cases (group D < 60-, positive-reference who were expected to have an optimal outcome) and ≥ 60 years in 89 cases (group D ≥ 60-, negative-reference, expected to have a worse outcome).

Results. in terms of study design, the recipient features were comparable among the three groups according to age, sex, viral infection (HCV vs. no-HCV) and MELD score, but group D ≥ 60+ had a lower ischemia time than the other groups: mean value 415±106 minutes vs. 465±111 (D < 60-), p< 0.05 and vs. 476±94 (D ≥ 60-), p < 0.05. After a median follow-up of 3 years, the 1 and 3 year graft survival of group D ≥ 60+ (84% and 76%) was comparable to group D < 60- ( 89% and 76%) and was significantly higher than group D ≥ 60- (71% and 54%), p < 0.005.

Conclusions. histological selection and low ischemia time allow equivalent graft outcome after liver transplantation between grafts from older and younger donors.

FP 3.06

Societal reintegration and Economic implications following orthotopic liver transplant

Molinari, Michele; Gillis, Amy; Walsh, Mark

Dalhousie University, Surgery, Halifax, Canada

Background. Data on the impact of OLT on the patients’ integration in their communities and its financial consequences at a personal and familiar level are lacking. Primary aims of this study were to assess employment rate, productivity and activity index of patients after OLT in Atlantic Canada.

Methods. From September 2006 to January 2007 a cross sectional study was performed using validated Work Productivity and Societal Reintegration Questionnaires. Participants were interviewed by phone or during follow-up visits and were adults at least 3 years post OLT, without communication impairments. All data were prospectively collected. Categorical data were analyzed by Chi-Square and Student's t test for continuous variables; P values less than 0.05 with two tail distribution were considered significant.

Results. Among eligible 158 patients, 47 were randomly selected. 45 (95%) participated and 2 declined for personal reasons. 15 patients (33%) were full time employed and 12 (52%) were employed in the same position as before OLT. 13 individuals (28%) were on disability while the remaining were students or housekeepers. 11 patients (24%) had retired. After OLT, 19 patients (42%) experienced financial restrictions preventing access to care or necessary medications due to significant reduction in their annual personal ($28,300 vs 26,500, P < 0.005) and household income (44,000 vs 43,700, P < 0.05). Overall, 77% patients reported that OLTx had a negative impact on their financial status in comparison to their pre-OLT status (P < 0.005). However, productivity and activity index showed overall acceptance of current societal role and sequlae of OLTx had little impact on activities of daily life at this time.

Conclusion. In Atlantic Canada, patients undergoing OLTx for end stage liver disease have an employment rate of 33%, consistent with available literature. Socially, 84% of patients are satisfied with their current role in society and are able to perform most daily activities without difficulty.

FP 4.01

ISOLATED SEGMENTAL BILE DUCT INJURY AFTER LAPAROSCOPIC CHOLECYSTECTOMY. CLINICAL PRESENTATION, DIAGNOSIS, TREATMENT AND LONG TERM OUTCOME

de Reuver, Philip¹; Grossmann, Irene¹; Rauws, Erik²; Busch, Olivier¹; van Gulik, Thomas¹; Gouma, Dirk¹

¹Academic Medical Centre, Surgery, Amsterdam, Netherlands; ²Academic medical centre, Gastroenterology, Amsterdam, Netherlands

Background. Isolated segmental bile duct injury (ISBDI) is a distinct type of bile duct injury seen after laparoscopic cholecystectomy. The aim of this study was to determine the prevalence, clinical characteristics, diagnostic modalities and treatment outcome in ISBDI patients.

Patients and Methods. ISBDI patient data, obtained from a consecutive series of 500 bile duct injury patients referred to a tertiary centre, were analyzed. Patient characteristics, diagnostic modalities and treatment outcome were determined.

Results. Forty-two patients (8%) were identified among 500 bile duct injury patients having ISBDI. In only 5 patients (12%) ISBDI was diagnosed before referral to a tertiary centre. Postoperative symptoms in ISBDI patients are not different from overall bile duct injury patients. The mean interval between referral and accurate diagnosis was 126±361 days. Eighteen patients (31%) underwent surgery, 16 patients underwent endoscopy (38%) and 6 patients (14%) were treated by percutaneous radiological intervention. Surgical and endoscopic therapy of ISBDI patients is associated with higher morbidity compared to BDI patients. Postoperative abscesses occurred in 22% (4/18) in ISBDI patients vs. 7% (10/133) in BDI patients, p = 0.044; endoscopic failure 25% (2/8) in ISBDI patients vs. 4% (3/85) in BDI patients, p = 0.057).

Conclusion. ISBDI is a rare complication, difficult to diagnose, and associated with more treatment related morbidity compared to general bile duct injury patients.

FP 4.02

COMMON BILE DUCT INJURIES DURING CHOLECYSTECTOMY IN A POPULATION-BASED COHORT OF 1171 PATIENTS

Sandblom, Gabriel¹; Videhult, Per²; Ljungdahl, Mikael³; Wollert, Staffan³; Darkahi, Bahman⁴; Karlson, Britt-Marie³; Rasmussen, Ib Chirstian³

¹University Hospital, Department of surgery, Lund, Sweden; ²Ersta Hospital, Department of surgery, Stockholm, Sweden; ³University Hospital, Department of surgery, Uppsala, Sweden; ⁴Enköping Hos pital, Department of surgery, Enköping, Sweden

Background. Although common bile duct injury (CBDI) is considered one the most feared complication during cholecystectomy, it is so rare that in order to understand the epidemiology of CBDI we have to rely on large register studies.

Objective. The purpose was to assess the frequency and outcome of CBDI as a complication to cholecystectomy in a population-based setting.

Method. All patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala, a county with 303 000 citizens in Sweden, were registered prospectively.

Result. 1171 operations were registered. IOC was performed in 95% of the operations. The indication for surgery was ongoing cholecystitis in 114 (12%) patients, history of conservatively treated cholecystitis in 235 (20%) patients, and biliary colic in 813 (63%) patients. The operation was performed as a laparoscopic procedure in 79%. Nine cases of significant anatomical variants were recorded. In four cases these anatomical variants included an unusually short cystic duct, predisposing to CBDI in two of the operations. Four cases of CBDI (0.3%) were recorded. The CBDI included one perforation of the common bile duct (CBD) caused by the cholangiography catheter and one accidental application of a clip on the common bile duct (CBD) followed by CBD incision. Both these CBDI were treated successfully with a T tube In the third case an accidental CBD incision was repaired with a direct suture. In the last case total ligation and division of the right hepatic duct necessitated a reoperation and a bile duct reconstruction.

Conclusion. Common bile injuries are rare (0,3%) even in routine cholecystectomies. The injuries do not necessarily occur in complicated cases. Only one case needed more extensive surgery whereas the other three could be handled during the cholecystectomy. All patients performed well during follow-up. A prospective registration may help to improve quality and identify the reasons for serious complications.

FP 4.03

TYPE “C” EXTRAHEPATIC BILIARY ANATOMY – THE SURGEON'S PITFALL?

Rohatgi, Sanjeev¹; Shivathirthan, Nairuthya¹; Sheik, Vasim³; Kamat, Dinesh¹; Haldar, Premashish¹; Mathur, Surendra Kumar¹

¹Jagjivan Ram Hospital, Western Railway Hospital, Dept of G.I. Surgery, Maratha Mandir marg, Mumbai Central, Mumbai, India; ²Jagjivan Ram Hospital, Western Railway Hospital, Dept of Surgery, Mumbai, India

Introduction. Bile Duct Injury (BDI) following Cholecystectomy is a catastrophe.

Aims and Objectives. This retrospective study analyses 40 BDI patients in last 6 years admitted in this hospital, with aims to identify certain parameters which probably contributed to their injury. The study attempts to correlate the type of injury incurred based on the anatomy of the Extrahepatic Bile Duct & the patient parameters.

Materials and Methods. Patient's parameters studied were Sex, Body Mass Index (BMI), and history of Acute Cholecystitis and Cholangitis. Extrahepatic Biliary Anatomy was mainly studied by MRCP. Selectively ERCP, T–Tube Cholangiograms, PTBD & Fistulo grams were used.

Results. The study revealed that the commonest type of BDI was Strasberg's Type-E (25/40 patients 62.5%) with E-2 being the maximum (11/40 patients 27.5%). Variation of Extrahepatic Biliary Anatomy was seen in 31/40 (77.5%) the commonest variant was C-Type where the Right posterior Sectoral duct joins the Common hepatic Duct or the Left Hepatic Duct (16/40 patients 40.0%) Comparison of the type of the biliary anatomy with the type of BDI revealed that the Type-E BDI were more common with Type-C anatomy. Other factors like Male Sex, BMI >30, episodes of acute cholecystitis and cholangitis individually showed statistical significance at 5% levels with P values of 0.011, 0.004, 0.001 and 0.011 respectively. Maximum female patients were seen in Type C and E-2 injury.

Conclusion. Anatomical variation of the extrahepatic bile duct is one of the very important factors which determined the Bile Duct Injury in this study. The study showed assosciation of type of injury and anatomical parameters highly significant at 5% level (P value = 0.002) Anatomical variation of the C1 & C2 type had the maximum number of the bile duct injury and the higher level of injury. Patient (Male Sex & Obesity) & Inflammatory (Acute Cholecystitis & Cholangitis) parameters are additional contributory factors. An awareness of the dangerous Type-C anatomy is highlighted in this study.

FP 4.04

LONG TERM FOLLOW UP FOLLOWING REPAIR OF BILE DUCT INJURY-COMPARATIVE DATA ON IMMEDIATE AND EARLY REPAIR VERSUS LATE; A SINGLE UK CENTRE EXPERIENCE

Silva, Michael A; Perera, Thamara; Hegab, Bassem; Mayer, David; Bramhall, Simon R; Buckels, John A C; Mirza, Darius F

University Hopsital Birmingham NHS Trust -Queen Elizabeth, The Liver Unit, Birmingham, United Kingdom

Background. The incidence of iatrogenic bile duct injuries (BDI) during laparoscopic cholecystectomy is 0.3–0.6%. We present our experience in the management of BDI.

Method. Data was collected prospectively between 1991 and 2007. Long term outcome in terms of re–intervention and morbidity were recorded in immediate ‘on-table’ repair (group 1), early (within 21 days) (group 2) and late repair (group 3). Strasberg's classification was used to stage BDI.

Results. There were 163 patients referred with bile duct injury related problems, 53 (33%) male, median age 53 years (20 – 83). Median days to referral was 20 (0 – 241 months) following injury. Seventy five percent (122) were type E injuries, with 15% type D while type C, B and A accounted for 8 (5%), 2 (1%) and 6 (4%) respectively. Median follow-up after initial BDI was 75 (1 – 355) months. Ninety nine of 135 (99/135; 73%) surgically managed patients underwent repair at our centre {19 (19%), 37 (37%) and 43 (44%) in each group respectively}. Four patients (4/37; 11%) in group 2 needed revision compared to none (0/19) and 01(1/43; 2%) in group 1 and 3 respectively (p = 0.12). There was no difference in the need for non-surgical intervention (13%, 18% and 11% respectively; p = 0.86), incidence of recurrent cholangitis (13%, 16% and 5% respectively; p = 0.19) and biliary stricture (17%, 11% and 21% respectively; p = 0.4) among the three groups. No difference was observed in each group in terms of morbidity free long term follow up (Long term morbidity; 11, 29 and 20 patients respectively: p = 0.97).

Conclusion. On table and early repair of BDI has a good out come with long term results in terms of morbidity being comparable with that of late.

FP 4.05

BILE DUCT INJURIES FOLLOWING CHOLECYSTECTOMY FOR GALL STONE DISEASE: SURGICAL AUDIT FROM A TERTIARY CARE CENTER IN NORTH INDIA

Ranjit, Hari V; Anand, Prakash; Biju, Pottakkat; Anu, Behari; RK, Singh; Ashok, Kumar; Rajan, Saxena; VK, Kapoor

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Department of Surgical Gastroenterology, Lucknow, India

Background. There have been few reports of bile duct injury (BDI) following cholecystectomy (Ccx) from tertiary care institutions.

Objectives. To study the incidence, management and outcome of BDI following Ccx.

Methods. Retrospective analysis of data of BDIs sustained during about 5700 Ccxs performed for gall stone disease between January 1989 and June 2007.

Results. Laparoscopic cholecystectomy (LC) was attempted in about 4300 and completed laparoscopically in about 4000 patients; open cholecystectomy (OC) was done in about 1400. There were 57 BDIs-47 in attempted LC and 10 in OC. Major BDIs (25/57) included bile duct transection (type E) in 8, lateral CBD injury (type D) in 14 and injury to aberrant duct (type C) in 3 patients; minor BDIs (8/57) included injury to subvescical duct (type A) in 3 and cystic duct leak (type A) in 5 patients; BDIs could not be classified in 24/57(43%) patients. 22/57(38%) injuries were detected intra operatively and definitive repair was done in 21 (RYHJ-7, CBD repair with T tube drainage -5 and primary repair – 9). 35/57 (62%) injuries were detected post operatively; they presented as biloma in 15, bile leak in 16 and biliary peritonitis in 4. Of 35 patients with injury detected post operatively, 15 underwent endoscopic stenting and 9 had percutaneous drainage (8 of these had combined endoscopic and percutaneous management and 7 required surgical re-exploration) and 11 were managed conservatively. 5/57 (9%) patients with BDI died-4 had biliary peritonitis and 1 had biloma; one patient who died had associated vascular injury also. The cause of death was sepsis in all cases. On follow up, one patient developed bile duct stricture, which was managed endoscopically.

Conclusion. BDIs can occur even in experienced hands at tertiary centres. Incidence of major BDI was 0.4% in 5700 Ccx performed by us. Early detection of BDI and the judicious management with a combination of endoscopic, percutaneous and surgical methods can reduce the morbidity and mortality.

FP 4.06

SURGICAL MANAGEMENT OF PORTAL BILIOPATHY IN EHPVO

Ponnambathayil, Shaji; Dhar, Puneet; Surendran, S udhindran; OV, Sudheer

Amrita Institute of Medical Sciences, GI and HPB Surgery, Cochin, India

Background. In portal hypertension particularly in extra hepatic portal venous obstruction (EHPVO) functional or structural biliary changes may result in extensive porto-venous collaterals which is termed portal biliopathy. We review our experience in surgical management in patients of symptomatic portal biliopathy.

Methods. Over the last 8 years 93 patients presented with EHPVO of whom 23 required surgical management. Of these, 7 had features of portal biliopathy. We present a review of these EHPVO patients with portal biliopathy from a prospectively maintained computerised database.

Results. Presenting features were jaundice in 5 (cholangitis in 4); Gastrointestinal bleeding in 3 and symptomatic hypersplenism in one. Commonest structural change observed was combined involvement of extrahepatic and bilateral intrahepatic biliary system (Type III b, n = 5). Five patients had Common bile duct calculi and 2 had gall bladder calculi. Three patients underwent portosystemic shunting and 4 patients had hepaticojejunostomy (without severe portal hypertension or manifest GI bleed), although they were prepared for a shunt as well. One patient each in shunt and bypass groups developed recurrent cholangitis but responded to conservative management. A patient with hepaticojejunostomy required a subsequent shunt for ectopic variceal bleed. Follow-up serum Bilirubin reduced faster (Range 4–57 weeks) than alkaline phosphatase levels (Range 4– 208 weeks).

Conclusions. EHPVO is not very rare in South India. Jaundice is the commonest presentation, and Type III b is the most frequently encountered anatomical anomaly. Surgery can relieve most symptomatic patients. Direct hepaticojejunostomy is possible in selected patients without severe portal Hypertension.

FP 5.01

PROPOSAL OF NEW CLASSIFICATION FOR CYSTIC DUCT CARCINOMA

Yokoyama, Yukihiro; Nishio, Hideki; Ebata, Tomoki; Abe, Tetsuya; Igami, Tsuyoshi; Oda, Koji; Nimura, Yuji; Nagino, Masato

Nagoya University Graduate School of Medicine, Surgery, Nagoya, Japan

Background. Farrarfs criteria for cystic duct carcinoma (histopathologic diagnosis of a carcinoma strictly limited to the cystic duct) are impractical especially when making diagnosis of primary cystic duct carcinoma in its advanced stage. Therefore, in our previous study, we proposed a new definition of cystic duct carcinoma: a gallbladder tumor, the center of which is located in the cystic duct. In this study, we further propose a new classification for cystic duct carcinomas diagnosed by our definition.

Methods. This study included 44 surgical patients with cystic duct carcinoma diagnosed by our criteria. These patients were further classified into two groups: hepatic hilum type (HH, n = 29) in which the tumor mainly invades the hepatic hilum, and cystic confluence type (CC, n = 15) in which the tumor mainly involves the confluence of the cystic duct. The clinicopathologic features of these two groups were retrospectively analyzed.

Results. There was more papillary or well differentiated adenocarcinoma in CC type as compared with HH type. The perineural and vascular invasion were more common in HH type than in CC type. The survival rate tends to be higher in CC type than in HH type (P = 0.064). Moreover, we found a significantly different gender ratio between these two groups (female was predominant in HH type, whereas male was predominant in CC type).

Conclusion. Our new classification showed two distinct types of cystic duct carcinoma, which may help in making diagnosis and planning treatment strategy for an advanced biliary carcinoma originated in the cystic duct.

FP 5.02

ADJUVANT THERAPY AFTER SURGICAL RESECTION IN STAGE III GALLBLADDER CANCER

Dulla, K V Prasad¹; Behari, Anu¹; Rastogi, Neeraj²; Singh, Rajneesh K¹; Kumar, Ashok¹; Saxena, Rajan¹; Kapoor, Vinay K¹

¹SanjayGandhi PostGraduate Institute of Medical Sciences, Gastrosurgery, Lucknow, India; ²SanjayGandhi PostGraduate Institute of Medical Sciences, Radiotherapy, Lucknow, India

Background. Surgical resection is the treatment of choice for gallbladder cancer (GBC). A large number of patients, however, have recurrence after surgical resection.

Aim. This study is aimed to know the effect of adjuvant therapy on overall survival after surgical resection in patients with loco-regionally advanced GBC.

Methods. Between 1989 and 2005, 108 patients with stage III GBC underwent resection [simple cholecystectomy (SC) n = 66 or extended cholecystectomy (EC) n = 42] with or without adjuvant therapy. 63 patients who received post-operative adjuvant therapy (Group A) were compared with 45 patients who did not receive any adjuvant therapy (Group B). Adjuvant therapy included external radiotherapy and chemotherapy with 5-flurouracil.

Results. Age, sex, clinical presentation and surgical procedures were comparable between the two groups. Group A included 37 (59%) patients who underwent SC and 26 (41%)patients who underwent EC. Group B included 28 (62%) patients who underwent SC and 17 (38%) patients who underwent EC. Median survival in Group A was 19 (mean = 38) months compared to 11 (mean = 17) months in group B (p = 0.001). 12 of 13 patients who survived beyond 5 years had received adjuvant therapy. Median survival of patients undergoing SC alone, SC with adjuvant therapy, EC alone and EC with adjuvant therapy was 10, 17, 17 and 25 months, respectively, with no statistical difference in survival between the last three groups.

Conclusions. In patients with stage III GBC adjuvant therapy improved survival. Patients who underwent simple cholecystectomy with adjuvant therapy had similar survival as those who underwent extended cholecystectomy.

FP 5.03

THE RECENT CHANGING PATTERN OF SURGICAL TREATMENT AND OUTCOMES IN PATIENTS WITH GALLBLADDER CANCER: 18 YEAR SURGICAL EXPERIENCE

Yang, Sung Hoon

Seoul National University College of Medicine, Surgery, Seoul, Korea, Republic of

Methods. From 1987 to 2004, 368 consecutive patients surgically treated for GB cancer were included in this single?center analysis. We divided the 18year study period into Period I (1987–1995) and Period II (1996–2004). Clinical characteristics, changing patterns of surgical treatment and outcomes were compared between two periods.

Results. The incidental detection without symptoms was increased more than twice (p = 0.015). The patients with stage 0 and I was similar between two periods (p = 0.410). The patients with stage II was significantly increased than previous period I (p = 0.037), but the patients with stage III and IV was significantly decreased (p = 0.045). In the patients with T1 or T2 disease, there were no significant differences according to the surgical procedures between two periods (p > 0.05, all). In the patients with T3 and T4 disease, the proportion of SC decreased significantly (p < 0.001), but that of aggressive surgery including major hepatectomy and/or pancreaticoduodenectomy (PD) increased significantly (p = 0.002). The operative mortality and curative resection rate were not significantly different between the two periods (p = 0.256 and p = 0.154, respectively). The overall 5-year survival for patients underwent surgical treatment was improved (21.1%-41.5%) and 5-year survival for patients underwent curative resection was improved (42.9%-67.8%). The 5-year survival for the patients underwent major hepatectomy and/or PD were improved (0%-35.6%).

Conclusions. The improved surgical outcome compared with the previous period is may be due to the increase of the detection for early stages, the increase of aggressive surgery including major hepatectomy and/or PD for the advanced stage.

FP 5.04

FIVE-YEAR SURVIVORS AFTER SURGERY FOR GALLBLADDER CANCER INVOLVING THE EXTRAHEPATIC BILE DUCT

Nishio, Hideki; Ebata, Tomoki; Igami, Tsuyoshi; Yokoyama, Yukihiro; Uehara, Keisuke; Abe, Tetsuya; Oda, Koji; Nagino, Masato

Nagoya University Graduate School of Medicine, Division of Surgical Oncology, Nagoya, Japan

Background. Outcome of surgery for gallbladder cancer (GBC) involving the extrahepatic bile duct (EHBD) is dismal and five-year survivors have been rarely reported.

Aim. To clarify clinical features of the long-term survivors.

Methods. One hundred three patients who underwent surgery for GBC involving EHBD between August 1978 and July 2002 were surveyed for more than 5 years after surgery and were enrolled in the study. Clinical and histological features were analyzed.

Results. The study patients consisted of 33 men and 70 women with an average age of 63 years. There were eleven 5-year survivors (5-year group) with 12% of 5-year survival rate, consisting of 6 men and 5 women. Gallbladder cancer was located at the neck in 5, both the body and the neck in 2, and the cystic duct in 4. Various hepatic resections were performed in 8 patients (major resection, n = 7), whereas, the remaining 3 underwent cholecystectomy with EHBD resection. Although all patients underwent R0 resection for M0 disease, regional lymph node metastasis was found in 3 patients. The 5-year group was compared with 33 patients who underwent R0 resection for M0 disease but did not survive for 5 years after the surgery (non 5-year group). Univariate analyses using 13 variables revealed that □gperineural invasion□h (p = 0.096) and □glymph node metastasis□h (p = 0.078) tended to be associated with the non 5-year group.

Conclusions. There was no significant difference between the 5-year and the non 5-year groups. GBC involving EHBD should be aggressively resected as only curative resection can offer long-term survival for patients with the advanced tumor.

FP 5.05

IS RESECTION OF EXTRAHEPATIC BILE DUCTS AN ESSENTIAL COMPONENT OF RADICAL SURGERY FOR GALLBLADDER CANCER IN NONJAUNDICED PATIENTS?

Singhal, Dinesh; Chaudhary, Adarsh

Sir Ganga Ram Hospital, Surgical Gastroenterology, New Delhi, India

Background. Gallbladder cancer (GBC) without jaundice is an uncommon clinical entity. The role of routine extrahepatic bile duct (EHBD) resection in such patients during radical cholecystectomy (RC) remains to be elucidated. We resect EHBD for specific indications only and have prospectively evaluated the oncologic validity of our policy.

Patients and Methods. Thirty consecutive non-jaundiced GBC patients (Group I, EHBD resection, n = 12 and Group II, EHBD preserved, n = 18) underwent RC between 2003 – 2007. The main outcome measures were perioperative complications, microscopic R0 resection, medium term disease free survival (DFS).

Results. There were 15 males and 15 females, median age of 51 (range 30 – 72) years. The two groups were comparable for demographic data, postoperative complications, hospital stay and histopathological stage. At Kaplan Mier analysis, the median DFS was significantly associated with T stage (P = 0.004), N stage (P = 0.003) and TNM stage (P = 0.005) but not with EHBD resection (P = 0.802). Cox regression analysis showed that only the TNM stage (P = 0.04) was the independent predictor of DFS.

Conclusions. Following RC for non- jaundiced GBC patients, DFS is determined by TNM stage and not EHBD resection. Hence extrahepatic bile duct resection may be performed for specific indications only.

FP 5.06

GALLBLADDER POLYP: CRITICAL APPRAISAL

Aldouri, Amer; Malik, Hassan; Lodge, Peter; Prasad, K R; Wyatt, Judi; Dexter, Simon; Toogood, Giles

St james's university hospital, Leeds, United Kingdom

Gallbladder polypoid lesions (GBP) are relatively common findings on US examinations (4%), in the majority of cases they are benign; however gallbladder cancer (GBC) could present as GBP or arise from adenomatous GBP, especial in high-risk patients. Researchers from Mayo clinic advocated cholecystectomy for GBP in patients with primary sclerosing cholangitis. We retrospectively analysed all patients who had US examinations in Leeds Teaching Hospitals NHS Trust (LTH) aiming to find whether GBP in patients who migrates from high risk area (India) are more likely to be malignant compared to that in White people. Between January 1998 and July 2006, 137655 abdominal US examinations performed in LTH. All reports of these US have been retrieved from our radiology department database and reviewed retrospectively. After exclusion of follow-up that and US performed for renal or pelvic organs, 71431 US reports were included in this analysis. All pathology reports of gallbladders removed during the same period (5780) have been included in the analysis. Single GBP detected in 2% (No.1431) of all examined patients, stratification of data according to ethnic background revealed that 1.9% (1341) of white patients had single GBP, 2.2% (26) of Indian and 1.8% (64) of others ethnic subgroups. GBC diagnosed in 28 patients, four had GBP diagnosed by US. The prevalence of GBC in White patients with GBP was 0.1% (2/1341) compared to 7.6% (2 /26) among patients with Indian Background. Regression analysis revealed that age >60 years, Indian ethnic background, GB wall thickness, single GBP and GBP > 10mm in size are significant risk factor for GBC. This analysis suggests that solitary GBP in patients with Indian background should be considered to be highly suspicious for cancer and further imaging (EUS) may be advisable.

FP 6.01

NONINVASIVE QUANTITATIVE ASSESSMENT OF HEPATIC STEATOSIS IN THE RAT LIVER USING 3.0 TESLA 1H-MAGNETIC RESONANCE SPECTROSCOPY

Marsman, Hendrik A¹; van Werven, Jochem R²; Nederveen, Aart J²; ten Kate, Fibo JW³; Stoker, Jaap²; van Gulik, Thomas M¹

¹Academic Medical Center, Surgery, Amsterdam, Netherlands; ²Academic Medical Center, Radiology, Amsterdam, Netherlands; ³Academic Medical Center, Pathology, Amsterdam, Netherlands

Background. Hepatic steatosis has been recognized as a serious risk factor for adverse outcome after liver resection and transplantation. Gold standard for quantitative steatosis determination is histological assessment of a needle biopsy. However, this method is unreliable due to heterogenous parenchymal distribution of steatosis, and is associated with complications. 1H-Magnetic Resonance Spectroscopy (1H-MRS) using a conventional MRI scanner allows non-invasive quantification of steatosis by measuring resonance signals of proton containing fatty acid chains in liver tissue. This modality has never been validated as a diagnostic tool for quantitative steatosis determination.

Objective. To validate 1H-MRS measurements in a rat steatosis model and to investigate a correlation with histological and biochemical steatosis determination.

Methods. Steatosis was induced by feeding rats a methionine choline deficient (MCD) diet for 0, 1, 3 or 5 weeks (n = 5 per group). 3.0 Tesla 1H-MRS measurements of rat livers, using a scanning voxel size of 15×10×8 mm (1200 mm³), were compared to histological steatosis as assessed by a blinded pathologist, triglyceride content and total fatty acids measured by gas chromatography.

Results. Histological steatosis ranged from 10% to 95% after 1 to 5 weeks MCD diet, respectively. A significant correlation was observed between 1H-MRS and histopathological macrovesicular steatosis (R = 0,931, p < 0.0001). Also, 1H-MRS correlated significantly with triglycerides content (R = 0,956, p < 0.0001) and total fatty acids assessed by gas chromatography (R = 0,943, p < 0.0001).

Conclusion. 3.0 Tesla 1H-MRS measurements in a rat steatosis model is strongly correlated with morphological and biochemical assessment of parenchymal fat content. These results encourage clinical application of 1H-MRS for non-invasive pre-operative measurement of steatosis during risk assessment of patients requiring liver resection.

FP 6.02

CONTRAST-ENHANCED INTRAOPERATIVE ULTRASONOGRAPHY IN STAGING BEFORE HEPATECTOMY.

Jersenius, Ulf¹; Isaksson, Bengt²; Lundell, Lars²; Mihocsa, Laszlo³

¹Karolinska University Hospital Huddinge, GastroCentrum Kirurgi, Stockholm, Sweden; ²Karolinska Universitetssjukhuset Huddinge, Surgery, Stockholm, Sweden; ³Karolinska Universitetssjukhuset Huddinge, Radiology, Stockholm, Sweden

Introduction. Intraoperative Ultrasonography is the most accurate method to stage malignant lesions in the liver. Using contrast-enhanced intraoperative ultrasonography the staging becomes even more accurate. The method is routine in many centres. An optimal pre operative staging is essential in hepatic surgery for malignant liver lesions to obtain complete tumour clearance, increase the safety for the patients and possible prolong survival for the group of patients.

Objective. To evaluate the diagnostic yield of contrast-enhanced intraoperative ultrasonography compared to pre operative imaging techniques with clinical consequences in terms of changes in operative strategy.

Methods. The contrast agent SonoVue ®)was used in all patients. One hundred consecutive patients, 48 women and 52 men, median age 65 year (17–84), with hepatic malignancies were examined with contrast-enhanced intraoperative ultrasonography. The examinatrion of one radiologist well experienced with contrast-enhanced intraoperative ultrasonography. All patients were examined within two weeks before the hepatectomy. Sixty patients were diagnosed with liver metastases from colo-rectal cancer metastases, 31 with hepatocellular cancer and nine for other malignant tumours.

Results. When comparing the per operative imaging with contrast-enhanced intraoperative ultrasonography and the routine staging, new information was revealed in 25 of the 100 patients (25%), leading to changed operative strategy. Fourteen patients had colo-rectal cancer metastases, six hepatocellular cancer and five other malignanat tumours. In 21 of the cases the new information implemented larger resections, in two cases less resections and two patients were found to be not resectable.

Conclusion. Contrast -enhanced intraoperative ultrasonography is a valuable tool in order to optimize the surgical treatment of hepatic malignancies. Contrast-enhanced intraoperative ultrasonography acquire a central role in an updated per operative staging of patients with hepatic malignancies.

FP 6.03

ETIOLOGY, DIAGNOSIS AND INTERVENTIONAL RADIOLOGICAL MANAGEMENT OF SPLANCHNIC ARTERY ANEURYSMS: A REVIEW OF 32 CASES

Moses, Vinu¹; Kumar NK, Shyam¹; Babu, Surendra¹; Mammen, Thomas¹; Venkatramani, Sitaram²

¹Christian Medical College, Vellore, Department of Radiology, Vellore, India; ²Christian Medical College, Vellore, Department of Hepatobiliary Surgery, Vellore, India

Background. Although diagnosed splanchnic artery aneurysms are rare, autopsy studies suggest that they are more frequent than abdominal aortic aneurysms. Splanchnic artrery aneurysms are important to diagnose because over 25% rupture with a mortality of 50–70%.

Objective. To assess etiology, presenting symptoms, diagnosis and management of splanchnic aneurysms in a tertiary care hospital in South India.

Methods. Records of 32 cases with splanchnic aneurysms (2000 – 07) diagnosed and treated by endovascular embolization in Radiodiagnosis Department were analyzed.

Results. Etiology included post-inflammatory, post-traumatic, iatrogenic, infection, atherosclerotic and idiopathic. Pseudoaneurysm secondary to pancreatitis (34%) was the most common identifiable etiology. The most common presentation was hematemesis and melena. The common sites of aneurysm were hepatic artery pseudoaneurysms (31%) and splenic artery pseudoaneurysms (31%). Endovascular treatment was attempted in all cases, with a success rate of 81%. Three cases (9%) had re-bleeds after endovascular treatment, two (6%) of which underwent endovascular re-embolization and one (3%) underwent surgical ligation. Two cases (6%) who underwent successful endovascular embolization, died due to co-morbid conditions.

Conclusion. Splanchnic aneurysms have high mortality and morbidity. This warrants their prompt diagnosis and management. Although CT and MR angiography are slowly replacing conventional angiography in the diagnosis of splanchnic aneurysms, conventional angiography offers a therapeutic option. Endovascular repair of splanchnic aneurysms is preferred as it avoids the morbidity and mortality associated with surgical repair, and provides good outcome.

FP 6.04

CLINICAL VALUE OF CONTRAST-ENHANCED (SONOVUE®) INTRAOPERATIVE ULTRASOUND FOR CHARACTERIZATION OF FOCAL LIVER LESIONS

Tan, Felicia¹; Tan, Yu-Meng¹; Low, Albert²; Chung, Alexander³; Cheow, Peng Chung³; Ooi, London¹; Lo, Richard²

¹National Cancer Centre, Department of Surgical Oncology, Singapore, Singapore; ²Singapore General Hospital, Diagnostic Radiology, Singapore, Singapore; ³Singapore General Hospital, General Surgery, Singapore, Singapore

Objectives. The aim of the study was to assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool for detection and characterization of focal liver lesions during hepatic surgery.

Materials and Methods. Forty-one patients scheduled to undergo liver resection were studied. Focal liver lesions were detected by preoperative computed tomography (CT) imaging or magnetic resonance imaging (MRI) of the liver. Following exploration, IOUS was performed using an HDI-5000 scanner (Philips) and a finger probe with pulse inversion harmonic (PIH) capability. CE-IOUS in the PIH mode was performed in a standardized protocol (low MI:0.02 – 0.04) after intravenous injection of 2.4 – 4.8 ml of Sonovue. All detected lesions on postcontrast scans were counted and mapped. Any alteration in surgical management was documented. The excised liver specimen was sent for pathological examination to ascertain its true histology. The CE-IOUS and histopathological findings were compared and correlated. Blinded analysis of the recorded procedure was also performed.

Results. A total of 84 liver lesions were studied. CE-IOUS altered surgical management in 8 patients (19.5%), and detected additional lesions in 15 patients (36.5%). CE-IOUS altered the preoperative diagnosis in 4 patients (9.5%) and was correct in all patients (100%). Surgical management was unchanged in 7 patients despite additional lesions detected on CE-IOUS. Two benign lesions were wrongly diagnosed as malignant on CEIOUS (A thrombosed haemangioma and the other a regenerative nodule). One hepatocellular carcinoma was wrongly diagnosed as a regenerative nodule on CE-IOUS. The sensitivity for CE-IOUS was 98.7%, positive predictive value 97.5% and overall accuracy 96.4%. Conclusion CE-IOUS improves detection and characterization of focal liver lesions. This in turn led to alteration in surgical management. CE-IOUS may represent the new gold standard of imaging in hepatic surgery.

FP 6.05

A COMPARISON OF LESIONS PRODUCED BY RADIOFREQUENCY, CRYOTHERAPY AND MICROWAVE ABLATION IN THE LIVER.

Bhardwaj, Neil¹; Strickland, Andrew D²; Ahmad, Fateh²; West, Kevin³; Lloyd, David M²

¹Leicester Royal Infirmary, Hepatobiliary surgery, 6th floor Balmoral Building, Infirmary square, Leicester, United Kingdom; ²Leicester Royal Infirmary, Hepatobiliary surgery, Leicester, United Kingdom; ³Leicester Royal Infirmary, Histopathology, Leicester, United Kingdom

Background. Microwave tumour ablation (MTA), radiofrequency (RF) and cryotherapy utilise thermal energy to destroy unresectable primary or secondary liver tumours. Adequate destruction of tumour tissue is dependent upon uniform ablation volume and resistance to the heat sink effect.

Aims/Objectives. To compare the unablated/ablated boundary and the heat sink effect within the ablations induced by cryotherapy, MTA and RF in the rat liver.

Methods. A total of 84 rats underwent a laparotomy. For each of the 3 ablative modalities, 21 rats were assigned to each group and the liver was ablated. Twenty-one rats were used as a control arm and received no treatment other than a laparotomy. All rats were sacrificed at 48 hours and the livers analysed with H&E.

Results All specimens demonstrated a sharply demarcated boundary between the ablated and unablated tissue to the naked eye. Histologically, RF and Cryotherapy demonstrated irregular boundaries, intra-lesional viable hepatocytes, particularly cells in proximity to blood vessels and a large inflammatory response between the two zones. Microwave produced a histologically sharp demarcation between the two zones, no intralesional or perivascular survival and a completely uniform ablation area.

Conclusion. RF and cryotherapy rely on conduction of thermal energy in order to ensure cytotoxic temperatures are reached within an ablation zone. This method can often be haphazard and subsequently be prone to the corrupting effects of blood vessels, particularly at the peripheries of a treatment area. Microwaves on the other hand produce uniform ablation volumes as they exert a ‘field effect’ and are therefore less prone to the heat sink effect. This may mean that microwave ablation may be more effective in treating unresectable liver tumours, particularly those in close proximity to blood vessels.

FP 6.06

IMPACT OF ENDOSCOPIC ULTRASOUND (EUS) ON PANCREATICO-BILIARY PRACTICE IN A TERTIARY REFERRAL CENTRE. A NEW BENCHMARK IN DIAGNOSTIC YIELD?

Cherian, PT; Hejmadi, RK; Tanierre, Phillipe; Wigmore, SJ; Mirza, DF; Mayer, D; Bramhall, SR; Buckels, JAC; Mahon, Brin

University Hospital, Birmingham, United Kingdom

Aim. The reported median diagnostic yield from EUS fine needle aspiration cytology (FNA) is 78% (range 39–93%). We report a single centre experience in the diagnostic work-up of solid pancreatic masses.

Methods. In a consecutive series of 429 EUS examinations performed over a 12-month period by a single operator, 108 were on non-cystic pancreatic or biliary lesions. Data was collected prospectively and the accuracy of FNA was assessed retrospectively using either surgery or repeat imaging as the benchmark.

Results. 101 of the 108 FNAs (94%) were diagnostic, 4 were falsely negative (FN) and 3 atypical and considered equivocal. There were 78 pancreatic lesions, 64 were true positives (TP), 11 true negatives (TN), 1 with atypical cytology and 2 FN (both GISTs) (96% diagnostic). In 9 sub-ampullary lesions there were 2 TPs, 6 TNs and 1 FN (subsequent T2 N0 adenocarcinoma) (89% diagnostic). There were 21 bile duct lesions of which 10 were TPs, 8 TNs, 2 atypical and 1 FN (86% diagnostic). It is possible that with longer follow up these rates might change.

Conclusion. In a high-volume practice a median diagnostic yield from EUS and FNA of greater than 90% is achievable and should be the aim in order to minimize patient distress, discomfort and allow early patient management planning.

FP 7.01

PREOPERATIVE PREDICTION OF COMMON BILE DUCT STONES

Videhult, Per¹; Sandblom, Gabriel²; Ljungdahl, Mikael³; Wollert, Staffan³; Darkahi, Bahman⁴; Liljeholm, Håkan⁴; Karlson, Britt-Marie³; Rasmussen, Ib Christian³

¹Ersta Hospital, Department of surgery, Stockholm, Sweden; ²University Hospital, Department of surgery, Lund, Sweden; ³University Hospital, Department of surgery, Uppsala, Sweden; ⁴Enköping Hospital, Department of surgery, Enköping, Sweden

Background. Optimal planning of a cholecystectomy requires reliable prediction of the risk of encountering common bile duct stones (CBDS) since this calls for more resources and experienced surgeons and personel.

Objective. To explore how ALP, bilirubin and available preoperative clinical variables can be used to predict the presence of common bile duct stones in a large population-based setting.

Methods. All operations in the Uppsala county, Sweden, with a population of 303 000, were registered prospectively 2003–2005. Data included indication for surgery, preoperative liver tests (alkaline phosphatate (ALP) and bilirubin), age, gender and findings at intraoperative cholangiography.

Results 1199 patients, including 794 women (66%), underwent cholecystectomy 2003–2005. Mean age was 48 years, standard deviation 15 years. Intraoperative cholangiography was successfully performed in 1119 (95%) of the patients. In 152 cases a pathological cholangiography was achieved. In a multivariate logistic regression analysis, elevated liver function markers (bilirubin >50 mmol/l and/or ALP > 5 microkat/l) and age above median were found to significantly and independently predict the presence of common bile duct stones, whereas history of acute pancreatitis, cholecystitis or gender did not. The positive predictive value (PPV) and negative predictive values (NPV) for the liver function markers were 40% and 94%. The PPV and NPV for age were 12% and 92%.

Conclusion. Liver function markers are the single most reliable predictors of CBDS. The only variable besides the liver function markers that predict CBDS is age, whereas a history of cholecystitis or acute pancreatitis does not.

FP 7.02

ACCURACY OF INTRAOPERATIVE CHOLANGIOGRAPHY

Videhult, Per¹; Sandblom, Gabriel²; Ljungdahl, Mikael³; Wollert, Staffan³; Darkahi, Bahman⁴; Liljeholm, Håkan⁴; Karlson, Britt-Marie³; Rasmussen, Ib Christian³

¹Ersta Hospital, Department of surgery, Stockholm, Sweden; ²University Hospital, Department of surgery, Lund, Sweden; ³University Hospital, Department of surgery, Uppsala, Sweden; ⁴Enköping Hospital, Department of surgery, Enköping, Sweden

Background. Although intraoperative cholangiography (IOC) is a widely used method for detecting common bile duct stones (CBDS), its accuracy has not been fully evaluated in large non-selected patient samples.

Objective. The purpose of this study was to assess the sensitivity, specificity and predictive value of dynamic IOC regarding its ability to diagnose CBDS in a population-based setting, and to assess the morbidity associated with the investigation.

Method. All patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala, Sweden, with a population of 303 000, were registered prospectively. The outcome of cholangiography was validated against the postoperative clinical course.

Result. Altogether 1171 patients operations were performed 2003–2005. IOC was performed in 1117 patients (95%). Common bile duct stones were found in 134 patients (11%). One perforation of the common bile duct caused by the IOC catheter was recorded. Sensitivity was 97%, specificity 99%, negative predictive value 99%, positive predictive value 95%, and overall accuracy 99%. In 7 of the 134 cases where IOC indicated CBDS, no stones could be verified on exploration. In 4 of the 979 cases where IOC was normal, the clinical course indicated overlooked CBDS.

Conclusion. Intraoperative cholangiography is a safe and accurate method for detecting common bile duct stones with 5% false positive findings and 0,1% false negative findings.

FP 7.03

LONG-TERM Results AFTER LAPAROSCOPIC TRANSVERSE CHOLEDOCHOTOMY FOR COMMON BILE DUCT STONES

Lezoche, Emanuele¹; Paganini, Alessandro M.¹; Sarnari, Jlenia²; Guerrieri, Mario²; De Sanctis, Angelo²; Rotundo, Adriana¹

¹Policlinico Umberto I, Department of Surgery "P. Stefanini", Rome, Italy; ²Azienda Ospedaliera Umberto I, Clinica di Chirurgia Generale e Metodologia Chirur, Ancona, Italy

Background. Transverse rather than longitudinal choledochotomy reduces the risk of CBD ischemia and long-term stricture. Aim was to evaluate the long-term results of laparoscopic transverse choledochotomy (TC) during laparoscopic cholecystectomy (LC) in a consecutive series of unselected patients.

Methods. from April 1991 to February 2007, CBD stones were present in 363 out of 3455 patients (pts) (10.5%) (139 males, 224 females, mean age 57.6 years, range 12–96 years) who underwent LC. The indications for laparoscopic TC were multiple ductal stones (> 5), larger stones (> 8 mm), stones in the common hepatic duct, narrow cystic duct, failure of a trans-cystic duct approach. A pre-requisite was the presence of a dilated CBD (> 8 mm). After discharge, the follow-up study was conducted by yearly ambulatory visits, laboratory exams, telephone contacts with the patient or family doctor, ultrasound or Cholangio-MRI. The procedure was completed laparoscopically in 348 patients (95.9%), with a TC in 144 patients (41.4%), who are the object of this study, or a trans-cystic duct approach in 204 (58.6%).

Results. Biliary drainage was employed in 122 of 144 cases (84.7%). Major complications occurred in 8 cases (5.6%) and mortality in one high risk patient (0.7%). Retained and recurrent ductal stones occurred in 11 (7.6%) and in 5 patients (3.5%), respectively. No patient was lost to follow-up (mean 113.1 months, range 40.0–188.9). No signs of bile stasis and no biliary stricture were observed. One-hundred-eighteen patients are alive with no biliary symptoms; 25 elderly patients have died from unrelated reasons.

Conclusions. This experience confirms the long-term safety of laparoscopic TC with no long-term stricture. It reduces the need for endoscopic sphinterotomy in most patients with CBD stones, with a reduction in the diagnostic and therapeutic burden for the patient and a reduction in hospital stay.

FP 7.04

Clinical epidemiological analysis of 309 ERCPs performed in Nova Scotia in 2006 for choledocholithiasis and gallstone pancreatitis.

Molinari, Michele¹; Walsh, Mark¹; Nason, Amy²

¹Dalhousie University, Surgery, Halifax, Canada; ²Dalhousie University, Halifax, Cameroon

The ideal management of choledocholithiasis and gallstone pancreatitis is controversial. With the advancement of diagnostic modalities, endoscopic retrograde cholangiopancreatography (ERCP) should be performed only when intervention is needed. Referral patterns for ERCP, and patients’ management are influenced by resources and location. Limited information is available for the clinical use and outcomes of ERCP in Atlantic Canada. Aim of this study was to assess the diagnostic, therapeutic and success rates of ERCP performed in a high volume tertiary medical center in Nova Scotia.

Methods. A retrospective observational study was performed over one year period (January 1 to December 31, 2006) at the QEII hospital. ERCP data of 565 procedures were reviewed by two independent investigators. All data discrepancies were analyzed and resolved. Demographic characteristics, indications for ERCP, interventions, diagnosis and outcomes were captured. Procedures were then divided into 2 groups: therapeutic or diagnostic. Therapeutic ERCPs were defined when successful stone extraction or sphincterotomy for sphincter dysfunction were obtained.

Results. Within the 12 month period, 309 ERCPs were carried out for presumed choledocholithiasis (No 273, 88.3%) or gall stone pancreatitis (No 36, 21.7%) on a population with mean age of 62 (SD + 17.9). Therapeutic ERCP was performed in 175 (64.1%) patients with choledocholithiasis and in 12 (33.4%) individuals with pre-ERCP diagnosis of pancreatitis. Inability to cannulate the papilla was observed in 8 (2.9%) patients with choledocholithiasis and 4 (11.1%) individuals with pre-ERCP diagnosis of pancreatitis.

Conclusion. As ERCP is invasive, ideally it should be indicated only as a therapeutic modality. Our findings suggest that in Atlantic Canada, diagnostic ERCPs are still performed in 35.9% of choledocholithiasis and 66.6% of gall stones pancreatitis. Implementing better referral patterns and patient selection would optimize resources and decrease complications.

FP 7.05

TREATMENT OF COMPLICATED HEPATOLITHIASIS AND INTRAHEPATIC BILIARY STRICTURES BY TRANSPARIETAL CHOLANGIOSCOPY

Fiocca, Fausto¹; Salvatori, Filippo M²; Santagati, Alessio³; Ceci, Vincenzo³; Donatelli, Gianfranco³; Cereatti, Fabrizio³; Bruni, Antonio⁴; Bezzi, Mario⁵

¹Policlinico Umberto I-University "La Sapienza", Emergency Endoscopic Surgery, Roma, Italy; ²Policlinico Umberto I-University "La Sapienza", Radiology, Roma, Italy; ³Policlinico Umberto I-University, Emergency Endoscopic Surgery, Roma, Italy; ⁴Policlinico Umberto I-University Roma, Rdiology, Roma, Italy; ⁵Policlinico Umberto I-University Roma, Radiology, Roma, Italy

Background. Percutaneous cholangioscopy (PCS) is an endoscopic tool complementary to percutaneous cholangiography (PTC) to find small biliary stones and for differential diagnosis of ductal lesions of uncertain aspect. Its advantages include the direct approach to areas where stones are difficult to locate, to perform associated procedures such as balloon dilatation of biliary strictures, crushing of intractable stones by electrohydraulic lithotripsy (EHL).

Patients And Methods from 1990 to 2006 492 pts were admitted for management of biliary disease. PCS were performed with a 3 mm or a 4.9 mm scope after a matured (4–7 days) PTC; 22 cases through a biliary fistula of a previously surgically inserted T tube. 349 pts (71%) had intractable stones in the biliary tree: failure of ERCP, stones more than 1.5 cm or for not accesible CBD at ERCP for previous surgery. 143 pts (29%) had strictures of the biliary tree of uncertain origin. Stones were crushed with EHL (Olympus Walz 2) with 3 and 4.5 F probes under direct endoscopic vision and fragments flushed with saline injection. Direct biopsy of visible lesions were performed.

Results all 349 pts were successfully treated with stones' clearance after a mean of 1.8 sessions: 229 (65%) of them with EHL after ballon dilatation of stenosis if present. No related mortality; major complications were 8 (2.3%) massive bleeding that required embolization and 2 (0.6%) perforations of the main bile duct that were treated conservatively. Minor complications were 37 (10.6%) pts who experienced nausea and vomiting for fluid overload, minor bleeding and cholangitis. 41 (11.8%) pts had stones recurrences after 8–60 months and were successfully retreated.

Conclusions. PCS with a PTC approach and EHL is a feasible and easy miniinvasive procedure for treatment of complicated retained or recurrent biliary stones, they require a team of skilled radiologist and endoscopist. PCS and EHL when conducted with sufficient care and decision is effective in all the cases.

FP 7.06

A 24-YEAR FOLLOW-UP OF PATIENTS WITH SILENT GALLSTONES SHOWED A SIMILAR LONG-TERM RISK OF CHOLECYSTECTOMY AS IN THE GENERAL PUBLIC

Malte, Schmidt¹; Søndenaa, Karl¹; Christoph, Schleer²; Trygve, Hausken³

¹Haraldsplass Deaconal Hospital, Department of Surgery, Bergen, Norway; ²Haraldsplass Deaconal Hospital, Department of Radiology, Bergen, Norway; ³University of Bergen, Department of Medicine, Bergen, Norway

Introduction. We examined the risk of getting symptomatic gallstone disease (GSD) or having a cholecystectomy (C) with silent gallstones (GS).

Objective. In 1983, 259 persons (145 women (56%), 114 men, mean age 51.4 years) from a random population were found by ultrasonography (US) to have GS. In 2007, a follow-up study with US and clinical consultation was done. Eighty-nine persons consented to an examination (Group 1 = 49 women, 40 men), 45 answered a letter or telephone questionnaire (Group 2 = 17 women, 28 men), together 134. The rest had either died (n = 98), refused follow up (n = 12), or were not traced (n = 15). One thousand and thirty-two persons (531 women (51.5%), 501 men, mean age 44 years) constituted a Control Group (CG). Interim cholecystectomy and overall mortality rates were confirmed through hospital and official public records.

Reuslts. A total of 10.4% (27/259) in the study population had had a cholecystectomy, i.e. Groups 1–2: 9 persons (6.7%), deceased: 11 (11.2%), the rest: 7 (25.9%). In Group 1, 30.5% (25/82) had gallstones at US. Of these, 11 (44%) had had abdominal pain at one stage. 31.6% of the rest (18/57) also had had abdominal pain. In Group 2, another 11.6% (5/43) had had abdominal pain. In CG, 20.3% (209/1032) had died, compared with 37.1% (equal portion men and women) in the gallstone group.

Conclusion. The incidence of C in persons with asymptomatic gallstones was slightly different than that of the general public (6.6%) which may be age and gender dependent. The increased mortality rate was not caused by GSD. We have at present no obvious explanation for the lower incidence of gallstones in 2007 compared with 1983.

FP 8.01

PLATELET TRANSFUSIONS DURING LIVER TRANSPLANTATION ARE ASSOCIATED WITH POST-OPERATIVE MORTALITY DUE TO ACUTE LUNG INJURY

Pereboom, Ilona TA; de Boer, Marieke T; Lisman, Ton; Porte, Robert J

University Medical Center Groningen, Hepatobiliary Surgery and Liver Transplantation, Groningen, Netherlands

Background and Objective. Platelet transfusions have been shown to be a strong independent risk factor for graft failure and patient mortality after orthotopic liver transplantation (OLT). No previous studies investigated the mechanisms of patient death and graft failure as a result of platelet transfusions during OLT. In this study these mechanisms were evaluated.

Methods. A series of 449 adult patients undergoing a first OLT between 1989 and 2005 in our center were included in this study. Reasons for postoperative graft failure and patient death were assessed in patients who did or did not receive perioperative platelet transfusions.

Results. 90-days graft survival was significantly reduced in patients who received platelet transfusions during OLT (75% versus 90%, p < 0.001). The main reason for graft failure in these patients was patient death (20% versus 5%, p < 0.001). 90-days patient survival was also significantly reduced in patients who received platelet transfusions during OLT (79% versus 94%, p < 0.001). This increased mortality could be attributed to an increased occurrence of acute lung injury, which was more frequent in patients receiving platelet transfusions during OLT (p = 0.004). Surprisingly, liver-related thrombotic complications were equally distributed between patients receiving platelet transfusions and patients who were not transfused.

Conclusions. This study confirms the detrimental effect of platelet transfusions in patients undergoing OLT. Patient death is the main reason for graft failure in patients who received platelet transfusions during OLT. Acute lung injury is the main reason for patient death in these patients. These findings support previous calls for a cautious use of platelet transfusions in patients undergoing liver transplantation, because of serious adverse events and increased mortality due to acute lung injury.

FP 8.02

HIGH PRIMARY NON FUCNTION AND RETRANSPLANTATION RATE IN NON HEART-BEATING DONOR (NHBD) LIVER TRANSPLANTATION UNDER PATIENT DRIVEN ALLOCATION.

Sainz Barriga, Mauricio; Dezza, Maria Clara; Berrevoet, Frederik; Haentjens, Ivo; Rosetto, Anna; Colenbie, Luc; Rogiers, Xavier; de Hemptinne, Bernard; Troisi, Roberto

Ghent University Hospital Medical School, Hepatobiliary and Liver Transplant Service, Ghent, Belgium

Introduction. The non heart-beating-donor (NHBD) has reemerged as a tentative to expand the donor pool. We reviewed a single center experience comparing liver transplantation (LT) with controlled NHBD vs. brain death donor (BDD) under patient driven allocation.

Methods. Between October 2003 and August 2007, 512 LT were performed. Sixteen NHBD were compared with 118 BDD primary LT. Fisher and T-Test were used when appropriate. Survival was analyzed by Kaplan-Meier and Long Rang test.

Results. Sixty-three percent of BDD were extended criteria donors. Fifty percent of NHBD grafts were shipped from abroad. Recipient mean MELD was 15±5 and 18±7 respectively for NHBD and BDD (p = 0,03). Mean CIT was 3±1.6 hours and 9±2.3 hours respectively for NHBD and BDD (p < 0.001). Biliary complications rate was 31.5% and 17% respectively for NHBD and BDD (p = 0.1). Cholestasis was significantly lower in BDD (p < 0,001). Primary non function incidence was 12% and 1%; and retransplantation rate was 31% vs. 6%, (p < 0,001) respectively for NHBD and BDD (p < 0,01). Seventy-one percent of NHBD failed grafts were shipped from other centers. Graft survival was 55% and 82% respectively for NHBD and BDD recipients at 4 years (p = 0,007), while graft survival was 56% and 69% respectively for NHBD and BDD (p = 0.38) when compared only with extended criteria donor.

Conclusion. In our experience, LT with NHBD is characterized by a higher retransplantation rate and cholestatic evolution respect to BDD, specially when shipped from abroad. Graft survival is comparable to extended criteria donors.

FP 8.03

PRE-TRANSPLANT SCORING IN PREDICTING IN-HOSPITAL MORTALITY FOLLOWING LIVER TRANSPLANTATION

Bonney, Glenn¹; Stuart, Murdoch²; Attia, Magdy²; Aldersley, Mark A²; Toogood, Giles J²; Pollard, Stephen G²; Lodge, J Peter A²; Prasad, K Rajendra²; Pras ad, K Rajendra²

¹St James University Hospital, Hepatobiliary and Transplantation, Beckett Street, Leeds, United Kingdom; ²St James University Hospital, Hepatobiliary and Transplantation, Leeds, United Kingdom

Background. In recent years, much research has been carried out into factors that effect short and long term outcomes in liver transplantation. As a scoring system, MELD has been shown to predict outcomes in liver transplantation. Here we assess MELD and other physiological scores in predicting in-hospital mortality.

Methods. A prospectively collected database of 696 recipients of liver transplants performed at one centre from 1998–2005 was analysed. The physiological scores analysed included Donor Risk Index, MELD at transplantation, Acute Physiological and Chronic Health Evaluation (APACHE) II and III score and Simplified Acute Physiological Score (SAPS) II.

Results Recipient demographics including age, diagnosis, ethnicity and ABO mismatch did not significantly affect in-hospital mortality. On univariate analysis, APACHE II APACHE III, SAPS II and MELD significantly predicted in-hospital mortality (p < 0.0001, p < 0.0001, p < 0.0001, p = 0.03 respectively). On multivariate analysis SAPS II was the only independent predictor of in-hospital mortality (p < 0.0001 with a odds ratio of 3.149.

Conclusion. SAPS II independently predicts in-hospital mortality in liver transplant recipients and may be useful in resource utilisation in these patients.

FP 8.04

EXTRACORPOREAL PORTAL BLOOD ARTERIALIZATION WITH A NEW DEVICE TO TREAT TOXIC ACUTE LIVER FAILURE IN THE SWINE MODEL

Nardo, Bruno; Tsivian, Matvey; Neri, Flavia; Bianchi, Elisa; Piras, GianLuca; Puviani, Lorenza; Cavallari, Giuseppe; Bertelli, Riccardo; Vincenzo, Pacile

S. Orsola Hospital, University of Bologna, Bologna

Background. The present study aimed to determine whether the portal blood arterialization by a new liver extracorporeal device (L.E.D.) is effective in treating swine with toxic administration leading to acute liver failure (ALF).

Methods. Eight swine with ALF induced by intraperitoneal injection of carbon tetrachloride in oil solution at a dose of 450 mg/Kg of body weight were randomly divided into two groups: four animals received L.E.D. treatment 24 hours after the intoxication. and four swine were not-treated (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system. An extracorporeal device was interposed between the outflow and the inflow in order to monitoring the hemodynamic parameters. Each treatment lasted 6 hours. Serum and liver samples were collected in both groups. The survival was assessed at 1 week.

Results. L.E.D. treatment yielded beneficial effects for carbon tetrachloride induced-ALF swine with decreased serum ammonia, transaminases and total bilirubin as compared with the untreated group. INR recovered rapidly in the L.E.D. group remaining significantly lower than in untreated animals. The 7-day survival of L.E.D. group swine was significantly higher than that of untreated animals, with a statistically significant difference (p < 0.05). Three swine in the L.E.D. group survived at 1 week while none of the swine in the control group were alive at that time.

Conclusions. Arterial blood supply in the portal system through the L.E.D. is easily applicable, efficacious, safe and cost effective and may represent a novel approach for ALF swine induced by carbon tetrachloride intoxication.

FP 8.05

NEW INSIGHTS INTO PROTECTION OF HEPATIC FUNCTION BY REMOTE ISCHEMIC LIMB PRECONDITIONING IN THE LATE PHASE OF HEPATIC ISCHEMIA REPERFUSION INJURY.

Tapuria, Niteen; Junnarkar, Sameer; Fuller, Barry; Seifalian, Alexander M; Davidson, Brian R

Royal Free Hospital, HPB & Liver transplant surgery, London, United Kingdom

Background. Ischemia reperfusion injury (IRI) may lead to nonfunction or dysfunction of transplanted liver grafts. At the Royal Free (UK) experimental studies by intravital microscopy have demonstrated that remote ischemic limb preconditioning (RIPC) modulates hepatic microcirculation by increasing RBC velocity, sinusoidal flow, sinusoidal perfusion and decreasing neutrophil adhesion as well as apoptosis to protect liver function in the early phase of hepatic reperfusion injury. This is the first study to focus on the role of RIPC in protection of hepatic function in the late phase of reperfusion injury.

Aim. To investigate the effect of RIPC on late phase of reperfusion injury in an animal model of 24 hour hepatic ischemia reperfusion injury.

Material and Methods. A rat model of IRI with 45 minutes of partial liver ischemia (70%) followed by 24 hours of reperfusion was used for this study. Two animal groups studied included IRI-24 and RIPC + IR-24. The animals were preconditioned by 4 cycles of right hind limb ischemia (5minutes), reperfusion (5 minutes) prior to ischemia. Hepatic microcirculation was assessed by studying velocity of RBC flow, sinusoidal perfusion, sinusoidal flow and sinusoidal diameter under intravital microscopy. The number of neutrophils adherent to endothelium/mm2 and the numbers of stained apoptotic cells/HPF were assessed by intravital microscopy. Liver functions were assessed.

Results. There was no significant difference in the RBC velocity, sinusoidal flow or sinusoidal diameter between the IR-24 and RIPC + IR-24 groups. Sinusoidal perfusion was significantly better in the RIPC + IR-24 group. Neutrophil adhesion and apoptosis were significantly reduced and liver functions were significantly better in the RIPC group.

Conclusion. Modulation of hepatic microcirculation and neutrophil activation by RIPC in the late phase of hepatic IR is a key mechanism in protection of liver function. The role of modulation of neutrophil activation to prolong graft survival needs further investigation.

FP 8.06

OXYGENATED PERFUSION: RESUSCITATION OF CELLULAR ENERGY METABOLISM AND MITOCHONDRIAL FUNCTION DURING ORGAN PRESERVATION.

Roy, Debabrata¹; Morten, Karl²; Ashley, Neil²; Elker, Doruk¹; Southerland, Andrew¹; Guerriero, Dino¹; Coussios, Constantin¹; Friend, Peter J¹

¹John Radcliffe Hospital, Nuffield Department of Surgery, Oxford, United Kingdom; ²John Radcliffe Hospital, Nuffield Department of Obstetric and Gynaecology, oxford, United Kingdom

Introduction. Livers from non-heart-beating-donors (NHBD) may be important in alleviating the donor organ shortage. However, the liver does not tolerate prolonged warm ischaemia followed by cold preservation and, as a result, the application of non-heart-beating-donors has had limited impact in clinical liver transplantation to date. We have investigated whether addition of normothermic recirculation prior to retrieval complements the already proven benefit of normothermic preservation.

Methods. After 60 minutes of warm ischaemia, porcine livers were treated by normothermic recirculation (n = 5, NR), by in situ oxygenated perfusion for 1 hour followed by normothermic preservation for 23 hours. Group C (Control, n = 5) did not receive NR, but were otherwise treated in the same way. We assessed liver function during preservation and during 24 hours of subsequent reperfusion (a surrogate for transplantation). The apoptotic and necrotic changes after reperfusion were examined by TUNEL and haematoxylin staining.

Results. Cellular ATP levels declined sharply during 60 minutes of warm ischaemia (by 90% of the basal level, p < 0.01). NR improved mitochondrial function (mitochondrial respiratory control ratio, p < 0.05) and ATP levels significantly (p< 0.01). This effect was maintained throughout the period of warm preservation and associated with greater functional recovery of the NR livers with superior bile production (p < 0.05), base deficit (p < 0.05) and reduced hepatocellular (p < 0.01) damage. Both apoptosis and necrosis were attenuated in the NR group with significantly greater destruction of architecture on histology in group C livers.

Conclusions. NHBD livers are resuscitated by a combination of normothermic recirculation and normothermic preservation. This may have important clinical implications.

FP 9.01

NECESSITY OF ADVANCED TRAINING IN HEPATO-PANCREATO-BILIARY SURGERY

Chang, Yeon-Jeen; Jaocbs, Michael; Mittal, Vijay

Providence Hospital and Medical Centers, Department of Surgery, Southfield, United States

Background. Hepato-Pancreato-Biliary (HPB) surgeries require comprehensive knowledge, meticulous surgical technique and a good institutional support system. Advanced training in HPB surgery is available at select centers, however, no approved fellowship has been established yet.

Objective. Determine the level of training in HPB surgery received during General Surgery Residency (GSR) and assess whether additional training is needed in order to focus practice in HPB surgery.Method.: All GSR Programs (GSRP) in the US were invited to participate in a survey of attitudes and experience in HPB surge ry. Results were compared to the requirements established by the Resident Regulation Committee, the 2006 General Surgery Log Database, and the training criteria suggested by the International Hepato-Pancreato-Biliary Association (IHPBA).

Results. Eighty of 250 GSRP (32%) responded to the survey. 80% of GSRP feel that their graduating residents have sufficient training in HPB surgery. However, 38% of the programs refer >50% of their biliary cases to an HPB surgeon, 28% have an independent HPB service, and 35% have transplant centers that perform >50% of the hepatic surgeries. The average number of pancreatic cases per graduating resident in 2006, as reported by Accreditation Council for Graduate Medical Education (ACGME), was 10.2±7.3 (mean±SD), with Whipple and distal pancreatectomies compromising <50% of those cases (4.7±4.6). The average number of hepatic resections was 8.6±5.1, and 5.3±1.3 for complex biliary cases. All these numbers fulfill the minimal number of index cases required by ACGME, though they fall short of the 25 cases in each category suggested by the IHPBA.

Conclusion. Though HPB Surgery is an essential part of GSR training, a significant portion of HPB surgery is done at transplant centers or by HPB surgeons. Therefore, guidelines must be established to assure adequate training. Furthermore, when HPB surgery is the main focus of the future practice, residents should seek additional training.

FP 9.02

THE ROLE OF SURGICAL APPRENTICESHIP IN MODERN HPB TRAINING.

Gilmour, Jeff

The Royal Infirmiry of Edinburgh, Edinburgh, United Kingdom

Introduction. Surgical training has often been considered as an apprenticship. Decision making skills are passed on from trainer to trainee as both work together through a long series of problematic situations. This and other apprenticeship like aspects of training have been eroded in recent years by changes to working practice and other constraints. This is of particular concern in HPB training where so many advanced techniques and complex clinical decision making skills are required.

Objective. To estimate the proportion of surgical decision making that is evidence or experience based and to explore apprenticeship like mechanisms of training.

Methods. A combination of qualitative and quantitative methods namely; questionnaire, reflective practice exercises and observational techniques were employed to study the basis of clinical decision making of over 20 HPB/general surgeons and trainees in 400 operations/OPD consultations focusing on the interaction between trainer and trainee and how this facilitates such decision making.

Results. 29% of decisions were evidence based (22% for trainees and 40% for trainers). 54% of trainee decisions were influenced by trainer interaction (past or present). Effective clinical decision making skills were observed to be transferred from trainer to trainee but this required time and a good rapport. All subjects acknowledged that this apprenticeship like interaction facilitated experience based practice which was an important supplement to evidence based practice.

Conclusion. Whenever possible clinical decision making should be evidence based however good evidence is often unavailable and consequently many decisions are experience based. In order to optimise the training of HPB surgeons attention should be paid to the underlying mechanisms by which clinical skills such as decision making, are acquired. A greater effort should be made to preserve and enhance some of the traditional apprenticeship like aspects of training.

FP 9.03

KEEPING IT TOGETHER: WHAT MAKES A DIFFERENCE TO CARERS IN ACUTE HPB CANCER SERVICES

Byrne, Clare¹; Poston, Graeme J²; Griffin, Andrea²

¹University Hospital Aintree NHS Foundation Trust, HPB (Liver) Unit, Digestive Diseases Centre, Lower Lane, Liverpool, United Kingdom; ²

Background. Meeting the needs of carers as an integral part of managing those affected by HPB cancer is increasingly being recognised. However, the emphasis tends to be on care delivered in the community. This paper reports on a study which identified the key aspects of carer involement in acute HPB cancer care.Method.: 27carers, and 17 bereaved carers affected by HPB cancer were interviewed and completed measures of psychological well-being (HADS and GHQ12).

Results. Fisher's exact was significant for psychological distress and information in carers (.029). Key issues influencing access to information, sensitive communication, carer inclusion/exclusion at disclosure, coordination of care and carers other social responsibilities were identifie. Fisher's exact was almost significant for fatigue and anxiety in carers (0.74), which was not associated with burden of care, but with the emotional strain associated with healthcare professional's failure to acknowledge their role as carer with information and support needs, their emotional relationship to the patient and their personal loss.

Discussion. There is indication that during the acute phases of investigation, diagnosis, or at recurrence and transition to incurable disease, carers have specific needs which need to be addressed in conjunction with the needs of the patient. Delay in including carers has consequences for psychological well being both when caring and for adjustment when bereaved. The importance of the role of a key source of information and support in HPB cancer, and the potential to coordinate, mediate and manage inclusion of carers in togetherness with the patient and partnership with health professionals is explored.

FP 9.04

CAN THE RISK OF POSTOPERATVE INFECTIOUS COMPLICATIONS BE REDUCED BY PROPHYLACTIC PEROPERATIVE ANTIBIOTICS?

Videhult, Per¹; Sandblom, Gabriel²; Ljungdahl, Mikael³; Wollert, Staffan³; Darkahi, Bahman⁴; Liljeholm, Håkan⁴; Karlson, Britt-Marie³; Rasmussen, Ib Christian³

¹Ersta Hospital, Department of surgery, Stockholm, Sweden; ²University Hospital, Department of surgery, Lund, Sweden; ³University Hospital, Department of surgery, Uppsala, Sweden; ⁴Enköping Hospital, Department of surgery, Enköping, Sweden

Introduction. The benefit from prophylactic treatment with antibiotics during routine cholecystectomy is controversial. OBJECTIVE To explore the risk of postoperative infections in a population-based cohort of patients operated for gallstone disease and to compare the infection rate between patients who received antibiotic prophylaxis with those who did not.

Methods. All operations in the Uppsala county, a county with 320 000 citizens in Sweden, were registered prospectively 2003–2005. Data included indication for surgery, open/laparoscopic approach, prophylactic treatment with antibiotics and postoperative adverse events, readmittance due to postoperative complications. Complicated procedures were defined as operations for which acute cholecystitis, exploration of the common bile duct or gallbladder perforation were recorded.

Results. Altogether 1199 patients underwent cholecystectomy. Prophylactic antibiotic treatment was given to 755 patients (63%). Minor infections were recorded in 12 patients (1.0%) and major infections, including intra-abdominal abscesses, pneumonia and urosepsis, were recorded in 7 patients (0.6%). Infections were recorded for 4 (0.5%) of the patients receiving antibiotics and 15 (4.3%) of those who did not (p < 0.05). None of the patients receiving antibiotics had any major infection. In patients undergoing complicated procedures infections were recorded for 1/54 (1.9%) of the patients receiving antibiotics and 12/194 (6.2%) of those who did not (no significance).

Conclusion. The risk of postoperative infection is influenced not only by the use of prophylactic antibiotics. Although antibiotics slightly reduce the risk of infections, the incidence of serious infections is so low that the benefit from prophylactic treatment with antibiotics should be questioned. The reduced risk for infections has to be weighed against the risk of the risk of drug resistance.

FP 9.05

BIOCHEMICAL STRESS IN MAJOR SURGERY – WHIPPLE'S vs HEPATECTOMY/ANTERIOR RESECTION

Kan, Yuk-Man; Paulvannan, Subramanian; Jah, Asif; Sadat, Umar; Huguet, Emmanuel L; Jamieson, Neville V; Praseedom, Raaj K

Addenbrooke's Hospital, Hepatobiliary & Transplant Surgery, Cambridge, United Kingdom

Introduction. Biochemical markers predicting morbidity and mortality in patients undergoing major surgical procedures have been studied with varying degrees of sensitivity. Albumin is a precursor of the acute phase reaction and significant drops can be used as an indicator of stress/sepsis. The aim of this study was to use albumin as a marker to determine the severity of operative stress from major surgical procedures and its consequence on morbidity and mortality.

Methods. Between 2002 & 2007, at our institution, 125 pancreaticoduodenectomy were performed. Albumin levels were taken pre-operatively, on day 1, day 3, day 5 and day 7. ASA grade, operative time, blood loss and complications were recorded prospectively. Twenty patients undergoing hepatectomy for metastatic disease and 20 patients with anterior resect ion for rectal carcinoma were used as controls.

Results. In all patients, albumins levels dropped markedly on day 1 to 50% for pancreaticoduodenectomy, 57% in hepatectomy and 65% in anterior resection (all, p < 0.05). The albumin level remained persistent low with minimal recovery in patients with pancreaticoduodenectomy throughout the post operative period with a median value of 58% of baseline levels by day 7 (p > 0.5). In contrast, there was a steady recovery in albumin levels for those who had had hepatectomy or anterior resection and by day 7, albumin had recovered to 73% & 85% of the baseline levels respectively (p < 0.05).

Conclusions. Albumin levels are markedly reduced and remain low in the early post operative period in patients having major surgical procedures and this was most marked in pancreaticoduodenectomy. Recovery of albumin levels occurs within the first week of major surgery but this is noticeably absent in Whipple's procedure. This reflects the severity of biochemical and operative stress in this procedure and persists significantly post-operatively. Nutritional support must be maximised and careful assessment is necessary in this period.

FP 10.01

ARE ROUTINE MEASUREMENTS OF SERUM AMYLASE AND LIPASE HELPFUL IN THE DIAGNOSIS OF ACUTE ABDOMINAL PAIN? A PROSPECTIVE STUDY

Sutton, Paul A¹; Purcell, Gemma²; Whiting, Frances¹; Wright, Tom J¹; Smith, Janette¹; Humes, David J¹; Lobo, Dileep N¹; Morgan, Linda²

¹Nottingham University Hospitals, Wolfson Digestive Diseases Centre, Nottingham, United Kingdom; ²Nottingham University Hospitals, Department of Clinical Chemistry, Nottingham, United Kingdom

Background. The routine measurement of serum lipase and amylase in patients with acute abdominal pain has become standard practice for many Emergency Departments in the United Kingdom as a response to 4 hour admission targets. The biochemical diagnosis of acute pancreatitis is made in our unit with an amylase >1000 U/l and >600 U/l for lipase.

Aim. To identify the role of amylase and lipase in the screening of patients presenting with acute abdominal pain.

Methods. All adult patients presenting to the Emergency Department having serum amylase and lipase measured within a six week period were identified, and a prospective review of their case notes was undertaken.

Results. A total of 542 patients were studied; 52% female, mean (SD) age 47 (22) years. 510 patients had routinely requested enzymes measured, whilst only 32 had them measured on clinical suspicion of pancreatitis. In only 7 (1.3%) was acute pancreatitis diagnosed using our biochemical threshold for lipase, with 3 of these being identified on routine screening. In addition to those with pancreatitis, 11 patients had a raised lipase attributable to other upper GI pathology. Only 1 patient had a raised amylase (with a normal lipase), which was attributable to a perforated duodenal ulcer. Where no clinical suspicion of pancreatitis exists, 170 patients will need to be screened to identify one case resulting in an excess cost of £754.80 (US$ 1509.60).

Discussion. The routine testing of serum amylase and lipase in all patients presenting with acute abdominal pain is costly and requests should be guided by clinical suspicion.

FP 10.02

DESCRIBING CT FINDINGS IN SEVERE ACUTE PANCREATITIS USING MORPHOLOGIC TERMS: AN INTERNATIONAL INTEROBSERVER STUDY

Van Santvoort, Hjalmar C¹; Bollen, Thomas L²; Besselink, Marc¹; Banks, Peter A³; Boermeester, Marja A⁴; Van Eijck, Casper H⁵; Evans, Jonathan⁶; Freeny, Patrick C⁷; Grenacher, Lars⁸; Hermans, John J⁹; Horvath, Karen D¹⁰; Hough, David¹¹; Lameris, Johan S¹²; van Leeuwen, Maarten S¹³; Mortele, Koenraad J¹⁴; Neoptolemos, John P¹⁵; Micheal G, Sarr¹⁶; Vege, Santhi Swaroop¹⁷; Werner, Jens¹⁸; Gooszen, Hein G¹

¹University Medical Center Utrecht, Surgery, Utrecht, Netherlands; ²St Antonius, Radiology, Nieuwegein, Netherlands; ³Brigham's and Womans Hospital, Harvard Medical School, Gastroenterology, Boston, United States; ⁴Academic Medical Center, Surgery, Amsterdam, Netherlands; ⁵Erasmus Medical Center, Surgery, Rotterdam, Netherlands; ⁶Royal Liverpool University Hospital, Radiology, Liverpool, United Kingdom; ⁷University of Washington Medical Center, Radiology, Seattle, United States; ⁸University of Heidelberg, Radiology, Heidelberg, Germany; ⁹Erasmus Medical Center, Radiology, Rotterdam, Netherlands; ¹⁰University of Washington Medical Center, Surgery, Seattle, United States; ¹¹Mayo Clinic, Radiology, Rochester, United States; ¹²Academic Medical Center, Radiology, Amsterdam, Netherlands; ¹³University Medical Center Utrecht, Radiology, Utrecht, Netherlands; ¹⁴Brigham and Women's Hospital, Harvard Medical School, Radiology, Boston, United States; ¹⁵Royal Liverpool University Hospital, Surgery, Liverpool, United Kingdom; ¹⁶Mayo Clinic, Surgery, Rochester, United States; ¹⁷Mayo Clinic, Gastroenterology, Rochester, United States; ¹⁸University of Heidelberg, Surgery, Heidelberg, Germany

Background. Clear communication regarding CT findings in severe acute pancreatitis (SAP) is essential for proper treatment decisions and clinical research. The current terminology from the Atlanta Symposium (e.g. pseudocyst, pancreatic abscess) has recently shown very poor interobserver agreement, creating the potential for patient mismanagement (Besselink Pancreas 2006). Objective, descriptive terminology might be a valuable alternative.

AIM. The aim of this study was to determine the interobserver agreement for a new set of descriptive, morphologic terms for CT findings in SAP.

Methods. 17 reviewers (8 radiologists, 7 HPB surgeons and 2 gastroenterologists) in 3 US and 5 European centres renowned for their experience in pancreatic disease independently reviewed 55 digital CTs of patients with SAP. Percentage agreement (PA) (median, interquartile range [IQR]) for 9 descriptive, morphologic terms was calculated among all reviewers and separately among the 8 radiologists and 9 clinicians. PA was defined as poor (<0.50), moderate (0.51–0.70), good (0.71–0.90), and excellent (0.91–1.00).

Results. Overall agreement was good to excellent for the terms'collection' (PA = 1; IQR 0.68-1),'relation with pancreas' (1; 0.68–1),'content' (0.88; 0.87–1), ‘shape’ (1; 0.78–1), ‘mass effect’ (0.78; 0.62–1)'loculated gas bubbles' (1; 1–1) and'air-fluid level' (1; 1–1). Overall agreement was moderate for'extent of pancreatic nonenhancement' (0.60; 0.46–0.88) and'encapsulation of collection' (0.56; 0.48–0.69). PA was greater among radiologists than clinicians for'extent of pancreatic nonenhancement' (PA = 0.75 versus 0.57, P = 0.008),'encapsulation' (0.67 versus 0.46, P = 0.001), and'content' (1 versus 0.78, P = 0.008).

Conclusion. Interobserver agreement for the new set of descriptive, morphologic terms is good to excellent. Therefore, we recommend that subjective (interpretative) definitions to describe CT findings in SAP (e.g. pseudocyst) should no longer be used in radiologic reports.

FP 10.03

Gabesate mesylate and early disobstruction of papilla improve the course of severe acute pancreatitis

Bassi, Nicolò

Regional Hospital, IV Dpt Surgery, Treviso, Italy

Purpose. Gallstones is the more frequent cause of acute pancreatitis in Italy. It is well known that severe pancreatitis occurs for longer time obstruction of the papilla. Mortality rate is around 6%. In this study we analysed 1026 patients with acute pancreatitis. We verified that the course of severe pancreatitis could be improved by medical treatment with gabesate mesilate and the early disobstruction of the papilla.

Methods. From January 1993 until December 2006, 1026 patients were admitted in our Department with diagnosis of acute pancreatitis. In 599 patients aetiology was related to gallstones. 195 had severe pancreatitis. Diagnosis was confirmed by laboratory tests if Amilasy and Lipasi level was twice the normal range with associated increasing of Bilirubin, Alkaline phoshatase and ãgt levels. Abdominal ultrasonography were carried out on each patient. CT scan or ColangioWirsungMRI were performed in the majority of patients, while ERCP only when necessary.

Results. 195 patients with severe pancreatitis were evaluated. 158 of 195 patients with severe pancreatitis were treated with gabesate mesylate from the day of admission (period 1995–2006, group A). In 92 patients of 158 early disobstruction of the papilla occurred (within 48 hours), spontaneously or by ERCP. 37 pts. (period 1993–1995, group B) did not received gabesate mesylate and disobstruction occurred in 18 pts. In group A only 37% of pts underwent surgical operation vs 70% in grou p B (p< 0.05).

Conclusion. our study conducted in a cohort of patients with documented gallstone severe pancreatitis, provided further evidence that prompt treatment with gabesate mesilate with early disobstruction of the papilla could improve the course of severe pancreatitis.

FP 10.04

FULMINANT ACUTE PANCREATITIS: 10 YEARS AFTER OUR DEFINITION AND FIRST REPORT.

Secchi, Mario; Quadrelli, Lisandro; Rossi, Leonardo; Serra, F; Forte, J

IUNIR and HIG, Surgery, Rosario, Argentina

In 1992, a clinically-based classification system for Acute Pancreatitis (AP) was proposed at the Atlanta Symposium. Fulminant Pancreatitis (FP) is a non- agreed definition, but some patients with severe AP progress to an early fulminant and lethal disease. We first defined FAP in 1998. We proposed those cases of severe AP which showed failure or dysfunction of three or more organs (multisystemic organ failure: MOF) within 48 hours after onset of symptoms: British Journal of Surgery Vol.85 Suppl.2 (July): 80–81, 1998.

Methods. 1132 patients having AP of any etiology were prospectively studied in four surgical centers over the last 20 years. Our aim was to analyze fulminant cases of severe AP and detect incidence, etiology, organ involvement in MOF and mortality impact. Severity was determined by APACHE II (severe cases: >15 points) and by our Original INDEX (severe cases: >0.40). Mortality referred to those hospitalized cases.

Results. 150 severe cases were detected; 19 of these cases (12%) were fulminant. The following causes were identified: lithiasis (11 patients [4 alcohol-associated]), alcohol abuse (3 patients), dyslipimia (2 patients), post-ERCP (2 patients), and post-papillotomy (1 patient). All cases of FP showed MOF with some organ functions involved: lung and kidney in all 19, heart in 9, liver in 8, endocrine pancreas in 8, brain in 6 and hemostasia in 4. The mean APACHE II was 29±8 and the INDEX was 0.58±0.9. All patients were treated in ICUs with a multidisciplinary approach (early TEN, ATB treatment and systemic support), and 15 patients of 19 (78%) died after early systemic complications (n = 10) and late local complications (n = 5) while on treatment. The mortality rate for non-fulminant severe cases was 14% (6 cases of 131) (X2: p = 0.018).

Conclusion. Fulminant pancreatitis is a special entity in cases of severe AP with MOF detected within 48 hours after onset of symptoms, with 78% of mortality. Our definition and prospective study provides a new approach for the early treatment of severe AP.

FP 10.05

DIFFERENT PATTERNS OF THE CYTOKINE EXPRESSION IN PERIPHERAL WHITE BLOOD CELLS OF PATIENTS WITH ACUTE NECROTIZING AND EDEMATOUS PANCREATITIS

Dambrauskas, Zilvinas¹; Gulbinas, Antanas²; Berberat, Pascal O³; Giese, Nathalia³; Giese, Thomas⁴; Barauskas, Giedrius⁵; Pundzius, Juozas⁵; Friess, Helmut³

¹Institute for Biomedical Research, Kaunas University of Medicine, Kaunas, Lithuania; ²Institute for Biomedical Research, Kaunas, Lithuania; ³Heidelberg University, Department of Surgery, Heidelberg, Germany; ⁴Heidelberg University, Institute of Immunology, Heidelberg, Germany; ⁵Kaunas University of Medicine, Department of Surgery, Kaunas

Background. Acute pancreatitis (AP) is an inflammatory disorder associated with a complex cascade of immunological events. Analysis of the local and systemic immune status and inflammatory response might contribute to the better understanding of underlying pathophysiological mechanisms and introduction of novel treatment Methods.

Methods. The total of 30 patients with edematous (n = 17) and necrotizing (n = 13) acute pancreatitis were prospectively entered into the study. The EDTA samples of peripheral blood were drawn within 24–72 hours after onset of AP, and white blood cells (WBC's) were isolated using the erythrocyte lysis buffer immediately after collection. The mRNA expression of 30 different cytokines and adhesion molecules was determined in blood WBC's by quantitative reverse transcriptase-polymerase chain reaction (QRT-PCR). Clinical data related to the severity of the disease and accompanying complications was also collected for each patient for further statistical analysis.

Results. Disease severity scores (APACHE II, Imrie and MODS) were significantly higher in the group of patients with necrotizing AP compared to those with edematous AP. There was a statistically significant correlation between these severity scores and expression of certain cytokines in the peripheral blood WBC's. A marked increase in the expression of IL-10 and CD-11b was observed in circulating WBC's of patients with necrotizing AP, while expression of IL-4, IL-8, IFN-γ and CD25 was downregulated in the same group of patients when compared with edematous AP patient group. Expression of IL-1b was also significantly lower in the group of patients who developed systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS) and died within the first two weeks.

Conclusion. Consequent infiltration of peripheral organs by aberrantly activated inflammatory cells might be a detrimental event leading to the development of severe necrotizing AP and MODS.

FP 10.06

SELECTIVE EMBOLISATION FOR BLEEDING VISCERAL ARTERY PSEUDOANEURYSMS IN PANCREATITIS.

Sethi, Harsheet¹; Peddu, Praveen²; Prachalias, Andreas³; Kane, Pauline²; Karani, John²; Heaton, Nigel⁴; Rela, Mohamed⁴

¹Kings College Hospital, HPB Surgery, London, United Kingdom; ²Kings College Hospital, Radiology, London, United Kingdom; ³Kings College Hospital, General Surgery, London, United Kingdom; ⁴Kings College Hospital, HPB Surgery and Liver Transplantation, London, United Kingdom

Background. Pancreatitis is associated with arterial complications in 4–10% of patients, with untreated mortality approaching 90%. Timely intervention at a specialist centre can reduce the mortality to 15%. We present a single institution experience of selective embolisation as first line management of bleeding pseudoaneurysms in pancreatitis.

Methods. A retrospective analysis of all patients admitted to our centre with acute and chronic pancreatitis from January 2000 till June 2007 identified 16 patients with visceral artery pseudoaneurysms. 69% of these were male and 63% were smokers. In 50% of the patients, bleeding complicated initial presentation of pancreatitis. Alcohol was the offending agent in 10 patients, gallstones in 3, trauma, drug induced and idiopathic pancreatitis in one each. All patients had a contrast CT scan and 15 of the 16 patients underwent coeliac axis angiography through a femoral approach.

Results. The pseudoaneurysms ranging from 0.9 to 9.0cm affected the Splenic artery in 7, Hepatic in 3, Gastroduodenal and Right gastric in 2 each, and Left gastric and Pancreaticoduodenal in 1 each. One patient developed spontaneous thrombosis of the pseudoaneurysm. 14 patients had effective coil embolisation of the pseudoaneurysm. One patient needed surgical exclusion of the pseudoaneurysm following difficulty in accessing the coeliac axis radiologically. There were no episodes of rebleeding and no in-hospital mortality.

Conclusion. Pseudoaneurysms are unrelated to the severity of pancreatitis and major haemorrhage can occur irrespective of their size. Co-existent portal hypertension and sepsis increase the risk of surgery. Angiography and selective coil embolisation is a safe and effective way to arrest the haemorrhage.

FP 11.01

SYMPTOMATIC POLYCYSTIC LIVER DISEASE: SURGICAL MANAGEMENT AND LONG-TERM QUALITY OF LIFE OUTCOMES

Russell, Robert¹; Feurer, Irene D.²; Wisawatapnimit, Panarut³; Pinson, C. Wright¹

¹Vanderbilt University Medical Center, Hepatobiliary Surgery and Liver Transplantation, Nashville, TN, United States; ²Vanderbilt University Medical Center, Surgery and Biostatistics, Nashville, TN, United States; ³Vanderbilt University Medical Center, College of Nursing, Nashville, TN, United States

Background/Aims. Surgical management is the mainstay of treatment for patients with symptomatic polycystic liver disease (PCLD). The aim of this study was to analyze immediate and long-term outcomes along with post-operative health-related quality of life (HRQOL) in patients undergoing operation for symptomatic PCLD.

Methods. A retrospective analysis of clinical, operative, and follow-up data was carried out for patients with symptomatic PCLD undergoing surgery from May 1991 to March 2007. The primary outcome measures assessed were mortality, recurrence of symptoms, and HRQOL. HRQOL data was obtained by mailed questionnaire using the SF-36® Health Survey (SF-36). Data are reported as mean±SD.

Results. 20 patients (age = 52±11 years) underwent surgery for symptomatic PCLD. Comorbidities included polycystic kidney disease in 50% and cerebral aneurysms in 5%. Thirteen patients had fenestration and resection, six patients had fenestration only, and one patient underwent liver transplantation. There was no operative mortality and the overall morbidity rate was 35%. The mean follow-up was 74±59 months. Six patients reported recurrence of symptoms at a mean of six years, but none required repeat operative intervention. Fifteen patients returned SF-36 health surveys (mean follow-up = 92±56 months). Overall, physical HRQOL scores (39±14) were one standard deviation below the general population mean while mental HRQOL scores (46±9) approximated the general population mean (50±10 for PCS and MCS).

Conclusions. Fenestration, fenestration with resection and, much less frequently, liver transplantation are acceptable management strategies depending on the extent and distribution of the cysts. These twenty patients had no operative mortality, reasonable morbidity, and good long term relief of symptoms. Nevertheless, this disease process has a significant effect on patients’ physical HRQOL. Mental HRQOL is maintained.

FP 11.02

CLOSTRIDIUM DIFFICILE INFECTION IN HPB AND TRANSPLANT SURGERY: INCREASING CONCERNS?

Bhati, Chandra S¹; Gills, Martin²; Bramhall, Simon R¹; Mayer, David A¹; Buckels, John AC¹; Mirza, Darius F¹

¹Queen Elizabeth Hospital, Liver Unit, Birmingham, United Kingdom; ²Queen Elizabeth Hospital, Department of Microbiology, Birmingham, United Kingdom

Background. With the increasing use of broad-spectrum antibiotics in surgical patients, antibiotic-associated diarrhoea is becoming more common. Clostridium Difficile Infection (CDI), can range in severity from asymptomatic to severe and life threatening, and this increases the morbidity as well cost to health services.

Objectives. The aim of this study was to identify the patients with C. difficile infection associated diarrhoea (CDAD) in HPB and liver transplant patients and associated risk factors.

Methods. All patients between 1/06/2004 to 30/05/2007 period who had positive C difficile toxin in stool were entered into a database retrospectively using the hospital based microbiology database and computer system. Supplementary information including demographic information, past medical history, operative details and complications were obtained from HPB and transplant database as well as local medical records. Risk factors in the form of exposure to antibiotics, type of antibiotics, previous history of any operation, GI intervention, associated co morbid factors and complications were noted.

Results. During this period 371 liver transplants and 1832 HPB cases were performed in the unit and 83 (3.7%) patients were positive for C difficile toxin.

	HPB	Transplant
No of patients	57(3.1%)	26(7%)
Mean age	61.7 yrs (SEM1.989)	49.9yrs(SEM 2.76)
Medan age	63.1 (17.2–85 years)	55 (18– 69 years)
Age ≥65 year	34 (60%)	7 (27%)
No. exposed to antibiotic/multiple antibiotic at time of CDAD or within 14 days	45*/26 *N/A = 8	23/10
Leucocytosis on day of CDAD	43 (75.4%)	16 (62%)
Hospital stay(Median)	22 days(7–132)	40 days(7–255)
30 days mortality after CDI	8 (14%)	2 (0.8%)

Co morbid factors found in HPB patients were diabetes mellitus (8.8%), history of previous operation (52.6%), previous GI surgery (17.5%) and more then one previous surgery (14%). Ciprofloxacin and co-amoxiclav were found to be commonly associated with CDI in HPB patients while piperacillin in transplant patients. Two patients had positive evidence that CDI contributed to sepsis and death in HPB cohort while none in transplant cohort. No evidence of fulminate colitis were found.

Conclusion. CDI is increasing with the use of antibiotics in HPB and transplant patients. It increases the morbidity and health cost. Old age, previous history of operation and exposure to multiple antibiotics remains major co factors for CDI.

FP 11.03

SURGICAL TREATMENT OF HYDATID LIVER DISEASE. STUDY BASED ON THE DATA OF LITHUANIAN ECHINOCOCCUS REGISTER.

Prof. Strupas, Kestutis¹; Sokolovas, Vitalijus¹; Jurgaitis, Jonas¹; Paskonis, Marius¹; Brimas, Gintautas¹; Marcinkute, Audrone²; Barakauskiene, Ausrine³

¹Vilnius University Hospital Santariðkiø Klinikos, Vilnius, Lithuania; ²National Tuberculiosis and Infectious disease University Hospital, Vilnius, Lithuania; ³National Pathology Center, Vilnius, Lithuania

Background. Surgery remains the main treatment modality for hydatid liver disease. There are still debate about the best approach. Conservative surgery has opposed to radical surgery were the cyst is totally removed, including the pericyst, by total pericystectomy or partial hepatectomy. The short preoperative chemotherapy with mebendazol/abendazol as well, as the postoperative chemotherapy treatment according to the guidelines of European Echinococcosis Register, is very important for prophylaxis of recurrences of hydatid disease.

Objective. This study is based on the data of Lithuanian Echinococcosis Register. Register was founded in 2003 and have tide relations with European Echinococcosis Register. Study results shows that radical resection of hepatic hydatid disease is a safe and effective treatment.

Methods. In prospective study data from 2003/06 were collected until 2007/01. Totally 76 patients were included in Lithuanian Echinococcosis Register. 18 cases of Echinococcus granuliosus (hydatid disease) and 58 cases of Echinococcus multilocularis (alveolar hytadid disease). In all cases diagnosis was obtained using serology test (ELISA), radiological modalities (US, ST, MRB), and in rare cases – biopsy. Chemotherapy with mebendazol/abendazol received all patients. Patients suitable for operation chemotherapy received preoperatively and postoperatively.

Results. From entire series, 25 patients (34%) were feasible for radical operation. Two types of radical operations were performed- pericystectomy or partial hepatectomy. Others 51 (66%) received only palliative treatment and chemotherapy. In the radically operated group there were no operative and postoperative mortality. There were no complications and recurrence of disease in 36 month of follow up.

Conclusion. Results shows that radical surgery with preoperative and postoperative chemotherapy is the first choice treatment for hydatid liver disease.

FP 11.04

DETERMINATION OF THE RIGHT-SIDED BORDER OF THE CAUDATE LOBE IN HUMAN LIVERS

Kogure, Kimitaka¹; Ishizaki, Masatoshi¹; Suehiro, Taketoshi¹; Shimura, Tatsuo¹; Kuwano, Hiroyuki¹; Yorifuji, Hiroshi²; Takata, Kuniaki³; Makuuchi, Masatoshi⁴

¹Gunma University, Graduate School of Medicine, Department of General Surgical Science (Surgery I), Maebashi, Japan; ²Gunma University, Graduate School of Medicine, Department of Neuromuscular and Developmental Anat, Maebashi, Japan; ³Gunma University, Graduate School of Medicine, Department of Anatomy and Cell Biology, Maebashi, Japan; ⁴Japanese Red Cross Medical Center, Tokyo, Japan

Background. Resection of malignant liver tumors should encompass the anatomical segment that includes the tumor-bearing region. Combined resection of the tumor-bearing segment and the caudate lobe is conventionally performed for hilar cholangiocarcinoma. However, the right-sided border of the caudate lobe has been a matter of controversy.

Objective. This study was conducted to clarify the real dissection line in performing the complete resection of the caudate lobe.

Materials And Methods. The thirty-four adult cadaveric livers were submitted for the study. By identifying both feeding areas of the caudate lobe portal veins and the posterior superior portal branches the border between the caudate lobe and the right liver was determined.

Results. The caudate lobe consisted of three subsegments, i.e. Spiegel lobe, paracaval portion and caudate processus. Each subsegment had its own specific portal vein branches ramifying from the left and right portal veins, and rarely from the portal vein. The number of the portal vein branches of the caudate lobe was variable in each case. In our 34 cases, their number ranged from one to six and each number of cadaver was 3, 9, 11, 7, 2 and 2, respectively. There were two types of the right-sided border between the caudate lobe and the right liver. In 23 cases the border did not exceed the line coinciding with the right-sided wall of the IVC. In another 11 cases, the border removed to the right side from the right-sided wall of the IVC. In these cases the thickness of the hepatic tissue of the caudate lobe exceeding the right-sided wall of the IVC was between 2–20 mm.

Conclusion. The study revealed that the caudate lobe is completely resected if dissection line was situated on at least 20 mm right side from the right-sided wall of the IVC.

FP 11.05

A SINGLE INSTITUTIONAL EXPERIENCE IN THE MANAGEMENT OF AMOEBIC LIVER ABSCESS

Rajasekar, Arthanari¹; Rajasekaran, Rasapan²

¹Sri Gokulam Hospital, Surgical Gastroenterology, 3/60 Meyyanur Road, Salem, India; ²Sri Gokulam Hospital, Radiology, Salem, India

Introduction. Liver abscess, particularly amoebic is a major health problem in India. We report our experience in the management of amoebic liver abscess.

Patients and Methods. From April 2001 to August 2006, a total of 124 patients with liver abscess were treated. Patients with abscess size of 5cm in ultrasound were treated with medical therapy, abscess size 5cm to 10cm with ultrasound guided aspiration of the abscess and abscess size more than 10cm with ultrasound guided percutaneous insertion of catheter.

Results. Mean age was 43 years. Male: Female ratio was 98: 26. Sixty seven patients (54%) consumed toddy an extract from the palm tree and 38 patients (30.5%) consumed liquor. Seventy three (59%) patients had one abscess the remaining patients had more than one abscesses. In 70% of the patients right lobe of the liver was predominantly affected. Forty three patients (35%) were managed conservatively, 6 patients latter required percuatenous ultrasound guided aspiration due to persistent pain. Fifty three patients (43%) underwent percutaneous ultrasound guided aspiration. Seventeen patients (14%) required percuatneous catheter insertions. Eleven patients (9%) presented with ruptured liver abscess, 1 patient with loculated collection percutaneous insertion of drainage tube was done, 9 patients underwent laparoscopic drainage of abscess and 1 patient required laparotomy There was no mortality. Two patients developed bleeding per rectum., colonoscopy revealed amoebic granuloma in the caecum in both this patients.

Conclusion. Amoebic liver abscess is common in males who drink toddy and is more common in the right lobe. Small sized abscess can be managed conservatively and abscess more than 5 cm will require percutaneous aspiration or insertion of a drain. Patients presenting with intraperitoneal rupture can be managed by laparoscopic technique.

FP 11.06

HAS INCIDENCE OF HEMOBILIA INCREASED WITH INCREASING CONSERVATIVE MANAGEMENT OF BLUNT LIVER INJURIES?

Thumma, Venu Madhav¹; Varma, Vibha²; Nagari, Bheerappa²; Regulagadda, Adikesava Sastry²

¹Nizams Institute Of Medical Sciences, Surgical Gastroenterology, Punjagutta, Hyderabad, India; ²Nizams Institute Of Medical Sciences, Surgical Gastroenterology, Hyderabad, India

Background. Hemobilia is described after percutaneous interventions or following blunt trauma with varying frequencies.

Aim. To observe whether the trend toward conservative management of major liver trauma has resulted in an increased incidence of hemobilia and to evaluate the role of selective hepatic artery angiography in timing, diagnosis and management.

Methods. The study period was divided into two halves. During the initial half (1997–2001) 40 cases and during the later half (2002–06) 55 cases of blunt liver trauma were managed.

Results. During the initial half 10 (25%) were managed conservatively (8 grade I and 2 grade II injuries). All the grade III injuries were operated. There was no incidence of hemobilia in the initial group. During the latter half 20 cases (36%) were managed conservatively (8 grade I, 6 grade II and 6 grade III injuries). Three of them (1 grade I and 2 grade III) developed hemobilia. Another patient with grade III injury who was managed surgically also developed hemobilia. The mean interval between the initial injury and the diagnosis of hemobilia was 2 months. Selective angiography was done in all and it successfully localized the bleed in only two patients who were actively bleeding. In the remaining two patients the bleeding lesions were successfully localized when the procedure was repeated during the active bleed. Pseudoaneurysm of a branch of right hepatic artery was found in all the four patients and was treated successfully with selective embolisation. There were no deaths and no complications.

Conclusion. Increased frequency of hemobilia in liver injuries in the latter half of the study especially in grade III injuries throws a suspicion whether predominant conservative initial management is responsible. Selective arterial embolisation is the treatment of choice with a substantial rate of success and a low incidence of serious complications in treatment of traumatic hemobilia

FP 11.07

SURGICAL EXPERIENCE WITH ECHINOCOCCOSIS IN A SINGLE CENTER IN THE NETHERLANDS

Stoot, Jan¹; Jongsma, Kees²; Terpstra, Onno³; Breslau, Paul⁴

¹University Hospital Maastricht, Department of Surgery, maastricht, Netherlands; ²Harbor Hospital Rotterdam, department of Surgery, Rotterdam, Netherlands; ³Leiden University Medical Center, Department of Surgery, Leiden, Netherlands; ⁴

Background. Hydatid disease of the liver remains endemic in the world and is an import disease in the Netherlands. Although PAIR(Puncture Aspiration Injection and reaspiration) has been investigated by several groups, there is still no consensus about the best treatment.

Objective. We performed a single center retrospective study to evaluate clinical presentation, treatment and outcome of surgically treated patients for echinococcosis.

Methods. Records of hundred consecutive surgically treated patients were analysed retrospectively on relapse of disease, infection, complications and mortality. In this study the frozen seal technique was used for radical surgery.

Results. At clinical presentation the majority of complains consisted of abdominal pain(n = 80), abdominal mass, (n = 40), fever(n = 18) and urticaria(n = 10). Also, cardiac decompensation, anaphylaxis and jaundice were seen at presentation. Serology(ELISA, IMF) confirmed diagnosis in 85% and liverfunction-tests were only disturbed with envolvement of hepatic ducts. In all cases echinococcosis was diagnosed by Computed Tomography or ultrasound. The majority of the cysts was seen only in the liver. Surgery was performed in all cases(n = 103) with the frozen seal technique. Mean age was 36(7–70). Eleven complications were recorded in total: 7 minor complications(6 infections and one pneumonia) and 4 moderate/major complications(two biliary fistula, abces and peritonitis). With a mean follow-up of 24 months, relapse of disease was seen in 5 cases, of whom 4 needed surgical treatment. No mortality was observed in this study. This is in contrast with the mortality rate found in literature.

Conclusion. This method of surgery is safe and effective. Future studies have to prove its position in the treatment of hydatic disease as new developments show promising Results.

FP 11.08

COAGULATION STATUS IN EXTRAHEPATIC PORTAL VENOUS OBSTRUCTION IN INDIAN POPULATION: PRE AND POST SHUNT EVALUATION

Dash, Nihar Ranjan; Pal, Sujoy; Sahni, Peush; Chattopadhyay, Tushar Kanti; Sharma, Aribam D

AIIMS, New Delhi, GI Surgery, Delhi, India

Background. The etiology of extra hepatic portal venous obstruction (EHO) remains unsubstantiated. Hypercoagulable state is one strongly implicated in western studies. However the demographic and clinical features of EHO in Indian population are different.

Objective. To evaluate the coagulation status in Indian patients with EHO both before and after proximal splenorenal shunt (PSRS).

Material And Method. Between Nov.03 and Nov.05 all cases of EHO with bleed and/or hypersplenism, who underwent PSRS, were prospectively studied. Whole blood samples on day 0,5 and 180 were tested for coagulation status by using Thromboelastograph (TEG). The results were compared with 141 historical controls of the TEG reference manual. The shunt patency was assessed by ultrasound Doppler findings and endoscopic evaluation of varices. Attempt was made to find correlation among the coagulation spectrum and other parameters.

Results. 37 patients (16 females) were studied. Mean age was21.8yrs (12–45). Mean platelet count was 74000/cumm (25–196). Post operatively one patient had transient ascitis and one had intraperitoneal bleed requiring surgical hemostasis. Shunt block was detected in only one case. Day 0 values showed hypercoagulable state in 18.9% cases and hypocoagulable state in 10.8% cases (significant changes in R, K, MA, Angle, TEG index in comparison to control). A hyper coagulable state was observed on the Day 5. 23(62%) cases could be followed up. The Values were near normal by day 180. There was no significant correlation between TEG parameters with platelet count, bilirubin or prothombin time. The TEG index remained high at more than +2.5 in the only case of shunt block.

Conclusion. Significant number (29.7%) of EHO patients had coagulation disorder. A reversal in the hypercoagulability occurs following PSRS even though there is occurrence of hypercoagulability in the immediate postoperative period. Persistence of hypercoagulability may predict shunt thrombosis. A larger comparative study is needed.

FP 11.09

REVIEW OF PANCREATIC TRAUMA AT ALFRED HOSPITAL, MELBOURNE

Choi, Julian¹; Warwick, Andrea¹; Burton, Paul²; Usatoff, Val²; Hassen, Sayed²; Evans, Peter²

¹Alfred Hospital, Surgery, Melbourne, Australia; ²Alfred Hospital, Melbourne, Australia

Backgrounds. Pancreatic injury is relatively uncommon in patients with abdominal trauma. However, it is associated with significant morbidity and mortality.

Aims. The aims of this review are; to examine mechanism of pancreatic injury and to grade its severity; to study its management and outcomes at Alfred hospital.

Methods. A review of trauma database was performed to identify patients with pancreatic trauma, admitted to Alfred hospital between January 2002 and July 2007 and their charts were reviewed.

Results. Between 2002 and 2007, 53 patients were admitted to Alfred hospital with pancreatic trauma. The mean age and mean ISS (injury severity score) was 34.8 years old and 27.1 respectively. 45 patients (85%) had a blunt and 8 (15%) had a penetrating injury to pancreas. 36 patients (68%) had a minor (grade 1–2: pancreatic contusion or minor laceration) and 17 (32%) had a major pancreatic injury (grade 3–5: pancreatic ductal injury, transection or massive disruption of pancreatic head). The grading of pancreatic trauma was based on findings at laparotomy or on abdominal CT. ISS for minor and major pancreatic injury groups were 48.8 and 32.9 respectively. 45% of patients with minor pancreatic injuries were successfully managed with conservative treatment. 20 patients in this group required laparotomy including 7 splenectomies, 4 bowel resections, and 1 distal pancreatectomy. Amongst 17 patients with the major pancreatic injury, 8 patients underwent distal pancreatectomy and splenectomy; 4 pancreatico-duodenectomy; 1 spleen preserving distal pancreatectomy; 1 bile duct repair; 1 uncinate process resection and 1 duodenal repair. There were 8 deaths in this series with mortality rate of 15%. 7 deaths in the minor pancreatic injury group were due to severe head injuries.

Conclusion. 53 pancreatic trauma patients were admitted over 5 years with 32% having major pancreatic injuries. The mortality rate from pancreatic injury was 1.9%. The pancreatic trauma is uncommon and its management demonstrtates an excellent outcomes.

FP 12.01

EIGHT YEARS EXPERIENCE ON RADIOFREQUENCY ABLATION FOR LIVER MALIGNACIES ----A REPORT OF 803 CASES

Chen, Min-Shan¹; Zhang, Yao-Jun¹; Li, Jin-Qing¹; Liang, Hui-Hong¹; Zhang, Ya-Qi¹; Lin, Xiao-Jun¹; Lau, Wan Y²

¹Department of Hepatobiliary Surgery, Cancer Centre of Sun Yat-Sen University, Guangzhou, China; ²Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

Objective. To summarize the 8-year experience on radiofrequency ablation (RFA) for liver malignancies and explore the effect and prognostic factors. Methods Between August 1999 and February 2007, 803 patients with liver malignancies, [672 with primary liver cancer (PLC) and 131 with liver metastasis] were treated with RFA. 781 cases were performed percutaneously under the guidance of ultrasound, 8 cases percutaneously under the guidance of CT, 9 with laparoscopy and 5 with laparotomy. 117 cases were treated by RFA combined with percutaneous ethanol injection and 108 cases by RFA combined with transcathetal arterial chemoembolization. The morta lity, morbidity, complete ablative rates, loco-recurrence rates and survival rates were calculated. Results For 803 liver malignancies, the mortality was 0.25%, the morbidity was 0.37%, the complete ablative rate was 92.49%, the loco-recurrence rate was 13.80% and the 1, 2, 3, 4, 5-year survivals were 95.05%, 85.62%, 75.70%, 60.67% and 47.47%, respectively. According to the tumor size, the 1, 2, 3, 4, 5-year survivals for tumors ¡Ü3.0cm were 97.20%, 90.1%, 84.76%, 76.93% and 60.37%, respectively, for tumors 3.1–5.0cm 94.85%, 84.52%, 70.37%, 45.78% and 41.53%, respectively, and for tumors £¾5.0cm 85.44%, 67.33%, 46.40%, 14.30% and 0%, respectively (P£¼0.001). For the 672 PLCs, the 1, 2, 3, 4, 5-year survivals for stage ¢ña (Chinese staging system) were 97.84%, 91.53%, 84.58%, 77.10% and 61.92%, respectively, for stage ¢ñb 93.86%, 83.67%, 69.82%, 45.12% and 42.20%, respectively, for stage ¢ò86.17%, 67.33%, 47.28%, 17.19% and 0%, respectively, and the 1, 2-year survivals for stage ¢ó were 67.84% and 0%, respectively (P£¼0.001).

Conclusions. RFA is a safe and effective method for liver malignancy, and the tumor size and stage are important prognostic factors.

FP 12.02

LIVER SURGERY FOR COLORECTAL METASTASES: Results AFTER 10 YEARS OF FOLLOW-UP

Vigano', Luca; Ferrero, Alessandro; Lo Tesoriere, Roberto; Sgotto, Enrico; Russolillo, Nadia; Capussotti, Lorenzo

Ospedale Mauriziano “Umberto I”, Surgery, Torino, Italy

Background. Liver surgery is the gold standard treatment of colorectal liver metastases with five-year survival rates of 30–40%. Anyway after 5 years some patients are alive with recurrence and metastases can occur later on. Longer follow-up data are needed.

Aim. to analyze survival results, late recurrence rate and prognostic factors of survival in patients with at least 10 years of follow-up.

Methods. 125 patients undergoing liver resection for colorectal liver metastases between 1985 and 1996. Patients with postoperative mortality (4 cases) or dead before 10 years of follow-up without any evidence of tumor recurrence (7) were excluded. The analysis was performed on 114 patients.

Results. Actual 5- and 10-year survival rates were 21.1% and 15.8%. Eighteen patients were alive 10 years after liver resection, 16 were disease free (5 cases after reresection). Actual 5- and 10-year disease-free survival rates were 16.7% and 14.0%. In patients with recurrence, reresection significantively improved survival (p < 0.001). More than 90% of recurrences occurred before 5 years of follow-up, but 28.6% of patients disease-free at 5 years developed recurrence. Multivariate analysis evidenced 4 independent negative prognostic factors of survival: synchronous metastases (p = 0.038), >3 metastases (p < 0.001), metastatic infiltration of nearby structures (p < 0.001) and postoperative morbidity (p = 0.001). Thirty-nine patients without negative prognostic factors had 10-year overall and disease-free survival rates of 33.3% and 30.8%.

Conclusions. Patients with 1 to 3 metachronous metastases without infiltration of nearby structures have the best long-term results and about one third of them are alive 10 years after liver resection. Postoperative morbidity worsens long-term outcomes. Risk of recurrence is high even later than 5 years of follow-up. Reresection should be performed whenever possible.

FP 12.03

OUTCOMES FOLLOWING INTENSIVE SURVEILLANCE FOLLOW-UP FOLLOWING HEPATIC RESECTION FOR COLORECTAL METASTASES

Gomez, Dhanwant; Sangha, Vicky K; Morris-Stiff, Gareth; Malik, Hassan Z; Toogood, Giles J; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. With the increase in hepatic resection being performed in patients with colorectal liver metastasis (CRLM), hepatobiliary units have follow-up protocols which mainly consist of computer tomography of the thorax and abdomen (CT). However, the appropriate interval follow-up period is still controversial. The aim of the study was to determine the number of patients identified with recurrence in 3 monthly intervals and determine whether there is a difference in survival.

Methods. Patients undergoing resection for CRLM from January 1993 to March 2007 were identified from the hepatobiliary database.

Results. 705 primary resections were performed during the study period. There were 434 (62%) patients that developed recurrence during the follow-up period, of which 398 (56%) patients developed recurrence within the first two years of follow-up. Disease recurrence was detected at 3, 6, 9, 12, 15, 18, 21 and 24 months on surveillance CT follow-up in 112 (28%), 86 (22%), 40 (10%), 61 (15%), 33 (8%), 29 (7%), 13 (3%) and 24 (6%) patients, respectively. Patients who did developed recurrence during these time points were treated with resection in 29 (26%), 20 (23%), 13 (33%), 24 (39%), 8 (24%), 7 (24%), 5 (38%) and 16 (67%) patients, respectively. Patients with disease recurrence at 3 (p < 0.001), 6 (p = 0.002), 9 (p < 0.001) and 12 (p < 0.001) months that were treated with liver and/or lung resection had a significantly better overall survival compared to patients treated with chemotherapy. If 3-monthly CT scanning is performed within the first 2 years as our unit's protocol, the additional patients with recurrence detected were 198 (50%) patients. In addition, patients with recurrence within the first year of follow-up managed with surgery have a significantly better long-term outcome.

Conclusion. Intensive 3 monthly surveillance follow-up detect CRLM recurrence which is treatable by means of further resection. Patients with recurrence treated with re-resection have improved long-term survival.

FP 12.04

PERIOPERATIVE CEA MEASUREMENTS TO PREDICT CURABILITY AFTER LIVER RESECTION FOR COLORECTAL METASTASES

Jaeck, Daniel; Oussoultzoglou, Elie; Rosso, Edoardo; Pessaux, Patrick; Bachellier, Philippe

Hopital de Hautepierre, Centre de Chirurgie Viscérale et Transplantation, Strasbourg, France

Background. Despite various multimodality treatments, definitive cure remains still elusive for a majority of patients with resected colorectal liver metastases (CLM). Better tools for appropriate patient selection are needed to identify those who most likely will benefit from radical resection and adjuvant therapy. The aim of this study is to prospectively evaluate peri-operative carcinoembryonic antigen (CEA) blood levels as a predictor of outcome after curative intent resection of CLM.

Patients and Methods. From January 2000 to December 2004, 213 patients received CLM resection with curative intent out of 233 patients operated for CLM. The CEA blood level was routinely measured one week before and 6 weeks after liver resection. The 213 patients were divided into three groups: A) patients with normal pre- and post-operative CEA blood levels (n = 69); B) patients with elevated preoperative and normal postoperative CEA blood levels (n = 111); C) patients with elevated pre- and post-operative CEA blood levels (n = 33). The ability of peri-operative CEA levels to predict outcome after curative intent resection was investigated.

Results. The overall 1-, 3- and 5-year survival rates were 92.0%, 66.3% and 35.8% respectively with a median survival of 32.2 months. The 5-year overall and disease-free survival in group A was 50.2% and 21.9%, group B 38.5% and 18.3% and group C 0% and 0% (P < 0.0001). The multivariate analysis, only peri-operative CEA blood level, hepatic pedicle lymph node involvement and number and size of liver metastases were independent prognostic factors for overall survival.

Conclusion. This study could demonstrate the predictive value of peri-operative CEA levels. Moreover these CEA levels showed better predictive value than available clinical scores and biological characteristics of the primary tumor and of liver metastases. CEA levels as early as 6 weeks postoperatively may be helpful in selecting patients for adjuvant chemotherapy after surgical resection of CLM.

FP 12.05

INTRAHEPATIC LYMPHATIC INVASION INDEPENDENTLY PREDICTS POOR OUTCOMES AFTER HEPATECTOMY IN PATIENTS WITH COLORECTAL CARCINOMA LIVER METASTASES

Korita, Pavel¹; Wakai, Toshifumi¹; Shirai, Yoshio¹; Sakata, Jun¹; Takizawa, Kazuyasu¹; Cruz, Pauldion¹; Ajioka, Yoichi²; Hatakeyama, Katsuyoshi¹

¹Niigata University Graduate School of Medical and Dental Sciences, Division of Digestive and General Surgery, Niigata City, Japan; ²Niigata University Graduate School of Medical and Dental Sciences, Division of Molecular and Diagnostic Pathology, Niigata City, Japan

Background. D2–40 monoclonal antibody immunoreactivity is specific for lymphatic endothelium and therefore provides a marker of lymphatic invasion. We hypothesized that intrahepatic lymphatic invasion reflects the nodal status of colorectal carcinoma liver metastases and may function as an adverse prognostic factor.

Methods. A retrospective analysis of 1 05 consecutive patients who underwent resection for colorectal carcinoma liver metastases was conducted. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity for D2–40 monoclonal antibody. The median follow-up time was 124 months.

Results. Of 105 patients, 13 were classified as having intrahepatic lymphatic invasion. All tumor foci of intrahepatic lymphatic invasion were detected within the portal tracts. Intrahepatic lymphatic invasion was significantly associated with hepatic lymph node involvement (P = 0.039). Survival after resection was significantly worse in patients with intrahepatic lymphatic invasion (median survival time of 13 months; cumulative 5-year survival rate of 0%) than in patients without (median survival time of 40 months; cumulative 5-year survival rate of 41%; P < 0.0001). Patients with intrahepatic lymphatic invasion also showed decreased disease-free survival rates (P < 0.0001). Intrahepatic lymphatic invasion thus independently affected both survival (relative risk, 7.666; 95% confidence interval, 3.732–15.748; P < 0.001) and disease-free survival (relative risk, 4.112; 95% confidence interval, 2.185–7.738; P < 0.001).

Conclusions. Intrahepatic lymphatic invasion is associated with hepatic lymph node involvement and is an adverse prognostic factor in patients with colorectal carcinoma liver metastases.

FP 12.06

ADRENAL METASTASES IN PATIENTS WITH COLORECTAL LIVER METASTASES

de Haas, Robbert J; Rahy Martin, Aida C; Wicherts, Dennis A; Azoulay, Daniel; Castaing, Denis; Bismuth, Henri; Adam, René

Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France

Background. Within the literature, only few cases exist describing adrenal metastases (AM) from colorectal cancer. Furthermore, adrenal involvement by colorectal cancer is generally considered as incurable systemic disease.

Aim. To evaluate if this patient group should still be considered as having a dismal prognosis, we reviewed our experience in treating patients with AM, initially referred for colorectal liver metastases (CLM).

Methods. Patients resected for CLM at our hospital between January 1993 and December 2006 who developed AM were included in this study. Comparison regarding long-term outcome was made to all other patients resected for CLM but without AM during the same period.

Results. Hepatectomy (HR) was performed in 795 patients, of whom 13 (2%) developed AM, after a mean of 26 months after first CLM diagnosis. The remaining 782 patients (98%) were without AM. Four patients (31%) presented with solitary AM, while in 9 patients (69%) other organs were also involved. Nine patients (69%) underwent adrenalectomy, the other 4 (31%) were treated by systemic chemotherapy. Median survival after first HR was 45 months (95% confidence interval (CI) 33–58) in the AM group, compared to 59 months (95% CI 50–68; P = 0.20) in patients without AM. After AM diagnosis, median survival was 23 months (95% CI 19–28). Median survival after adrenalectomy (N = 9) was 23 months (95% CI 13–31), versus 30 months (95% CI 19–42) after chemotherapy (N = 4) (P = 0.12). If adrenalectomy was combined to HR (N = 3), median survival after AM diagnosis was 23 months, vs. 20 months in case of metachronous adrenalectomy (N = 6). At last follow-up, 9 patients died of disease progression (69%), and 4 were alive with recurrence (31%).

Conclusion. Adrenal involvement in patients with metastatic colorectal cancer has a dismal prognosis, but does not reduce significantly the survival of patients resected from liver metastases. Prolonged survival can be achieved by an aggressive treatment including liver resection, adrenalectomy, and systemic chemotherapy.

FP 12.07

EXPRESSION PATTERNS OF RAS COMPONENTS: NOVEL FACTORS INVOLVED IN LIVER REGENERATION AND TUMOUR STIMULATION

Zhu, Jin; Harun, Nadia; Malcontenti-Wilson, Cathy; Fifis, Theodora; Muralidharan, Vijayaragavan; Christophi, Chris

Austin Hospital/University of Melbourne, Department of Surgery, Heidelberg, Australia

Background. Partial hepatectomy is the standard treatment for patients with colorectal cancer liver metastasis. Liver regeneration following hepatectomy has been correlated with increased tumour growth and metastases due to upregulation of growth factors and cytokines. Key components of the Renin-Angiotensin System (RAS) are novel growth regulatory factors possessing angiogenic and mitogenic activity and have been shown to contribute to tumour growth.

Objective. This study investigates the local expression pattern of the RAS components in a mouse model of liver regeneration.

Methods. CBA mice were divided into two groups: 70% partial hepatectomy and sham controls. Tissues and serum were collected at days: 1, 2, 4, 6, 8 and 10 post hepatectomy. Liver regeneration was quantitated by evaluation of hepatocyte proliferation using Ki67 IHC. Expression of local RAS components was detected by real-time PCR, IHC and RIA methods. Serum levels of HGF and TGF-β1 were determined by ELISA.

Results. Hepatectomy significantly increased hepatocyte proliferation with a peak at Day2 post-operation. Among the RAS components, the expression of Angiotensinogen, Angiotensin converting enzyme (ACE), and MAS receptor were significantly up-regulated after hepatectomy, and peaked at Day1, Day4, and Day10 respectively. AngiotensinII type I receptor (AT1) expression was found to be the same in both groups. In normal and sham livers, the expression of AngiotensinII type II receptor (AT2) was negative, but positive expression of AT2 appeared at late phase during liver regeneration. Additionally, Serum HGF and TGF-β1 levels peaked at Day6 and Day8 after hepatectomy, respectively.

Conclusion. This is the first study to show upregulation of RAS components which are closely related to tumor growth and metastasis during different stages of liver regeneration. These components may provide new intervention targets for prevention of tumour recurrence after liver resection, and contribute to overall improvement in patient outcomes.

FP 12.08

ASSESSMENT OF REGIONAL HEPATIC LYMPH NODE METASTASES IN PATIENTS UNDERGOING HEPATECTOMY.

Jersenius, Ulf¹; Isaksson, Bengt²; Kylander, Christian³; Lundell, Lars³; Dlugosz, Rafal⁴; Söderdahl, Gunnar⁴; Björnstedt, Mikael⁵

¹GastroCentrum Kirurgi, Karolinska Universitetssjukhuset Huddinge, Stockholm, Sweden; ²Karolinska University Hospital Huddinge, Suregry, Stockholm, Sweden; ³Karolinska University Hospital Huddinge, Surgery, Stockholm, Sweden; ⁴Karolinska University Hospital Huddinge, Transplantation surgery, Stockholm, Sweden; ⁵Karolinska University Hospital Huddinge, Pathology, Stockholm, Sweden

Introduction. Metastases from colorectal cancer to regional hepatic lymph nodes may indicate an aggressive disease and are considered to be a negative prognostic factor for survival. Macroscopic nodular involvement is usually judged as a contraindication for a hepatectomy. The prevalence of microscopic lymph node metastases, systematically explored in the regional lymph node stations, is scarcely assessed in prospective studies.

Objective. The aim in this study was to assess the number of patients with regional hepatic microscopic lymph node metastases at the time for hepatic resection due to colo rectal cancer secondaries.

Methods. In 57 consecutive patients, at the time for hepatic resection, systematic lymph node clearance were performed in three regional hepatic lymph node stations: the hepato-duodenal ligament, the celiac trunc and retropancreatically between the aorta and the inferior caval vein. The first 44 patients were evaluated only with routine staining. To further evaluate micrometastatic disease the last 13 patients were also evaluated with immunohistochemistry using cytokeratin 20 and MNF 116.

Results. Among the 57 patients 290 regional hepatic lymph nodes were examined with routine stain. Metastases were found in 15 nodes collected from 5 patients. In one of the 13 patients examined with immunohistochemistry 2 micrometastases were found. These metastases were not seen in routine staining.

Conclusion. Regional hepatic lymph node metastases were found in 9% of the patients with liver metastases from colorectal cancer at the first hepatectomy. Additional metastases are possible to detect with immunohistochemistry. The impact of micrometastases on survival and the need for changed onco-surgical strategies in the treatment of these patients have to be addressed.

FP 12.09

IMMUNE RESPONSES FOLLOWING THERMAL ABLATION IN A MURINE MODEL OF COLORECTAL LIVER METASTASES

Lin, Wen Xu; Fifis, Theodora; Nikfarjam, Mehrdad; Malcontenti-Wilson, Caterina; Muralidharan, Vijayaragavan; Christophi, Christopher

University of Melbourne, Austin Health, Department of Surgery, Heidelberg 3084, Australia

Background. Thermal ablation is a recommended treatment for selected patients with unresectable colorectal cancer liver metastase s. Some studies report lower recurrence after TA compared to liver resection, however recurrence still occurs. Experimental studies suggest that destruction of tumor tissue in situ may stimulate host immunity against cancer.

Aim. To investigate the induction of immune responses after thermal ablation and to determine the temporal & spatial distribution of T cells; Kupffer cells and the expression of IFNγ.

Methods. A murine liver metastatic tumor model was used. Thermal ablation of selected tumors was performed 21 days after tumor induction. Tissues were collected from ablated and sham treated livers and tumors at the time of treatment and at several time points, up to 7 days after treatment. Localisation of CD3+ T cells, Kupffer cells and IFNγ levels were assessed using immunohistochemistry. Livers of un-induced mice were used as controls.

Results. CD3+ T cells and Kupffer cell numbers were significantly elevated in tumor bearing livers compared to un-induced livers and were found to accumulate at the tumor-host interface and around tumour vessels. Thermal ablation treatment caused an immediate and significant increase in CD3+ T cells and Kupffer cell frequencies and levels of IFNγ in the ablated tumors compared to shams. High levels persisted for all the time points tested. At 24 hours post treatment, there was a decrease from initial high levels followed by a progressive increase reaching a maximum between days 5–7. Similar increases were observed in tumors distant to the ablation site suggesting a systemic immune response.

Conclusion. Thermal ablation induces immune responses which may be anti tumor, and may account for lower tumour recurrence compared to liver resection. Understanding the immunological mechanisms associated with thermal ablation may enable manipulation of the response for more effective treatment of colorectal liver metastases.

FP 13.01

RESECTION FOR HEPATOCELLULAR CARCINOMA: PRE-OPERATIVE BIOPSY INCREASES TUMOUR RECURRENCE

Young, Alastair L; Malik, Hassan Z; Abu-Hilal, Mohammed; Guthrie, J Ashley; Wyatt, Judy I; Prasad, K Raj; Toogood, Giles J; Lodge, J Peter A

St James's University Hospital, Hepatobiliary and Transplant Surgery, Leeds, United Kingdom

Background. In Western countries Hepatocellular Carcinoma tends to present at a larger size, which can be a contraindication to transplantation and often resection. Although diagnosis by imaging and alpha-fetoprotein is usually straightforward, non-specialist units continue to use biopsy to prove the diagnosis before transfer for specialist surgical opinion.

Aims/Objectives. We have looked at the impact of pre-operative biopsy on our post-resection results for Hepatocellular Carcinoma.

Methods. We retrospectively analyzed all Hepatocellular Carcinomas resected in our unit over the last 14 years. Survival data were calculated and univariate and multivariate analyses was carried out to determine impact of pre-operative, operative and histological factors affecting outcome.

Results. We identified 101 patients who had resection for Hepatocellular Carcinoma. Of these 48 were classified as giant (>10cm). Overall survival at 1, 3 and 5 years was 78%, 56% and 50%. Size did not influence survival, although more complex surgical techniques were required for giant tumors. Predictors of poorer disease free survival were positive resection margin (p = 0.001), multiple tumors (p = 0.001), pre-operative biopsy (p = 0.002) and macroscopic vascular invasion (p = 0.015). On multivariate analysis only pre-operative biopsy and multiple tumours remained significant.

Conclusion. Our data shows excellent outcomes following resection for Hepatocellular Carcinoma in a Western Centre with a preponderance of large tumors. This supports the management of such patients in large volume units which are fully equipped and experienced in the management of these complex patients. Pre-operative biopsy should be avoided as this unnecessary manoeuvre appears to have worsened our long term Results.

FP 13.02

IS FATTY LIVER DISEASE AN IMPORTANT RISK FACOR IN THE PATHOGENESIS OF HEPATOCELLULAR CARCINOMA?

Morris-Stiff, Gareth¹; Khan, Aamir¹; Gomez, Dharwant¹; Davies, John¹; Treanor, Darren²; Wyatt, Judy²; Toogood, Giles J¹; Prasad, K Raj¹

¹St James University Hospital, Hepatobiliary and Transplant Surgery, Leeds, United Kingdom; ²St James University Hospital, Histopathology, Leeds, United Kingdom

Background. HCC is a relatively uncommon tumour in the United Kingdom, but when diagnosed, it is frequently seen in the absence of viral hepatitis or chronic liver disease (CLD), however the presence of fatty liver disease is frequently noted. The aim of this study was to investigate whether these steatotic changes may be important in the pathogenesis of HCC in this setting.

Methods. All patients undergoing resection of a HCC were included. In addition to patient demographics, and a history of liver disease, details of alcohol consumption and risk factors for fatty liver disease were collected including: diabetes mellitus; hypertension; and hyperlipidaemia. Patient c-reactive protein and fibrinogen levels were also collated as were viral screen Results. Pathology specimens were reviewed to determine the presence of liver pathology other than HCC, including cirrhosis and fatty liver disease.

Results. 87 patients undergoing resection of HCC were assessed including 63 males and 24 females with a median age of 58 years. 40 patients had a history of chronic liver disease including: HBV (n = 15); non-viral cirrhosis (n = 12); HCV (n = 6); haemochromatosis (n = 4); and other (n = 3). 47 patients had no known predisposing factors of which 18 had fatty changes noted on the biopsies including: mild (n = 8); moderate (n = 9) and severe (n = 1) although none had cirrhosis. Only 5 patients with CLD had steatosis. All patients with steatosis alone had 2 or more diagnostic factors for non-alcoholic fatty liver disease (NAFLD) and none consumed large volumes of alcohol.

Conclusions. In this Western series of HCCs, a large proportion of patients had no underlying CLD identified pre-or post-resection. Importantly, 18/86 (20.9%) had steatosis as the only finding other than HCC, all of whom fitted criteria for NAFLD. The data would suggest that NAFLD may be an important risk factor for HCC and further studies are required to determine the pathogenesis of HCC in this setting.

FP 13.03

THE CLINICAL SIGNIFICANCE OF DIHYDRO-PYRIMIDINE DEHYDROGENASE AND THYMIDYLATE SYNTHASE MESSENGER-RNA EXPRESSIONS IN HEPATOCELLULAR CARCINOMA

Nii, Akira¹; Shimada, Mitsuo²; Ikegami, Toru²; Imura, Satoru²; Morine, Yuji²; Kanemura, Hirohumi²; Arakawa, Yusuke²; Sugimoto, Koji²

¹Department of Surgery, the University of Tokushima, Tokushima, Japan; ²Department of Surgery, the University of Tokushima, Tokushima, Japan

Backgrounds. Dihydro-Pyrimidine Dehydrogenase (DPD) and Thymidylate Synthase (TS) are considered to be key enzymes that work during metabolizing 5FU system. Recently, it has been also known as a key factor for forecasting the prognosis of patients with cancers. However, little has been known regarding its significance in hepatocellular carcinoma.

Aims. The clinical significance of DPD mRNA and TS mRNA of hepatocellular carcinomas was investigated. METHDS: Seventy-nine patients, who underwent hepatic resection for hepatocellular carcinomas, were involved in this retrospective study. The mRNA levels of the resected specimens were evaluated in quantative fashion using real-time RT-PCR. The clinical impacts of these levels were evaluated, in relation to prognosis and various clinicopathological variables. The RNA levels were classified in high expression (+) or low expression (-) by a mean value.

Results. Four groups were classified, DPD-/TS-group (n = 27), DPD-/TS + groups (n = 13), DPD + /TS-groups (n = 13), and DPD + /TS + groups (n = 26). There was no significant difference in their background data. The 3-year and 5-year survival rates were 72% and 55% in DPD + /TS + groups, and 42% and 29% in DPD-/TS- group. The survival rate was significantly higher in DPD + /TS + groups than in DPD-/TS-group (p < 0.05). On the other hand, recurrence free survival rate did not show a significant difference between the groups. The higher DPD group had significantly more cases with positive micro-metastasis, clinical Stage IV and AFP > 400 ng/ml. The higher TS group had significantly less cases with ICG15min >20%.

Conclusions. The combination of DPD and TS mRNA expression might be a useful diagnostic tool for expecting the post-surgical prognosis of hepatocellular carcinoma, both from tumor-related and hepatic function-related aspects. Further investigations, regarding their relationship with chronic liver disease associated hepatocellular carcinomas, are required.

FP 13.04

PREDICTION OF MICROSCOPIC PORTAL VEIN INVASION OF HEPATOCELLULAR CARCINOMA: PERFUSION DEFECT AREA RATIO ON CT DURING ARTERIAL PORTOGRAPHY

Shirabe, Ken¹; Kajiyama, Kiyoshi²; Tsujita, Eiji²; Abe, Tomoyuki²

¹Aso-Iizuka Hospital, department of hepato-gastroenterological surgery, Iizuka city, Japan; ²Aso-Iizuka Hospital, Department of Surgery, Iizuka, Japan

Backgrounds. Microscopic portal invasion (mpi) of cancer cells in hepatocellular carcinoma (HCC) is poor prognostic predictor after hepatic resection.

Aim. To predict mpi preoperatively, we propose the perfusion defect area ratio (PPDAR) on CTAP. We clarify whether PPDAR can predict mpi of HCCs. PATIENTS: Forty-six patients with HCC, who underwent hepatectomy, were enrolled into this study, on condition that (1) no preoperative therapy was performed, (2) the patients underwent CTAP, MRI and/or CT, (3) HCC less than 5cm in diameter, (4) no diagnosis of portal vein invasion on preoperative ultrasonography, CT, MRI, hepatic angiography and CTAP.

Methods. (1) Definition of PPDAR: We measured the maximum area of HCC nodule on CT or MRI (maximum area). Maximum portal perfusion defect area on CTAP was measured. The perfusion defect ratio is calculated as follows: maximum portal perfusion defect is divided by maximum area. (2) To evaluate the portal perfusion defect ratio in prediction of mpi, forty-six patients were divided into two groups; group I: the patients with HCC, of which the portal perfusion defect ratio was less than 1.6 (n = 36), and group II: the patients with HCC, of which PPDAR was no less than 1.6 (n = 10). The cliniopatological backgrounds were compared between two groups.

Results. The mean PPDAR was 1.4 (0.7∼5.8) and median was 1.3. In group II, the incidence of mpi was seven of ten patients (70%) and five of 36 (14%) in group I. The incidence of mpi in group II was significantly higher than in group I (P = 0.0012). There was no difference between group I and II in size of HCC. Poorly differentiated HCC in group I was significantly more common than in group II (P = 0.04).

Conclusion. The portal perfusion defect ratio is a good preoperative predictor for mpi of HCC. In HCCs with high PPDAR no less than 1.6, the occult portal vein invasion of cancer cells is predicted. Then, we would design the anatomic hepatic resection rather than wedge resection in HCC with high PPDAR no less than 1.6.

FP 13.05

Comparison of noninvasive diagnosis of hepatic fibrosis and portal vein pressure: serum PIIIP vs CDS vs APRI

Ueno, Shinichi; Sakoda, Masahiko; Kubo, Fumitake; Hiwatashi, Kiyokazu; Tateno, Taro; Kurahara, Hiroshi; Mataki, Yuko; Shinchi, Hiroyuki; Natsugoe, Shoji; Aikou, Takashi

Kagoshima University, Department of Surgical Oncology, Kagoshima, Japan

Background. In hepatic tumor resection, the grade of hepatic inflammation and fibrosis and the elevation of portal vein pressure are risk factors. When fibrosis progresses, Type III collagen increases compared with Type I collagen, and it is known that the serum concentration of N-terminal peptide of type III procollagen (PIIIP), the precusor of type III collagen, rises. Comparison of preoperative PIIIP level with the conventional liver functional parameters: the liver cirrhosis discrimination score (CDS, Bonacini et al.) and AST to platelet ratio index (APRI, Wai et al.) was performed.

Methods. All patients with hepatic tumor underwent hepatic resection between 1998 and 2002 were analyzed. PIIIP was measured at the time of hospitalization and made 0.3–0.8U/ml the normal range. The degree of liver fibrosis was estimated by quantification at F0-4 using biopsy-specimen of the non-cancerous region of the liver preoperatively. Portal vein pressure was measured immediately after the skin incision.

Results. 1) There was a significant correlation between CDS and APRI (r = 0.6), however, no correlation was seen between PIIIP and the other 2 indices. 2) Serum PIIIP, CDS and APRI were correlated with the degree of fibrosis and portal vein pressure, respectively. Correlation coefficient values of APRI were more higher (0.62, 0.55 respectively) than those of PIIIP or CDS. 3) The average values of PIIP and APRI were 0.88±0.29 and 1.79±1.0 in F3–4 group, whereas 0.70±0.31 and 0.91±.69 in F0–2 groups. Most patients with advanced fibrosis (F3–4) showed both PIIIP > 0.8 and APRI > 1.5.

Conclusion. The APRI is most reliable of the progress of fibrosis and high portal vein pressure among the 3 parameters for the patients undergoing hepatic resection. If the levels of APRI and PIIIP are high, the liver is accompanied by advanced fibrosis with a high possibility.

FP 13.06

ASSESSMENT OF PERIOPERATIVE PERIOD USING BTR AFTER RESECTION OF HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENTS±

Abe, Akihito; Kubota, Keiichi

Dokkyo University Hospital, Department of Gastroenterological Surgery, Tochigi, Japan±

Aim. Examination of liver function by use of indocyanine green (ICG) enables to determine the extent of possible resection and contributes to lowering postoperative morbidity and mortality. However, patients with normal level of ICG sometime had complications after operation. We evaluated the clinical usefulness of BTR□iBranched-chain amino acids and Tyrosine Ratio□jin patients after liver resection for HCC patients.

Material and methods. During the period from April 2005 to August 2007, a total of 111 liver resections for HCC were performed at the 2nd Department of Surgery at Dokkyo University school of Medicine. BTR was measured in 40 cases including in this study. We divided them into two groups, group A with ICG □†20% and group B with ICG□…19%. The risk factors selected in the univariate setting included serum liver function test (LFT), serum coaglating factors (CF) and post operative stay (POS).

Results. BTR value was significantly lower in the group A (3.2) than in group B (4.7) (P < 0.05). Also, LFT, CF and POS tended to be better in the group B than group A. However, in group B, some patients had low BTR (less than 3.0). Those patients had prolonged POS more than 50 days and suffered from uncontrollable sever effusion and ascites.

Conclusion. Preoperative BTR value is a good indicator of perioperative period morbidity. Even if ICG-R15 value is good, a case with low BTR value should be paid attention after hepatectomy.

FP 13.07

ELEVATED NEUTROPHIL-LYMPHOCYTE RATIO PREDICTS POORER OVERALL AND DISEASE-FREE SURVIVAL FOLLOWING RESECTION FOR HEPATOCELLULAR CARCINOMA

Gomez, Dhanwant¹; Malik, Hassan²; Farid, Shahid²; Toogood, Giles²; Lodge, J Peter A²; Prasad, K Rajendra²

¹St. James's University Hospital, Department of Hepatobiliary Surgery and Transplant, Beckett Street, Leeds, United Kingdom; ²St. James's University Hospital, Department of Hepatobiliary Surgery and Transplant, Leeds, United Kingdom

Aims. To analyse the impact of an elevated neutrophil to lymphocyte ratio (NLR) on the overall and disease-free survival following curative resection for Hepatocellular carcinoma (HCC).

Patient and Methods. Patients undergoing curative resection for HCC from January 1996 to December 2006 were identified from the Hepatobiliary database. Data analysed included demographics, laboratory analyses and histopathology data.

Results. Seventy-three patients were identified with a median age of 65 years (range: 15 – 85 years) and median follow-up of 16 months (range: 12 – 120 months). The 1-, 3- and 5-year overall survival rates were 76%, 56% and 56% respectively. An elevated NLR was the only adverse predictor of overall survival. On univariable analysis, multiple tumours within the liver, nodal disease, large tumour size, involved resection margin, vascular invasion, pre-operative biopsy and an elevated NLR were predictors of poorer disease-free survival. Multiple tumours within the liver and an elevated NLR were independent predictors of poorer disease-free survival. The median disease-free survival of patients with an elevated NLR was 8 months compared to 72 months for those with a low ratio.

Conclusion. The presence of an elevated pre-operative NLR is an independent predictor of poorer overall and disease-free survival following curative resection for HCC.

FP 13.08

LONG TERM OUTCOME OF LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA IN NON-CIRRHOTIC NON-FIBROTIC LIVER WITHOUT VIRAL HEPATITIS OR ALCOHOL ABUSE.

LUBRANO, Jean; Huet, Emmanuel; Tsivildis, Basile; François, Arnaud; Goria, Odile; Riachi, Ghassan; Scotté, Michel

Rouen University Hospital, Rouen, France

Background. Hepatocellular carcinoma (HCC) occurs mostly in cirrhotic liver. Less than 10% of HCC arise in normal liver parenchyma.

Aims. The aims of our study was to analyse clinical presentation, surgical outcome and prognosis factors in our series of patients operated for HCC arising in strictly normal liver parenchyma without cirrhosis, fibrosis, steatosis and underlying viral hepatitis or alcohol abuse.

Methods. Between January 1986 and 2005, 321 patients were referred to our institution for HCC. Among them, 20 patients (6.2%) were operated for HCC arising in non-cirrhotic non-fibrotic liver parenchyma. Pathological examinations were reviewed according to Chevallier fibrosis and Metavir viral score. Pre-, per- and postoperative data were reviewed to analyse their influence on tumor recurrence and survival.

Results. Median age was 57 years (35–80). Morbidity and morality rate were 10% and 5% respectively. 1, 3 and 5-year survival rate were 85, 70 and 64% respectively and disease free survival at 1, 3 and 5 years were 84%, 66% and 58% respectively. In univariate analysis, survival was influenced by a preoperative cytolysis, R0 resection, recurrence and recurrence within 1 year. In multivariate analysis, recurrence and recurrence within 1 year significantly decreased survival. In 8 patients, recurrence occurred in a median delay of 15 months (2–70). Within patients with recurrence, survival was not influenced by reoperation (P = 0.65). Overall survival rates at 1, 3 and 5 years were 75%, 37% and 25% respectively. In case of recurrence, death occurred with a median delay of 12 months.

Conclusions. These results for HCC arising in normal liver parenchyma justify liver resection and underline the strong differences with HCC in cirrhotic liver. With a median survival of 12 months, in front of recurrence after curative resection of HCC in noncirrhotic liver, orthotopic liver transplantation should be discussed as salvage treatment rather than rehepatectomy.

FP 13.09

LIVER RESECTION VS TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA ON CIRRHOSIS: AN INTENTION TO TREAT ANALYSIS.

Ercolani, Giorgio; Ravaioli, Matteo; Grazi, Gian Luca; Dazzi, Alessandro; Di Gioia, Paolo; Bertuzzo, Valentina; Cescon, Matteo; Del Gaudio, Massimo; Vetrone, Gaetano; Zanello, Matteo; Tuci, Francesco; Pinna, Antonio daniele

Hospital Sant'Orsola-Malpighi, University of Bologna, Department of Surgery and Transplantation, Bologna, Italy

Background. Optimal treatment with liver resection (LR) or liver transplantation (OLT) for patients with hepatocellular carcinoma (HCC) on cirrhosis remains still controversial.

Methods. From 1999 to 2005, we treated 316 cirrhotic patients with HCC: 78 LRs and 238 were listed for LTs. The outcome of LT for HCC was compared with that of resected patients. A further step was to analyze the outcome in the group of patients with MELD score less than 12 and single nodule inferior to 6 cm. Finally, an intention to treat analysis was done including patients lost during waiting time in the LT group: patient survival was analyzed from the time that patients were resected or listed for OLT.

Results. Median age was higher in the LR compared to the LT group (65 year old vs 57, p < 0.05); median MELD score was lower in the LR group (9 vs 14, p < 0.05). Mean number of nodules was inferior in the LR group (1.2±0.6 vs 1.8±1, p < 0.05); mean tumor diameter was higher in the LR group (3.9±2.5 cm vs 2.7±1.2 cm, p < 0.05). Among the 238 listed patients, 165 (69%) were transplanted, 32 (13.4%) died during the waiting time and 21 (8.8%) were excluded for tumor progression. The overall 3-year survival was 55% in the resected group and 78% in the transplanted group (p < 0.05). The overall recurrence rate was 39.7% in the LR group and 12.3% in the LT group (p < 0.05). However, by selecting patients with MELD score less than 12 and single tumor with maximum diameter less than 6 cm, the overall 3-year survival was 62% in the resected group (46 patients) and 73% in the transplanted group (20 patients) (p = n.s.). In the intention to treat analysis, 3-year survival remained 61% for the LR group and was 61% for LT group (p = n.s.).

Conclusions. LR remains an effective treatment for single HCC in well compensated patients; in this set of patients LR may be preferable than OLT in particular if waiting list is expected to be quite long.

FP 14.01

PORTAL VEIN RESECTION IN COMBINATION WITH HEPATECTOMY FOR HILAR CHOLANGIOCARCINOMA: AUDIT OF 51 CASES

Gi-Won, Song; Lee, Sung-Gyu; Lee, Young-Joo; Park, Kwang-Min; Hwang, Shin; Kim, Ki-Hun; Ahn, Chul-Soo; Moon, Deok-Bog; Ha, Tae-Yong; Jung, Dong-Hwan

Asan Medical Center, Surgery, Seoul, Korea, Republic of

Background. Although portal vein resection (PVR) can increase the chance for curative resection, there are controversies in regard to the balance between risk and effect on survival of patients with hilar cholangiocarcinoma(CCC) Therefore, we performed retrospective study to elucidate the safety and survival impact of PVR for hilar cholangiocarcinoma.

Patients and Method. Between June 1989 and June 2005, surgical interventions with curative intent were performed on 301 patients and 259 patients underwent resection. Among them, 51 patients underwent combine PVR. We analyzed survival data of 259 patients and compare the survival and clinicopathological factors between group with PVR and without PVR.

Results. The 1-, 3-,5-year survival rate of 186 patients underwent curative resection were 83.3, 42.0 and 29.3%, respectively. And 7 patients have been survived more than 5 years. Surgical mortality was occurred in 11(4.3%) patients. When we compared the differences of clinicopathological characteristics between PVR(+) and PVR(−) groups, Bisthmus-Corlette type IV, infiltrative type, presence of perineural invasion, lymphovasculr tumor emboli and LN metastasis were more frequent in PVR(+) group. Survival rate was significantly lower in PVR(+) group (18.8%vs26.7%). Total 5 mortalities were occurred but, mortality directly related with PVR was occurred in only 1 case. Surgical morbidity and postoperative liver function profile were not different between two groups. In PVR group, actual tumor invasion into portal vein was observed in 28 patients. And tumor invasion on pathological exam did not affect survival within PVR(+) group.

Conclusion. Although mortality rate of hepatectomy combined with PVR is higher, incidence of mortality directly related to PVR is low. Therefore, combined liver and PV resection can be performed with acceptable mortality. Although PV resection has negative impact on survival, combined liver and PVR can offer long-term survival to some patients with advanced hilar CCC.

FP 14.02

Nodal Metastasis in Distal Bile Duct Cancer: Mode of Spread and Prognosis

Matsubara, Hideo; Ebata, Tomoki; Nishio, Hideki; Igami, Tsuyoshi; Nagino, Masato

Nagoya University Graduate School of Medicine, Division of Surgical Oncology, Nagoya, Japan

Background. Although nodal involvement is widely accepted as an important prognostic factor in distal bile duct cancer, correlation between the mode of nodal involvement and prognosis has not fully addressed.

Methods. A total of 104 patients with distal bile duct cancer who underwent pancreatoduodenectomy were retrospectively reviewed. Lymph nodes in the hepatoduodenal ligament (No. 12), adjacent to the pancreas head (No. 13), along the common hepatic artery, and along the superior mesenteric artery (No.14) were routinely dissected as regional nodes. The former two and the latter two were classified n1 and n2, respectively, based on the Japanese classification.

Results. Nodal metastasis was observed in 33 of 104 (32%) study patients. The number of involved node was single in 11 patients, two in 11, three in 2, and more than three in 9 patients, while n1 and n2 (or more) metastasis was present in 28 and 6 patients, respectively. No.13 was most frequently involved (n = 17), followed by No 12 (n = 16) and No 14 (n = 14). The survival for the patients with nodal metastasis was significantly lower than that without (5-year survival rate: 13% vs 31%, respectively, p = 0.014); the survival was not different between the patients with n1 metastasis and those with n2 or more metastasis. The number of metastatic nodes was associated with survival: 5 year survival rate of 33% in single, 9.1% in two, 14% of 3 or more (p = 0.04). The survival for patients with No 12 metastasis was significantly lower than those without (5-year survival rate 16% vs 27%, respectively, p = 0.024). No significant difference in survival was seen between the patients with or without nodal metastasis in the other location.

Conclusion. Two or more involved nodes strikingly worsen the survival in distal bile duct cancer. In addition, No 12 is a key prognostic when involved.

FP 14.03

POPULATION TRENDS IN HILAR/EXTRAHEPATIC CHOLANGIOCARCINOMA.

Chan, Anthony; Sheen, Aali; Siriwardena, Ajith

Manchester Royal Infirmary, Hepatobiliary Surgery Unit, Manchester, United Kingdom

AIMS Hilar and extrahepatic cholangiocarcinoma (EHC) is a rare, and usually rapidly fatal cancer. Obtaining long-term epidemiological trends is difficult for such an uncommon cancer. This study utilises the Surveillance, Epidemiology and End Results (SEER) Program to provide a detailed longitudinal epidemiological overview of the management of EHC.

Methods. Data were extracted on malignant EHC including demographic profile, stage and survival. The frequency and incidence data query were limited to the original SEER 9 regist ries (1973 through 2004), to the primary site of extrahepatic bile duct (code C24.0) and to cholangiocarcinoma histology (codes 8160–8162) as defined by the International Classification of Disease for Oncology. Trends in incidence were adjusted to age and evaluated using a Percentage Change (PC) between 1973 and 2004 and Annual Percentage Change (APC) calculated using weighted least-squares. Survival data were set to observed 5-year survival and queried using the actuarial method.

Results There were 805 cases of EHC, constituting 0.03% of all cancer registrations in SEER between 1973 and 2004. The overall incidence of EHC between 1973 and 2004 is 1.24 per million, increasing from 0.14 cases per million in 1973 to 4.54 cases per million in 2004; this annual increase of 12.23% per year is statistically significant (p < 0.01). The majority of EHC are diagnosed with regional (32.7%) spread. While 29.4% have unknown staging, only 16.6% have localized disease. Most EHC have unknown histological grading (75.7%), 4.3% are well differentiated, 11.1% moderately differentiated, 8.3% are poorly differentiated and 0.6% anaplastic. Overall observed 5-year survival rate of 6.2%.

Conclusion. EHC is a rare cancer. Although the number of registrations is increasing suggesting an increase in incidence, factors such as greater access to imaging and lower thresholds for diagnosis may be contributory. The majority of patients have regional disease at the time of diagnosis and that 5-year survival is dismal.

FP 14.04

PROGNOSIS AFTER SURGERY FOR BILE DUCT CANCER WITH A POSITIVE DUCTAL RESECTION MARGIN

Higuchi, Ryota¹; Ota, Takehiro²; Furukawa, Toru³; Araida, Tatsuo⁴; Hamano, Mie²; Takesita, Nobuhiro²; Yazawa, Takehisa⁵; Tezuka, Tohru⁶; Yagawa, Yohsuke²; Yasuda, Hideki⁶; Yamamoto, Masakazu²

¹Institute of Gastroenterology, Tokyo Women's Medical University and Teikyo University Chiba Medical Center, Surgery, Tokyo, Japan; ²Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan; ³International Research and Educational Institute for Integrated Medical Science, Tokyo Women□fs Medical University, Tokyo, Japan; ⁴Tokyo Women□fs Medical University Yachiyo Medical Center, Tokyo, Japan; ⁵Department of Surgery, Institute of Gastroenterology, Tokyo Women□fs Medical University, Tokyo, Japan; ⁶Teikyo University Chiba Medical Center, Department of Surgery, Chiba, Japan

Background. In patients with positive ductal resection margins after resection for bile duct cancer, the prognosis may be different between patients with residual carcinoma in situ and those with residual invasive carcinoma.

Aim. We investigated the prognosis after resection for bile duct cancer with a positive ductal resection margin.

Methods. We retrospectively analyzed 306 patients with bile duct cancer who underwent resection. We measured prognosis in patients who underwent curative resection, non-curative resection according to the status of the ductal margin and other factors for bile duct cancer.

Results. Hilar and superior bile duct cancer were seen in 116 cases, and middle and inferior bile duct cancer in 190 cases. The curative and non-curative resection rates were 67% (204/306) and 33% (102/306), respectively. 36 patients had non-curative resection according to the status of the ductal margin (carcinoma in situ in 13 cases, invasive carcinoma in 23 cases). The 5-year survival rate of patients with curative resection, those with positive ductal margins in carcinoma in situ, those with residual invasive carcinoma and those with non-curative resection (according to other factors) were 44, 47, 23 and 11%, respectively. There was a significant difference between the 5-year survival rates of patients with curative resection and those with non-curative resection (P < 0.0001), and those with curative resection and those with positive ductal margins with residual invasive carcinoma (P = 0.0058).

Conclusion. The prognosis in patients with positive ductal margins in carcinoma in situ was as long as in those with curative resection. On the other hand, The prognosis in patients with positive ductal margins with residual invasive carcinoma was poor, so appropriate additional resection should performed in cases with positive ductal margins with residual invasive carcinoma according to the clinical classification of the tumor and the patient's condition.

FP 14.05

RESULTS AND PROGNOSTIC PREDICTORS FOLLOWING RESECTION FOR INTRAHEPATIC CHOLANGICARCINOMA

Gomez, Dhanwant¹; Morris-Stiff, Gareth²; Bonney, Glenn K²; Toogood, Giles J²; Lodge, J Peter A²; Prasad, K Rajendra²

¹Leeds Teaching Hospital NHS Trust, HPB and Transplantation Unit, Beckett Street, Leeds, United Kingdom; ²Leeds Teaching Hospital NHS Trust, HPB and Transplantation Unit, Leeds, United Kingdom

Aims. To analyse the results and prognostic predictors affecting the overall and disease-free survival following potentially curative resection for intrahepatic cholangiocarcinoma (IHCC).

Patient and Methods. Patients undergoing curative resection for IHCC during the period from January 1996 to December 2006 were identified from the hepatobiliary database. Data analyzed included demographics, laboratory analyses and histopathology data.

Results. Twenty-seven patients were identified with a median age of 57 years (range: 32 – 84 years). The 1-, 3- and 5-year overall and disease-free survival rates were 74%, 16% and 16%, and 44%, 15% and 15%, respectively. On univariate analysis, age (<65 years), female gender, neutrophil to lymphocyte ratio (NLR) >5, vascular invasion and lymph node involvement were predictors of poorer overall survival. Multivariable analysis did not identify any independent predictors of overall survival. A NLR >5 was the only adverse predictor of disease-free survival. The median disease-free survival of patients with NLR >5 was 6 months compared to 18 months for those with NLR <5. There was a significant association between patients with a NLR >5 and satellite lesions, vascular invasion and lymph node involvement.

Conclusion. Long-term outcome following curative resection of IHCC is poor. However, the presence of a pre-operative NLR >5 is a predictor of poorer overall and disease-free survival and may have a role in selection of patients for aggressive resection.

FP 14.06

IS INTENSIVE RADIOLOGICAL FOLLOW-UP OF CHOLANGIOCARCINOMA WORTHWHILE?

Murphy, Laura; Morris-Stiff, Gareth; Gomez, Dhanwant; Toogood, Giles J.; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospitals NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. There is now accumulating evidence as to the benefits of screening for recurrences following resection of colorectal metastases, since the results of resection of these recurrences provides similar survival as surgery for first time metastases.

Aims. To evaluate the efficacy of intensive CT-based radiological follow-up in relation to the diagnosis and treatment of recurrence following resection of cholangiocarcinoma.

Patients and Methods. All patients achieving an R0 resection of either intrahepatic (IHC) or hilar (HC) cholangiocarcinoma were identified from a prospectively maintained database. Protocol CT scans were performed at 3, 6, 9, 12, 18 and 24 months following resection. All CT scans were reviewed to determine the timing and distribution of recurrences and the database was interrogated to determine the management and outcome of recurrent disease.

Results. During the period of the study 46 patients (26 IHC and 20 HC) were deemed suitable candidates for recruitment to the screening program. To-date, protocol CT scanning has identified recurrences in 21 of 26 (88.5%) undergoing resection of IHC and 11 of 20 (55%) of patients with HC. Despite pre-clinical recognition of recurrences, none of the patients were suitable for re-resection due to widespread dissemination or inadequate hepatic reserve. Following recurrence, death occurred within a median of 3.5 months in both groups.

Conclusions. Despite close radiological follow-up, cross-sectional imaging with CT following curative resection of IHC and HC did not show any benefit in terms of identification of recurrences suitable for re-resection and cannot therefore be justified.

FP 14.07

MALIGNANCY COMPLICATING CHOLEDOCHAL CYST

Singh, Shivendra¹; Bora, Giri Raj¹; Mandal, Sanjoy¹; Gondal, Ranjana²; Agarwal, Anil¹

¹G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ²G. B. Pant Hospital and Maulana Azad Medical College, Pathology, New Delhi, India

Background and Aim. Malignancy is a recognized complication of long standing Choledochal cyst (CDC), Malignancy is more commonly seen in the cyst itself, however the entire hepato-pancratic-biliary region is at risk. We herein report our experience of malignancy associated with CDC.

Material and Method. Of the 204 patients admitted with diagnosis of Choledochal cyst between January 2001 to June 2007, there were fifteen cases (7.35%) of malignancy. Clinical presentation, management and follow up of these patients were analyzed in detail.

Results. A total of 15 patients of CDC with malignancy were diagnosed over the period. 11 patients (5.39%) were found to have Carcinoma Gall bladder and 4 patients (1.96%) had Cholangiocarcinoma. There were 14 females and 1 male with a mean age of 44.5 years (range 20 to 72 years). Eleven had type I and 4 type IVa CDC. Of the 11 GBC pts. 1 had metastatic disease on preop. work-up Of the remaining 10 taken up for surgery, resection was not possible in 2 patients, one due to detection of metastasis and in the other due to locally advanced disease. Resection was performed in 8 patients. Radical Cholecystectomy with excision of Choledochal cyst was performed in 5 and additional resection of adjacent organs was required in 3 patients. In Cholangiocarcinoma group, metastatic disease on preoperative work up in 1 and intra-operative findings in another 2 patients. One patient underwent Whipple's PD with cyst excision. Resection was R0 in all patients treated with curative intent. Carcinoma Gall bladder had resectability rate of 72.72% while Cholangiocarcinoma had 25%. Overall resectability was 60%. Overall mortality in surgical group was 1/13 (7.96%). This patient had postoperative pancreatitis and developed multiorgan failure. Major Perioperative morbidity was 2/13 (15.38%).

Conclusion. Choledochal Cyst has a definite risk of Malignancy, which was 7.35% in the current series. Therefore all CDC should be excised upon diagnosis.

FP 14.08

PATENCY OF PERCUTANEOUSLY INSERTED METAL STENTS IN PATIENTS WITH MALIGNANT BILE DUCT OBSTRUCTION

Sandblom, Gabriel¹; Dahlstrand, Ursula²; Nyman, Rickard³; Ericsson, Lars-Göran³; Rasmussen, Ib Christian²

¹University Hospital, Department od Surgery, Lund, Sweden; ²University Hospital, Department of Surgery, Uppsala, Sweden; ³University Hospital, Department of radiology, Uppsala, Sweden

Background. An effective bile duct drainage is crucial for the quality of life in patients with jaundice due to obstruction of the bile ducts by non-operable tumours. This can be achieved by percutaneous stenting, although the stents will inevitably clog, dislocate or fracture if the patient lives long enough.

Objective. To assess the patency of metal stents inserted percutaneously and to explore risk factors for stent failure, in particular type of stent and how its localisation is in relation to the obstruction.

Methods. All patients who were treated at the Uppsala University Hospital, Sweden, with percutaneous stenting for malignant bile duct obstruction 2000–2005 were identified retrospectively. From the patient histories, data on the localisation of the obstruction and type of stent used, date and cause of death and date of stent failure were extracted. Stent patency was defined as the duration from the insertion of the stent until the date of failure. In case cause of death was directly related to failure of the stent, the date of death was defined as patency endpoint.

Results. Altogether 64 patients, 34 women and 30 men, were identified. Mean age was 71 years, standard deviation 11 years. The median patency was estimated to 347 days, the first quartile 103 days and the third quartile 492 days. Stent diameter more than 10 millimeter and distal localisation of the stricture were found to be associated with significantly longer patency in univariate Cox proportional hazard analysis. In multivariate Cox proportional hazard analysis, only the localisation of the stricture was found to be independently and significantly associated with patency.

Conclusion. Percutaneous inserted metal stent is a good alternative for patients with obstructive jaundice and a life expectancy not exceeding one year. It may give an instant relief from the symptoms associated with the jaundice. The patency is, however, poor for Klatskin tumours. By using metal stents with a diameter of at least 10 mm the patency may be prolonge

FP 14.09

A PROSPECTIVE LONGITUDINAL STUDY OF QUALITY OF LIFE FOLLOWING LIVER RESECTION FOR HEPATOBILIARY MALIGNANCIES

Dasgupta, Dowmitra¹; Smith, Adam B²; Hamilton-Burke, Werbena³; Prasad, KRajendra²; Toogood, Giles J²; Velikova, Galina²; Lodge, J Peter A²

¹St. James's University Hospital, HPB and Transplant Surgery, Beckett Street, Leeds, United Kingdom; ²St. James's University Hospital, HPB and Transplant Surgery, Leeds, United Kingdom; ³St James's University Hospital, HPB and Transplant Surgery, Leeds, United Kingdom

Introduction. Quality of life assessment is an important indicator of treatment efficacy. No prospective longitudinal studies using a validated quality of life (QOL) instrument assessing short and long term quality of life in those patients undergoing liver resections for hepatobiliary malignancies exist.

Methods. Patients undergoing liver resections for hepatobiliary malignancies in a 1 year period from July 2002 were enrolled. They completed the European Organization for Research and Treatment of Cancer Core questionnaire (EORTC QLQ- C30), pre operatively, 6 months, 12 months and between 36 and 48 months post operatively. Quality of life over time and its relation to several clinical factors was analysed.

Results. 103 patients were enrolled in this study, predominantly with metastatic colorectal cancer (n = 74). Patient compliance with completion of QOL data at each time point was 99%, 97%, 97% and 77.2% respectively. Most functional scales and the global QOL scale showed a non-significant trend to deterioration at 6 months and return to pre-operative level at 12 months. Physical functioning deteriorated significantly at 6 months (t = 2.36, p = 0.02) and did not return to baseline at 12 months (t = 3.19, p = 0.002). Pain and dyspnoea showed a moderate increase at 6 months (t = 2.13, p = 0.036 and t = 2.96, p = 0.004 respectively) and 12 months (t = 2.29, p = 0.024 and t = 3.66 p < 0.0001 respectively). Fatigue was worse at 6 months (t = 2.22, p = 0.029), but returned to pre-operative levels at 12 months (t = 0.96, p = 0.34). No difference in symptoms or functional scales was observed between patients undergoing major or minor liver resection. Survivors without recurrence at 36–48 months show better QOL than patients with recurrent disease.

Conclusion. Generally QOL deteriorates in the first 6 months and then improves to baseline levels. There is no difference in QOL between patients undergoing major and minor resections. Recurrence free survivors continue to improve their QOL in the long term. Further studies on QOL and cost effectiveness required.

FP 15.01

CAN WE TREAT PATIENTS WITH CHRONIC PANCREATITIS SUCCESFULLY?-NEW ASPECTS BY IMMUNOLOGICAL BACKGROUND

Farkas, Gyula Jr¹; Takacs, Tamas²; Farkas, Gyula¹; Mándi, Yvette³

¹Department of Surgery, University of Szeged, Szeged, Hungary; ²Ist Department of Internal Medicine, University of Szeged, Szeged, Hungary; ³University of Szeged, Department of Medical Microbiology and Immunology, Szeged, Hungary

Introduction. Cytokine regulation may be important as concerns the susceptibility to the development of chronic pancreatitis; transforming growth factor-β1 (TGF-β1) plays a central role in the pathogenesis of pancreatic fibrogenesis.

Aims. The aim of our study was to analyse the relevance of TGF-β1 polymorphisms in patients with chronic pancreatitis.

Methods. Of the 83 patients enrolled in the study, 43 were treated medically and 40 patients underwent surgical intervention. Healthy blood donors (n = 75) served as controls. The polymorphisms of TGF-β1 were determined by the ARMS method, serum TGF-β1 levels were detected by ELISA.

Results. No correlation was found between the genotipes and the histological varietes of chronic pancreatitis. There was a higher frequency (50%) of the TT genotype of TGF-β1 with a concomitant higher TGF-β1 level in the plasma (5.2±1.7 ng/ml) in patients with chronic pancreatitis than in healthy blood donors ( 28%, and 2.8±0.9 ng/ml respectively). The number of TT homozygotes differed significantly between the patients who underwent surgical intervention and the controls, and even between the operated and the non operated patients. Those patients who had TT genotipe with high serum levels of TGF-β1 were rehospitalized or underwent further operations. The frequency of the T/C genotype was significantly higher in both groups of patients than in the controls (58%, and 58% vs 40%). Successfully treated patients were found only with T/C or C/C genotipes and low serum levels of TGF-β1.

Conclusion. The correlations of the TGF-β1 with chronic pancreatitis underline the importance of these cytokines in the pathomechanism of the disease. Moreover, it seems that the TT genotype of TGF-β1 might be a risk factor for the development of a severe form of chronic pancreati tis, as a prognostic sign for a future surgical intervention or even reoperation.

FP 15.02

EVIDENCE OF VARIATIONS IN INDICATION FOR ELECTIVE SURGERY FOR SYMPTOMATIC CHRONIC PANCREATITIS

Shah, Nehal; Siriwardena, Ajith

Manchester Royal Infirmary, Hepatobiliary Surgical Unit, Manchester, United Kingdom

Background. Surgical treatment can provide good relief of symptoms in symptomatic chronic pancreatitis (CP) with procedures being categorised broadly as main duct drainage, duodenum-preserving pancreatic head resection (DPPHR) or Whipple-type pancreaticoduodenectomy. Although many reports describe good outcome after surgery, there is little information on the starting point for intervention, namely, the indications for surgery; and thus this study examines contemporary indications for elective surgical intervention in CP.

Methods. A computerised search of the National Library of Medicine's “PUBMED”, “EMBASE” & “COCHRANE” database was undertaken for the period January 1997 to March 2007 using the keywords “surgery” and “chronic pancreatitis”. Of the 1232 resulting hits, exclusions of reports that gave no original data provided a final study sample of 38 reports providing outcome data on 3518 elective operative procedures for CP. Data were then extracted on indication, type and outcome of surgery.

Results. Data were available on 3518 patients undergoing surgery for CP. Abdominal pain was the principal indication for surgery in 85%, suspicion of underlying cancer in 15%, weight loss in 14% and other indications in 8%. DPPHR was the most commonly performed with Puestow's (lateral pancreaticojejunostomy, LPJ) being second and Whipple or pylorus preserving third. Most reports did not give information on relation between type of surgery and defined indication and the choice of procedure is dictated by unit preference.

Conclusions. Although abdominal pain is the commonest indication for surgery in CP, there is no evidence of standardisation of pain symptoms across units and elective procedures appear to be selected principally by unit preference. This study highlights for the first time, the need for standardisation of indications for surgery in CP. In turn, only this standardisation will allow meaningful comparison of results across units.

FP 15.03

SALVAGE AFTER PRIMARY TREATMENT FAILURE OF SURGERY FOR TREATMENT OF CHRONIC PANCREATITIS

Vashist, Yogesh K¹; Bogoevski, Dean²; Liebl, Lena²; Cataldegirmen, Guellue²; Gawad, Karim²; Schneider, Claus²; Mann, Oliver²; Izbicki, Jakob R.²; Yekebas, Emre F.²

¹University Clinic Hamburg-Eppendorf, General, Visceral- and Thoracic Surgery, Martinistrasse 52, Hamburg, Germany; ²University Clinic Hamburg-Eppendorf, General, Visceral- and Thoracic Surgery, Hamburg, Germany

Pain relief is the primary goal of surgery for chronic pancreatitis (CP). Salvage in case of pain after surgical treatment include both ‘redo’-surgery and non-surgical interventions. Here, we report on our institutional experience with respect to surgical salvage after primary treatment failure. Among 702 patients treated surgically for CP, 45 presented with pain recurrence and subsequently underwent different redo-procedures. For measurement of quality of life, a validated EORTC-questionnaire including a pain score was used. The number of re-operations varied between 2 and 5 operations. Follow-up ranged from 12 to 126 months after the redo-operations. The entire cohort of 45 patients had primarily undergone duodenum-preserving pancreas head resection in different modifications. After primary surgery, median global pain score did not adequately decrease. Imaging evaluation showed at least one of the following pathologies: recurrence of inflammatory mass in the pancreatic head, stenosis or stones in the pancreatic duct remnant, and parenchymal calcifications and pseudocysts. In 37 patients organ preserving pancreatic redo-resections preserving adjacent organs were carried out, while in 2 patients classical resectional procedures and in 3 patients stepwise near subtotal pancreatectomy had to be performed. No perioperative mortality was registered. Following redo-operation, surgical morbidity accounted for 24.4%. No statistical difference in morbidity was detected between the index and redo-procedures. Median pain score decreased significantly after redo-procedures from 86 median (range: 62–100) to 25 (range10–46; p = 0.0001; t-test) compared to the status after the index operation. Therapeutic nihilism after failure of primary surgical treatment in CP patients is not justifiable. Based on the individual complaints and morphological findings in imaging investigations, surgical salvage procedures offer reasonable chances to achieve pain relief as the eventual success parameter of any treatment for CP.

FP 15.04

RESECTION OF PANCREATIC CANCER IN CHRONIC PANCREATITIS IMPROVES OUTCOME

Bedi, MMS; Sharma, Mohit; Gandhi, Manish; Hariharan, Ramesh

Lakeshore Hospital & Research Center, GI Surgery, Cochin, India

Background. Cancer superimposed on chronic pancreatitis has a poor prognosis and earlier reports had described a dismal outcome with resection.

Aim. to analyse the results of resectional surgery to determine survival, and quality of life. Type of study: Retrospective analysis of prospectively compiled data and prospective record of QOL after surgery Patients: 33 patients with pancreatic cancer superimposed on chronic pancreatitis underwent resectional surgery during the period 1998 to 2006. There were 15 males and 18 females. All patients were diabetic (11 oral hypoglycemic agents, and remainder on insulin). All patients had intractable pain, and 21 were jaundiced. 26 patients underwent radical Whipple's pancreaticoduodenectomy, and 7 distal pancreatectomy with splenectomy. Additional organ resections were performed in 7 (colon in 5, small bowel in 1, liver nodule excision in 1).

Results. there was no mortality. Hospital stay ranged between 11 and 29 days (median 17). 32 complications occurred in 17 patients (morbidity 55%). Over a median follow up of 44 months (3 to 73), 17 patients had died over periods ranging from 7 to 28 months. 16 patients were alive over a maximum follow up of 73 months. QOL studies revealed excellent or good quality of life in 73% of patients.

Conclusion. resection of pancreatic cancer in chronic pancreatitis may improve survival, and quality of life with the potential for long term survival

FP 15.05

SURGERY FOR CHRONIC PANCREATITIS WITH PORTAL HYPERTENSION – IS IT ANY DIFFERENT.

Singh, Rajneesh Kumar; Behari, Anu; Kumar, Ashok; Saxena, Rajan; Kapoor, Vinay

Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Dept of Surgical Gastroenterology, Luycknow, India

Background. Surgery for chronic pancreatitis in the presence of portal hypertension is associated with high morbidity and mortality. We present our experience of surgery with and without portal hypertension.

Methods. Of the 170 patients operated for chronic pancreatitis, 147 did not have (Group A) and 23 had portal hypertension (Group B). Surgical procedures were-pancreatic resection (distal pancreatectomy or pancreaticoduodenectomy) or combined resection/ drainage in 24, drainage alone (longitudinal pancreatico-jejunostomy) in 128. The additional procedures were Freys’ head coring (23), biliary surgery (42), gastro-jejunostomy (6) and splenectomy (19). The two groups (A & B) were compared for patients’ characteristics and the results of surgery.

Results. The patients with chronic pancreatitis and portal hypertension (group B) had a larger number of male patients, pseudocysts, hemorrhage and a lower mean hemoglobin, while other preoperative patient characteristics were comparable. During surgery the group with portal hypertension (group B) had a larger proportion of splenectomies, required more blood transfusion and had greater postoperative morbidity. Overall 3 patients required re-operation for complications and there was only one postoperative mortality (0.7%). The duration of surgery, re-operation and postoperative mortality were similar in the two groups. At a mean follow-up of 598 days (±654), 74.7% patients were pain free or had mild pain (similar in the two groups). Subset analysis showed that portal hypertension lead to increased postoperative morbidity (p < 0.01) in patients undergoing pancreatic resection but not in patients undergoing drainage alone.

Conclusion. It can be concluded that although surgery for chronic pancreatitis with portal hypertension is associated with increased blood loss and morbidity, more so with resectional surgery, but with adequate management the re-operation rate and mortality are low and long term relief of pain is similar to the patients without portal hypertension.

FP 15.06

REOPERATION AFTER SURGERY FOR CHRONIC PANCREATITIS

Van der Gaag, Niels A; Boermeester, Marja A; Busch, Olivier RC; Van Gulik, Thomas M; Gouma, Dirk J

Academic Medical Center, Surgery, Amsterdam, Netherlands

Background. The main indication for surgery for chronic pancreatitis (CP) is intractable pain, for which, depending on location/extent of disease, different options exist: drainage alone (pancreaticojejunostomy), drainage/(limited) resection (Frey/Beger) or pure resection (pancreatoduodenectomy-PD; tail resection). Although excellent outcomes after surgery have been reported, reoperation for recurrent pain or local symptoms (cholestasis; gastric outlet obstruction (GOO); pseudocyst) is required for a minority of patients, mainly due to progression of disease.

Aim. To evaluate reoperation rates for pain or local symptoms after different surgical procedures for CP.

Methods. Records of 235 patients (146 drainage; 46 drainage/resection; 38 tail resection; 5 PD), operated between Jan-1992 and Sep-2006 for pain due to CP, were reviewed.

Results. Two patients died postoperatively, 3 patients were lost to follow-up. Median follow-up was 60 months. Overall reoperation rate was 12% (27/230), with a break down according to procedure of 8% (11/144) for drainage, 11% (4/38) for tail resection, 20% (1/5) for PD and 24% (11/45) for drainage/resection (P = 0.02). Overall reoperation rate for recurrent pain was 4% (9/230), however was significantly higher after drainage/resection than when compared to drainage alone: 11% (4/45) vs. 3% (4/144)(P = 0.036), respectively. Reoperation rates for local symptoms were: cholestasis 4% (12/230), pseudocyst 2% (5/230), GOO 2% (5/230) and malignancy 1% (3/230).

Conclusion. Overall reoperation rate following surgery for CP was 12%. Although some consider drainage alone as an incomplete surgical intervention for CP, because of a higher risk of recurrence of pain or local symptoms, this could not be confirmed in this study in terms of reoperation. A higher reoperation rate was found for pain after drainage/resection as compared to drainage alone. This higher rate likely reflects the presence of more extensive and/or progressive disease.

FP 15.07

CYSTIC PANCREATIC NEOPLASMS: A SINGLE CENTER EXPERIENCE

Joseph, Philip¹; Vyas, Frederick²; Sanghi, Ravish²; Eapen, Anu³; Thomas, Susanna⁴; Sitaram, Venkatramani²

¹Christian Medical College Hospital, Department of General Surgery, Ida Scudder road, vELLORE, India; ²Christian Medical College Hospital, Department of General Surgery, vELLORE, India; ³Christian Medical College Hospital, Department of Radiodiagnosis, vELLORE, India; ⁴Christian Medical College Hospital, Department of Pathology, Vellore, India

Background. Cystic neoplasms of the pancreas are rare. With proper surgical treatment, cystic neoplasms are one of the few curable tumors of the pancreas.

Objective. To review our experience with cystic neoplasms of the pancreas over a 5 year period from 2002–2007.

Methods. Medical records of patients diagnosed with cystic neoplasm of pancreas were retrospectively examined.

Results. A total of 27 patients (24 females, 3 males) underwent operative therapy for cystic neoplasms of the pancreas. Their mean age was 32 years. The presenting symptoms were abdominal pain (15), vomiting and abdominal mass (3); jaundice (2); pancreatic fistula following laparotomy and biopsy and percutaneous drainage of cyst elsewhere (1 each) and acute abdomen following intra-abdominal rupture of the neoplasm (1). Six patients were asymptomatic. Abdominal mass was palpable in 12 patients. All patients underwent computed tomography of the abdomen. The location of the tumor was in the head (6), body (8) and tail of pancreas (13). Surgical management consisted of 6 pancreatico-duodenectomies, 20 distal pancreatectomies (2 spleen sparing) and 1 subtotal pancreatectomy with resection of portal vein. Two patients underwent simultaneous resection for co-existent renal cell carcinoma. The histological diagnosis included solid cystic pseudo-papillary neoplasm (13), mucinous cystadenoma (8), neuroendocrine carcinoma (2), and one each of serous cystadenoma, mucinous cystadenocarcinoma, islet cell tumor and Von-Hippel-Lindau syndrome. Post operative complications included pancreatic leak (4), wound dehiscence with enterocutaneous fistula (1), thrombosis of superior mesenteric vein (1). There was no mortality. At a median follow up of 20 months, none of the patients had evidence of recurrent disease.

Conclusion. Cystic neoplasms are being diagnosed with improvements in imaging. Preoperative FNAC is not required. Since survival of patients with cystic neoplasm is better than adenocarcinoma, an aggressive approach for surgical resection is advocated.

FP 15.08

SOLID CYSTIC PSEUDO-PAPILLARY TUMOR OF THE PANCREAS: A SINGLE CENTER EXPERIENCE

Vyas, Frederick¹; Joseph, Philip²; Sanghi, Ravish³; Eapen, Anu⁴; Sitaram, Venkatramani³

¹Christian Medical College Hospital, Department of General Surgery, Vellore, India; ²Christian Medical College Hospital, Department of General Surgery, Vellore 632004, India; ³Christian Medical College Hospital, Department of General Surgery Unit 4, Vellore, India; ⁴Christian Medical College Hospital, Department of Radiology, Vellore, India

Background. Solid cystic pseudo-papillary tumor of the pancreas is a rare exocrine neoplasm, which tends to affect young females. Surgical resection remains the treatment of choice as it offers excellent prognosis. Aims and Objectives: We present our experience in the management of these rare neoplasms highlighting their varied presentation and surgical management.

Methods. Medical records of all patients diagnosed with solid cystic pseudo-papillary neoplasm at our institution over a 5 year period from 2002–2007 were reviewed.

Results. There were 13 females ranging in age from 10 to 51 years (mean 25 years). Nine patients presented with abdominal pain, three with abdominal mass, one was asymptomatic, one had nonspecific symptoms and one presented with pancreatic fistula following biopsy of the mass. A palpable mass was found on examination in 9 patients. The mean transverse diameter of the mass on CT scan was 9.38 cms. Preoperative histological diagnosis was available in 4 patients; 2 patients underwent open biopsy in another hospital and 2 patients had diagnosis confirmed by FNAC. The tumor was located in the head of the pancreas in 4 patients, in the body in 3 and in the tail of pancreas in 6 patients. Surgical procedures included distal pancreatectomy with splenectomy (8), pancreatico-duodenectomy (4) and subtotal pancreatectomy with portal vein excision and splenectomy (1). Negative margins of resection were achieved in all. There is no recurrence till date over a median follow up of 25 months (range 3–60).

Conclusion. Solid cystic pseudo-papillary tumors vary considerably in their presentation and location in pancreas. Pre-operative histological/cytological confirmation of diagnosis is not necessary. Distant metastasis is uncommon. Surgical resection offers excellent prognosis; the operation should be tailored according to the location of the tumor in the pancreas.

FP 15.09

OUTCOMES OF CONSERVATIVE, ENDOSCOPIC AND SURGICAL TREATMENT IN THE MANAGEMENT OF PANCREATIC PSEUDOCYST

Akolekar, Deepika; Oniscu, Gabriel C; Hidalgo, Ernest; Powell, James; Ravindran, Ravi; Wigmore, Steve J; Garden, O James; Parks, Rowan W

Royal Infirmary of Edinburgh, Department of Clinical and Surgical Sciences, Edinburgh, United Kingdom

Background. Pancreatic pseudocyst is a common complication following acute and chronic pancreatitis.

Aims. The aim of this study was to compare the outcome of conservative, endoscopic and surgical treatment of pancreatic pseudocysts (PPC) in a specialist hepatobiliary centre.

Methods. All patients who were treated for PPC between 1995 and 2006 were identified from Lothian Surgical Audit database and details regarding their presentation, treatment and outcome were analysed.

Results 190 patients (102 males, 88 females) were treated for PPC over this period. Pseudocyst formation was a consequence of acute pancreatitis in 128 patients, chronic pancreatitis in 47 and acute on chronic pancreatitis in 15 patients. The commonest etiology was alcohol (49%) followed by gallstone disease. Primary treatment was conservative in 27 patients, percutaneous in 5, endoscopic in 60, and surgical in 98 patients with a median pseudocyst size of 5 cms, 6.5 cms, 7.8 cms and 10 cms respectively. Primary treatment was successful in 68 surgical patients (87.7%) and only in 18 patients (30%) treated by endoscopic drainage. Secondary intervention was frequently required following endoscopic procedures. The overall success rate of surgical treatment was 93%. The surgical morbidity rate was 15%. Median follow up was 52 months (5–71 months). Outcomes of the various treatment procedures are shown in the table below.

Procedure	n	Resolution	Failure	Recurrence
Endoscopic transgastric drainage	35	9 (25.7%)	23 (65.7%)	3 (8.5%)
Endoscopic transpapillary drainage	24	9 (37.5%)	15 (62.5%)	–
Combined transgastric and transpapillary	2	1 (50%)	1 (50%)	–
Percutaneous drainage	5	3 (60%)	–	2 (40%)
Cystgastrostomy	55	51 (92.7%)	–	4 (7.2%)
Cystjejunostomy	38	36 (94.7%)	–	2 (5.2%)
Laparoscopic cystgastrostomy	2	2 (100%)	–	–
Distal Pancreatectomy	18	17 (94.4%)	–	1 (5.5%)
External drainage	6	5 (83.3%)	–	1 (16.6%)
Cystduodenostomy	1	1 (100%)	–	–

Conclusion. Surgical drainage of pancreatic pseudocysts is associated with a good success rate and low morbidity. Although minimally invasive techniques are indicated in selected patients, open surgical drainage remains an effective treatment option.

FP 16.01

PREDICTIVE VALUE OF INVERSE RELATIONSHIP BETWEEN SERUM BILIRUBIN AND ALKALINE PHOSPHATASE LEVELS FOR HEPATIC RECOVERY AFTER LIVER RESECTION

Jah, Asif; Sadat, Umar; Kan, Yuk-Man; Drage, Martin; Paulvannan, Subramanian; Gibbs, Paul; Praseedom, Raaj K; Jamieson, Neville V; Huguet, Emmanuel L

Addenbrooke's Hospital, Hepatobiliary and Transplant Surgery, Cambridge, United Kingdom

Background. Hepatic insufficiency is a serious complication of major liver resection. Early prediction of insufficiency would allow early initiation of appropriate care. Previous studies have discussed the post-operative changes in liver function tests (LFTs) but insufficient data exist regarding their value in predicting hepatic insufficiency.

Aim. To study the trends of LFTs after liver resection with a view to predicting hepatic insufficiency, cholestasis and protracted post-operative recovery.

Methods. A total of 122 non-cirrhotic patients who underwent liver resections for colorectal liver metastases between September 2002 and October 2006 were evaluated. LFTs were noted pre-operatively and on post-operative days 1, 3, 7, 14 and 28. Patients were divided into 2 groups on the basis of their post-operative course. Group I (112 patients) had an uneventful hepatic recovery while Group II (10 patients) had prolonged cholestasis and/or liver failure. Pattern of changes in serum bilirubin (SB), alkaline phosphatase (ALP), bilirubin to alkaline phosphatase (SB/ALP) ratio and alanine transaminase (ALT) were compared using a 2-sided, paired t-test.

Results. There was a significant peak in SB and SB/ALP ratio on day 1 (p < 0.001) in those patients who had an uneventful recovery (Group I). SB and SB/ALP ratio diminished by day 3 and returned to normal by day 7. In contrast, patients who developed hepatic insufficiency (Group II), SB and SB/ALP ratio continued to rise beyond day 1, peaking on day 3 (p < 0.004) and remained significantly raised on day 7 and beyond (p < 0.004). In both groups, ALT peaked on day 1 and thereafter continued to fall irrespective of SB and ALP levels.

Conclusion. An inverse relationship exists between trends of SB and ALP levels after liver resection. SB and SB/ALP ratio which continue to rise at day 3 may be useful in the early identification of patients who are likely to develop hepatic insufficiency.

FP 16.02

HYPERBARIC OXYGENATION DECREASES THE HEPATOTOXICITY OF DOXORUBICIN AND INDUCES LIVER REGENERATION

Firat, Ozgur¹; Kirdok, Ozgur¹; Makay, Ozer¹; Gurcu, Baris¹; Uguz, Alper¹; Ilgezdi, Savas²; Karabulut, Bulent³; Yilmaz, Funda⁴; Zeytunlu, Murat¹; Coker, Ahmet¹

¹Ege University Hospital, General Surgery, Izmir, Turkey; ²Neoks Hyperbaric Oxygen Cure Center, Izmir, Turkey; ³Ege University Hospital, Medical Oncology, Izmir, Turkey; ⁴Ege University Hospital, Pathology, Izmir, Turkey

Background. Portal vein embolisation (PVE) is a technique to enhance resectability based on liver's capability of regeneration. In the chemotherapeutically injured livers regeneration is restricted secondary to hepatocellular injury. We aimed to investigate whether hyperbaric oxygenation (HBO) can alleviate the hepatotoxicity of chemotherapy and induce regeneration in the injured liver.

Methods. Forty rats were allocated to four groups (n = 10 for each) and subjected to either right portal vein ligation (RPVL – groups I, II, III) or sham operation (group IV) under sterile conditions. Rats in group II and III were administered 2 ìgr/gr doxorubicin seven days before laparotomy. Rats in group III were exposed to HBO sessions at 24th, 48th and 72nd hour postoperatively. On postoperative 7th day rats were sacrified. Degree of liver injury was assessed by AST, ALT and albumin levels. Liver regeneration was assessed by mitotic index (MI).

Results. Highest values of serum AST, ALT and the lowest values of serum albumin were seen in group II (DOXO + RPVL). HBO showed a tendency to correct these alterations. A significant increase was seen in AST and ALT of group II when compared with group I (RPVL only) (p < 0.008). In group III (DOXO + RPVL + HBO), these values were decreased to non–significant values according to group I (p > 0.05). Levels of serum albumin were statistically decreased in all RPVL groups. Changes with doxorubicin administration and HBO showed slightly but not significant differences in albumin levels (p > 0.05). However, a notable increase in group III elevated serum albumin levels almost equal to group I, which doxorubicin was not administrated. The MI values were significantly increased in the left lobes of all RPVL groups when compared with group IV (p < 0.008). Furthermore, MI levels of group III were significantly higher than those of group I (p < 0.008).

Conclusion. HBO decreases the injury secondary to chemotherapy and induces liver regeneration, therefore has potential to contribute to the treatment of HCC.

FP 16.03

LIVER REGENERATION INCREASED BY PORTAL VEIN ARTERIALIZATION IN TWO ACUTE LIVER FAILURE MODELS IN THE RAT.

Nardo, Bruno¹; Tsivian, Matvey¹; Neri, Flavia¹; Bianchi, Elisa¹; Piras, Gianluca¹; Puviani, Lorenza¹; Cavallari, Giuseppe¹; Pariali, Milena²

¹S. Orsola Hospital, University of Bologna, Bologna; ²S. Orsola Hospital, University of Bologna, Biomedical Research Center

Background/Aim. We aimed to determine whether an additional supply of oxygenated blood achieved by portal vein arterialization (PVA) is protective in rat ALF caused by hepatectomy or toxin administration.

Methods. ALF was induced in SD rats by performing an extended hepatectomy or by giving i.p. 1 ml/kg CCl4. Afterwards, rats were divided to receive PVA, by connecting the left renal artery to the splenic vein with a stent following left nephrectomy and splenectomy, or to left nephrectomy and splenectomy only (control rats). Hepatocyte regeneration was assessed by calculating the mitotic index, the bromodeoxy uridine (BrdU) incorporation and the ratio liver/body weights. Liver injury was evaluated by the serum ALT level and necrotic cell count. The 10-day survival was assessed in separate groups of rats.

Results. As expected, the PVA procedure significantly increased pO2 and oxygen saturation in the portal blood compared to controls (pO2: 63±1.6vs39±2.9 mmHg; O2 sat.%: 93.1±0.7 vs 67.0±0.5). PVA significantly improved survival compared to controls in both ALF models (90% hepatectomy: 90vs30%; CCl4: 100vs40%). Accordingly, in the toxic ALF, serum ALT levels and cell necrosis were significantly reduced by PVA (at 24h: 843±344vs1493±562U/L and 32±7vs64±15%). The BrdU staining was significantly greater in PVA than control rats in both experimental models. Similar results were obtained when the mitotic index was measured. The ratio liver/body weight after hepatectomy recovered significantly faster in arterialized rats. Finally, when PVA was performed in healthy rats, all the parameters studied were not significantly affected.

Conclusions. These data indicate that the additional supply of arterial oxygenated blood through PVA promotes a rapid and extensive regeneration leading to a faster restoration of liver mass after partial hepatectomy and resolution of toxic-induced massive liver necrosis in rats. Thus, this technique may represent a novel tool for optimizing hepatocyte regeneration during acute liver failure.

FP 16.04

HBV DNA LOAD DOES NOT CORRELATE WITH HEPATIC HISTOLOGY IN CHRONIC HEPATITIS B

Mahtab, Mamun¹; Rahman, Salimur¹; Khan, Mobin¹; Kamal, Mohammad²; Karim, Fazal³; Ahmed, Faroque¹; Hussain, Fawaz¹; Podder, Provat¹

¹Bangabandhu Sheikh Mujib Medical University, Department of Hepatology, Dhaka, Bangladesh; ²Bangabandhu Sheikh Mujib Medical University, Department of Pathology, Dhaka, Bangladesh; ³Dhaka Mahanagar Hospital, Department of Medicine, Dhaka, Bangladesh

Background. Compare correlation between HBV DNA and grade and stage of histopathology in chronic hepatitis B (CHB).

Methods. Liver biopsies done in 159 patients. 62.9% had wild type HBV infection and rest 37.1% pre-core/core-promoter mutant (PC/PCM) infection. DNA was measured by PCR.

Results. In wild type CHB, 97% had moderate-high DNA and 3% had low-moderate. In PC/PCM CHB, 74.6% had moderate-high DNA and rest 25.4% had low-moderate. In wild type CHB, in moderate-high DNA group 78.4% had minimal-mild chronic hepatitis (CH) (HAI-NI 0–8) and 21.6% had moderate-severe CH (HAI-NI 9–18). 66.6% and 33.3% patients with low-moderate DNA had minimal-mild and moderate-sev ere CH respectively. In moderate-high DNA group, 77.3% patients had minimal-moderate fibrosis (HAI-F 0–2) and 22.7% had severe fibrosis-cirrhosis (HAI-F 3–4). Figures were 33.3% and 66.6% respectively in patients with low-modaerate DNA. In PC/CPM patients, in moderate-high DNA group 79.5% had minimal-mild CH and 20.5% had moderate-severe CH. 93.3% and 6.7% patients with low-moderate DNA load had minimal-mild and moderate-severe CH respectively. In moderate-high DNA group, 68.2% patients had minimal-moderate fibrosis and 31.8% had severe fibrosis-cirrhosis. These figures were 86.7% and 13.3% respectively in patients with low-moderate DNA.

Conclusion. Study shows that high HBV DNA does not correlate with necro-inflammation and fibrosis in liver either wild type or PC/CPM CHB.

FP 16.05

IN VIVO INDUCTION OF SPECIFIC IMMUNITY AGAINST HEPATOCELLULAR CARCINOMA(HCC) BY FUSION OF HCC PATIENT-DERIVED DENDRITIC CELLS AND HCC CELLS

Yin, Xiaoyu¹; Wang, Liang²; Lu, Mingde³; Huang, Jiefu³; Liang, Lijian³

¹The First Affiliated Hospital/Sun Yat-Sen University, Department of Hepatobiliary Surgery, Guangzhou, China; ²The First Affiliated Hospital/Zhejiang University, Department of Surgery, Hanzhou, China; ³The First Affiliated Hospital, Department of Hepatobiliary Surgery, Guangzhou, China

Background. It has been shown that fusion of dendritic cells(DCs) and tumor cells is able to activate autologous T lymophocytes to generate specific cytotoxic T lymphocytes in vitro. However, its efficacy in inducing specific anti-tumoral immunity in vivo has not been well-documented.

Aims. Using severe combined immunodeficiency(SCID) murine model of reconstructed human immune system, the ability of fusion of HCC patient-derived DCs and HCC cells to induce specific immunity against HCC in vivo was evaluated.

Methods. Human immune system was reconstructed on SCID mice by intra-peritoneal injection of peripheral blood lymphocytes from HCC patients, ie, hPBL-SCID murine model. Fusion of HCC patient-derived DCs and Co60-irradiated HepG2 cells (DCs/HepG2) was achieved by 50% polythyleneglycol. hPBL-SCID mice were vaccinated with DCs/HepG2, Co60-irradiated HepG2, DCs + Co60-irradiated HepG2 and DCs, respectively, and then challenged with subcutaneous inoculation of HepG2. Tumor growth in SCID mice was monitored. Serum levels of human IL-2, IL-12, ∣Ã-INF and AFP in SCID mice were detected. Cytotoxicity of SCID mice-derived splenocytes against HepG2 was evaluated.

Results. Fusion of DCs and HepG2 cells was confirmed by fluorescence microscopic examination. HepG2 Tumor growth on SCID mice was dramatically inhibited in DCs/HepG2 group, compared with HepG2 group, HepG2 + DCs group and DCs group (p < 0.01). Serum levels of human IL-2, IL-12 and ∣Ã-INF in mice were significantly greater in DCs/HepG2 group as compared with HepG2 group, HepG2 + DCs group and DCs group (p < 0.05). DCs/HepG2 group has a markedly lower serum AFP level than HepG2 group, HepG2 + DCs group and DCs group (all p < 0.05). Splenocytes from DCs/HepG2 group had significantly greater cytotoxicity against HepG2 as compared with HepG2 group, HepG2 + DCs group and DCs group (all p < 0.05).

Conclusions. Fusion of HCC patient-derived DCs and HCC cells was capable of inducing specific antitumoral immunity in vivo, and represented as a promising approach for HCC immunotherapy.

FP 16.06

ISOLATION AND CHARACTERIZATION OF A NOVEL SUBSET OF ED2 (CD163)^dimHEPATIC MACROPHAGES DISTINGUISHABLE FROM CONVENTIONAL KUPFFER CELLS IN RAT LIVERS

Wu, Gordon; He, Yao; Sadahiro, Tomohito; Klein, Andrew

Cesars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, United States

Introduction. We previously identified 2 subsets of ED2+ cells from rat livers using flow cytometry.

Objective. The current study was designed to define the phenotypic and functional properties of these 2 macrophage subsets.

Methods. An ED2^high and ED2^dim subgroup of hepatic macrophages were isolated from normal and cholestatic livers by FACS and subjected to phenotypic and functional characterization. Expression of genes relating to myeloid lineage differentiation, inflammatory cytokines and ECM remodeling enzymes was studied using quantitative real time PCR.

Results. The ED2^high cells in culture exhibited morphology, growth pattern and phagocytic activity consistent with the general description of Kupffer cells. The ED2^dim cells were smaller in size, monocyte-like in cellular morphology and weak in phagocytosis. Transmission electron microscopy demonstrated that both subsets of ED2+ cells are characteristic of monocyte/macrophage origin. In addition to expression of low levels of macrophage-related surface markers such as CD14, CD68, and CD163, the ED2^dim cells expressed mRNA encoding for myeloid lineage differentiation markers ERMP12 and ERMP20 but not markers for T (CD3), B (CD19) and NK (CD94) cells. ED2^dim cells isolated from cholestatic livers induced by bile duct ligation expressed higher levels of, when compared with ED2^high cells, TNFα(3-fold > ED2^high, p = 0.02), IFNγ (11-fold, p = 0.018), RANTES (7-fold, p = 0.02), TIMP1 (3-fold, p = 0.004) and MMP9 (2-fold, p = 0.037), but lower levels of IL1β (1/4-fold that of ED2^high, p = 0.003) and Fucose receptor ( 1/3 fold, p = 0.04).

Conclusion. The ED2^dim cells appear to be a novel subset of hepatic macrophages which exhibits morphology, phenotype and function distinguishable from classic Kupffer cells. The fact that the ED2^dim cells expressed high levels of inflammatory cytokines (TNFα, INFγ and RANTES) and ECM remodeling enzymes (TIMP1 and MMP9) suggests that these cells may play an important role in liver inflammation and tissue repair.

FP 16.07

CHOLESTASIS ENHANCES COAGULATION DISTURBANCES DUE TO ISCHEMIA REPERFUSION INJURY

Kloek, Jaap¹; Levi, Marcel²; Heger, Michal¹; Gouma, Dirk¹; van Gulik, Thomas¹

¹Academic Medical Center, Department of Surgery, Amsterdam, Netherlands; ²Academic Medical Center, Department of Internal Medicine, Amsterdam, Netherlands

Background. Cholestasis is associated with increased morbidity and mortality in patients undergoing major liver surgery. An additional risk is induced when vascular inflow occlusion is applied giving rise to liver ischemia reperfusion (I/R) injury. I/R injury ultimately leads to microcirculatory perfusion failure. The role of the coagulation system in this type of injury is relatively underexposed.

Objective. The aim of this study is to determine the effects of hepatic I/R injury on the coagulation system in cholestatic rats.

Methods. Wistar rats were randomized into 2 groups: The 1st group (n = 24) was subjected to 30m partial liver ischemia 7 days after bile duct ligation (BDL); the 2nd (control) group (n = 24), was subjected to ischemia without preceding BDL (sham laparotomy). Animals were sacrificed pre-I/R and after 6, 24, and 48h reperfusion. Liver damage parameters, activation of coagulation and fibrinolysis were assessed before and after I/R.

Results. Serum AST and ALT levels were higher after 6 and 24h of reperfusion in cholestatic rats (P < 0.05). Hepatic necrosis, wet/dry ratios of liver tissue and neutrophil influx measured by myeloperoxidase activity were increased in the cholestatic group after up to 48h reperfusion (P < 0.05). Liver synthetic function was decreased in the cholestatic group as reflected by prolonged prothrombin time at 6 and 24h reperfusion (P < 0.05). Furthermore, cholestasis resulted in a significant augmentation of ischemia-induced activation of coagulation. I/R in cholestatic rats resulted in a 12fold vs. 7fold (P < 0.01) increase in markers for thrombin generation, (thrombin-antithrombin (TAT) complex levels) and a 6fold vs. 2fold (P < 0.01) increase in fibrin degradation products (FDP), (cholestatic vs. control, resp.). In addition, the cholestatic rats showed significantly increased levels of plasminogen activator inhibitor (PAI-1) after 6 and 24h reperfusion.

Conclusions. Liver I/R injury including disturbance of the coagulation system is severly enhanced in the presence of cholestasis.

FP 16.08

BUCILLAMINE INHIBITS NEUTROPHIL ACTIVATION AND DECREASES LIVER WARM ISCHAEMIA REPERFUSION INJURY

Junnarkar, Sameer¹; Tapuria, Niteen²; Mani, Ali Reza³; Fuller, Barry²; Seifalian, Alexander²; Davidson, Brian²

¹Royal Free And University College Medical Schooll, Academic Department of Surgery, London, United Kingdom; ²Royal Free Hospital, London, United Kingdom; ³Royal Free And Universdity Hospital Medical school, Academic Department of Medicine, London, United Kingdom

Introduction. Liver t ransplantation and resection surgery involve a period of ischaemia and reperfusion to the liver which initiates an inflammatory cascade resulting in liver and remote organ injury. Bucillamine is a low molecular weight thiol antioxidant that is capable of rapidly entering cells. Our previous studies have shown that bucillamine reduces warm ischaemia reperfusion injury in liver. Hypothesis- Bucillamine may reduce warm ischaemia reperfusion injury by reducing neutrophil activation.

Aim. To use a well described model of liver ischaemia reperfusion to determine the effect of Bucillamine administration on neutrophil adhesions and cytokine production. Neutrophil activation is explored as possible mechanism.

Materials and Methods. Effect of bucillamine was studied in a rat model of liver ischaemia- reperfusion injury with 45 minutes partial (70%) ischaemia and 3 hours reperfusion. Liver injury was assessed by serum transaminases (AST and ALT) and propidium iodide staining of apoptotic hepatocytes on intravital microscopy. Leukocyte adhesions were assessed on Intravital microscopy. Cytokine response was assessed by measuring serum CINC-1 levels. Results- The model produced a significant liver injury with elevated Transaminases and an acute inflammatory response. Bucillamine reduced the liver injury as indicated by a reduced AST (932±200.8 vs. 2072.5±511.79, p < 0.05) and ALT (861.4±262.63 vs. 2079.25±322.33, p < 0.05). The number of apoptotic cells at the end of 3 hours of reperfusion was also significantly lesser in the Bucillamine group (p >0.001). Serum CINC-1 levels were found to be lesser in animals given Bucillamine with a very significant difference at 24 hours post reperfusion (p < 0.001). There also was significantly lesser neutrophil adhesion in the Bucillamine group at the end of 3hours of reperfusion.

Conclusions. Bucillamine therapy reduces the deranging effects of warm ischaemia reperfusion y inhibiting neutrophil activation.

FP 16.09

METHOXYPOLYETHYLENE GLYCOL MODIFIED -ALBUMIN (PEG-Alb) ENHANCED THE COLD PRESERVATION PROPERTIES OF UW SOLUTION IN RAT LIVER GRAFTS.

Sanabria, Juan¹; Abbas, Rime¹; Dingam, David²; Malholtra, Deepak²; Brunengraber, Henry¹

¹University Hospital-Case Medical Center, Surgery, Cleveland, United States; ²University of Toledo Medical Center, Biochemistry, Toledo, United States

Background. Liver grafts preserved in cold undergo changes mainly manifested by morphological changes of the sinusoidal endothelium. Swollen and fragmented cytoplasm translates into poor portal blood flow, increase release of liver enzymes and low bile production upon liver reperfusion.

Aim. To determine if the addition of higher molecular weight polyethylene glycol modified albumin to the University of Wisconsin (UW) preservation solution ameliorates the cold preservation injury of liver grafts.

Methods. Mehtoxypolyethylene glycol 5000 activated with cyanuric chloride was covalently coupled to human albumin (Peg-Alb) at multiple sites. The Isolated Perfused Rat Liver model was used (IPRL). Human and Rat hepatocytes cell lines were preserved in cold under similar preservation solutions. Effects were studied after rewarming of cells on Glutathione turn over by mass spectrometry. Apoptosis of SLC's on liver tissue and cell lines were evaluated by Tunel assay and flowcytometer techniques. Table 1. IPRL results of grafts preserved with UW solution and UW solution plus PEG- Alb. Group (n = 4) Portal Blood flow AST Bile production ml/g of liver/minute U/g of liver ul/g of liver Control neg UW (1h) 0.93 + 0.033** 2.1 + 1.08** 10.5 + 5.97 Control pos UW (30h) 0.19 + 0.010 14.4 + 0.34 0 + 0 PEG-Alb & UW (30h) 0.98 + 0.005** 28.4 + 1.03 3.5 + 7.54 Alb & UW (30h) 0.05 + 0.007 26.9 + 2.45 0 + 0 ** p < 0.05 by ANOVA Preliminary results showed Gluthatione turnover was significantly decreased in all groups compared to negative controls. In contrast, apoptosis of SLC was similar in the PEG-Alb group when compared to the negative control group but significantly decreased in the PEG-Alb group when compared to other groups.

Conclusions. The addition of high molecular albumin to UW preservation solution appears to ameliorate endothelial injury of cold preserved liver grafts as judged by better portal vein blood flow, increased bile production and decreased SLC apoptosis in well preserved hepatocytes.

FP 17.01

SURGICAL AMPULLECTOMY: A SAFE AND COMPLETE TREATMENT OF PRESUMED BENIGN AMPULLOMAS

Sauvanet, Alain¹; Lesurtel, Mickaël¹; Goasguen, Nicolas¹; Ponsot, Philippe²; Couvelard, Anne³; Palazzo, Laurent²; Ruszniewski, Philippe²; Belghiti, Jacques¹

¹Hospital Beaujon, HPB Surgery, Clichy, France; ²Hospital Beaujon, Gastroenterology, Clichy, France; ³Hospital Beaujon, Pathology, Clichy, France

Aims. Presumed benign ampullomas (PBA) can be treated by pancreaticoduodenectomy (PD), or endoscopic/surgical ampullectomy (SA). SA needs to exclude preoperatively invasive carcinoma (Ca.) and aims to obtain tumor-free margins to avoid the need for subsequent PD. This study evaluated both feasibility and results of SA.

Methods. From 1995 to June 2007, 34 patients (age: 38–79 yrs) underwent SA for PBA revealed by pain/cholangitis (n = 11), pancreatitis (n = 5), fortuitously (n = 17) or during follow-up after SA. All 34 patients underwent side-viewing duodenoscopy with biopsies and endoscopic ultrasound (EUS). Preoperative biopsies revealed low-grade (LGD; n = 22) or high-grade (HGD; n = 6) dysplasia adenoma, or inflammatory/normal mucosa (n = 6). EUS staging was uT1N0 in all cases. Intraoperative frozen section (FS) was done routinely on resection margins. Patients were informed of the need for PD in case of invasive Ca. on definitive pathologic examination.

Results. One patient (3%) had immediate conversion into PD (gross aspect suggestive of invasive Ca. confirmed by FS). Four intraoperative complications (3 duodenal disinsertions, one pancreas divisum unrecognized preoperatively) were successfully treated. At FS, 6 biliary sections and 3 pancreatic ductal margins were tumor-positive, that led to perform 9 additional ductal resections (all tumor-free at FS). Size of PBA ranged from 8 to 65mm (mean: 20 mm). There was no mortality and postoperative course was uneventful in 25 patients (76%). Definitive pathologic examination revealed R0 resection (n = 33) including 22 adenomas (14 LGD, 8 HGD), 5 micro-invasive Ca. (T1NOD0), one invasive Ca. (T1NOD1, general condition precluding PD), and 5 others benign lesions. With a median 24 months follow-up (range: 3–72), 3 (9%) patients had symptoms. Tumor recurrence occurred in 3 (9%) (no reoperation).

Conclusions. SA with routine FS can treat PBA with no mortality, less morbidity than PD and tumor-free margins. After complete endoscopic work-up, probability of subsequent PD is very low.

FP 17.02

OUTCOMES OF PANCREATIC SURGERY IMPROVE AFTER ESTABLISHING A HEPATO-PANCREATO-BILIARY SERVICE IN A COMMUNITY HOSPITAL

Mittal, Vijay; Kansakar, Erina; Chang, Yeon-Jeen; Jacobs, Michael; Silapaswan, Sumet; Ferguson, Lorenzo A.; Kestenberg, William; Mittal, Vijay

Providence Hospital and Medical Centers, Surgery, Southfield, United States

Background. Hepato-Pancreato-Biliary (HPB) surgeries are complex procedures with high rates of complications, which require a good institutional system that can effectively minimize the morbidity and mortality of these patients. A HPB service comprises a team of surgeons, fellows, nurse practitioners, medical oncologists, radiation oncologists, interventional radiologists, gastroenterologists and operating room staff.

Objective. To assess the patient and institutional advantages of establishing a HPB service for pancreatic cancer patients.Method.: Patients undergoing pancreatoduodenectomy at Providence Hospital and Medical Centers were included in the study. Length of stay (LOS), institutional costs, morbidity and mortality, and patient satisfaction were compared between 1990–1999 and 2000–2007 when a HPB service was implemented.

Results. A total of 217 pancreatic carcinomas were diagnosed during 1990–1999, as compared to 330 cases during 2000–2007. The total number of pancreatoduodenectomies increased from 32 cases (15% of total) during 1990–1999 to 103 (31% of total) in 2000–2007. Average Whipple's procedure increased from 3.5 cases to 14 cases per year. The LOS decreased 40% from an average of 21 days to 12 days. Mortality rate decreased from 3.1% to 0%. Morbidity decreased from 62.5% to 25%. Institutional costs decreased from $35,500 to $ 28,000 per patient. Overall patient satisfaction had increased during 2000–2007.

Conclusions. Establishing a HPB service has improved the cost-effectiveness of our institution in treating patients with pancreatic disease. Due to this HPB service, patients receive focused and efficient care. Such a ser vice should be implemented in all community hospitals.

FP 17.03

THE ANALYSIS OF AGE STANDARDIZED MORTALITY RATES FOR PANCREATIC CANCER ACROSS THE WORLD

Saied, Abdouslam¹; Hariharan, Deepak¹; Patel, Bijendra¹; Kocher, Hemant²

¹Barts & the London School of Medicine & Dentistry, Institute of Cancer, London, United Kingdom; ²The Royal London Hospital, Barts and the London HPB centre, London, United Kingdom

Background. Pancreas cancer is the fourth commonest cause of cancer related mortality across the world, with incidence equalling mortality.Method.: Age-Standardized (world) mortality Rate [ASR (W)] for pancreatic cancer were extracted separately for males and females from a data base maintained by International Agency for Research on Cancer for 51 countries across the world (Europe-33 countries, Americas-8 countries and Asia-10 countries) and trends analysed for the period 1960– 2002; as well as the last decade available (1992–2002).

Results. From 1960–2002, the ASR (W) due to pancreatic cancer showed a steady increase across all the countries studied with more male deaths than female deaths. North America [ASR range (W) 6–8] and countries in central Europe [ASR (W) range 8–12] showed highest mortality for both sexes. However, the period 1992–2002, the ASR (W) remained static across most countries for both sexes. The highest mortality rates (for both sexes) were seen in Central Europe [range: men (8–12), women (4.5–7)] while Canada was the only country that showed a decline [men (7.5 to 6.4), women (5.9 to 5)].

Conclusion. Our results indicate that though there was an initial increase in ASR (W) for pancreatic cancer, the change has not been seen in the last decade. This probably reflects standardisation and consolidation of diagnostic tests for pancreatic cancer.

FP 17.04

PANCREATIC LEAK: WHAT HAVE WE LEARNT?

Bhange, Snehal; Patil, Bhushan; Singh, Rajinder; Adhikari, Devbrata; Shetty, Tilakdas; Joshi, Rajeev

T. N. Medical College & B.Y.L. Nair Ch. Hospital, General Surgery, Mumbai, India

Background. “God put the pancreas in the back, because he did not want surgeons messing with it”- Harold Ellis. Pancreatic surgeries are associated with high operative morbidity and mortality mostly due to pancreatic leak.

Objective. Compare the leak rates following pancreatic surgeries and look for an association between local recurrence and pancreatic leak in malignancy. Is occurrence of a leak an independent predictor of disease free survival (DFS) after curative resection?

Method. Records of 261 patients (126 pancreatico-duodenectomies and 135 cases of surgeries for benign pancreatic disorders) were analysed from February 1999 to July 2007.

Result. Clinically significant leak was present in 22 patients. 20 cases were following pancreatico-duodenectomy, 1 each were following enucleation of insulinoma and necrosectomy. Trivial leaks were seen in 18 cases, 14 following pancreatico-duodenectomy, 3 following distal pancreatectomies and 1 following a Puestow's procedure. Of the 22 significant leak cases, 2 had to be re- explored, 5 succumbed while the rest were successfully managed conservatively as were the trivial leaks. Leak rate following pancreatico-duodenectomy was 26.98% (34/126) and mortality was 7.93%(10/126) while for benign pathologies it was 4.44%(6/135) and 1.48% (2/135) respectively which was statistically significant. Of 34 patients with leak following pancreatico-duodenectomy, 26 had DFS of 1 year or less (76.47%) and on imaging and biopsy they were found to have local recurrence. Of the remaining 92 patients only 8 (8.69%) had recurrence at 1 year or less and this too was statistically significant.

Conclusion. Leak rate is significantly higher following surgeries for malignancies and is associated with higher mortality. Based on our small cohort it was also seen that leaks are associated with a lower DFS. We postulate that the occurrence of a leak could be an independent predictor of diminished DFS and this needs to be validated by larger study groups.

FP 17.05

A SIMPLE INFLAMMATION –BASED PROGNOSTIC SCORE IS AN INDEPENDENT PREDICTOR OF SURVIVAL IN AN UNSELECTED SEQUENCE OF 252 PATIENTS WITH PANCREATIC CANCER

McMillan, DC; Jamieson, NB; Glen, P.; Carter, R; McKay, C.J.; Imrie, Clem

Glasgow Royal Infirmary, Lister Department of Surgery, Glasgow, Scotland, United Kingdom

Background. The outlook for patients with ductal adenocarcinoma of the head of the pancreas remains poor, having the lowest 5-year survival rate of any cancer. Selection of patients for either surgery, palliative chemotherapy or supportive care is of crucial importance. There is increasing evidence that the presence of a systemic inflammatory response plays an important role in predicting survival in patients with cancer. This has recently been formalised in an inflammation based prognostic score, modified Glasgow Prognostic Score (mGPS, 0 = C-reactive protein <10 mg/l, 1 = C-reactive protein >10 mg/l and 2 = C-reactive protein >10 mg/l and albumin < 35g/l)1. The aim of the present study was examine the value of the mGPS in an unselected cohort of patients with pancreatic cancer. Study: Of our 252 patients; 65 underwent potentially curative resection, 59 had a palliative bypass procedure and 128 palliative treatment only. On follow-up 241 (96%) patients died of their cancer. On univariate survival analysis age (p < 0.05), clinical TNM stage (p < 0.001), mGPS (p < 0.001) and treatment (p < 0.001), were associated with cancer specific survival. On multivariate survival analysis of the significant variable only age (HR 1.28, 95% CI 0.99–1.65, p = 0.062), clinical TNM stage (HR 1.62, 95% CI 1.34–1.97, p < 0.001) and the mGPS (HR 1.54, 95% CI 1.32–1.80, p < 0.001) were independently associated with cancer specific survival.

Conclusion. These results support the inclusion of the assessment of the systemic inflammatory response, the mGPS, in the routine pre-treatment assessment of patients with pancreatic cancer. The mGPS may impact future treatment algorithms.

FP 17.06

THE USE OF A WOUND PROTECTOR LOWERS SURGICAL SITE INFECTION RATES AFTER PANCREATICODUODENECTOMY

Stokes, Jayme B; Swenson, Brian R; Bauer, Todd W; Adams, Reid A

University of Virginia, Department of Surgery, Charlottesville, VA, United States

Background. Surgical site infections remain the third most common complication of pancreaticoduodenectomies.

Objective. To evaluate the effects of a wound edge protector on surgical site infection rates following pancreaticoduodenectomy.

Methods. Wound edge protectors were implemented at our institution on all PDs occurring after September 2004. Patients undergoing pancreaticoduodenectomy 30 months prior to and after this date were identified. A retrospective review of prospectively collected database was performed, and demographic, medical history and 30 day surgical outcomes data were recorded. Surgical site infections were defined in accordance with the Centers for Disease Control guidelines.

Results. Ninety-seven pancreaticoduodenectomies were performed between June 2002 and March 2007. Forty-six patients underwent surgery without a wound protector (control group), while 51 patients protectors placed. Both groups were similar with regards to demographics, medical and social history, previous radiotherapy and chronic steroid use. Preoperative skin prep and perioperative antibiotic use was the same in both groups. Patients in the control group were more likely to have an ASA greater than 2 (p = 0.02). The SSI rate was 28% in the control group and 11.7% in the wound protector group (p < 0.05). Patients with wound protectors were less likely to develop superficial wound infections (5.9% vs. 19.6%; p < 0.05). There was an absolute reduction in deep wound and organ space infections; however, these did not reach statistical significance due to the small sample size. There was no correlation between demographic or perioperative characteristics that were more likely in the SSI group.

Discussion. In our study, the addition of wound protectors reduced SSI rates after pancreaticoduodenectomy by more than 50% suggesting that intraoperative contamination of the wound edge plays a large role in the development of SSI. Additional prospective studies are needed to further evaluate these findings.

FP 18.01

LIVING LIVER DONOR MORTALITY UPDATE-TIME FOR A REGISTRY

Ringe, Burckhardt¹; Strong, Russell²

¹Drexel University College of Medicine, Center for Liver, Biliary and Pancreas Disease, Philadelphia, United States; ²University of Queensland, Princess Alexandra Hospital, Brisbane, Australia

Living donation has become a life saving option for end stage liver disease patients who have no chance of receiving a deceased donor organ. Although donor safety has always been the major concern, there is no accurate information on donor deaths. The authors reviewed the medical literature, to update the worldwide living liver donor mortality rate. To verify the accuracy of the information a certainty (C) level was assigned to each source: C1, direct report by member representing the transplant program where the fatality occurred; C2, indirect publication by author not involved in the care; and C3, information based on verbal presentation or personal communication. A total of 33 living liver donor deaths could be identified. 12 cases were classified as C1: donor deaths and programs identified, and details of the complications published. There were 8 C2 fatalities, and 13 cases were considered C3. During the International Liver Transplantation Society Meeting held in June 2007, four more deaths could be added to the cases collected previously by the authors. 8 deaths occurred in Europe, 8 in North America, 5 in South America, 10 in Asia, and 2 in Africa. Based on estimated 13,700 living donor liver transplants performed, the donor death rate is at least 0.1–0.3%. Only C1 cases allowed to characterize donor risk factors: preoperative medical conditions, psychosocial abnormalities, right lobe donation, and postoperative surgical complications. In order to maintain informed consent and confidence in this procedure, it is imperative to report all living donor deaths. Unfortunately, the discrepancy between published and unpublished cases has not changed, and the dilemma of rumor versus facts prevails. As long as the information available is incomplete, it seems justified to publish reviews like this, however, the only way to get accurate information is direct reporting by the transplant program where the fatality occurred. It is time for an international living donor mortality registry.

Table 1.

	Control (n = 46)	Wound Protector (n = 51)	p-value
Female Gender	21 (45.7%)	31 (60.8%)	0.14
Age (years)	62.9 (+12.3)	61.6 (+13.4)
Minority Race	7 (15.2%)	3 (5.9%)	0.18
Past Medical History
Diabetes	11 (23.9%)	12 (26.1%)	0.81
Smoking	32 (69.6%)	32 (62.8%)	0.88
Alcohol Use	1 (2.2%)	2 (4.4%)	1.00
COPD	5 (10.9%)	2 (4.4%)	0.23
Recent Weight Loss	5 (10.9%)	6 (13%)	0.75
Chronic Steroid Use	2 (4.4%)	3 (6.5%)	1.00
Previous Radiotherapy	1 (2.2%)	0 (0%)	0.49
Body Mass Index > 25	23 (50.0%)	21 (40.4%)	0.45
ASA >2	24 (52.2%)	15 (29.4%)	0.02
Elevated Creatinine	1 (2.2%)	0 (0%)	0.51
Decreased Albumin	2 (4.4%)	7 (13.7%)	0.16
Malignant Pathology	42 (91.3%)	44 (86.3%)	0.44
OUTCOMES
Surgical Site Infection	13 (28%)	6 (11.7%)	0.04
Superficial	9 (19.6%)	3 (5.9%)	0.041
Deep Space	3 (6.5%)	0 (0%)	0.064
Organ Space	1 (2.2%)	3 (5.9%)	0.359

FP 18.02

ROLE OF INTRAOPERATIVE CONTINUOUS RENAL REPLACEMENT THERAPY IN LIVING DONOR LIVER TRANSPLANTATION

R, Anand¹; Kakodkar, Rahul¹; Kumaran, Vinay¹; Saigal, Sanjiv²; Saraf, Neeraj²; Nundy, Samiran¹; Soin, Arvinder S¹

¹Sir Ganga Ram Hospital, Surgical Gastroenterology & Liver Transplantation, New Delhi, India; ²Sir Ganga Ram Hospital, Gastroenterology, New Delhi, India

Background. Renal dysfunction in patients with end-stage liver disease has been traditionally associated with a grim prognosis, sometimes even precluding liver transplantation. Recent studies have suggested that patients with pretransplant renal dysfunction requiring perioperative renal replacement therapy can be managed effectively and achieve reasonable survival. However, the impact of increased metabolic demand caused by renal failure on a partial graft and eventual outcome in patients undergoing living donor liver transplant (LDLT) is not clear.

Aim. To evaluate the role of intraoperative continuous renal replacement therapy (CRRT) in the outcome of patients with preoperative renal dysfunction undergoing living donor liver transplantation.

Methods. Prospectively maintained database of 150 consecutive patients undergoing LDLT at a single center between January 2005 and May 2007 was reviewed. Patients with pre-operative renal dysfunction (serum creatinine > 2 mg/dl) and/or oliguria due to hepatorenal syndrome were given elective intraoperative CRRT by continuous veno-venous hemofiltration (CVVH). Patients developing renal failure in the postoperative period requiring renal support were excluded. Indications for liver transplant and renal support, operative details and postoperative course were studied.

Results. Five patients (4 chronic liver disease, 1 acute liver failure) required CVVH. Median MELD score was 16 (14–36). CVVH was discontinued in all patients postoperatively by 48 hours, as adequate urine output was established. There was no postoperative mortality. At a median follow-up of 222 days (119–287), all patients have satisfactory liver graft and kidney function.

Conclusion. Intraoperative CRRT is a feasible and well-tolerated modality which allows otherwise high-risk patients with renal dysfunction to undergo live donor liver transplant without additional morbidity or mortality.

FP 18.03

LIVING DONOR LIVER TRANSPLANTATION: A EUROPEAN LIVER TRANSPLANT REGISTRY (ELTR) REPORT ON 2043 CASES

Adam, René¹; Karam, Vincent¹; Rogiers, Xavier²; Tokat, Yaman³; Lerut, Jan⁴; Broelsch, Christopher⁵; Neuhaus, Peter⁶; De Hemptine, Bernard⁷; Castaing, Denis¹; O'grady, John⁸; Kalicinski, Piotr⁹; Boillot, Olivier¹⁰; Klempnauer, Jurgen¹¹; Revillon, Yann¹²; Belghiti, Jacques¹³; Garcia-Valdecasas, Juan¹⁴; Burra, Patrizia¹⁵

¹Hôpital Paul Brousse, Centre Hépatobiliaire, Villejuif, France; ²Universitatskrankenhaus Eppendorf, Dept of Hepatobiliary Surgery, Hamburg, Germany; ³Ege University Medical School, 4Department of Surgery-Division of Hepatobiliary, Izmir, Turkey; ⁴Catholic University of Louvain, Cliniques Universitaires Saint Luc, Brussels, Belgium; ⁵C. U. K. GHs Essen, Klinik für Allgemeine und Transplantationschirurgi, Essen, Germany; ⁶Charité- Campus-Virchow klinikum, Klinik für Allgemein-Viszeral- und Transplantation, Berlin, Germany; ⁷Universitair Ziekenhuis, Dienst voor Levertransplantatie en Digestieve Heel, Ghent, Belgium; ⁸King's College Hospital, Transplantation Unit, London, United Kingdom; ⁹Children's Memorial Health Institute, Department of Pediatric Surgery and Organ Transpla, Warsaw, Poland; ¹⁰Hôpital Edouard HERRIOT, Unité de transplantation hépatique, Lyon, France; ¹¹Medizinische Hochschule Hannover, Klinik für Viszeral-und Transplantationschirurgie, Hannover, Germany; ¹²CHU Necker Enfants Malades, Sce de Chirurgie Infantile, Paris, France; ¹³Hôpital BEAUJON, Sce de Chirurgie Digestive, Paris, France; ¹⁴Hospital Clinic I Provincial de Barcelona, Barcelona, 16Gastrointestinal Surgery Department, Barcelona, Spain; ¹⁵Universitat degli Studi di Padova, Department of Surgery & Gastroenterological Scienc, Padova

Living Donor Liver Transplantation (LDLT) is increasingly used in Europe but results concerning donor and recipient outcome have not been extensively evaluated. From October 1991 to June 2006, LDLT accounted for 2043 of the 63552 (3%) transplants performed in 71 centers. We compared the outcome of LDLT to that of Full Size Cadaveric Liver Transplantion (FSCLT). LDLT that was initially reserved for pediatrics is now used mainly in adults (71% of cases in 2005). The right liver was donated to 91% of adults and the left lobe was donated to 85% of children. Overall 5-yr graft and patient survivals were 67% and 73%, and were better in children (76% and 83%) than in adults (55% and 63%-p < 0.01). At a range from 2–32 days following LDLT, mortality occurred in 4 of the 2043 donors (0.2%) due to pulmonary embolism (1), sepsis (2) and cardiac failure (1). Early donor morbidity (3 months) was 21%. As compared to FSCLT performed during the same period, LDLT was used more often for cancers (23% vs 13%, p < 0.01) and less often for fulminant hepatitis (3% vs 7%, p < 0.01) and retransplantation (2% vs 10%, p < 0.01). In children, 5-yr graft and patient survivals were better with LDLT than with FSCLT, (76 and 83% vs 69% and 81%–p < 0.01). By contrast, in adults, survivals were lower than those of the FSCLT (55% and 64% vs 62% and 69%-p < 0.01). In conclusion, although LDLT represents only 3% of all transplants, it has significantly performed over time. Donor mortality is 0.2% with an early morbidity of 21%. Disparities in graft and patient survivals are likely due to differences in the indications for transplantation, including more frequent application of LDLT to adult patients with cancer. Website: www.eltr.org

FP 18.04

Biliary compications after living donor liver transplantation -cause and treatment

Tashiro, Hirotaka; Itamoto, Toshiyuki; Amano, Hironobu; Ohdan, Hideki; Oshita, Akihiko; Ishiyama, Kohei; Asahara, Toshimasa

Hiroshima University, Surgery, Hiroshima, Japan

Background. In living-donor liver transplantation (LDLT), biliary complications are recognized as a significant cause of post-transplantation morbidity.

Methods. Ninety patients who underwent LDLT with duct-to-duct biliary reconstruction at Hiroshima University Hospital were enrolled in this study. The mean follow-up was 24 months (range, 3–76 months). 24 patients underwent the basiliximab-based immu nosuppressive therapy and 66 patients underwent non-basiliximab-based immunosuppressive therapy. The development of biliary complications after LDLT was retrospectively analyzed. Biliary complications were initially treated by endoscopic or radiological modalities.

Results. Biliary leakages and strictures occurred in 13 (14%) and 26 (29%) of the 90 patients, respectively. Stepwise multivariate analysis demonstrated bile leakage to be an independent risk factor for the development of biliary stricture (p = 0.001) and basiliximab-based immunosuppressive therapy to be an independent protective factor for postoperative biliary leakage (p = 0.005). The total one-week total doses of steroids were significantly lower in basiliximab-based immunosuppressive regimes (mean dose, 545mg) than in non-basiliximab-based ones (mean dose, 1060mg) (p = 0.01). All patients with biliary leakage were successfully treated with endoscopic or radiological modalities except two patient who was treated by surgical treatment. Endoscopic or radiological modalities were successful as primary treatment modalities in 17 (65%) of 26 patients with biliary strictures. Lastly, 7 patients were treated surgically with long-term success, except for one patient with chronic cholangitis who died after 16 months.

Conclusions. Steroid-sparing basiliximab-based immunosuppressive therapy reduced the incidence of biliary leakage and biliary leakage was the independent factor for biliary stricture. The non-surgical and surgical treatments for biliary complications were satisfactory.

FP 18.05

REFINED PROCEDURES FOR LEFT LOBE GRAFT PROCUREMENT FROM LIVING DONORS

Shimada, Mitsuo; Ikegami, Toru; Imura, Satoru; Morine, Yuji; Kanemura, Hirofumi; Arakawa, Yusuke

The University of Tokushima, Department of Surgery, Tokushima, Japan

Introduction. Major obstacle in adult-to-adult living donor liver transplantation (LDLT) is requirement of larger grafts, which may jeopardize the donor safety. We have reported the feasibility of a left lobe graft including middle hepatic vein (MHV) and a left caudate lobe even in adult-to-adult LDLT (Arch Surg 2002, Transplant Int 2004, and Am J Transplant 2006). Our refinements both in donor evaluation and in donor surgery are introduced. Method: The donor was fully evaluated by 3D-liver image software, which calculates volume distribution of all the intrahepatic vessel branches. A part of the anterior segment, which is drained by the tributaries of MHV, was added to the left lobe graft. Surgical techniques were as follows: after minimal separation of the hilar structures, the first Glissonian pedicles were taped. After taping the infrahepatic inferior vena cava (IVC), a cotton tape was passed between the right and middle/left hepatic veins through on the IVC to the cranial side of the hilar plate, all enabling the hanging maneuver. aDivision of the hepatic parenchyma was performed just on the left side of the right anterior pedicle. After in situ bile leakage test, the cutting point of the left hepatic duct was secured by intraoperative cholangiography. Five living donors underwent left hepatic lobectomy by these techniques.

Results. The mean graft volume (GV) and the GV/standard liver volume ratio (GV/SLV) were 474g and 42.6%, respectively. A mean additional volume gain and its ratio to the standard left lobe volume were 42ml and 7.6%. Immediate graft function of these three patients was excellent. The CT scan performed on the 7th post-operative day confirmed excellent blood perfusion in the whole graft including the additional segment. Neither complication attributable to small-for-size graft nor this technique was observed.

Conclusions. Our refined method for the left lobe graft procurement from living donors is a promising approach to overcome the small graft and make further improvements in LDLT.

FP 18.06

OPEN DOOR POLICY OF LIVING DONOR LIVER TRANSPLANTATION FOR LIVER TUMOURS: PANACEA OR OVERKILL?

Soin, Arvinder S¹; R, Anand¹; Kakodkar, Rahul¹; Kumaran, Vinay¹; Saigal, Sanjiv²; Saraf, Neeraj²; Nundy, Samiran¹

¹Sir Ganga Ram Hospital, Surgical Gastroenterology & Liver Transplantation, New Delhi, India; ²Sir Ganga Ram Hospital, Gastroenterology, New Delhi, India

Background. While live donor liver transplantation (LDLT) is ideal for cirrhosis with small unresectable hepatomas without extrahepatic or gross vascular spread, its role is controversial in benign or metastatic liver tumours, resectable or large hepatomas, or HCC with segmental vascular spread.

Aim. To see if recipient/donor outcomes justify a liberal policy in accepting tumour patients for LDLT.

Methods. Of 179 liver tumour referrals for LDLT since 2004, 128 were not transplanted due to extrahepatic/gross vascular spread or lack of donors. 14 (12 HCCs, 2 hepatoblastomas) underwent resection (Group R). 37 patients had LDLT including 30 right and 7 left lobes. 14 were within Milan (Group M), 10 within UCSF (Group U), and 10 beyond these criteria (Group B). 3 non-cirrhotics had tumors (HCC, neuroendocrine metastases and hemangioendothelioma) replacing most of the liver. Posttransplant immunosuppression was Tacrolimus-based. 16 randomly selected patients were converted to Sirolimus at 2 months.

Results. Of 34 cirrhotics, 1 had Child's A, 9 Child's B and 24 Child's C disease. 11 had HBV, 21 HCV, 1 alcoholic, 1 tyrosinemia and 1 cryptogenic cirrhosis. One patient each had tumour thrombosis of segment 5 portal vein and segment 7 hepatic vein. Overall/disease free survival at a mean follow up of 16 months (1–40) were 91% (34/37) and 90% (33/37). Mortality was due to myocardial infarction on day 9 in 1 (Group M), pulmonary metastases at 4 months in 1 (Group B), and hepatic vein obstruction on day 27 in 1 (Group U). One Group U patient with seg 5 portal vein recurrence is alive at 40 months with scar recurrence. There was no recurrence/death in the Sirolimus group. In Group R, operative mortality was zero but HCC recurred in 4 (33%). The 2 hepatoblastoma patients are well at 4,27 months. All donors did well.

Conclusions. LDLT is worth doing for all HCC patients without extrahepatic/gross vascular invasion, and in those with large neuroendocrine secondaries and benign tumours replacing the liver. Resected HCCs often recur.

FP 19.01

DETERMINANTS OF OUTCOME AFTER PANCREATIC NECROSECTOMY

Kudari, Ashwinikumar; Doley, Rudraprasad; GSB, Kishore; Yadav, Thakur Deen; Gupta, Rajesh; Wig, Jai Dev

PGIMER, General Surgery, Chandigarh, India

Background. The aim of this study was to identify factors associated with outcome after pancreatic necrosectomy.

Methods. One hundred patients who underwent pancreatic necrosectomy from July 2002 to June 2007 were studied. Patients were divided into two groups, group A – patients who died after pancreatic necrosectomy and Group B- patients who survived after pancreatic necrosectomy. Various factors like age, sex, etiology, mean APACHE II score at admission, CTSI, pre operative percutaneous drainage of peripancreatic fluid collection, organ failure and the presence of infected pancreatic necrosis between two groups were studied.

Results. There were 28 patients in group A and 72 patients in Group B. The mean age of patients in group A and B 34.21 and 36.28 respectively. The initial median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 8.5 and 7.79 in group A and B respectively. Patients who died had higher APACHE II scores at presentation. Survivors had significantly longer times to surgery than those who died (P = 0.038). 15 patients in group A and 47 patients in group B underwent pre operative percutaneous drainage of infected peripancreatic collection and its effect on the outcome was not statistically significant (p = 0.279). 26 patients in group A and 70 patients in group B had infected pancreatic necrosis and the effect on outcome was not statistically significant (p = 0.317). All patients in group A and 9 patients in group B had multi organ failure. Presence of multiorgan failure was associated with increased mortality (p = 0.000). Logistic regression analysis showed that only postoperative APACHE II score and multiorgan failure were an independent predictor of increased mortality.

Conclusion. Increasing APACHE II score and presence of postoperative multiorgan failure were the most important predictors of outcome after pancreatic necrosectomy.

FP 19.02

GADOLINIUM CHLORIDE BUT NOT GLYCINE REDUCES HEPATIC AND PANCREATIC ORGAN INJURY IN ACUTE ALCOHOLTOXIC PANCREATITIS.

Schneider, Lutz¹; Hartwig, Werner¹; Longerich, Thomas²; Hackert, Thilo¹; Fritz, Stefan¹; Krych, Ralf¹; Gebhard, Martha-Maria³; Buchler, Markus W¹; Werner, Jens¹

¹University of Heidelberg, General Surgery, Heidelberg, Germany; ²University of Heidelberg, Department of Pathology, Heidelberg, Germany; ³University of Heidelberg, Department of Experimental Surgery, Heidelberg, Germany

Background. Alcoholic pancreatitis is associated with a high incidence of systemic complications. Hepatic Kupffer cells seem to mediate systemic complications in acute necrotizing pancreatitis. Destruction or blockade of Kupffer cells by GdCl3 or glycine are known to be hepato-protective in liver transplantation. The aim of our study was to evaluate the protective effects of Kupffer cell blockade in a model of acute necrotizing pancreatitis after chronic alcohol exposure.

Methods. Rats were feed for 6 weeks prior to induction of acute necrotizing pancreatitis with either alcohol or control diet without alcohol. Necrotizing pancreatitis was induced using intraductal GDOC and intravenous caerulein infusion. In the therapy group animals received either gadolinium chloride (10mg/kgKG) or glycine (1.5mmol/kgKG) prior to induction of acute necrotizing pancreatitis. Hepatic microcirculatory disturbances regarding leukocyte-endothelial-interaction and microperfusion as well as histomorphologic changes of the pancreas and liver were determined at 6 hours after induction of disease.

Results. Alcohol feeding leads to increased pancreatic and hepatic injury in acute necrotizing pancreatitis with high amounts of sticking leukocytes in hepatic venuoles and sinusoids. Gadolinium chloride and glycine reduced leukocyte sticking and improved microcirculatory perfusion of the liver. Hepatic and pancreatic organ damage was reduced by gadolinium chloride whereas glycine had no effects on histomorphologic changes.

Conclusions. Alcohol exposure aggravates pancreatic and hepatic injury in acute pancreatitis. Destruction of Kupffer cells by gadolinium chloride is effective in attenuating microcirculatory as well as histomorphologically derangements whereas Kupffer Cell inhibition by glycine does not reduce morphologic injury.

FP 19.03

GALANIN TYPE 2 RECEPTORS ARE INVOLVED IN CAERULEIN-INDUCED ACUTE PANCREATITIS IN THE MOUSE

Saccone, Gino¹; Zotti, Mario TG¹; Bhandari, Mayank¹; Schloithe, Ann C¹; Carati, Colin J²; Toouli, James¹

¹Flinders Medical Centre, Surgery, Bedford Park, Australia; ²Flinders Medical Centre, Anatomy and Histology, Bedford Park, Australia

Background. Acute pancreatitis (AP) is a common clinical condition and can be fatal. The mechanisms underlying the onset and progression of AP are incompletely understood. Our recent studies have implicated the neurotransmitter galanin in AP in a possum model. Galanin has 3 receptors (types 1, 2 and 3) however the receptor(s) involved in AP are unknown.

Objectives. Determine if galanin receptor 2 is involved in AP by treatment with a selective chimeric peptide antagonist, M871.

Methods. AP was induced in mice by 7 hourly intraperitoneal injections of caerulein (50µg/kg). For comparison, the non-selective galanin antagonist galantide (GT) was also tested. GT (40nmol/kg) or M871 (20 or 40nmol/kg) was administered with each caerulein injection. Control mice received GT (40nmol/kg) or M40 (40nmol/kg) or saline. Pancreata were harvested at 12 hours to measure myeloperoxidase activity, a marker of inflammation. Pre- and post-AP blood was collected to measure plasma amylase and lipase activities. M8971 was generously provided by U Sollenberg, Stockholm University. Statistically analysis utilised the Mann-Whitney test.

Results. M871 treatment did not alter the AP-induced plasma amylase or lipase activities, but the 40nmol/kg dose reduced myeloperoxidase by 54% (p < 0.05). GT treatment suppressed the AP-induced plasma amylase and lipase activity by 65% and 66% respectively and myeloperoxidase activity by 78% (all p < 0.05).

Conclusion. M871 reduced the AP-induced pancreatic myeloperoxidase activity suggesting that the galanin receptor 2 is involved. Treatment with GT was more effective in ameliorating AP implying that other galanin receptors are involved. Supported by BioInnovation SA, Flinders Technologies and the FMC Foundation.

FP 19.04

A SIMPLIFIED PROGNOSTIC SYSTEM FOR ACUTE PANCREATITIS. A 20-YEARS COMPARATIVE STUDY.

Secchi, Mario¹; Rossi, Leonardo¹; Quadrelli, Lisandro¹; Serra, Fernando²; Forte, Jose³

¹IUNIR-Medical School and HIG, Surgery, Rosario; ²Hospital Provincial, Surgery, Rosario, Argentina; ³HECA, Surgery, Rosario, Argentina

Introduction. In 1987 we proposed a new Prognostic System (Index) for predicting severity of AP. In 1992 a clinically-based classification system for Acute Pancreatitis (AP) was proposed at the Atlanta Symposium: severe cases were defined on the basis of an APACHE II and Ranson criteria.

Methods. 1132 patients having AP of any etiology were prospectively studied in four surgical centers over the last 20 years. Our original prognostic system (Index) included clinical and serological parameters: abdominal pain, ileus, ascitis, shock, creatininemia, calcemia, lipasemia, amylasemia, bilirubin, glycemia, and leukocytosis: a point from 0 to 2 or 3 given for each parameter according to its category; thus a healthy or cured patient was given 0 point, while a very seriously ill patient was given 20 points. The resulting sum is always divided by the maximum possible: 20; and so healthy or cured patients will average 0.00 and the most seriously ill patients 1.00. (severe cases:>0.40). 300 consecutive cases were prospectively studied to compare the new system with two standard score systems: APACHE II (equal or more than 8 points) (at day 1 and 2) and Ranson (equal or more than 3 points)(within two days after admission). We compared sensibility and specificity to predict a severe attack within two days of admission.

Results. 44 (14%) severe cases were confirmed when major organ failure occurred (complicated), and 258 (86%) cases were mild (uncomplicated). Etiology was lithiasic for 85% of cases. Sensibility to detect severe cases was 95% for our Index, 78% for APACHE II and 88% for Ranson. Specificity was 97% for Our index, 86% for APACHE II and 95% for Ranson. Positive Predictive Value was 0.95, 0.78 and 0.88, respectively. Kappa: 0.3224(NS) Ji2: 0.07(NS).

Conclusion. Our INDEX is a simple method with a high sensibility and specificity to predict severe attacks of AP as well as the other methods are, but provides daily clinical follow-up information for all patients with AP

FP 19.05

THE EFFECTS OF HYPERBARIC OXYGEN THERAPY ON LIPID PEROXIDATION IN A RAT MODEL OF SEVERE ACUTE PANCREATITIS

Koh, Shir Lin¹; Muralidharan, Vijayaragavan²; Christophi, Christopher²

¹The University of Melbourne, Surgery, Austin Health, Heidelberg, Australia; ²The University of Melbourne, Surgery, Heidelberg, Australia

Background. The annual incidence of acute pancreatitis is 30–40 per 100 000 population. Severe acute pancreatitis occurs in 15–20% of patients and is associated with significant tissue necrosis. There is evidence that ischemia-reperfusion plays a critical role in the pathogenesis of severe acute pancreatitis. During ischemia-reperfusion, there is an excessive release of radical oxygen species. This leads to lipid peroxidation of the acinar cells membranes. Hyperbaric oxygen has been shown to improve the survival rate of rats with severe acute pancreatitis.

Aim. This study investigates the effects of hyperbaric oxygen on lipid peroxidation in a rat model of severe acute pancreatitis.

Methods. Thirty male albino Wistar rats (250–300 g) were induced with the disease by biliopancreatic infusion of 0.1ml/100g of 4% sodium taurocholate at a constant pressure of 20mmHg. Rats were randomized for hyperbaric oxygen treatment. Endpoints were at days 1, 2 and 3 post-induction. Pancreas was macroscopically scored and collected for analysis at the endpoints. The level of malondialdehyde, an end product of lipid peroxidation, of the pancreas was measured by thiobarbituric acid reactive substances assay. The level of antioxidant enzyme, superoxide dismutase, in the rat serum was measured. Statistical analysis was performed with 2-independent sample T-test or Mann-Whitney test.

Results. Hyperbaric oxygen decreases the level of malondialdehyde on days 1 and 2. On day 3, the treated group shows a higher level of malondialdehyde. There is a trend of reduction in the level of malondialdehyde in the treated groups at earlier endpoints. However, there is no statistical difference between any groups. The level of superoxide dismutase was lower in the treated groups, showing a statistical significance on day 1 (p = 0.016).

Conclusion. Hyperbaric oxygen may improve the condition of severe acute pancreatitis by reducing the extent of lipid peroxidation.

FP 19.06

OUTCOMES FROM PERCUTANEOUS PANCREATIC NECROSECTOMY

Lochan, Rajiv¹; French, Jeremy J¹; Scott, John²; Rose, John²; Jackson, Ralph²; White, Steve A¹; Charnley, Richard M¹

¹Freeman Hospital, Hepato-Pancreato-Biliary Unit, Dept of Surgery, Newcastle upon Tyne, United Kingdom; ²Freeman Hospital, Dept of Radiology, Newcastle upon Tyne, United Kingdom

Introduction. Open pancreatic necrosectomy procedures are associated with significant morbidity and mortality. We have sought to increase alternative methods of necrosectomy. Percutaneous necrosectomy (following CT guided access of the necrosis cavity) is an effective, minimally invasive technique for treatment of necrosis associated with the body and tail of the pancreas.

Aim. Evaluation of the results of percutaneous necrosectomy.

Methods. All patients who underwent this procedure were identified and then patient and disease characteristics including outcome were identified.

Results. Between 1999 and 2007, 39 patients (19 with multi-organ failure) underwent percutaneous necrosectomy as the primary means of treatment. The median (range) APACHE2 disease severity score at presentation was 16 (3–34). There was no difference (p = 0.108) in the APACHE2 scores before [16 (3–34)] and immediately after [15 (9–35)] percutaneous drainage. The total number of necrosectomy procedures performed was 138 and the median (range) was 3 (1–11). There were 6 major procedure related complications (4.3%) – colonic perforations in 3, portal vein thrombosis in 23 and retro-peritoneal haemorrhage (early in the experience and treated by packing) in 1 patient. Two patients needed multiple open necrosectomies (20 and 22 procedures each) to control necrosis. Of the remaining 37 patients, 8 needed additional [median (range)] 1(1–8) open necrosectomies; 3 other patients underwent endoscopic neecrosectomy. Twenty-eight patients recovered from the illness, 3 of these needing long-term renal support. Eleven patients died (28%).

Conclusion. Percutaneous necrosectomy is an effective minimally invasive technique in the treatment of necrostizing pancreatitis

FP 20.01

ENDOSCOPIC GALLBLADDER STENTING (EGBS) FOR LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS

Yagawa, Yohsuke; Sugimoto, Maki; Yasuda, Hideki; Koda, Keij; Yamazaki, Masato; Tezuka, Tohru; Kosugi, Chihiro; Higuchi, Ryota

Teikyo University Chiba Medical Center, Department of surgery, 3426–3 Anesaki Ichihara Chiba, Japan

Background. Impacted cholecystolithiasis and occluded cholesystitis have an increased risk of complications associated with cholecystectomy. Percutaneous or transpapillary naso-gallbladder drainage (PTGBD, ENGBD) were usually accomplished preoperatively in such situation, but involved the risk for deviation of the drain followed recurrence of symptoms. The aim of this study was to evaluate the safety and usefulness of endoscopic gallbladder stenting (EGBS) for the treatment for acute cholecystitis.

Methods. Seven patients with acute cholecystitis who underwent endoscopic retrograde cholangiography with gallbladder stent placement were subjected in this retrospective study. EGBS entailed placement of a single-pigtail polyethylene stent between the gallbladder and the duodenum at ERCP. The advantages and techniques of EGBS were described.

Results. Benefits of such stenting could be the disimpaction of gallstones and the drainage of obstructed gallbladder. Drainage is expected to achieve after being pushed back the obstructing stone into the gallbladder. No procedure-associated morbidity or mortality was found. EGBS resulted effective bile drainage and resolution of their symptoms immediately in all patients, adjusting adequate preoperative period. During Lap-Chole, EGBS enabled to clarify inflamed cystic duct, thereby made operative dissection easier. There were no bile duct injuries or mortalities. No intraoperative or postoperative complications occurred. There were no stent deviations.

Conclusion. EGBS is a beneficial procedure to perform safer laparoscopic cholecystectomy for inflamed occluded cholecystitis. This approach is noninvasive, safe, and effective in preventing tube deviation from the gallbladder, potential morbidity and mortality.

FP 20.02

MANAGEMENT OF POSTTRAUMATIC BILE DUCT STRICTURES

Vishnevsky, Vladimir; Kubyshkin, Valery; Ikramov, Ravshan; Shevchenko, Tatjana; Olesov, Oleg; Efanov, Mikhail

Vishnevsky Institute of surgery, abdominal surgery, Moscow, Russian Federation

Background. The management of patients with posttraumatic biliary stricture is a challenging problem. This study reports the short and long-term outcome of patients undergoing surgical procedures for posttraumatic stricture of extrahepatic bile ducts.

Materials And Methods. From 1986 to January 2005, 150 patients underwent surgical procedures for posttraumatic stricture of extrahepatic bile ducts. The main cause of trauma was cholecystectomy (92.7%) including laparoscopic procedure (30.2%). The most effective diagnostic techniques to identify the type of stricture were magnetic resonance cholangiopancreatography (sensitivity − 93.3%). According to H. Bismuth (2000) there were following types of strictures: III-80 (53,4%), IV-36 (24%), V- 14 (9,3%). Only 20 (13,3%) patients underwent biliary reconstruction for type II stricture. The main type of operation was a Roux-en-Y hepaticojejunostomy. The overwhelming factors that affect outcome were width of anastomosis (¡Ý15 mm) and complete excision of fibrotic tissue. We could perform it in all patients with type II stricture, in 92.5%-with type III; 70%-IV; 57%-V (§â < 0.05).

Results. Mortality and morbidity was 1,3% and 38%, respectively. 86 patients have median follow-up of 6.4 ¡[Agrave] 0.5 years (range, 1 C20 years). The poor outcome has been reported in 14 (16,3%) patients who had relapse of stricture. All those patients underwent biliary reconstruction for type IV stricture primarily. The main causes that significantly affected poor outcome were narrow anastomosis and incomplete removing of fibrotic tissue. All patients with recurrent stricture underwent biliary reconstruction again. Satisfactory result was obtained in 10 patients.

Conclusion. The best choice for posttraumatic biliary stricture is the surgical reconstructive procedure that provides acceptable results in majority of patients. Significantly high risk of recurrence is connected with type IV stricture, incomplete removing of fibrotic tissue and narrow anastomosis.

FP 20.03

LAPAROSCOPIC EXCISION OF CHOLEDOCHAL CYSTS

Chinnuswamy, Palanivelu; Palanisamy, Senthilnathan; Ramakrishnan, Pathasarathi; Gs, Maheshkumaar; Rangaswamy, Senthilkumar; Subbiah, Rajapandian

GEM HOSPITAL, GI SURGERY, COIMBATORE, India

Background. Choledochal cysts are congenital dilatations of the extra hepatic biliary system that typically affect the pediatric population. The currently accepted mode of treatment for choledochal cysts is total excision with hepatico jejuonostomy by conventional approach.

Methods And Results. We performed our first laparoscopic choledochal cyst excision in 1996 and have successfully performed 31 surgeries in our institute. We report our experience in the laparoscopic management of choledochal cyst from 1996. We analyzed the data of thirty one patients who had undergone choledochal cyst excision in our institute from 1996 to 2007. Twenty two patients were males and nine patients were females. The mean age of the patients was 26.5 years (8 – 48). All the patients underwent ultrasound examination, liver function tests and CT scan of the abdomen or MRCP. The choledochal cyst was Type 1 in 25 patients (83%) and Type IV A in 6 patients (17%). Twenty four (77.41%) patients had anomalous pancreato biliary junction. The mean operative time was 220 minutes (160 – 320 mts). The patients were extubated immediately after the surgery and sent to ICU. The mean ICU stay for these patients was 1.3 days. The patients were allowed to take liquids on the 2nd post operative day, after the passage of flatus. The mean duration for starting oral fluids was also 1.3 days. The patients were discharged on 5 th post operative day. The mean duration of hospital stay was 5.6 (4 to 21 days). Laparoscopic excision of choledochal cyst offer the additional advantages of the minimal access surgery such as better cosmesis; quicker recovery and decreased wound related complications, this gains more importance as this disease involves younger age group patients active, and highly motivated individuals who seek a cosmetically and functionally appealing result after surgery and would aspire to return to work as soon as possible. These procedures have the potential to replace the conventional approach in the near future as the standard of care.

FP 20.04

A SURGEON AS FIRST ASSISTANT REDUCES THE INCIDENCE OF CBD INJURIES DURING LAPAROSCOPIC CHOLECYSTECTOMY

Martin, Matt¹; Earle, Kristen²

¹Central Carolina Surgery, PA, Greensboro, North Carolina, United States; ²Moses Cone Hospital Systems, Central Carolina Surgery, PA, Greensboro, North Carolina, United States

Background. This retrospective review supports the hypothesis that a surgeon acting as first assistant during laparoscopic cholecystectomy will reduce the incidence of significant CBD injuries. This is important at a time when payers seek to reduce payment for this member of the team and this can place a solo surgeon in a difficult situation when trying to recruit a surgeon to assist.

Methods. Central Carolina Surgery, PA is a single specialty general surgery group of 19 surgeons that have performed 9,056 laparoscopic cholecystectomies since merging in October 1999. In those cases, 81% of the cases had surgeons as first assistants and 66% of the cases were performed with intraoperative cholangiography. Six cases of CBD injury that required bile duct enterostomy for r econstruction occurred during this period for an incidence of 0.06625%. Only three of these injuries were occurred with the laparoscopic method alone. The other three injuries occurred after the procedure had been converted to open for another reason.

Discussion. When this same group of surgeons learned to perform laparoscopic cholecystectomy in 1990 their published series [Surgical Endoscopy: (1993) 7: 300–303] of 762 cases had 98% of cases performed with a surgeon as first assistant and no CBD injuries. Only 27% of those 762 cases had intraoperative cholangiograms.

Conclusions. This single practice experience supports the use of a surgeon as first assistant to lower the incidence of CBD injures.

FP 20.05

QUALITY CONTROL IN A POPULATION-BASED COHORT OF PATIENTS UNDERGOING CHOLECYSTECTOMY

Sandblom, Gabriel¹; Videhult, Per²; Ljungdahl, Mikael³; Wollert, Staffan³; Darkahi, Bahman⁴; Liljeholm, Håkan⁴; Karlson, Britt-Marie³; Rasmussen, Ib Christian³

¹University Hospital, Department of surgery, Lund, Sweden; ²Ersta Hospital, Department of surgery, Stockholm, Sweden; ³University Hospital, Department of surgery, Uppsala, Sweden; ⁴Enköping Hospital, Department of surgery, Enköping, Sweden

Background. Although the introduction of the laparoscopic technique has stimulated quality improvement in specialised centres, the outcome as it is practised in the community at large is less well known.

Objective. To assess the complication rate and outcome of cholecystectomy in a population-based cohort.

Methods. All patients undergoing cholecystectomy in the county of Uppsala, which has a population of 303 000, have been registered prospectively.

Results. Altogether 1199 patients underwent cholecystectomy 2003–2005. The indication for surgery was ongoing cholecystitis in 114 (12%) cases, history of conservatively treated cholecystitis in 235 (20%) cases and other reasons in 813 (63%) cases. The risk for bleeding exceeding 100 millilitres assessed in a multivariate logistic analysis was found to significantly associated with male gender (Odds Ratio [OR] 1.5), age above median (OR 1.7), open approach (OR 12.6), ongoing cholecystitis (OR 3.0) and previous history of cholecystitis (OR 1.7). The risk for conversion from laparoscopic to open surgery was found to be significantly associated with operation for ongoing cholecystitis (OR 3.0) and history of previous cholecsytitis (OR 2.4). The risk for operation time exceeding 120 minutes was significantly associated with male gender (OR 1.3), age above median (OR 1.3), ongoing cholecystitis (OR 2.4) and previous cholecystitis (OR 2.1).

Conclusion. Ongoing cholecystitis and history previous of cholecystitis were associated with increased risk of bleeding, conversion to open surgery, long operation time and long postoperative stay. Although conservative treatment and delayed operation may lead to less risk of bleeding and postoperative complications than surgery during ongoing cholecystitis, this has to be traded off with the inconvenience of repeated admission and risk of recurrence.

FP 20.06

LAPAROSCOPIC CHOLECYSTECTOMY BENCHMARKS USA

Voyles, Carl

Surgical Clinic Assoicates, Department of Surgery, University of Mississippi, Jackson, Mississippi, United States

Introduction. Laparoscopic cholecystectomy is a common operation worldwide.

Objective. To outline cost-effective quality benchmarks essential for international comparison and improvement.

Methods. From a single-surgeon series of 4500 LCs, the most recent experience of 100 LC's in a free-standing ambulatory surgery center (ASC) was compared to a corresponding in-hospital experience of 218 patients (16 months; same surgeon).

OR setting	ASC	Hospital
Number	100	218
Age	41	60
Female	79%	61%
Mean OR time	22 minutes	29 minutes
Median OR time	21 minutes	24 minutes
% operative cholangiogram	24%	46%
Same day discharge	92%	31%
Next am discharge	8%	53%
2nd day or later discharge	0	16%
Transfusion	0	0.5%
Readmission	1%	3%

Results. The ambulatory patients were younger and more likely to be female with less severe disease than the hospital population (reflected by # of operative cholangiograms). In the hospital group, there were 2 primary open operations and 2 conversions to open operation. Only one of 152 same day discharges from ASC or hospital was readmitted to the hospital (CMV hepatitis). Same day discharge was by nursing protocol (208 minutes after operation); postoperative follow-up was by telephone only in 36% of patients. There were no adverse events associated with early discharge or avoidance of operative cholangiogram. In the hospital group, 4 of 6 subsequent readmissions were related to age or underlying disease; 2 complications were from surgical intervention (intra-abdominal hematoma and small bowel obstruction).

Conclusions. Given appropriate patient selection and team coordination, elective outpatient LC can be performed very safely in the ASC or hospital. Outcomes from the ASC provide useful benchmarks for the elective cholecystectomy.

FP 21.01

RESULTS OF LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENTS INFECTED WITH HIV

VIBERT, Eric; DUCLOS-VALLEE, Jean-Charles; AZOULAY, Daniel; ADAM, René; SAMUEL, Didier; CASTAING, Denis

Paul Brousse hospital (AP/HP), Centre Hepato Biliaire, VILLEJUIF

Introduction. Antiretroviral therapy (ART) for human immunodefiency virus (HIV) has improved survival of patients. End-stage liver disease due to hepatitis B virus (HBV) and hepatitis C virus (HCV) have been successfully treated by liver transplantation (LT) in HIV patient. Hence, LT for hepatocellular carcinoma (HCC) in HIV patients was possible with usual selective criteria (Milan criteria).

Objective. Assessment of intent-to-treat survival results of LT in HIV patients.

Methods. From 1999 to 2007, among 118 cirrhotic HIV patients listed for LT, 20(16%) patients presented HCC. Cause of cirrhosis was HCV(n = 15), HBV(n = 2) and HCV/HBV (n = 2). Excepted one patient, HCC was the main reason of listing. When feasible, chemoembolization (TACE) and/or radiofrequency (RF) was performed before listing or during waiting-time (WT). Rate and cause of drop-out (DO), overall survival and recurrence were analyzed.

Results. At listing, mean MELD was 15±6, mean number of nodules and diameter wer 1.6±1 and 27±8 mm respectively with 18/20(90%) patients within Milan criteria. Except one, all patients have been treated by RF (n = 7) and/or TACE (n = 14). The rate of DO was 7/20 (35%) due to malignant progression (n = 5) and HIV progression (n = 2). One living-related and 12 cadaveric LT were made. Mean delay of WT was 7 months. One patient died postoperatively due to hepatic arterial rupture. ART discontinued after LT during a median of 24 days. On specimen, 5/13(38%) patients were outside Milan criteria. Poor differentiation and vascular invasion were found in 4/13(30%) and 5/13(38%) patients, respectively. Mean follow-up was 18±3 months. Hepatic recurrence have occurred in 3/13(23%) at 2, 3 and 37 months after LT. These 3 patients were died and others (n = 10) are alive without recurrence. Intent-to-treat survival at 2-year was 65% (5 patients at risk).

Conclusion. LT in infected HIV patient with HCC is reasonable but the high rate of DO due to tumor progression required a cautious management on WT list

FP 21.02

LIVER TRANSPLANTATION FOR HEPATITIS C (HCV): 10 YEAR REVIEW

Doyle, M B Majella¹; Anderson, Christopher, D²; Vachharajani, Neeta²; Lowell, Jeffery A²; Chapman, William C²

¹Washington University, Transplant and HPB, St Louis, United States; ²Washington University, Department of Surgery, Section of Transplant, St Louis, United States

Background. Hepatitis C (HCV) remains the leading indication for liver transplantation in adults in the U.S., but is associated with near universal HCV recurrence, increased graft loss, and reduced long-term survival. Older donors in HCV recipients are reported to result in an accelerated rate of recurrence.

Aim. This study was undertaken to investigate the results of liver transplantation over a 10 year period at a single, large volume transplant center.

Methods. From 1997 to 2006, 579 liver transplants were performed at our institution. Pediatric recipients (n = 90) (15.5%), were excluded from analysis. In the remaining 489 (84.4%) adult patients 187 (39%) had HCV and 302 (61%) had other indications. A prospectively maintained database was utilized for the current analysis.

Results. The median follow up was 55 months. Overall patient survival at 1, 3, and 5 years was 88.13%, 77.4% and 67.5% and graft survival was 85.48%, 74.83% and 63.85% in patients with HCV. There was no significant difference in patient or graft survival between HCV and non-HCV patients at 1 and 3 or 5 years. Recurrent HCV not requiring transplant but with clinically significant disease (grade II fibrosis) was 20% at 1 year but 62% by 8 years. Sixty-six patients received transplants using donors >65 years (15/187 HCV (8%), 41/302 (13.5%) non-HCV). No difference was demonstrated in short or long-term patient or graft survival comparing patients who received grafts from older vs. younger donors, or when older donors were used in HCV recipients.

Conclusion. HCV recurrence remains a significant cause of graft and patient loss following liver transplantation. The increasing use of marginal donors, including elderly grafts, does not appear to adversely affect long-term results and may be a source of additional organs for expanding liver transplant waiting lists.

FP 21.03

INTER-LABORATORY VARIABILITY IN ASSESSMENT OF THE MODEL OF END-STAGE LIVER DISEASE (MELD) SCORE

Lisman, Ton¹; van Leeuwen, Yvonne²; Adelmeijer, Jelle³; Pereboom, Ilona T.A.³; Haagsma, Elizabeth B.⁴; van den Berg, Aad P.⁴; Porte, Robert J.³

¹University Medical Center Groningen, Dept. of Surgery, CMC V, Y2144, Groningen, Netherlands; ²Leiden University Medical Center, Dept. of Clinical Epidemiology, Leiden, Netherlands; ³University Medical Center Groningen, Dept. of Surgery, Groningen, Netherlands; ⁴University Medical Center Groningen, Dept. of Gastroenterology and Hepatology, Groningen, Netherlands

Background. The model of end-stage liver disease (MELD) score is nowadays widely used to prioritise patients for liver transplantation. However, the lab-to-lab variation in MELD score in a single patient appears substantial.

Objective. To investigate the contribution of each individual MELD component (creatinine, bilirubin, and INR) to the inter-laboratory variation.

Methods. We sent 15 samples from patients listed for liver transplantation to seven different European laboratories who were asked to measure all three variables. In addition, 10 samples from patients on oral anticoagulant treatment were sent to the same labs for INR measurement.

Results. In all 15 samples, a substantial and clinically relevant variation in the calculated MELD score was observed between laboratories. The difference in MELD score between the highest and lowest scoring lab varied between 2 and 11 points (mean difference 4.8). The individual components of the MELD score all showed substantial lab-to-lab variability, with coefficients of variation of approximately 10%. The variation in creatinine measurements resulted in differences of up to three MELD points in a single patient when comparing the highest and lowest scoring lab. The variation in bilirubin measurements only accounted for a difference of 1 point between the highest and lowest scoring laboratory, but the variation in INRs resulted in differences of 2 to 12 MELD points. MELD scores or INR values were not substantially different in laboratories that used the Owren instead of the more widely used Quick methodology for determination of the INR. The variability in the INR in patients on oral anticoagulants was substantially less as compared to the variability in patients with liver disease.

Conclusion. We observed a large inter-laboratory variation in the MELD score. This variation in MELD score is primarily caused by the INR and to a lesser degree by serum creatinine levels. Variation in serum bilirubin levels has a minor impact on the inter-laboratory variations in MELD score.

FP 21.04

ADULT SPLIT LIVER TRANSPLANTATION- AN ANALYSIS OF BLOOD LOSS, COAGULATION TRENDS AND TRANSFUSION REQUIREMENTS.

Cherian, P Thomas; Pissanou, T; Tsourouflis, G; Gunson, B; Mayer, D; Wigmore, SJ; Mirza, DF; Buckels, JAC; Bramhall, SR

University Hosptial, Birmingham

Background. As one of several possible mechanisms to expand the organ pool, split deceased donor transplantation is increasingly being performed. Although more recently graft survival has become comparable to those of whole liver grafts (WLT), precise blood loss and transfusion requirements are still unknown.

Methods. Between Sept 1994 and April 2007, there were 1553 WLT (233 SLTs) performed. Of these 104 were adult, cadaveric, ex vivo SLTs, all of whom were incl uded in our study. We reviewed our prospectively collected database, clinical case notes and hospital records.

Results. Of the 104 patients 41were male and median age at transplant was 50 years. The indications for transplant were alcoholic cirrhosis(12), primary biliary cirrhosis(33), primary sclerosing cholangitis(16), viral hepatitis(16), and others(26). In 96 patients an 5,6,7,8,4 (trisegment) graft and in 7 patients a 5,6,7,8 segment graft was used. The mean drop in haemoglobin from the transplant was 3.1 gms(range 1.7 to 9.2). The median intra-operative transfusion requirements were studied. Apoprotinin when used (29 patients), significantly decreased transfusion requirements [from 5 RBC units to 3 (median) P< 0.05]. The source of bleeding after implantation was the liver capsule(5), cut surface(52), reteroperitoneal(18) and perianastamotic(9) where documented. Intra-operative Hb drop was significantly higher in the alcoholic compared to biliary cirrhosis group (4.5gms versus 3gms). Trends in blood product requirements and clotting was studied, which showed 23% patients needed blood products even after day 5.

Conclusions. The mean drop in haemoglobin from a SLT transplant was 3.1 gms (range 1.7 to 9.2). Apoprotinin when used made a significant decrease in transfusion requirements. The source of bleeding was the cut surface in the majority after implantation. However the higher intra-operative Hb drops in certain subgroups suggests that the explantation still accounts for most of the overall blood loss.

FP 21.05

HYPERNATREMIA IN DECEASED DONORS AND ITS EFFECT IN LIVER TRANSPLANTATION-INDIAN EXPERIENCE

kanchustambam, subba rao; gottimukkala,

apollo health city, HPB & Liver transplant surgery, hyderabad, India

ABSTRACT. Deceased donor hypernatremia has been reported that it may have an effect on the graft recovery in Liver transplantation. As the donors in India are scarce; we have used all livers including donor hypernatemia > 170 meq/dl with good success.

Aim. The aim of the study is to see if this has any effect over the graft function from Indian experience of Deceased donor liver transplants.

Methods. From Feb 2003 to Aug 2006, 32 Liver transplants were performed of which 24 were Deceased donor liver transplants. The donors divided into two groups group A Na < 155(13) and group B >155(11) (2 had > 175). All procured with UW solution preserved at 4 c. Mean Cold ischemic time were 11 .5 hrs and 10.3 hrs (highest 15.5hrs). Hospitals ICU stay varied from 4 days to 7days. The age of donors was 10 to 65 yrs.

Results There is no difference in the blood transfusion requirement. There is no primary non function in either group. The AST and ALT after 24hrs were higher in group 1 but did not affect the graft function. There is no difference in the prothrombin time. The 2 year survival was 86%.

Conclusion. The so called Marginal donors with Na > 155meq/dl did not effect either the early post operative period or the long term survival. Though the present study is a retrospective and involves a small number of donors, we might conclude that one should not refuse Livers based on any single marginal donor criteria.

FP 21.06

MANAGEMENT OF BILIARY COMPLICATIONS IN LIVER TRANSPLANTATION FROM DONATION AFTER CARDIAC DEATH (DCD)

El Sarrag, Ibrahim; Khan, Abdaal; Abdullah, Khalid; Ohali, Wael; Nafea, Osama; Abdulkareem, Abdulmajeed

King Abdulaziz Medical City, Hepato-biliary Sciences, Riyadh, Saudi Arabia

Introduction. A higher incidence of biliary complications after liver transplant has been noted in DCD livers.

Material and Methods. A retrospective review of biliary complications in DCD liver transplants managed at our center was performed over 2 year period (Jan, 2005 to Feb, 2007).

Results. 51 consecutive patients who had DCD liver transplants abroad were managed at our institution during this period. One immediate postoperative mortality was excluded. 50 charts were reviewed. There were 39 males and 11 females. The mean age was 57.1 yrs (9.84). The indication for transplant was HCV, 18 patients (including 2 with HCC), HBV, 14 patients (including 2 with HCC), HCV + HBV 5 patients, cryptogenic 12 (including 2 with HCC), one patient schistosoma and one patient with PSC. 17 patients had T-tubes placed after duct to duct reconstruction. Biliary complications occurred in 13 patients (26%). There were 6 leaks of which 4 were minor following T-tube removals, which were managed by ERCP + stent in 2 patients and percutaneous aspiration of collection in one patient. Only one patient required operative intervention with Roux-en-Y hepatico-jejunostomy. There were 8 strictures (16%) including one of left hepatic duct, 5 anastomotic and 2 multiple intra and extrahepatic strictures. All, except the left hepatic duct stricture were managed by interventional radiology±ERCP with stenting and balloon dilatations. The mean follow up was 16.2 months (8.4).

Conclusion. While DCD liver transplants have a higher biliary stricture rate, most can managed by non-operative means.

FP 22.01

CAN IMMUNOTHERAPY PREVENT RELAPSE OF TUMOR AFTER CURATIVE OPERATION FOR HCC?

Kotera, Yoshihito; Katagiri, Satoshi; Ariizumi, Shunniti; Takahasi, Yutaka; Masakazu, Yamamoto; Takasaki, Ken

Tokyo Women's Medical University, Surgery, Tokyo, Japan

Background. The cases of Hepatocelluler Carcinoma (HCC) with vesicular invasion or intra-hepatic metastasis are often relapsed tumor even after curative operation. To prevent recurrence of tumor, additional therapy is needed like chemotherapy or immunotherapy. In this study, we tried to predict the existence of vascular invasion or intrahepatic metastasis using conventional CTscan. Then we performed additional therapy such cases.

Patients and Methods. we chose 146 consecutive cases which performed hepatectomy in 2002 to 2005. Before the operation, we diagnosed whether simple nodule type HCC or simple nodule with extranodular growth type HCC on CT-scan. Then the patients who given the diagnosis of simple nodule with extranodular growth type HCC received immunotherapy or Trans arterial chemo embolization (TACE). Dendritic cell vaccine and CD3 activated T-lymphocyte were recruited for immunotherapy. Result: 62 cases out of 146 cases (42%) had whether vascular invasion or intrahepatic metastasis. 22 cases received immunotherapy (IT),22 cases received TACE and 24 cases received no additional therapy (NT). In these three groups, any differences were seen in background of the patients. Accuracy of diagnosis of gross finding was over 70%. 24 months Disease free survival (DFS24) for IT group and TACE group and NT group were 43%, 23%, 12% respectively. And there were significant difference in these groups. (p < 0.05).

Conclusion. Immunotherapy could prevent relapse of tumor with vascular invasion or intrahepatic metastasis.

FP 22.02

INTRA-LYMPHATIC IMMUNOTHERAPY OF INOPERABLE PATIENTS AFFECTED BY HEPATOCARCINOMA: Results OF A PILOT STUDY

Nardo, Bruno¹; Bertelli, Riccardo¹; Beltempo, Paolo¹; Puviani, Lorenza¹; Cavallari, Giuseppe¹; Tsivian, Matvey¹; Neri, Flavia¹; De Vinci, Caterina²; Pizza, Giancarlo²

¹University of Bologna, Bologna; ²University of Bologna, Immunotherapy Module-Operative Unit of Urology, D, Bologna

Background/Aim. intra-lymphatic injections of interleukin-2-activated (IL2) autologous peripheral lymphocytes (LAK), were offered on compassionate basis, to patients affected by inoperable hepatocarcinoma.

Methods. From January 2003 to March 2005, 31 patients were treated by monthly intra-lymphatic injections of LAK and 250 IU IL2. The lymphatic vessels of the foot were localized according to the technique for lymphography, and cannulated with a fine needle connected to a syringe containing LAK and IL2. The duration of a treatment-cycle was intended initially for six months, with restaging at three and six months with abdominal TC or ultrasonography, á-fetoprotein and liver function tests. Fifteen patients underwent at least three cycles of intra-lymphatic immunotherapy, with a mean follow-up of 7.2 months, among them 9 had a virus-related cirrhosis (3 HCV, 4 HBV, 2 HCV and HBV positive). In order to evaluate the efficacy of the treatment, the following parameters were considered: vascular infiltration or thrombosis, Child-Pugh classification, histological grading, lymphoadenopaty, viral status, levels of á-fetoprotein.

Results. No clinical adverse side effects were reported in the early and late period. A stabilization or relevant recovery in liver function tests was observed in 7 patients who underwent at least 6 cycles of intra-lymphatic immunotherapy (46.6%). The survival of patients who underwent 12 cycles of treatment resulted significantly higher as compared to those patients with less than 12 cycles. Both group had an higher survival as compared with an untreated control group.

Conclusions. The intra-lymphatic immunotherapy is a safe procedure and allow to ameliorate the liver function tests and to improve survival of patients with inoperable HCC. This preliminary clinical experience may encourage a clinical trials in order to establish the effective impact on pa tient survival as well as the enrolment criteria.

FP 22.03

TREATMENT OF MEDIUM AND LARGE HEPATOCELLULAR CARCINOMA USING PERCUTANEOUS COMPOSITE THERMAL ABLATION TECHNIQUE: AN ANALYSIS OF LONG-TERM SURVIVAL

Yin, Xiaoyu¹; Lu, Mingde²; Xie, Xiaoyan³; Xu, Huixiong³; Xu, Zuofeng³; Kuang, Ming⁴; Liang, Jinyu³

¹The First Affiliated Hospital, Department of Hepatobiliary Surgery, Sun Yat-Sen University, Guangzhou, China; ²The First Affiliated Hospital/Sun Yat-Sen University, Department of Hepatobiliary Surgery, Guangzhou, China; ³The First Affiliated Hospital, Department of Medical Ultrasonics, Guangzhou, China; ⁴The First Affiliated Hospital, Department of Hepatobiliary Surgery, Guangzhou, China

Background. Thermal ablation using radiofrequency(RFA) or microwave(MWA) is effective in curing hepatocellular carcinoma(HCC) <3 cm. However, its efficacy in treating medium- and big-sized HCC still needs to be improved.

Aims. To evaluate therapeutic efficacy of percutaneous composite thermal ablation technique for HCC between 3.0 cm and 7.0 cm.

Methods. By using multiple-needle insertion and multi-point energy application technique, percutaneous RFA or MWA was adopted to treat 109 HCC patients with at least one tumor between 3.0cm and 7.0cm. Fifty-eight patients were first-treated cases (no previous treatment), and 51 were recurrent cases after hepatectomy. Seventy patients had single tumor, and 39 had multiple tumors. There were 158 tumors, with a diameter <3.0cm in 34£¬3.0¡«5.0cm in 105, and 5.0¡«7.0cm in 19. Local therapeutic efficacy and long-term outcome were analyzed.

Results. Mortality and major complications incidence were 0% and 9.2%, respectively. Complete ablation rate was greater in tumors <3.0cm and 3.0¡«5.0cm than those 5.0¡«7.0cm, being 100% and 94.3% vs 78.9%, respectively (p < 0.05). With mean follow-up of 22.08 418.5 months, local tumor progression was more common in tumors with diameter of 3.0¡«5.0cm and 5.0¡«7.0cm than those <3.0cm(p < 0.05). Distant recurrence developed in 53.2% patients. 1-,3-,5- year survival rate was 75.8%,30.9%,15.4%, respectively. Univariate analysis showed that first-treated patients had a significantly better long-term survival than post-hepatectomy recurrent patients (p < 0.05), and patients with pre-ablation AFP < 200ug/L had a markedly greater long-term survival than those AFP > = 200ug/L (p < 0.05). Cox regression analysis demonstrated that both no previous treatment and pre-ablation AFP < 200ug/L were independent favorable prognostic factors (p < 0.05).

Conclusion. By using composite ablation technique, percutaneous thermal ablation was effective in treating HCC <7cm, especially <5cm. No previous treatment and pre-ablation AFP < 200ug/L were independent favorable prognostic factors.

FP 22.04

ETHANOL ABLATION OF HEPATOCELLULAR CARCINOMA SIZED UP TO 5 CM BY USING A MULTIPRONGED NEEDLE WITH SINGLE TREATMENT SESSION

Kuang, Ming¹; Lu, Ming D²; Xu, Zuo F³; Xie, Xiao Y⁴; Xie, Xiao Y³; Xu, Hui X³; Liu, Guang J³

¹The First Affiliated Hospital of, Department of Hepatobiliary Surgery, Sun Yat-Sen University, Guangzhou, China; ²The First Affiliated Hospital of Sun Yat-Sen University, Department of Hepatobiliary Surgery, Guangzhou, China; ³The First Affiliated Hospital of Sun Yat-Sen University, Department of Meical Ultrasonics, Guangzhou; ⁴

Objective. To investigate the initial efficacy of ethanol ablation (EA) in patients with hepatocellular carcinoma (HCC) sized up tp 5 cm by using a multi-pronged injection needle with single treatment session.

Methods. The study was performed with approval of the ethic committee, and written informed consent was obtained for all patients. A total of 100 patients with primary or recurrent HCC 5 cm or less in size were treated. Single tumors were seen in 85 patients, and 2 or 3 nodules seen in 15 patients. Primary HCC was observed in 57 patients and recurrent tumors were in 43 patients. Follow-up ranged from 3 to 28 months (mean, 15 months±6). Patients were observed for progression of the treated tumors and for appearance of new lesions in the liver. Risk factors to the local effectiveness, disease-free survival and overall survival were assessed with Chi-square test, univariate and multivariate analysis.

Results. Mean treatment session was 1.1. Primary effectiveness rate was 94% and was significantly related to tumor stage (P=.008) (? 3 cm, 100%; 3.1–5.0 cm, 87%), tumor pattern (P=.017) (encapsulated, 97%; noncapsulated, 81%), and existence of portal hypertension (P=.017). At the end of follow-up, local tumor progression rate was 12%. The 1-, and 2-year disease-free survival (DFS) rates in patients with primary or recurrent HCC were 81% and 62%, 47% and 36%, respectively. The independent predictors of DFS were tumor location (P=.0018), and occurrence of complication (P=.0016). The 1-, and 2-year overall survival (OS) rates in patients with primary or recurrent HCC were 96% and 82%, 84% and 46%, respectively. The independent predictors of OS were alpha-fetoprotein level (P=.0032), and recurrence (P=.0000) in all patients, and primary effectiveness rate (P=.003) in patients with primary tumors. Complication rate was 7%. No ablation-related death was observed.

Conclusions. The use of a multi-pronged injection needle may improve treatment efficacy of EA of HCC up to 5 cm in diameter within less

FP 22.05

PERCUTANEOUS RADIOFREQUENCY ABLATION FOR THE TREATMENT OF HEPATOCELLULAR CARCINOMA IN THE CAUDATE LOBE

Peng, Zhen-Wei¹; Chen, Min-Shan¹; Liang, Hui-Hong¹; Zhang, Yao-Jun¹; Li, Jin-Qing¹; Zhang, Ya-Qi¹; Lau, Wan Y²

¹Department of Hepatobiliary Surgery, Cancer Centre of Sun Yat-Sen University, Guangzhou, China; ²Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

Aims. This study aimed to evaluate the efficacy and safety of Percutaneous radiofrequency ablation (PRFA) for hepatocellular carcinoma (HCC) in the caudate lobe.

Patients and Methods. Between January 2001 and December 2006, 17 patients, twelve males and five females who were 33 to 68 years old (mean 54.3), with the caudate lobe HCCs [2.0–6.5cm in diameter (mean 3.1)] were treated with either PRFA alone (n = 14), or PRFA with percutaneous ethanol injection (n = 3) under ultrasound guidance. The right or anterior approach was used in 12 and 5 patients respectively.

Results. All procedures were performed successfully. There was no motility and major complication due to PRFA. 14 tumors (82.4%) were completely ablated after one to two sessions of treatment. During follow-up (range 3 to 60, mean 29.1 months), two (14.3%) developed local recurrence. Intrahepatic metastasis developed in 9 of 17 patients (52.9£¥). No distant metastasis was found. 4 patients died (23.5£¥), 3 from tumor progression and one from hepatic failure. The 1-, 2-, and 4-year overall survivals were 88.2%, 80.2%, and 72.2% respectively, and the progress free survivals were 47.1%, 20.2%, and 10.1% respectively.

Conclusions. PRFA is efficacious and safe for patients with HCC in the caudate lobe

FP 23.01

DETERMINANTS OF OUTCOME FOLLOWING NECROSECTOMY AND CLOSED DRAINAGE FOR NECROTIZING PANCREATITIS

Singhal, Dinesh¹; Chaudhary, Adarsh¹; Pervaiz, Azhar¹; Puri, Rajesh²; Kumar, Mandhir²; Sud, Randhir²

¹Sir Ganga Ram Hospital, Surgical Gastroenterology, New Delhi, India; ²Sir Ganga Ram Hospital, Gastroenterology, New Delhi, India

Introduction. Necrosectomy is the currently accepted treatment for infected pancreatic necrosis and some patients with sterile necrosis. This study was conducted to identify factors determining outcome after necrosectomy.

Patients and Methods. Forty-six patients (38 infected and 8 sterile) underwent necrosectomy and closed drainage of the lesser sac between 2003–2007. The impact of patient, disease and postoperative factors on complications and mortality was analyzed.

Results. There were 37 males and 9 females with a median age of 38 (range 15 – 67) years. Thirty (65%) had major complications and 9 (19.5%) died. The causes of death include delayed massive hemorrhage (4), persistent multiorgan failure (4) and pulmonary embolism (1). At stepwise logistic regression analysis, independent predictors of mortality were preoperative multiorgan failure (MOF), extrapancreatic necrosis and isolation of Candida in the drained pus. The latter was significantly associated with preoperative MOF and delayed massive hemorrhage. Prophylactic use of carbapenams emerged as an independent predictor for the presence of Candida.

Conclusions. The systemic and local severity of necrotizing pancreatitis determines the outcome following necrosectomy. Prophylactic use of carbapenams results in an increased isolation of Candida from the pus which is associated with major pre and postoperative complications.

FP 23.02

ORGAN FAILURE ASSOCIATED WITH SEVERE ACUTE PANCREATITIS

Wig, Jaidev¹; Kochhar, Rakesh²; Bharathy, Kishore GS¹; Kudari, Ashwini K³; Doley, Rudraprasad³; Yadav, Thakur D³; Gupta, Rajesh³

¹PGIMER, Chandigarh, India, General Surgery, Chandigarh, India; ²PGIMER, Chandigarh, India, Gastroenterology, Chandigarh, India; ³PGIMER, Chandigarh, India, Chandigarh, India

Background. The clinical course of severe acute pancreatitis may be complicated by the evolution of organ failure which is associated with increased mortality.

Aim. To study the incidence of organ failure in severe acute pancreatitis, contributing factors and their effect on outcome.

Methods. One hundred and sixty one patients with severe acute pancreatitis over a 4 year period were studied at a tertiary level university hospital. The effect of age, etiology, presence of bacterial infection, APACHE II scores and extent of necrosis on computed tomography on the occurrence of organ failure and mortality were analyzed.

Results. Organ failure was present in 52% of patients. Single, two and three organ failure was seen in 48.8%, 33.3%, and 17.8% respectively. Corresponding mean APACHE II scores were 10.24, 9.61, and 17.32. APACHE II score and extent of pancreatic necrosis on computed tomography correlated with number of organs failing (p<.001 and .003 respectively). Presence of infective necrosis however was not associated with increased incidence of organ failure (p=.462). 77.9% of patients without organ failure survived while mortality rate increased with increasing number of organs failing.

Conclusions. Organ failure in patients with severe acute pancreatitis predicted poor outcome. APACHE II score and extent of necrosis on computed tomography correlated with organ failure.

FP 23.03

A NEW NON-INVASIVE MODEL OF SEVERE ACUTE PANCREATITIS IN MICE

Hartwig, Werner¹; Schimmel, Eik¹; Hackert, Thilo¹; Bergmann, Frank²; Strobel, Oliver¹; Schneider, Lutz¹; Büchler, Markus W.¹; Werner, Jens¹

¹University of Heidelberg, Dept. of General, Visceral, and Transplant Surgery, Heidelberg, Germany; ²University of Heidelberg, Dept. of Pathology, Heidelberg, Germany

Background. A non-invasive model of necro-hemorrhagic pancreatitis induced by simultaneous cerulein/enterokinase (EK) infusion has recently been established in rats. Since the only presently available non-invasive model of severe pancreatitis in mice (CDE-diet) is associated with several shortcomings, the aim of the present study was to establish and characterize this new model in mice.

Methods. Male Bulb-C mice (20–25 mg) were used for experiments. Pancreatitis was induced by simultaneous infusion of cerulein (100 µg/kg/h) and EK (400–1600 U/kg/h). Controls were infused with saline, cerulein, or EK only. Animals were sacrificed six hours after start of infusions. Pancreatic and pulmonary injury were assessed by histology, wet-to-dry weight ratio, and myeloperoxidase activity in tissue. Systemic cytokine-, amylase-, and LDH-levels in blood were measured to assess the inflammatory reaction and cell injury. Long-term experiments were performed to determine survival in this model.

Results. Animals developed marked local and systemic organ injury with simultaneous cerulein/EK infusions. Pancreatic edema increased with high cerulein/EK infusions as compared to cerulein or EK alone. Likewise, pancreatic as well as pulmonary leukocyte sequestration was significantly higher with combined cerulein/EK infusions. Importantly, survival decreased in these animals. Pancreata showed cell necrosis, but not as strong as known from the rat model. Increased LDH and IL 1β-levels in serum reflected cell damage and the systemic inflammatory response in cerulein/EK infused animals.

Conclusions. Applying intravenous cerulein/EK infusions, a new model of lethal acute pancreatitis with associated systemic inflammatory response has been established. This easily reproducible and non-invasive model appears valuable for future investigations in genetically altered mice.

FP 23.04

THE GALANIN ANTAGONISTS GALANTIDE AND M35 BUT NOT C7 AND M40 AMELIORATE CAERULEIN-INDUCED ACUTE PANCREATITIS IN MICE

Bhandari, Mayank¹; Kawamoto, Masahiko¹; Thomas, Anthony²; Carati, Colin J³; Schloithe, Ann C¹; Toouli, James¹; Saccone, Gino TP¹

¹Flinders Medical Centre, Surgery, Bedford Park, Australia; ²Flinders Medical Centre, Anatomical Pathology, Bedford Park, Australia; ³Flinders Medical Centre, Anatomy and Histology, Bedford Park, Australia

Background And Aims. We have shown that the galanin antagonist galantide ameliorates acute pancreatitis (AP) in a possum model. We evaluated several galanin antagonists; C7, M35, M40 and galantide, for their ability to ameliorate AP in a cerulein mouse model.

Methods. AP was induced in male Swiss mice by 7 hourly intraperitoneal (i.p.) injections of caerulein (50µg/kg). Galantide (40nmol/kg), C7, M35 or M40 (20 or 40nmol/kg) were administered i.p. with each caerulein injection. Control mice received galantide, C7, M35 or M40 (40nmol/kg) alone or saline. Pancreata were harvested at 12 hours for histological examination and estimation of myeloperoxidase (MPO) activity. Plasma amylase and lipase activity were measured pre- and post-treatment. Data were analyzed using ANOVA or the Mann – Whitney test.

Results. Treatment with galantide, M35 and C7 (at 40nmol/kg) reduced plasma amylase and lipase activities in AP mice by 55–75% (p < 0.05). Administration of M40 (20 and 40nmol/kg) did not significantly alter plasma enzymemia when compared to the AP alone group. None of the antagonist alone or saline altered plasma enzyme activity above pre-treatment levels. Galantide, M35 and M40 significantly reduced the pancreatic MPO activity (by 75–83%) compared to the AP alone group (p < 0.05), whereas C7 increased MPO activity. C7 alone also increased MPO activity. Galantide and M35 (40nmol/kg) but not C7 or M40 treatment significantly reduced the AP-induced necrosis score by 31–50% compared to the AP alone group (p < 0.05). C7 alone increased the necrosis score compared with saline treatment alone.

Conclusion. Galantide and M35 ameliorated the severity of AP, but M40 and C7 had mixed effects, with C7 exacerbating some indices of AP. These data suggest that complex galanin pathways may be involved in this model of AP. Supported by BioInnovation SA, Flinders Technologies and the FMC Foundation.

FP 23.05

TRENDS IN THE MINIMALLY INVASIVE MANAGEMENT OF NECROTIZING PANCREATITIS: A SURVEY OF AUSTRALIAN AND NEW ZEALAND SURGEONS

Loveday, Benjamin PT¹; Rossaak, Jeremy I²; Mittal, Anubhav¹; Phillips, Anthony³; Windsor, John A¹

¹University of Auckland, Department of Surgery, Auckland, New Zealand; ²Auckland City Hospital, Department of Surgery, Auckland, New Zealand; ³University of Auckland, School of Biological Sciences, Auckland, New Zealand

Background. While there is consensus in published guidelines on the diagnosis and early management of acute pancreatitis, there is less agreement on how to manage infected pancreatic necrosis and its local complications.

Aims. The aim of this survey was to determine the trends in the minimally invasive management of necrotizing pancreatitis in Australia and New Zealand, and to identify barriers to the use of minimally invasive techniques.

Methods. In early 2007, members of the Australian and New Zealand Hepatic Pancreatic and Biliary Association were invited to complete an anonymous web-based survey. Following questions concerning demographics and pancreatitis caseload, a 5-point Likert scale was used to score the perceived role of percutaneous drainage and minimally invasive techniques in the management of infected pancreatic necrosis, pancreatic abscess, and pancreatic pseudocyst. A comparison was made between current management and that before 2002. Barriers to minimally invasive necrosectomy were identified and scored.

Results. Forty-four consultant surgeons completed the survey. Minimally invasive necrosectomy is considered to be increasingly important as a primary treatment for infected pancreatic necrosis (p = 0.0004) and percutaneous drainage as a secondary treatment for pancreatic abscess (p = 0.001). The complexity and anatomical location of the necrotic tissue were identified as major barriers to the use of minimally invasive necrosectomy by 24/42 (56%) and 20/42 (47%) participants, respectively. Conversely, lack of support from the intensive care unit and hospital managers were not considered a barrier by 39/42 (91%) and 35/42 (81%) participants, respectively.

Conclusion. Over the last 5 years the trend has been toward percutaneous drain age and minimally invasive necrosectomy for the management of necrotizing pancreatitis. Further research is required to determine the appropriate indications and techniques for these interventions.

FP 23.06

THE EFFECTS OF HYPERBARIC OXYGEN THERAPY ON APOPTOSIS AND PROLIFERATION IN A RAT MODEL OF SEVERE ACUTE PANCREATITIS

Koh, Shir Lin¹; Tan, Joon Win²; Muralidharan, Vijayaragavan²; Christophi, Christopher²

¹The University of Melbourne, Surgery, Austin Health, Heidelberg, Victoria, Australia; ²The University of Melbourne, Surgery, Heidelberg, Victoria, Australia

Background. The annual incidence of acute pancreatitis is 30–40 per 100 000 population. Severe acute pancreatitis occurs in 15–20% of patients and is associated with significant tissue necrosis. Apoptosis predominates in the milder form of pancreatitis. Hyperbaric oxygen has been shown to improve the survival rate of rats with severe acute pancreatitis. Hyperbaric oxygen acts through several mechanisms, possibly through the alteration of apoptosis and proliferation.

Aim. This study investigates the effects of hyperbaric oxygen on apoptosis and proliferation in a rat model of severe acute pancreatitis.

Methods. Forty male albino Wistar rats (250–300g) were induced with severe acute pancreatitis by biliopancreatic infusion of 0.1ml/100g of 4% sodium taurocholate at a constant pressure of 20mmHg. Rats were randomized for hyperbaric oxygen treatment with endpoints of days 1, 2 and 3 post-induction. Pancreas of rats was macroscopically scored at the endpoints. Sections of formalin-fixed pancreas were stained for apoptosis and proliferation with antibodies anti-caspase3 and anti-Ki67 respectively. Image-proplus software was used to quantify the percentage of apoptosis and proliferation in acinar cells. Statistical analysis was performed with 2-independent sample T-test or Mann-Whitney test.

Results. The rate of apoptosis in this disease is higher than that of a normal rat (p = 0.008 on day 1). Hyperbaric oxygen further increase the rate of apoptosis, reaching a statistical significance on day 1 (p = 0.04). The rate of proliferation is increased in the disease compared to normal, and hyperbaric oxygen therapy further increased the level of proliferation on days 2 and 3. There was no statistical significance between any groups.

Conclusion. Hyperbaric oxygen may improve the condition of severe acute pancreatitis by increasing the rate of apoptosis in acinar cells.

FP 24.01

CUMULATIVE SUM (CUSUM) PROVIDES AN OBJECTIVE MEASURE OF COMPETENCY IN ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY (ERCP) TRAINING

Connor, Saxon

Christchurch Hospital, Surgery, Christchurch, New Zealand

Introduction. Endoscopic retrograde cholangio-pancreaography (ERCP) is a complex and technically challenging procedure with a risk of significant complications. Recommendations exist as to how many ERCP's should be performed before a trainee is deemed competent however these are not individualised to the trainee. Cumulative sum (CUSUM) allows continuous monitoring of a proceduralists performance to identify acceptable outcomes. The aim of this study was to assess a trainees progress with ERCP (learning curve) by CUSUM analysis.

Method. A single trainee performed one supervised ERCP list per week between 06/05–07/07. Data was collected prospectively. Data was analysed by intention to treat. The Binary outcome measure was successful cannulation in patients with an intact sphincter of Oddi. Cumulative failure charting and sequential probability ratio testing was performed. Acceptable cannulation failure rates were set at 20%. Unacceptable cannulation failure rates were set at 35%. Type I and II error rates were set at 0.10.

Results. 208 ERCP's were performed. Median (range) age was 72 (21–94) years. Choledocholithiasis was the indication in 114 (55%) patients. Successful cannulation was achieved in 114 of 170 (67%) patients with intact biliary sphincters. Sphincterotomy was completed in 85 of the 89 (96%) patients in whom it was indicated. A therapeutic procedure was completed in 95 (95%) of 100 patients in whom it was indicated. Although cumulative failure charting suggested the trainee had not yet achieved satisfactory performance sequential probability ratio testing indicated that an acceptable outcome had been achieved for the last 105 consecutive ERCP's.

Conclusion. CUSUM enables sensitive and continuous monitoring of a trainees performance to objectively determine competence. Wider and systematic use would enable appropriate benchmarks to be identified and more objective assessment of a trainee's experience.

FP 24.02

LAPAROSCOPIC CHOLECYSTECTOMY AND ERCP: TREATMENT OF BILIARY STONES DISEASES

Fiocca, Fausto¹; Santagati, Alessio²; Ceci, Vincenzo²; Donatelli, Gianfranco²; Cereatti, Fabrizio²

¹Policlinico Umberto I-Università “La Sapienza”, Endoscopic Emergency Surgery, Roma, Italy; ²Policlinico Umberto I-University “La Sapienza”, Endoscopic Emergency Surgery, Roma, Italy

Introduction. Laparoscopic cholecystectomy (LC) is the gold standard technique for cholelithiasis, while common bile duct (CBD) stone treatment is still controversial. Our experience in pre-, intra-, and post-operative ERCP in pts undergoing LC in the last 5 years will be evaluated.

Patients, Methods And Results. 835 pts were referred to us from different Institutions. Pre-operative ERCP was performed in 674 pts with confirmed diagnosis of CBD stones at US or Magnetic Resonance or recurrent biliary pancreatitis. Endoscopic sphincterotomy (ES) was successfull in 658 (97.6%) while CBD clearance was successfull in 625 (92.7%). 49 pts were treated with transhepatic lithotripsy or surgically. Mortality was none, major complications 2, minor complications 6.8%, mean hospital stay 4.5 days. Intra-operative ERCP was performed in 75 pts in which an intra-operative cholangiography (IOC) showed CBD stones. ES was performed in all pts, some times with the help of the cholangiographic catheter, and CBD clearance was obtained in 68 pts (90.7%). 7 pts were successfully treated the day after with a new ERCP. Mortality was none, major complication 1, minor complications 4.9%, mean hospital stay 3.9 days. Post-operative ERCP was performed in 86 pts in which IOC was positive for stones: they were successfully treated 48–72 hours after LC with ES and CBD stones’ clearance. In three cases a catheter had been left through the cystic duct by the surgeon. No mortality or major complications, minor complications 5,3% and mean hospital stay 6.8 days.

Conclusions. Selective IOC is an important tool in doubt cases for better diagnosis of CBD stones that can be safely treated intraoperatively or postoperatively. Intraoperative ERCP may be preferred by the pt but it needs an expert endoscopist on duty while the postoperative approach offers optimal/

Results. The risk of failures of the endoscopic postoperative approach, which may impose further treatments, is related to complex CBD pathologies that must be ruled out preoperatively.

FP 24.03

SAFETY AND EFFECTIVENESS OF DAY-CASE LAPAROSCOPIC CHOLECYSTECTOMY-A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

Junnarkar, Sameer¹; Gurusamy, Kurinchi¹; Faroukh, Marwan²; Davidson, Brian Ritchie¹

¹Royal Free Hospital, Academic Department of Surgery, London, United Kingdom; ²Stoke Mandeville Hospital, Department of Surgery, Aylesbury, United Kingdom

Objective. To assess the advantages and disadvantages of day-case surgery compared to overnight stay in patients undergoing elective laparoscopic cholecystectomy. Design: Systematic review and meta-analysis. Data Sources: Cochrane library trials register, Medline, Embase, Science Citation Index Expanded and reference lists.

Review Methods. Randomised clinical trials comparing day-case and overnight stay in elective laparoscopic cholecystectomy were identified and data was extracted from these trials by two independent reviewers. For each outcome the relative risk, weighted mean difference or standardised mean difference was calculated with 95% confidence intervals based on available case-analysis.

Results. Five trials with 429 patients randomised to the day-case group (215) and overnight stay group (214) were included for the review. Four of the five trials were of low risk of bias. 49.1% of patients undergoing elective laparoscopic cholecystectomy during the period of the trials were recruited into the three trials which reported this. The withdrawal/ drop-out rate after randomisation varied between 6.5% and 12.7% in the different trials. There was no statistically significant difference between the two groups for morbidity, morbidity after discharge, prolongation of hospital stay, re-admission, proportion reviewed by doctor without being admitted, pain scores, patient quality of life, patient satisfaction, patient preference of treatment, return to normal activity, or return to work. 81.4% of day case patients were discharged on the day of surgery. There were no serious medical complications after discharge in the day-case group.

Conclusions. Day-case surgery is safe and can be planned in nearly half of the patients undergoing elective laparoscopic cholecystectomy. It can be completed successfully in more than four-fifths of these patients.

FP 24.04

RANDOMISED CLINICAL TRIAL OF LONGITUDINAL VERSUS TORSIONAL MODE ULTRASONIC SHEARS FOR LAPAROSCOPIC CHOLECYSTECTOMY

Ching, Siok Song; Sarela, Abeezar I; McMahon, Michael J

Leeds General Infirmary, Academic Unit of Surgery, Leeds, United Kingdom

Background. Ultrasonic shears are increasingly used in surgery for haemostatic cutting. Conventional ultrasonic shears such as the UltraCision Harmonic Scalpel® (Ethicon Endo-Surgery) use longitudinal mode (LM) vibration. The recently developed LOTUS™ system (S.R.A. Developments Ltd.) uses torsional mode (TM) vibration, which may provide theoretical advantages for faster cutting and better haemostasis.

Aims. To compare TM with LM shears for laparoscopic cholecystectomy.

Methods. During 2003–2007, 141 patients undergoing elective laparoscopic cholecystectomy were randomised to either TM or LM shears. Intra-operative events such as failure in haemostasis and time taken for dissecting the gallbladder off the liver bed were recorded. Post-operatively, a sample of suctioned fluid was analysed for haemoglobin concentration, [Hb]. Intra-operative blood loss was estimated by volume of suctioned fluid×[Hb]_fluid/[Hb]_blood. Mann-Whitney U Test and Chi-square Test were used for statistical analyses.

Results. There were 30 men and 111 women, median age 48 years (range 16–81). Seventy-one patients were randomised to TM shears and 70 patients to LM shears. Median intra-operative blood loss was 5.0 ml (IQR 1.0–15.9) with TM shears and 10.2 ml (IQR 2.5–18.6) with LM shears, p = 0.09. Median gallbladder dissection time was similar in both groups (16 min, IQR 10–28 vs 20 min, IQR 12–29, p = 0.16). Gallbladder perforation rates were 24% for TM shears and 33% for LM shears, p = 0.33. Other modalities of haemostasis (Surgicel® or electrosurgery) were required on 13 patients (18%) in the TM group compared with 21 patients (30%) in the LM group, p = 0.11. One patient in the LM group developed post-operative haemoperitoneum that required urgent laparoscopic exploration.

Conclusions. TM ultrasonic shears appear to be as effective as shears that utilise LM vibration. The results support the theoretical advantages of TM shears although statistical significance was not reach.

FP 24.05

CHOLEDOCHAL CYST: 13 YEARS EXPERIENCE OF A TERTIARY REFERRAL CENTRE IN INDIA, ANALYSIS OF 287 CASES OF BILE DUCT CYSTS

Bora, Giri Raj; Singh, Shivendra; Mishra, PK; Sachdev, AK; Chaudhary, A; Aranya, RC; Gondal, Ranjan; Agarwal, Anil

G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India

Background & Aim. Choledochal cyst (CDC) or Congenital Bile duct cyst is a rare disorder affecting biliary system. Due to recent improvement in imaging techniques and increased awareness more cases are being diagnosed and referred to for definitive surgical treatment.

Material and Methods. We present retrospective analysis of our prospective collected data over a period of 13 years at a tertiary referral centre in India.

Results. A total of 287 cases of Choledochal cyst were managed between Jan 1995 to July 2007. There were 67 (23.34%) pediatric and 220(76.66%) adult patients. Male to female ratio was 1: 3.28. Pain abdomen was most common presenting feature followed by jaundice, cholangitis, abdominal lump and pancreatitis. A history of prior biliary surgery was found in 53 (18.46%) patients. One hundred and sixty five patients had type I CDC, 116 type IVa, 3 type V and there was 1 patient each who had type II, type III and Type IVb CDC. Cystolithiasis was found in 32.69%. Patients with Type I, II and IV CDC underwent excision of extrahepatic portion of Choledochal cyst with Roux-en-Y Hepaticojejunostomy. Three patients of type V CDC underwent left hepatectomy. Thirty day mortality was 1.05% ( 1 patient had cerebral infarct, one patient due to postoperative pancreatitis following radical Cholecystectomy for associated gallbladder malignancy).

Conclusion. Study represents a large single centre experience dealing with Choledochal cyst. Malignancy and portal hypertension are complication associated with long standing Choledochal cyst. Choledochal Cyst excision with bilioenteric is safe procedure with accepted morbidity and mortality.

FP 25.01

PREOPERATIVE PORTAL VEIN EMBOLIZATION BEFORE MAJOR HEPATIC RESECTION IS A SAFE AND EFFICIENT PROCEDURE. A LARGE SINGLE INSTITUTION EXPERIENCE

JAECK, Daniel; GIRAUDO, Giorgio; OUSSOULTZOGLOU, Elie; ROSSO, Edoardo; PESSAUX, Patrick; BACHELLIER, Philippe

Hopital de Hautepierre, Centre de Chirurgie Viscérale et Transplantation, Strasbourg, France

Background. The aim of this study was to report the results of preoperative portal vein embolization (PVE) performed in a single institution.

Methods. Between January 1997 and March 2006, 146 patients requiring a right or extended right hepatectomy for primary or secondary liver tumors underwent PVE when the future remnant liver volume (FRL) was less than 30% of total liver. Liver volumes and hepatic function were evaluated before and after PVE.

Results. PVE was performed successfully in 145 patients. In one patient the catheterization of the portal branch failed. Complications occurred in 14 patients (10%) including a transitory fever (n = 9), a parenchymal hematoma (n = 1), a mild hemoperitoneum (n = 1), a mesenterico-portal venous thrombosis (n = 1), a pulmonary embolism (n = 1) and a systemic sepsis (n = 1). The prothrombine ratio and the platelet count were significantly lower 3 days after PVE. Insufficient hypertrophy of the FRL was observed in 12 patients and malignant disease progression in 19. The hypertrophy rate of the FRL 4 to 8 weeks after PVE was 47.7±31.9%. Pathological type of the liver tumor, cirrhosis, diabetes mellitus and chemotherapy did not affect the volume of the left liver hypertrophy. However, the time required to achieve an adequate liver hypertrophy was significantly shorter in patients with normal liver. One-hundred-fourteen patients (78.6%) subsequently underwent hepatic resection.

Conclusions. The results suggest that PVE is a safe and efficient procedure inducing adequate hypertrophy of the FRL before major liver resection.

FP 25.02

LIVER RESECTION WITH AND WITHOUT PRINGLE MANEUVER: A MATCHED PAIR ANALYSIS

Schön, Michael R¹; Zaatar, Mohamed¹; Kaps, Maria²; Hauss, Johann P.²; Scholz, Markus³; Wiegel, Natalie¹

¹Klinikum Karlsruhe, Surgery, Karlsruhe, Germany; ²Universtiy of Leipzig, Surgery, Leipzig, Germany; ³Universtiy of Leipzig, Medical Informatics and Statistics, Leipzig, Germany

Introduction. Several vascular occlusion techniques during liver resection have been discussed recently. Hepatic vascular inflow occlusion (Pringle maneuver) is associated with lower blood loss and a reduction of operative time. However ischemia-/reperfusion injury may play an important role in morbidity.

Methods. Out of 200 elective liver resections in 38 patients liver resection was carried out without Pringle maneuver (group A). Out of the remaining patients 38 patients were selected in a matched pair analysis in which liver resection was carried out with Pringle maneuver (group B). The two groups were well matched for age, gender, tumor size and resection extent, diagnosis, diabetes mellitus, simultaneous procedures, fibrosis/cirrhosis, ASA classification, and preoperative laboratory values. For statistical analysis the Mann-Whitney U-test was applied. A value of p < 0.05 was considered statistically significant.

Results. The postoperative outcome of both groups in means of blood transfusion, ICU- and hospital stay, complications, mortality rate and postoperative liver function tests was similar (p > 0,05). Further stratification for resection extent (small resection: 1–2 segments, and large resection: 3–5 segments) revealed no differences. Yet, applying the pringle manoeuvre in livers with fibrosis/cirrhosis was associated with significantly higher postoperative levels of transaminases (ALAT/ASAT, p < 0,03) when compared to resections without pringle maneuver.

Conclusion. Most cases of liver resection can be performed safely with or without pringle maneuver. However, fibrotic/cirrhotic livers which are known to be particularly susceptible for ischemia/reperfusion injury may benefit from omitting the pringle maneuver.

FP 25.03

TOTAL VASCULAR EXCLUSION (TVE): A USEFUL TECHNIQUE DURING COMPLEX HEPATIC RESECTIONS

Smith, Katherine; Morris-Stiff, Gareth; Gomez, Dhanwant; Toogood, Giles J; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. Acquisition of vascular control is imperative during extensive during complex hepatic resections. Whilst the Pringle man oeuvre may suffice in many cases, additional control of hepatic outflow may be required, this being termed total vascular exclusion (TVE).

Aims. To evaluate the indications and outcomes of TVE during complex hepatic resections.

Patients and Methods. The hepatobiliary database was interrogated to identify all cases in which TVE had been utilised. Those in which subsequent veno-venous bypass or an ex-vivo resection were subsequently used were excluded. Analysis included: demographic factors; operative data; and outcome in terms of postoperative complication rate and perioperative mortality.

Results. 40 cases were identified (27 males, 13 females with a median age of 56 years. The most common indications for surgery were: colorectal metastases (52.5%); cholangiocarcinoma (22.5%); and hepatocellular carcinoma (12.5%). The median number of Couinaud segments excised was 6 (range: 2–7). In 77.5% of cases a Pringle was used prior to TVE. The median duration of TVE was 27.5 minutes (range: 2–180). The median perioperative blood transfusion was 5 units (range: 0–42) and median plasma transfusion was 4 (range: 0–15). Additional procedures included: portal vein reconstruction (17.5%); IVC reconstruction (15%); and biliary reconstruction (42.5%). The morbidity rate was 55%, the 30-day mortality rate was 12.5%, and the median hospital stay was 14 days (range: 6–53).

Conclusions. Whilst the morbidity and mortality of complex resections is high, the use of TVE may facilitate resection of technically challenging lesions.

FP 25.04

A COMPARATIVE ANALYSIS OF CRUSH/CLAMP, STAPLER, AND DISSECTING SEALER HEPATIC TRANSECTION METHODS

Castaldo, Eric T.; Earl, T. Mark; Feurer, Irene D.; Pinson, C. Wright

Vanderbilt University Medical Center, Nashville, United States

Introduction. Several methods for hepatic parenchymal division exist. The primary aim of this study was to assess differences in post operative bile leaks and operative blood loss between 3 transection methods crush/clamp (CC), stapler (SP), or dissecting sealer (DS; TissueLink).

Methods. A single institution, retrospective cohort study was performed on data collected over a 3-year period in patients undergoing elective liver resection using the CC, SP, or DS. Patients were excluded if multiple methods of transection were used or if intraoperative death occurred. A bile leak was defined as 1) bile drainage for >7 days after surgery 2) post operative imaging demonstrating a fluid collection confirmed to be bile with percutaneous drainage and/or 3) reoperation in which a bile leak was identified. Blood loss was characterized as minor if <1000 mL and major if > = 1000 mL. The association of bile leak with transection type was assessed with a chi-squared test. A multiple logistic regression model was used to assess whether major blood loss was associated with transection method (reference group CC), vascular isolation, extent of liver resection (<2 Couinaud segments or > = 2 segments), and other concurrent major operations as covariates.

Results. Analyses included 141 patients (51 CC, 66 SP, and 24 DS). The overall rate of bile leaks was <3%. The risk of bile leak was no different between CC, SP, and DS (p = 0.23). The risk of major blood loss was increased with DS when compared to CC (OR = 3.09, p = 0.04), with no difference between SP and CC (p = 0.18). Major blood loss was not associated with extent of liver resection (p = 0.21) and a concurrent other major operation (p = 0.30) but was associated with vascular isolation (OR = 3.53, p = 0.03).

Conclusion. The risk of post operative bile leak is no different for hepatectomies using CC, SP, and DS. However, hepatectomy using DS is associated with an increased risk of major operative blood loss when compared to CC.

FP 25.05

TECHNIQUES FOR PARANCHYMAL TRANSECTION IN LIVER SSURGERY: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

PAMECHA, VINIYENDRA¹; Guruswamy, Kurunchi²; Junnankar, Sameer²; Sharma, Dinesh²; Davidson, Brian²

¹Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION, Pond Street, Hampstead, LONDON, United Kingdom; ²Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION, LONDON, United Kingdom

Background. Blood loss is one of the main factors affecting the outcome of liver surgery. Different parenchymal transection techniques have been described to decrease blood loss.

Objectives. To assess the benefits and risks of the different techniques of parenchymal transection during liver resections by review and meta-analysis of randomised controlled trials.

Methods. The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index were searched until September 2006. The inclusion criteria were all randomised clinical trials comparing different methods of parenchymal dissection. Data was collected on population characteristics, methodological quality, mortality, morbidity, blood loss, transection speed and hospital stays. Analysis was done using the fixed-effect model RevMan. If there was statistical heterogeneity, random-effects model was used. For each outcome the odds ratio (OR), weighted mean difference (WMD) or standardised mean difference (SMD) with 95% confidence intervals was calculated.

Results. Seven trials with 565 patients were included. The comparisons include CUSA vs clamp-crush (2 trials); RFDS (Radio Frequency Dissecting Sealer) vs clamp-crush (1 trial); sharp dissection vs clamp-crush technique (1 trial); and hydrojet vs CUSA (2 trials). One trial compared CUSA, RFDS, hydrojet and clamp crush technique. There was no significant difference between the techniques in mortality, morbidity, liver dysfunction, ITU and hospital stays. The blood transfusion requirements were lower in the clamp-crush technique than CUSA and hydrojet (OR 11.29, 95% CI 1.29 to 98.89). There was a tendency for lower transfusion requirements in the clamp-crush technique than with RFDS (OR 5.73, 95% 0.94 to 34.77). Clamp-crush technique was quicker than CUSA, hydrojet and RFDS (WMD −1.50, 95% CI −2.33 to −0.67).

Conclusions. The Clamp-crush technique is more rapid and associated with lower blood loss than other methods of parenchymal transaction and remains the gold standard for comparison of new Methods.

FP 25.06

IS ROUTINE PRINGLE MANOEUVRE NECESSARY IN MODERN LIVER RESECTION? AN ANALYSIS OF 248 CONSECUTIVE CASES OF NO-CLAMP HEPATECTOMY

Lee, Kit Fai; Wong, John; Ng, Wilson WC; Ling, Eva; Fok, Ka-Lun; Ng, Nancy; Lo, Xina; Mak, Nerissa OS; Lai, Paul BS

Prince of Wales Hospital, Surgery, Hong Kong, China

Background. Although Pringle manoeuvre helps to cut down blood loss during hepatectomy, the ischaemic insult brought to remnant liver cannot be under-estimated.

Objective. To evaluate the feasibility and possible benefits by abandoning routine Pringle maneuvre in liver resection.

Methods. Between June 2003 and May 2007, 248 consecutive liver resections (including 28 laparoscopic resections) were performed in our institute without using Pringle maneuvre. Extrahepatic dissection of porta structures and hepatic veins were done if possible. Liver was then transected with CUSA and haemostasis achieved by TissueLink dissecting sealer, ligatures and staples.

Results. There were 152 males and 96 females with median age of 54 years (range 22–80). Commonest indication was hepatocellular carcinoma (52.4%) and 31% of pateints had cirrhosis. Around 30% of cases were major hepatectomy. All liver resections were accomplished without Pringle maneuvre except in 6 cases, in which 2 were for extraction of portal vein tumor thrombus and 4 for control of bleeding. There were two in-hospital mortality (0.8%). One patient died of myocardial infarction and the other died of liver failure. Complications occurred in 63 patients (25.4%), of which one patient needed reoperation for bleeding from right adrenal gland. Median blood loss was 300 ml (range 20–2700) and 19 patients (7.7%) required transfusion. Median operation time was 240 min (range 70–490). The median postoperative hospital stay was 7 days (range 2–47).

Conclusion. Low blood loss can equally be achieved in hepatectomy without Pringle maneuvre. Furthermore, recovery is hastened by avoiding ischaemic insult to liver as denoted by low operative mortality and morbidity, and short post-operative hospital stay.

FP 25.07

RISK FACTORS FOR LIVER FAILURE AND MORTALITY AFTER MAJOR HEPATECTOMY ASSOCIATED WITH PORTAL VEIN RESECTION

JAECK, Daniel; ROSSO, Edoardo; PESSAUX, Patrick; OUSSOULTZOGLOU, Elie; BACHELLIER, Philippe

Hopital de Hautepierre, Centre de Chirurgie Viscérale et Transplantation, Strasbourg, France

Objective. To report the postoperative outcome of hepatectomy associated with portal vein resection (PVR) and to identify risk factors of clinical value for predicting liver failure and mortality. Summary Background Data: Partial resection of the portal vein during hepatectomy allows to increase the number of patients who may benefit from a potentially curative operation. However this procedure may increase posto perative morbidity and mortality. Little is known about risk factors for liver failure (LF) and mortality after such procedure.

Methods. Between July 1996 and February 2007, a total of 1348 patients were operated for liver disease in our institution. Among them 44 patients underwent liver resection associated with PVS. Medical records of these patients were prospectively collected and retrospectively analyzed.

Results. Ninety-three percent of the patients underwent a major hepatectomy. Overall morbidity was 57%, fifty-two percent of all complications were of grade III or IV according to Clavien's classification. Overall mortality was 9%. Irreversible LF was the only cause of death. Univariate analysis showed that male gender (P = 0.013), preoperative portal vein embolization (PVE) (P = 0.002), extent of liver resection (P = 0.009) were significantly associated with an increased risk of postoperative LF. Moreover, PVE (P = 0.024), extent of liver resection (P = 0.028), presence of steatosis (P = 0.021), occurrence of LF (P = 0.026) and re-laparotomy (P = 0.026) were significantly associated with increased risk of postoperative mortality.

Conclusion. The present study confirmed that major hepatic resection with PVS can be performed with acceptable overall morbidity and mortality. However preoperative selection of the patients should take in consideration gender, need for PVE, and the extent of hepatic resections to avoid irreversible LF and death.

FP 25.08

ANALGESIC EFFICACY OF CONTINUOUS WOUND INSTILLATION OF ROPIVACAINE FOLLOWING LIVER SURGERY ¡V A RANDOMIZED, DOUBLE-BLIND PLACEBO-CONTROL STUDY

Lai, Bo San Paul¹; Chan, Simon K C²; Li, Peggy T Y²; Wong, John³; Karmakar, M J⁴; Lee, K F³

¹Prince of Wales Hospital, Chinese University of Hong Kong, Surgery, Hong Kong, Hong Kong; ²Prince of Wales Hospital, Anaesthesia and Intensive Care, Hong Kong; ³Prince of Wales Hospital, Surgery, Hong Kong; ⁴Prince of Wales Hospital, Chinese University of Hong Kong, Anaesthesia and Intensive Care, Hong Kong

Introduction. Because of post-operative hepatic dysfunction and its associated coagulopathy, effective pain management modalities including epidural analgesia and NSAID drugs have to be avoided after liver surgery.

Objective. This study aims to investigate the efficacy of continuous wound instillation of local anaesthetics over the subcostal wounds after liver surgery.Method.: 49 patients undergoing elective liver surgery were recruited. All patients received standardized general anaesthesia and right subcostal incision. Two multi-orifices 16-gauge indwelling catheters were subcutaneous tunneled and buried within the musculo-fascial layer before skin closure. Patients were randomized to receive either ropivacaine 0.25% (R group) or saline (S group) infused at 4 ml/hour via an elastometric balloon pump (On-Q PainBuster, I-Flow Corp, California) for 3 days. Supplemental analgesia was provided by intravenous morphine patient-control analgesia (PCA).

Results. 43 patients completed the trial and 6 patients were excluded from study (2 laparoscopic procedure; 2 opened and closed; 1 developed cardiac complication intraoperatively and 1 developed TIA on day 2). There is no difference between the groups in age, ASA status and demographic data. Patients in ropivacaine group had significantly less pain at rest and after spirometry in 4, 12, 24, 48 and 72 hours post-operatively (P < 0.01). The total morphine consumption was significantly reduced (58 ¡Ó 30 vs. 86 ¡Ó 44mg, P < 0.05). Forced vital capacity was reduced post-operatively in both groups, but the reduction was more significant in control group at 12 and 24 hours (P < 0.05); but not in 4, 48 and 72 hours. There is no significant difference in extubation time, ICU and hospital length between the groups.

Conclusion. Continuous wound instillation of ropivacaine is more effective to reduce pain compared with placebo after major liver surgery.

FP 25.09

LAPAROSCOPIC SEGMENT VI LIVER RESECTION USING A LEFT LATERAL DECUBITUS POSITION: A MORE APPROPRIATE LAPAROSCOPIC TECHNIQUE

Belli, Giulio; Fantini, Corrado; D'Agostino, Alberto; Cioffi, Luigi; Limongelli, Paolo; Russo, Gianluca; Belli, Andrea

S. M. Loreto Nuovo Hospital, Department of General and HPB Surgery, Naples, Italy

Background. Although the laparoscopic technique for left-sided lesions, such as left lateral hepatic sectionectomy is well described in the literature, the best laparoscopic approach to segment VI resection is still debated.

Objective. We describe a laparoscopic technique for segment VI resection using a left decubitus position with the right side up of the patient facilitated by some personal tricks.

Methods. From January 2000 to December 2006 ten patients ( 6 men, 4 women; mean age, 61.3 years) underwent laparoscopic segmentectomy of the segment VI at our department. Eight patients presented with hepatocellular carcinoma on cirrhosis, and two had a liver metastases from colon cancer. We used a left decubitus position with the right side up in eight patients. Two early patients were operated on utilizing a more common supine position.

Results. The mean operative time was 125 min ( range 80–165 min) The average size of the lesions was 2.9 cm. (range 1.3 – 3.1). The laparoscopic procedure was carried out successfully in all cases. There were no deaths and no intraoperative or postoperative complications. Blood transfusions were not required. The main postoperative hospital stay was 7.6 days (range 5–12).

Conclusions. The key points of the technique are: patient in left decubitus position (right side up) with the surgeon facing the patient's abdomen; early and easier mobilization of the right liver cutting the triangular and the right coronary ligament but not the round and the falciform ligaments; the use of an esophageal retractor to facilitate the Pringle manoeuvre; the use of a tape passed around the right mobilized liver hanging and handling the segment VI; the liver transection performed in an ideal laparoscopic orthogonal position ( 90 degree) with the instruments in a more precise triangular position. The technique described may be a good option for patients with lesions in the segments VI with the advantage to perform a safer liver transection in a more appropriate laparoscopic position.

FP 26.01

LIVER TRANSPLANTATION FOR UNRESECTABLE HEPATOBLASTOMA: 20-YEAR EXPERIENCE IN A SINGLE CENTER

Mohanka, Ravi¹; Cruz, Ruy¹; Talukdar, Anjan²; Ranganathan, Sarangarajan³; Bond, Geoffrey²; Soltys, Kyle²; Mazariegos, George²; Marsh, Wallis¹; Marcos, Amadeo¹; Sindhi, Rakesh²

¹University of Pittsburgh Medical Center, Thomas E Starzl Transplantation Institute, Pittsburgh, United States; ²University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, United States; ³University of Pittsburgh Medical Center, Children's Hospital of Pittsbrugh, Pittsburgh, United States

Background. Hepatoblastoma is a rare but highly malignant liver tumor. Complete surgical resection after chemotherapy is the definitive treatment for hepatoblastoma; however, orthotopic or reduced-sized liver transplant can be an acceptable treatment strategy for patients with unresectable liver tumor.

Objective. The aim of this study was to present a single center's experience of liver transplant for hepatoblastoma in children. STUDY DESIGN: a retrospective analysis of 23 patients with unresectable hepatoblastoma who were referred for liver transplantation between March 1987 and August 2006 was conducted.

Results. the patient assessed had an age range from 15 to 77 months at time of diagnosis; median 32 months (12 girls/ 11 boys). Seventeen patients received whole grafts and 6 reduced sized. The time from the diagnosis to the transplant ranged from 3 to 39 months (median 7 months). Five patients present early rejection treated adequately with steroids. Twelve out of 23 patients were on chemotherapy after the transplant; the chemotherapy protocol varies but usually includes cisplatin, ifosfamide, vincristine and/or 5-fluoracil. Posttransplantation survival rate were 91% and 86% for 1 and 5 years respectively.

Conclusion. total hepatectomy and liver transplantation is a potentially curative treatment option for unresectable hepatoblastoma with low recurrence rate. Posttransplant chemotherapy is recommended in selected cases

FP 26.02

DE NOVO MALIGNANCIES AFTER LIVER TRANSPLANTATION

Bilbao, Itxarone¹; Sapisochin, Gonzalo¹; Dopazo, Cristina¹; Lazaro, Jose Luis¹; Castells, Luis²; Lopez, Iñigo¹; Balsells, Joaquin¹

¹Hospital Vall d′Hebron, Surgery Department, Barcelona, Spain; ²Hospital Vall d′Hebron, Hepatology Department, Barcelona, Spain

Introduction. De novo malignancy after transplantation, has been attributed to prolonged immunosuppression status , oncovirus activation and a direct oncogenic effect of immunosuppressive drugs.

Aims. To determine risk factors, clinical characteristics and outcomes of de novo tumors after liver transplant (LT) from a large single-center series. MATERIAL. From 1988 to 2007, 783 LT were performed in 725 patients. 59 patients (8.1%) developed de novo malignancy. Type of malignancies, clinical characteristics and outcomes have been analysed. In order to determine risk factors for malignancy a case-control study were done. Controls were matched by age±10 years, sex, diagnosis leading to LT and time from LT to diagnosis of tumour.

Results. Most of the tumours were solid 61% (lung, esophago-gastric, colo-rectal, prostata-bladder, oropharynge, etc), followed by skin tumors 34% and lymphoid cancer 5%. Mean time from LT to diagnosis was 54±32 months (r:4–130). Immunosuppression at induction was based on FK 506 59% (cases) vs 52% (controls) and CyA 41% (cases) vs 48% (controls), p = ns. After tumour diagnosis, CNI were decreased to half levels in 93%, completely stopped in 2%, and converted to m-TOR in 5%. All tumours except 3 were treated with surgery (45), radiotherapy (19), chimiotherapy (19), etc, as in non-transplanted population. Steroids withdrawal was achieved in 87% of cases vs 93% of controls (p = ns). Risk factors for malignancy were: intraoperative multitransfusion of RBC (p = 0.02) and the presence of portal thrombosis (p = 0.03). Recipient age over 65 years and previous intake of alcohol and smoking showed a tendency. (p = ns). Actuarial survival post-diagnosis for solid and haematological malignancies was poor: 69%, 36% and 3% at 1–2–3 years.

Conclusion. De novo malignancies is a real problem after liver transplantation, specially in aged candidates with previous history of alcohol and smoking with sever hepatopaty at time of transplant. Minimal immunosuppression must be administered in this high risk patients

FP 26.03

METHODS OF BILIARY RECONSTRUCTION IN LIVER TRANSPLANTATION: A META-ANALYSIS OF RANDOMISED CONTROL TRIALS

Mehta, Naimish¹; Guruswamy, Kurinchi²; Davidson, Brian²

¹Royal Free Hospital, Dept of HPB and Liver Transplant Surgery, Hampstead, London, United Kingdom; ²Royal Free Hospital, Dept of HPB and Liver Transplant Surgery, London, United Kingdom

Backgroud. Biliary complications have been reported in range of 20%–40% and remain a significant cause of morbidity following liver transplantation.

Aim. To determine the optimal method of biliary reconstruction during liver transplantation from literature review and meta-analysis.

Method. Evidence was evaluated from six randomised trials (until July 2007) related to the different techniques of biliary reconstruction during liver transplantation. We collected the data on the characteristics, methodological quality, mortality, biliary complications, operating time and hospital stay. 3 trials compared primary anastomosis with or without t-tube (n = 324); 1 trial compared primary anastomosis with or without biliary stent (n = 37); 1 trial compared side-to-side vs end-to-end biliary anastomosis (n = 100); and 1 trial compared duct-to-duct anastomosis with hepaticojejunostomy in right lobe living donor liver transplant recipients (n = 53). Two of the six trials were of low risk of bias.

Results. Primary anastomosis versus T-tube (n = 324): biliary complications were significantly higher in the t-tube group 44/148 vs 23/147. (RR 0.09, 95% CI 0.02 to 0.48). Similar proportion of patients required surgical treatment in both the groups. In primary anastomosis with or without stent group (n = 37): biliary complications were significantly lower in the primary closure (1/19 vs 9/18) group. In side-to-side vs end-to-end biliary anastomosis group (n = 100) and primary anastomosis vs hepaticojejunostomy group (n = 53): biliary complications were similar.

Conclusions. Duct to duct primary biliary reconstruction is associated with low risk of biliary complications. Alternative methods of reconstruction have either shown no impact (side to side biliary anastomosis, hepaticojejunostomy) or an increased risk of complications (with t-tube or stent).

FP 26.04

DOES HIGH RISK GRAFTS COMPROMISE OUTCOMES IN PATIENTS WITH CHOLESTATIC LIVER DISEASE?

Bonney, Glenn K; Attia, Magdy; Milson, Charlie E; Davies, Mervyn; Pollard, Stephen G; Toogood, Giles J; Lodge, J Peter A; Prasad, K Rajendra

St James' University Hospital, Department of Hepatobiliary and Tranpslantation, Leeds, United Kingdom

Background. The current organ shortage necessitates the use of marginal grafts in low risk liver transplant recipients, such as those with cholestatic liver disease. This will allow good grafts to be utilised in higher risk patients, such as those with alcohol and viral induced cirrhosis, to achieve good outcomes. However, there is a concern whether this allocation will adversely impact outcome in low risk recipients. The aim of this study was to analyse patient and graft survival following transplantation of low and high risk grafts into cholestatic, alcohol and viral induced cirrhotics.

Methods. A prospectively collected database of donors and recipients of liver transplants performed at one centre from 1998–2005 was analysed. The recipients were divided into cholestatic (n = 207), alcohol (n = 149) and viral-induced (n = 200) cirrhosis categories with diagnoses of primary biliary cirrhosis/primary sclerosing cholangitis, alcoholic cirrhosis and Hepatitis B/C induced cirrhosis respectively. The donor grafts were split into low- and high-risk categories based on the Donor Risk Index <1.8 and greater or equal to 1.8 respectively.

Results. There was no significant difference between the groups with respect to recipient age, gender, ethnicity, MELD score, year of transplantation and Donor Risk Index. There was no significant difference in patient and graft survival transplanted with low and high DRI grafts in the cholestatic group (p = 0.473). In comparison, there was a significantly poorer patient and graft survival in the alcoholic group receiving high DRI grafts (p = 0.05 and 0.04 respectively). There was similarly a poorer patient and graft survival in the viral induced cirrhosis group receiving high DRI grafts (p = 0.04 and 0.02 respectively).

Conclusion. High risk grafts, as evaluated here by the Donor Risk Index, can be transplanted into cholestatic liver disease without significantly compromising patient and graft survival when compared to low risk grafts.

FP 26.05

STENTING FOR VENOUS OUTFLOW PROBLEMS POST-LIVER TRANSPLANTATION

Oniscu, Gabriel C¹; Perera, Thamara¹; Gunson, Bridget¹; Buckles, John¹; Mirza, Darius¹; Brahmall, Simon¹; Mayer, David¹; Olliff, Simon²

¹The Queen Elizabeth Hospital, The Liver and Hepatobiliary Unit, Birmingham, United Kingdom; ²The Queen Elizabeth Hospital, Departmetn of Radiology, Birmingham, United Kingdom

Background. Venous outflow obstruction is a rare but serious complication post liver transplantation.

Aim. This study reviews the management and outcome of venous outflow problems following liver transplantation in a large single centre experience.

Methods. 31 patients with venous outflow problems were identified among 3000 patients who had a liver transplant between 1982–2007. Demographic, transplant and interventional data were retrieved from the prospective unit's database as well as radiology records.

Results. The incidence of venous outflow obstruction after liver transplantation is low (1.1%). 25 cases occurred following the first transplant and 6 occurred after re-transplants. All grafts were from heart beating donors and 30/31 were whole size grafts. 13 livers were implanted using a classic technique, whilst 18 cases had a piggyback technique (2 Brisbane). The mean time interval between transplantation and stenting was 210 days (range: 34 – 4178 days). 17 patients underwent TIPSS, 8 had hepatic vein stenting, 7 IVC stenting and 7 underwent PV stenting. 9 patients required a combination procedure (TIPSS + venous stenting or hepatic vein stenting + portal/IVC stenting). TIPSS was performed more often after classic OLT. The median survival post-stenting was 510 days (range:1–5232 days) and the main causes of death were sepsis (7), bleeding (2) and cerebral dysfunction (3). The 30-days mortality was 16.12% and the overall mortality was 51.6%. The failure rate was 48.38%. Two patients were re-transplanted post stenting. Survival post stenting was worse in patients that had a classic OLT compared to those that had a piggyback technique (Log Rank, p = 0.02). Survival was significantly worse after TIPSS compared to IVC or hepatic veins stenting (Log Rank, p = 0.02).

Conclusion. Venous stenting for outflow obstruction after liver transplantation should be attempted as the first line of treatment, despite the high risk of complications. TIPSS are associated with a worse outcome compared to other veno us stenting procedures.

FP 26.06

INFLUENCE OF THE LENGTH OF THE ANHEPATIC PHASE ON OUTCOME AFTER PRIMARY LIVER TRANSPLANTATION

IJtsma, Alexander J.C¹; Hilst, Christian S. van der²; TenVergert, Elisabeth M.²; Boer, Marieke T. de¹; Jong, Koert P. de¹; Peeters, Paul M.J.G.¹; Porte, Robert J.¹; Slooff, Maarten J.H.¹

¹University Medical Center Groningen, HPB Surgery and Liver Transplantation, Groningen, Netherlands; ²University Medical Center Groningen, Medical Technology Assessment, Groningen, Netherlands

The aim of this study was to assess the relation between the duration of the anhepatic phase and the outcome after liver transplantation (LT) in terms of patient and graft survival and graft dysfunction. A single center cohort of consecutive adult primary LT recipients transplanted with the piggyback technique using heart-beating donors without veno-venous bypass between 1994 and 2004 was analysed. The study group consisted of 182 patients. Study variables were donor age and BMI, recipient age, diagnosis and MELD score and peroperative RBC transfusions, blood loss and the duration of the cold and warm ischemia time and of the anhepatic phase. The functional anhepatic phase (FAHP, from clamping of native liver blood supply until recirculation) and anatomical anhepatic phase (AAHP, from removal of the native liver until recirculation) were separately analysed. ROC curves were constructed to determine optimal cut-off values. Initial poor function (IPF) was defined as ASAT > 2000 U/l and PT > 16 secs on days 2–7. Median AAHP was 76 mins (37–321). Median FAHP was 98 mins (45–321). IPF occurred in 21 patients (12%). In patients with an AAHP below 100 mins, the incidence of IPF was 11 out of 131 (8.4%) while in patients with an AAHP over 100 mins this was 10 out of 38 (26%) (p < 0.004). In patients with an FAHP below 120 mins, the incidence of IPF was 10 out of 115 (8.7%) while in patients with an FAHP over 120 mins this was 11 out of 55 (20%) (p < 0.04). The occurrence of IPF was the only study variable independently associated with patient survival. One year patient survival in patients without IPF was 91% versus 67% in patients with IPF (p < 0.001). A direct relation between the AAHP or FAHP duration and patient or graft survival could not be established. In conclusion, this study shows that LT patients with a prolonged functional (over 120 minutes) or anatomical (over 100 minutes) anhepatic phase have a two to threefold higher incidence of IPF. Patients with IPF had a significantly worse patient survival.

FP 26.07

MULTICENTER STUDY TO VALIDATE PREVIOUS PUBLISHED FORMULAS TO ASSESS RIGHT LOBE LIVER VOLUME

Gondolesi, Gabriel¹; Ghirardo, Silvio²; Tokat, Yaman³; Baris, Akim³; Makuuchi, Masatoshi⁴; Sugawara, Yasuhiko⁴; Mulligan, David⁵; Russell, Lyndsay⁵; Soejima, Yuji⁶; Yoshizumi, Tomoharu⁶; Belghiti, Jacques⁷; Dondero, Federica⁷; Pinna, Antonio⁸; Maseti, Michele⁹; Rogiers, Xavier¹⁰; Wilms, Christian¹⁰; de Santibañes, Eduardo¹¹; Gadano, Adrian¹¹; Podesta, Luis G.¹²; Andriani, Oscar¹²; Facciuto, Marcelo¹³; Emre, Sukru¹⁴

¹RMTI/Mount Sinai School of Medicine, New York, Liver Unit, Fundacion Favaloro, Buenos Aires, Argentina; ²Mount Sinai School of Medicine, Recanati/Miller Transplantation Institute, New York, United States; ³Ege University Medical School, Department of Organ Transplantation, Izmir, Turkey; ⁴University of Tokyo, HPB Surgery Division, Transplantation Division, Tokyo, Japan; ⁵Mayo Clinic Hospital, Transplantation Surgery, Phoenix, Arizona, United States; ⁶Kyushu University, Department of Surgery and Science, Fukuoka, Japan; ⁷Hospital Beaujon, Digestive Surgery, Clichy, France; ⁸Sant'Orsola-Malpighi Hospital, Department of Liver and Solid Organ Transplantatio, Bologna, Italy; ⁹Policlinico di Modena, Centro Trapianti de Fegato e Multiviscerale, Modena, Italy; ¹⁰University Hospital Hamburg Eppendorf, Department of Hepatobiliary Surgery, Hamburgo, Germany; ¹¹Hospital Italiano, Transplante Hepatico, Buenos Aires, Argentina; ¹²Fundacion Favaloro, Unidad de Cirugia HPB y Transplante Hepatico, Buenos Aires, Argentina; ¹³Westchester Medical Center, Department of Hepatobiliary Surgery and Liver Tran, Valhalla, New York, United States; ¹⁴Mount Sinai School of Medicine, New York, Department of Surgery, Yale School of Medicine, United States

Background. A simple formula for clinical estimation of whole liver weight was proposed (SLW = 772*BSA), right lobe liver weight (RLW) was estimated as 57% (R-57) of the SLW and applied in right lobe living donor liver transplant (RLLDLT).

Aim. To validate the accuracy and worldwide applicability of R-57, to compare it with images obtained volumes and with other formulas (OF) (De Land, North, Heineman, Mount Sinai, Urata), and in case of negative results to build a new formula (NewF) based on the collected data.

Material and Methods. From 1/02 to 7/05, 376 RLLDLT from 11 centers from Asia (2), North (3) and South America (2) and Europe (4) were enrolled. Data collected: Donor: weight(kg), height (cm), age, sex and race; Recipient: weight, age, sex; Right lobe: actual liver weight (ARLW) at the end of the back table flushing (grs), and estimated volume/weight according to CT, MRI or US. SLW and RLW were reported as mean and SD; mean ARLW and graft to recipient weight ratio (GRWR) were compared with the means of each estimation method using Bland-Altman (BA). Estimation methods were considered acceptable if results were within 20% of the true value, McNemar's test was used for comparison between them. Linear regression was used to develop the NewF.

Results. Donors: 45% males; age: 37±11 years; weight: 71.5±11.8 kgs; BSA: 1.81±0.18; Recipients: 35% males; age: 49±12 years; weight: 70.0±15 kgs; Right lobe: ARLW: 757.1±180.7; CT(n = 325):827.6±206.2; MRI(n = 31): 961.3±157.3; US(n = 20):726.5±155.9 grs; R-57: 799.6±81.1 (p < 0.05); NewF (=BSA*474): 757.5±142 grs (p<.5). GRWR: ARLW: 1.1±0.29; CT(n = 325):1.22±0.34; MRI (n = 31): 1.30±0.39; US(n = 20):1.11±0.29 grs; R-57: 1.18±0.24 (p < 0.05); NewF: 1.11±0.25 grs (p<.5). NewF estimates right lobe weight and GRWR (BA: 0.14%, disagreement: 17%) better than CT, US, R-57, and OF (p<.001).

Conclusions. R-57 was less accurate to predict RLW in the multicenter study than in the initial study. The new proposed formula allowed adequate estimation with worldwide applicability.

FP 26.08

CLINICAL SITUATION OF VHC (+) LIVER TRANSPLANT PATIENTS AFTER 10-YEAR OF SURVIVAL

Bilbao, Itxarone¹; Dopazo, Cristina¹; Lazaro, Jose Luis¹; Castells, Luis²; Sapisochin, Gonzalo¹; Lopez, Iñigo¹; Escartin, Alfredo¹; Balsells, Joaquin¹

¹Hospital Vall d′Hebron, Surgery Department, Barcelona, Spain; ²Hospital Vall d′Hebron, Hepatology Department, Barcelona, Spain

Objectives. To analyze the clinical situation of HCV(+) liver transplant patients with a survival of 10 years and to compare them with HCV(+) patients that have not survived this period.

Materials and Methods. From 1988 to 1997, 127 HCV (+) patients had a liver transplant with ¡Ý10-year follow-up. Of these, 43 are alive and 84 are dead. The average age was 57 years. The immunosuppressive induction was 82% CyA, and 18% FK. Both groups have been compared regarding demographic characteristics of recipient, donor and surgery, and short and long term complications. Causes of mortality in the group with <10 years survival have been also analyzed.

Results. The main causes of mortality were: relapse of HCV 26% and HCC 14%, sepsis-infection 16%, and medical causes 13%. Concerning recipient characteristics (univariant analyses), patients with short survival were older, and had higher incidence of pre-LT renal failure. There were no differences in donors or surgery, although older donors showed a tendency toward higher mortality in the recipient. In the group with long term survival, steroids were removed in greater percentage (100% vs. 51%). Patients with ¡Ý10 years survival showed lower incidence of rejection (43% vs 58%), infection (34% vs 42%) and renal failure (29% vs 60%), at one year post-LT. Alive HCV (+) patients 10 years after LT showed: 45% chronic renal failure, 79% arterial hypertension, 26% IDDM, 17% dyslipidemia, 66% HCV relapse in the graft as acute hepatitis.

Conclusion. In HCV (+) patients, age over 60 years, HCC indication for LT, and pre-LT renal failure are risk factors of lower survival on the long term. To achieve long survival after LT is essential to apply early agressive immunosuppressive regimens that could avoid rejection and the use of steroids, but late inmunosupression regimens avoiding CNI as much as possible.

FP 26.09

FEASIBILITY STUDY OF HEPATECTOMY WITH EXTENSIVE USE OF RFA FOR TREATING PATIENTS WITH MORE THAN 15 ENDOCRINE METASTASES TO THE LIVER

Elias, Dominique¹; Goéré, Diane¹; Leroux, Guillaume¹; Lo Dico, Rea¹; Ducreux, Michel²; Baudin, Eric²

¹Institut Gustave Roussy, Surgical Oncology, Villejuif, France; ²Institut Gustave Roussy, Medical Oncology, Villejuif, France

Aim. The aim of this study was to report the feasibility of a complete cytoreductive surgery combined with radiofrequency ablation (RFA) during one step, in patients with more than 15 liver metastases (LM) from well differenciated endocrine tumors.

Methods. A combination of anatomical bloodless hepatectomy to treat large or contiguous LM was done with an extensive use of RFA (with cooling of the bile duct, and trans-LM hepatectomy passing through LM preliminary ablated with RFA) to treat the remaining small LM (<25 mm). During surgery, the primary tumor, if present, was also resected.

Results. From January 2002 to May 2007, 16 patients underwent complete resection and/or ablation of mulptiple and bilobar LM from endocrine tumor, mostly originating from the duodeno-pancreas (n = 10/16). Liver resection consisted in 12 extended hepatectomy. The mean number of LM treated per patient was 25.7±17 (median, 20[16 – 89]). Resection of the primary was associated in 9 patients, resulting in 5 left pancreatectomy, 2 duodenopancreatectomy, 1 partial duodenectomy, 1 right colectomy. The mean duration of surgery was 332±71 min, and median intra-operative blood loss was 570±348 ml. There was no mortality. Morbidity was observed in 11 patients (69%). Two patients were reoperated. Other specific complications were 2 transient liver insufficiency, 1 caval thrombosis, 4 pleural effusions, 3 pancreatic fistulas.

Conclusion. This new approach allows to propose resection to a greater number of patients and to abandon the two-stage hepatectomy.

FP 27.01

ONE-STAGE ULTRASOUND-GUIDED HEPATECTOMY FOR MULTIPLE BILOBAR COLORECTAL METASTASES: AN ALTERNATIVE TO TWO-STAGE HEPATECTOMY

Del Fabbro, Daniele; Botea, Florin; Marconi, Matteo; Palmisano, Angela; Procopio, Fabio; Spinelli, Antonino; Donadon, Matteo; Montorsi, Marco; Torzilli, Guido

University of Milan, Istituto Clinico Humanitas IRCCS, Third Department of General Surgery, Rozzano (MI), Italy

Background. Two-stage hepatectomy with or without portal vein embolization allows to treat multiple bilobar metastases expanding surgical indications for these patients. However, it has some related drawbacks: two operations are needed, and some patients do not complete the treatment strategy for disease progression. Taking profit from our ultrasound guided resection policy we explored the safety and effectiveness of one-stage surgical procedures in patients otherwise recommended for the two-stage approach.

Methods. Eighteen (25%) patients with bilobar and more than 4 colorectal cancer liver metastases (CLM) among 73 consecutive patients who underwent surgery for that were selected. Total number of CLM preoperatively was 103 (median 5; mean 5.7; range 4–11). Surgical strategy was based on tumor-vessels relationship at intraoperative ultrasonography (IOUS) and on findings at color-Doppler IOUS.

Results. In-hospital mortality was nil. Tumor clearance was feasible at one stage in all patients but 2 who had explorative laparotomy. The overall morbidity rate was 25% (4/16). Major morbidity occurred in 1 patient (6%): not even one patient was reoperated. Blood transfusions were done in 2 (12.5%) patients. After a mean follow-up of 16 months (median 15; range 6–42), 3 patients are died for systemic recurrence, 7 patients are alive without disease, and 6 are alive with disease. No cut-edge local recurrence were observed.

Conclusions. IOUS-guided resection based on strict criteria allows surgical treatment at one stage in patients carrier of multiple, bilobar CLM. This strategy limits drastically the need for two stage hepatectomy, and with that overcome their drawbacks.

FP 27.02

EFFECTS OF PREOERATIVE TREATMENT WITH CYTOSTATIC AGENTS ON SHORT AND LONG TERM EFFECTS OF LIVER SURGERY FOR METASTASES FROM COLO-RECTAL CANCER

Haglund, Ulf; Duraj, Frans; Norén, Agneta; Urdzik, Jozef

University Hospital, Department of Surgery, Uppsala, Sweden

Background. Surgery is the only treatment of liver metastases from colo-rectal cancer with a potential to cure. There are evidence supporting that pre- and postoperative treatment with cytostatic agents may enhance the curative potential on liver surgery in these patients. On the other hand, increased risks of liver surgery following preoperative chemotherapy treatment have been reported.

Objective. To further evaluate this we investigated patients undergoing liver surgery for colo-rectal metastases in our institution.

Methods. We retrospectively investigated patients undergoing liver resection for colo-rectal metastases 1999 – 2006 using data collected prospectively in our liver surgery register.

Results. In total 179 patients had liver surgery for colo-rectal metastases during this period. Of them 83 (46%) had preoperative treatment with cytostatic agents most often including oxiliplatin or irinotecan. 96 (54%) had no such preoperative treatment. Age and sex distribution was similar in the two groups. There was no significant difference in operating time (157±60 vs 148±60 min; ns) or blood loss between the groups. Hospital or 30 day mortality was similar in the two groups (1.2% vs. 1.0%). Severe postoperative complications were few and did not differ in this material. Neither did the total number of postoperative complicatio©ns (10.8% vs. 10.4%). Long term survival tended to be longer in the group treated preoperatively with cytostatic agents. Observed 3 and 5 years survival as of January 2007 was 62% and 50%, respectively, with cytostatics. Corresponding data for patients without preoperative cytostatics was 59% and 43%, respectively (ns; n = 35).

Conclusion. Preoperative treatment prior to liver surgery for metastases from colo-rectal cancer did not significantly influence operating time, length of stay, or survival. Only a tendency towards improvment was seen in survival which may be due to a limited number of patients included early with other agents than commonly used today.

FP 27.03

PROGNOSIS FOLLOWING LAPAROSCOPIC LIVER RESECTION OF COLORECTAL METASTASES – IS IT COMPARABLE TO OPEN RESECTION?

Hatzifotis, Michael¹; Patel, Bhavik¹; Bryant, Richard¹; Shaw, Ian²; Martin, Ian³; Hopkins, George¹; Fielding, George¹; Nathanson, Leslie⁴; O'Rourke, Nicholas¹

¹Royal Brisbane Hospital, HPB Surgery, Brisbane, Australia; ²Prince Charles Hospital, Surgery, Brisbane; ³Wesley, HPB Surgery, Brisbane; ⁴Royal Brisbane Hospital, HPB Surgery, Brisbane

Introduction. It is well established in the published literature that 5 year survival following liver resection for colorectal metastases is improved by 40 – 60%.

Methods. We examined our last 230 laparoscopic liver resections between Jan 1998 and Jan 2007.

Results. Thirty eight percent (87/230) of resections were for colorectal metastases. There were 23 right hemihepatectomies, 7 left hemihepatectomies, 16 left lateral sectionectomies, 12 segmentectomies, 29 non-anatomical resections. The median duration of surgery was 120 minutes. The median blood loss was 300mls. There were 6 conversions to open. The average length of hospital stay was 6 days. The overall morbidity was 22%. The 30 day mortality was zero. The resection margins were positive in 4 patients. The average follow up duration was 40 months.

Discussion. The survival of patients in our series seems comparable to large open series of liver resections.

FP 27.04

SEVERE SINUSOIDAL OBSTRUCTION SYNDROME CORRELATES WITH WORSE POSTOPERATIVE OUTCOME AFTER MAJOR LIVER RESECTION AND COULD BE PREDICTED PREOPERATIVELY

Brouquet, Antoine¹; Scatton, Olivier¹; Zalinski, Stefane¹; Terris, Benoit²; Brezault, Catherine³; Mallet, Vincent¹; Goldwasser, Francois³; Soubrane, Olivier¹

¹Hospital Cochin, Liver Diseases, Paris, France; ²Hospital Cochin, Pathology, Paris, France; ³Hospital Cochin, Oncology, Paris, France

Background. Oxaliplatin-based chemotherapy (OBC) may induce sinusoidal obstruction syndrome (SOS) lesions in the non tumoral liver parenchyma (NTLP). The impact of these lesions on postoperative outcome following hepatic resection for colorectal liver metastases (CLM) is still debated.Aim. To define the risk of major hepatectomy according to severity of SOS syndrome, and determine predictive factors of SOS occurrence.

Methods. Between 1998 and 2006, 51 patients received preoperative OBC and underwent major liver resection for CLM. A detailed analysis and grading of steatosis and SOS in the NTLP was obtained for these patients. 90 day mortality and morbidity were studied according to SOS severity (no or mild lesions = SOS 1/2 vs moderate or severe lesions = SOS 2/3). We assessed preoperative factors that could predict SOS occurrence. Finally, the APRI scoring system was evaluated in this setting.

Results. 38 patients (74%) had SOS 2/3 lesions. Postoperative mortality (4%) was not correlated to the severity of SOS lesions (2 in SOS 2/3 group vs 0 in SOS 0/1 group). Severe SOS lesions were significantly associated with postoperative hepatic insufficiency (26/38 in SOS 2/3 vs 3/13 in SOS 0/1; p = 0.004) and ascitis (p = 0.03). All patients with severe liver failure had severe SOS lesions. On POD 5, serum bilirubin level was higher (54.8 vs 26.7; p = 0.03) and prothrombin rate was lower in patients with SOS 2/3 lesions (69.1 vs 79.1%; p = 0.04). Number of OBC cycles was not predictive of severe SOS occurrence. Preoperative elevation of AST and ALT levels (1.5 fold increase) (p = 0.03 and 0.04 respectively) and a low platelet count (<170000) were associated with SOS 2/3 (p = 0.002). Finally, ROC analysis revealed cut-off that predicts severe SOS lesions occurrence is APRI score 0.6 (AUC 0.852; sensibility 69%; specificity 90%).

Conclusion. Severe SOS lesions related to OBC significantly increased the risk of major liver resection. Occurrence of severe SOS lesions could be preoperatively predicted by the use of APRI score.

FP 27.05

HIGH PORTAL PRESSURE PREDICTS OF LIVER FAILURE AFTER MAJOR HEPATECTOMY COMBINED WITH PORTAL VEIN EMBOLIZATION FOR COLORECTAL LIVER METASTASES

JAECK, Daniel; ROSSO, Edoardo; OUSSOULTZOGLOU, Elie; PESSAUX, Patrick; GIRAUDO, Giorgio; BACHELLIER, Philippe

Hopital de Hautepierre, Centre de Chirurgie Générale et Transplantation, Strasbourg, France

Objective. The aim of the present study was to identify risk factors for liver failure (LF) in patients who underwent major hepatectomy combined with portal vein embolization (PVE) for colorectal liver metastases (CLM).

Background. Liver failure still remains one of the most serious complication after major liver resection due to an increased risk of postoperative morbidity and mortality. Preoperative PVE is recommended to prevent LF after major hepatectomy particularly in case of injured liver.

Patients and Methods. Between January 1997 and April 2006, a total of 76 patients underwent right or extended right hepatectomy combined with PVE for CLM in our department. LF was defined as following: serum bilirubin ≥ 50 µmol/L and/or prothrombin time < 50% at postoperative day five, and/or the presence of ascites requiring treatment with diuretics and/or percutaneous drainage. Portal venous pressure was measured at the time of PVE just before embolization.

Results. No patients died within 2 months after hepatectomy. Overall morbidity rate was 42.1%. Transitory LF occurred in 18 patients (24%). Age, gender, delay between PVE and liver resection, ICGR-15, extent of liver resection, steatosis, sinusoidal injury, degree of future remnant liver hypertrophy and the ratio (future remnant liver/body weight) were not found to be associated with an increased risk of postoperative LF. However, an increased portal pressure measured at the time of PVE procedure was significantly associated with an increased risk of postoperative LF (16.8±4.6 mmH2O versus 13.5±4.4 mmH2O, P = 0.0182).

Conclusions. The present study suggests that LF still occurs after major hepatectomy for CLM even in patients who underwent preoperative PVE, and seems predictable by a high preoperative portal pressure. Treatment of portal pressure by medical treatment may reduce the rate of post-operative LF.

FP 27.06

LONG TERM OUTCOME OF LIVER RESECTION FOR SYNCHONOUS COLORECTAL LIVER METASTASIS

Lubrano, Jean; Huet, Emmanuel; Xiao, Yquing; Michel, Pierre; Scotté, Michel

Rouen university hospital, Rouen, France

Background. Synchronous liver metastasis (LM) occurred in about 15 to 20% of colorectal cancers.

Aims. The aims of our study were to analyse surgical outcome, survival and prognosis factors in our series of patients operated for synchronous colorectal LM.

Methods. Between January 1990 and July 2006, 50 patients were operated for synchronous colorectal LM. Pre-, peri- and postoperative data were reviewed to analyse their influence on overall and disease free survival. Subgroup analysis was made to assess the influence of chemotherapy and the timing of surgery (simultaneous versus delayed liver resection) on overall and disease free survival.

Results. Median age was 64 years (33–89). Primary tumour was colon in 37 patients (18 right colon cancers) and rectal in 13 patients. 34 patients received preoperative chemotherapy with a median of 8 cycles (3–24) and 16 were operated without neoadjuvant treatment. 19 patients underwent simultaneous liver and colorectal resection and 31 patients a delayed liver resection. Morbidity and mortality rates were 30% and 2% respectively. 1, 3 and 5-year survival rates were 94, 61 and 25%, respectively and disease free survival at 1, 3 and 5 years were 62%, 30% and 15%, respectively. In multivariate analysis, recurrence and symptomatic primary tumour (obstruction or haemorrhage) significantly decreased overall survival. Disease free survival was strongly influenced by performing a R0 liver resection and by postoperative complications. Recurrence occurred in 36 patients with a median delay of 9 months (3–54). In these patients, survival was increased by second resection (p = 0.03). Morbidity, mortality, overall and disease free survival were not influenced by the timing of liver surgery (synchronous or delayed resection) or by preoperative chemotherapy.

Conclusions. Our results highlight the pejorative prognosis of synchronous colorectal LM. They confirm the safety of simultaneous liver and colorectal resection and the need for an aggressive surgical approach in case of liver recurrence.

FP 27.07

HEPATIC RESECTION FOLLOWING RESCUE CETUXIMAB TREATMENT FOR COLORECTAL LIVER METASTASES PREVIOUSLY REFRACTORY TO CONVENTIONAL SYSTEMIC THERAPY

Adam, René; Aloia, Thomas; Lévi, Francis; Wicherts, Dennis A; de Haas, Robbert J; Paule, Bernard; Bralet, Marie-Pierre; Bouchahda, Mohamed; Machover, David; Ducreux, Michel; Castagne, Vincent; Azoulay, Daniel; Castaing, Denis

Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France

Background. The value of cetuximab-containing chemotherapy in patients with irresectable colorectal liver metastases (CLM) resistant to first-line chemotherapy, is unknown.

Aim. This study aimed to determine the post-cetuximab outcomes after hepatic resection (HR) of heavily pretreated patients.

Methods. Between February 2004 and August 2007, 10 out of 198 patients (5%) with irresectable CLM resistant to initial chemotherapy were treated with cetuximab-containing regimens at our institution, and reconsidered for HR after response of CLM. During the same period, 22 patients from elsewhere were referred for HR while receiving cetuximab-containing regimens in the same clinical setting. Short-term and long-term outcomes were assessed.

Results. From the 32 patients switched to potential resectability after cetuximab-based therapy, 27 (84%) ultimately were submitted to HR during laparotomy. Twenty-one (66%) had failed at least 2 lines of pre-cetuximab chemotherapy. A median of 6 cycles of cetuximab + irinotecan (24/32), oxaliplatin (5/32), or both (1/32) was given. Postoperative mortality was 3% (1/32) with a complication rate of 44% (14/32). Complete tumor necrosis was observed in 2 patients (7%). After a median follow-up of 25 months after CLM diagnosis and 12 months after HR, 24 of the 27 resected patients (89%) were alive, 8 of whom (30%) were disease-free. Median overall (OS) and progression-free survival (PFS) from initiation of cetuximab therapy were 24 and 14 months, respectively. After HR, OS and PFS were 24 and 10 months, respectively.

Conclusion. Cetuximab allows to increase the resectability of patients with unresectable CLM refractory to conventional chemotherapy. In case of response, rescue surgery allows to reach median OS and PFS of 24 and 14 months from the onset of cetuximab therapy. Compared to the usual poor prognosis of patients resistant to initial chemotherapy (median OS around 12 months), this novel oncosurgical strategy could significantly benefit these advanced patients.

FP 27.08

REPEAT HEPATECTOMY IS SAFE AND EFFECTIVE FOR RECURRENT COLORECTAL LIVER METASTASES

Yeluri, Sashidhar¹; Prasad, K Rajendra²; Gomez, Dhanwant²; Malik, HZ²; Toogood, G J²; Lodge, J Peter A²

¹St. James's University Hospital, Department of HPB and Transplant Surgery, Beckett Street, Leeds, United Kingdom; ²St. James's University Hospital, Department of HPB and Transplant Surgery, Leeds, United Kingdom

Background. Hepatic resection represents the only potential cure for the treatment of colorectal liver metastases (CRLM). Nevertheless, the majority of patients develop disease recurrence following resection. The aim of th is study is to analyse the peri-operative and long-term outcomes of patients who undergo repeat hepatic resection for CRLM.

Methods. A prospectively maintained database was used to identify 687 patients who underwent resection for CRLM between 1993 and 2006. 105 of these patients underwent 119 attempts at re-resection (100 second, 10 third, 2 fourth and 3 unsuccessful). Records for these patients were reviewed retrospectively.

Results. There were 76 men and 29 women with a median age of 61 years. Of the repeat resections, 84 were minor resections (less than 3 segments). There were 5 postoperative deaths. Morbidity was 21.5% for repeat resections. The overall 1-, 3- and 5- year survivals were 90%, 46% and 24% respectively. On multivariate analysis CEA >10µg/L (p = 0.022) and tumour involvement at the resection margin (p < 0.001) were independent predictors of poor disease free survival. Tumour involvement at the resection margin was the only adverse prognostic factor for overall survival (p < 0.001).

Conclusion. Repeat liver resection for colorectal liver metastases is safe and in selected cases can provide long term survival.

FP 27.09

THE UTILITY OF CONTRAST ENHANCED INTRA-OPERATIVE ULTRASOUND FOR THE DETECTION OF LIVER METASTASES DURING SURGERY FOR PRIMARY COLORECTAL CANCER.

Shah, Ankur¹; Callaway, Mark²; Pope, IM³; Thomas, Michael G⁴; Finch-Jones, Meg D⁵

¹Bristol Royal Infirmary, HPB and Colo-rectal Surgery, Bristol, United Kingdom; ²Bristol Royal Infirmary, Radiology, Bristol, United Kingdom; ³Bristol Royal Infirmary, HPB Surgery, Bristol, United Kingdom; ⁴Bristol Royal Infirmary, Colo-rectal Surgery, Bristol, United Kingdom; ⁵Bristol Royal Infirmary, HPB Surgery, Bristol, United Kingdom

Background. CT scan is the most commonly used staging investigation for the detection of liver metastasis in colorectal cancer. Up to 20–25% of patients with colorectal cancer (CRC) have previously undetected liver metastases diagnosed when intraoperative ultrasound (IOUS) is used at the time of bowel resection. However, occult liver metastases (OLM) are still missed where IOUS is used routinely.

Aims. To assess the ability of IOUS to detect additional liver lesions/metastases at primary bowel surgery and to evaluate whether contrast enhanced IOUS (CE-IOUS) helps in the detection and characterization of OLM over and above non-contrast IOUS.

Methods. This is a single centre prospective study. Following multislice CT for staging, patients with a CRC were consented for IOUS followed by CE-IOUS. After surgical exploration, patients underwent IOUS of the liver. Contrast (Sulphur hexafluoride microbubbles/Sonovue®-4.8 ml) was injected and the IOUS repeated. The findings of CT, non-enhanced IOUS and CE-IOUS were compared. Changes in the staging or management were noted. If additional lesions were found, these were confirmed post-operatively with Iron oxide MRI of the liver.

Results. Over a 4month period in this ongoing study, eleven patients have been recruited. IOUS demonstrated additional lesions in 4 patients but changed staging or management in only 1 patient. However, contrast confirmed the benign or malignant nature of lesions in all of these 4 patients and changed management in 3 patients, and altered the staging in the fourth patient. Thus, CE-IOUS changed the management in 27% of patients compared to 10% of patients with non-enhanced IOUS.

Conclusion. In this pilot study, early results show the ability of IOUS to detect additional metastases is improved by CE-IOUS and this has led to an impact on the surgical staging and management.

FP 28.01

GASTRIN RECEPTOR EXPRESSION IS INCREASED IN HUMAN PANCREATIC CANCER AND IN ENDOTHELIAL CELLS OF PANCREATIC CANCER AND PANCREATITIS

Tobias, Amanda¹; Aloysius, Mark M²; Zaitoun, Abed M³; Bates, Timothy E⁴; Lobo, Dileep N²; Watson, Sue A¹

¹University of Nottingham, Division of Preclinical Oncology, Nottingham, United Kingdom; ²Nottingham University Hospitals, Division of Gastrointestinal Surgery, Nottingham, United Kingdom; ³Nottingham University Hospitals, Division of Pathology, Nottingham, United Kingdom; ⁴Nottingham University Hospitals, Division of Community Health Sciences, Nottingham, United Kingdom

Background. The gastrointestinal peptide gastrin has been shown to be an important growth factor in several gastrointestinal cancers and also pancreatic cancer, through the gastrin receptor, cholecystokinin-2 (CCK-2R). Increased gastrin secretion is also linked to angiogenesis.

Aims. To examine the correlation between CCK-2R expression and pancreatic cancer.

Methods. Tissue micro arrays of human pancreatic samples including cancer (n = 98), pancreatitis (n = 106), positive (n = 48) and negative (n = 59) lymph nodes and normal (n = 31) tissue as classified by a pathologist, were prepared. These were then stained with a specific CCK-2R antibody using an antigen retrieval method and visualisation with AEC. Staining was assessed by two people and scored according to area and intensity, 0 < 5%, 1 = low, 2 = medium, 3 = high. Sections were also scored positive or negative for CCK-2R staining in endothelial cells.

Results. Compared to normal tissue both cancer and positive lymph nodes had significantly higher CCK-2R expression (p < 0.001). Positive correlation was observed between CCK-2R expression in the tumour, peritumoural pancreatitis and corresponding endothelium. However, there was selective lack of expression in chronic pancreatitis and corresponding endothelium.

Conclusions. Expression of the gastrin receptor is increased in pancreatic cancer cells compared to normal. There is also an increase in endothelial cells expressing CCK-2R in pancreatic cancer compared to normal.

FP 28.02

DEREGULATION OF POTASSIUM CHANNELS EXPRESSION IN PANCREATIC ADENOCARCINOMAS

Brevet, marie¹; Ouadid-Ahidouch, halima²; Fuks, david³; Delcenserie, richard⁴; Bartoli, eric⁴; Regimbeau, Jean-Marc³; Chatelain, denis¹

¹hospitalo-universitary hospital, pathology, Amiens, France; ²hospitalo-universitary hospital, Laboratory of cellular and molecular physiology, Amiens, France; ³hospitalo-universitary hospital, digestive surgery, Amiens, France; ⁴hospitalo-universitary hospital, gastroenterology, Amiens, France

Carcinogenesis of pancreatic adenocarcinomas is still unknown. Potassium channels are plasmic membrane proteins involved in ions exchange between intra and extra cellular compartments. They are involved in proliferation and apoptosis mechanisms. A deregulation of their expression has already been shown in breast, lung and prostatic adenocarcinomas. The aim of this study was to compare the immunohistochemical expression of potassium channels in pancreatic adenocarcinomas and normal pancreas specimens.

Material and Methods. 20 specimens of pancreatic adenocarcinomas and 20 specimens of normal pancreatic tissue were included in the study. Immunohistochemistry with potassium channels antibodies (GIRK1, BKCa, Kv1.3, Kv1.1, ERG1 and TASK2) was realized on paraffin embedded specimens. Staining was evaluated by two pathologists and divided in 4 groups related to the intensity of the staining (−, +, ++, + + +).

Results. A high cytoplasmic expression of GIRK1 and ERG1 (++ or + + +) was observed in 87% and 96% of pancreatic adenocarcinomas whereas this intensity of expression was observed in only 50 and 75% of normal pancreas. For Kv 1.3, high expression was less frequent in adenocarcinomas compared to normal pancreas (4% versus 25%). No difference was observed for the three other channels (BKCa, Kv1.1 and TASK2).

Conclusion. For the first time, we show the deregulation of potassium channels expression in pancreatic adenocarcinomas. We show an over expression of GIRK and ERG1, involved in cellular proliferation and an under expression of Kv1.3 involved in apoptosis. These data have to be confirmed by real time PCR but these potassium channels are probably involved in the carcinogenesis of pancreatic adenocarcinomas and may be new targets for future therapeutics against this dramatical cancer.

FP 28.03

PROGNOSTIC SIGNIFICANCE OF PINCH SIGNALING IN HUMAN PANCREATIC ADENOCARCINOMA

Scaife, Courtney¹; Firpo, Matt¹; Emerson, Lyska²; Shea, Jill¹; Boucher, Kenneth³; Beckerle, Mary¹; Mulvihill, Sean¹

¹University of Utah, Surgery, Salt Lake City, United States; ²University of Utah, Pathology, Salt Lake City, United States; ³University of Utah, Biostatistics, Salt Lake City, United States

Introduction. Pancreatic adenocarcinoma remains one of the most poorly controlled solid organ malignancies in the United States. Prognostic markers for pancreatic cancer have failed to accurately predict patient prognosis. Recent interest has developed in the in tegrin-associated PINCH protein expression in human cancers to predict tumor invasiveness and aggressiveness. [8, 9 please delete] The goal of this study is to define the expression of PINCH protein in pancreatic adenocarcinoma which may predict poorer patient survival.

Methods. 20 cases of were randomly identified and the charts were reviewed for stage, nodal involvement, margin status, and disease-free and overall survival. PINCH expression was evaluated from parrafin-embedded blocks stained for PINCH expression in the tumor and the tumor-associated (TA) stroma. The comparison of PINCH expression to prognosis was evaluated by dividing the data into two groups near the median, and performing a likelihood ratio test using the Cox proportional hazards model.

Results. Preliminary data from 20 pancreatic cancer patients indicates a higher expression of PINCH protein in pancreatic adenocarcinoma versus normal pancreatic tissue. Additionally, high PINCH expression in the TA stroma is associated with decreased overall survival. The median survival was 884 days in subjects with low pinch compared to 337 days in 13 subjects with high pinch, for a hazard ratio of 2.3. There was no significant correlation between tumor tissue PINCH expression and survival.

Conclusions. In this study, the expression of the integrin-associated protein, PINCH, may predict tumor aggressiveness and patient survival. As has been demonstrated in breast cancer previously, the expression of PINCH in the peri-tumoral stroma is the most significant predictor of a poor outcome. PINCH expression may be a marker of an invasive leading edge of tumor or microscopically postive margins following resection.

FP 28.04

ALEMTUZUMAB INDUCTION AND STEROID-FREE IMMUNOSUPPRESSION IN PANCREAS TRANSPLANTATION

Rathnasamy Muthusamy, Anand Sivaprakash¹; Roy, Debabrata²; Elker, Doruk E²; Quiroga, Isabel²; Sinha, Sanjay²; Vaidya, Anil C²; Friend, Peter J²

¹Oxford Transplant Centre, Transplant Surgery, Churchill Hospital, Oxford, United Kingdom; ²Oxford Transplant Centre, Transplant Surgery, Oxford, United Kingdom

Background. Alemtuzumab (Campath) is a humanised anti-CD52 antibody, which depletes T & B lymphocytes and is known to be clinically effective in many lymphocyte-mediated conditions. The impact of Campath induction immunosuppression in pancreas transplantation was evaluated, with particular reference to the ability to minimise the use of steroids.

Methods. 126 transplants were performed in 122 patients; these included patients undergoing simultaneous pancreas kidney (SPK), pancreas after kidney (PAK) or a pancreas transplant alone (PTA). 30 mg of Campath was given IV on day 0 & 1with tacrolimus (trough levels of 8–12ng/ml) and mycophenolate mofetil for maintenance immunosuppression. Methyl Prednisolone was given IV before reperfusion of the grafts (pancreas-500mg, kidney-250mg). No steroids were used in the maintenance regimen. Patient and graft survival, rejection rate and adverse events were obtained retrospectively.

Results. There were 76 males and 46 females in the group with a median age of 42 (range 27–67). 97 patients underwent SPK, 23 patients had PAK while 6 had PTA. The median hospital stay was 15 days and median length of follow-up 10 months (range 0–36 months). Overall thirty-day mortality was 0.8%; overall patient survival was 97%. 98% of the patients are currently off dialysis and 94% have a functioning pancreatic allograft. 22 patients received anti-rejection therapy for 27 episodes (21.5%). 4 patients (3%) have had significant BK viruria, but still have functioning renal grafts. 7 patients (5.5%) have had positive CMV antigenemia resulting in antiviral therapy. 31 patients (25%) had re-operations. 86% have received no steroids post transplant, and 7 patients (6%) are currently on steroids. 1 patient developed post-transplant lymphoproliferative disorder at 10 months post SPK but has functional grafts.

Conclusion. Campath is safe and enables pancreas transplantation to be carried out without the need for maintenance steroids in 86% of cases and with an acceptable rejection rate.

FP 28.05

CELLULAR PROLIFERATION (CP), NFkB AND GENE MICROARRAY ANALYSIS OF OMEGA-3 FATTY ACID TREATED GEMCITABINE (GEM) RESISTANT PANCREATIC CANCER

Saied, Abdul; Razzak, Anthony; Hering, Justin; Trevino, Jose; Somasundar, P; Espat, Joseph

Roger Williams Hospital, Surgical Oncology, Providence, United States

Pancreatic cancer (PC) is a malignancy with high mortality. Patients are often treated with gemcitabine (GEM) chemotherapy; but chemoresistance is common. In the present experiments, the effects of omega-3 fatty acids (n-3 FA), GEM and combination treatment on CP in two PC cell lines, L3.6pl an intrinsically GEM sensitive cell line and L3.6 clone (L3.6 GEM RES), an experimentally created GEM resistant clone, were examined.

Methods. L3.6pl cells were cultured using standard protocol. GEM resistance was induced by exposure to 500 ng/ml of GEM, 5x greater than the IC50, for 48 hours, and increased to 3000 ng/ml in 500 ng/ml increments. Cells were treated with DMEM, 100M n-3FA emulsion, 100µM GEM or combination of 100µM n-3 FA and 100µM GEM for 12 hrs. n-6 FA emulsion was used as a lipid control. CP was measured with WST-1 assay. NFkB was assayed using EMSA. Genetic expression was evaluated using microarray, significance in differential expression denoted as ≥ 2x-change relative to media-only (control).

Results. In L3.6pl, a significant decrease in CP was observed in n-3 FAs compared to lipid control. In GEM alone, a 70% decrease in CP was observed, with no difference in n-3 FA or n-6 FA combo treatment, likely due to the GEM sensitivity of L3.6pl. In L3.6 GEM RES, GEM treatment alone did not significantly affect proliferation. However, proliferation was significantly decreased using n-3 FA alone or in combo with GEM. EMSA revealed a significant decrease in NFkB expression in all cells treated with n-3 FAs. Genetic data revealed significant alterations in genes responsible for CP, including: GADD45A, CDKN1A, CDKN1C and TP53.

Conclusion. Comparison of GEM sensitive PC versus GEM resistant PC clones reveals a significant decrease in CP with n-3 FA compared to media-only controls. In both PC cell lines, effects are optimized with combo n-3FA + GEM treatments. NFkB, an intracellular marker for chemoresistance, was decreased in cells treated with n-3 FAs; findings supported by genetic analysis.

FP 28.06

LYMPHATIC CONNECTIONS BETWEEN THE PANCREAS AND INTESTINE

Loveday, Benjamin PT¹; Mittal, Anubhav¹; Phillips, Anthony²; Windsor, John A¹

¹University of Auckland, Department of Surgery, Auckland, New Zealand; ²University of Auckland, School of Biological Sciences, Auckland, New Zealand

Background. Mesenteric lymph, conditioned by intestinal ischemia-reperfusion injury, has been shown to exacerbate the severity of acute pancreatitis (unpublished). It is not known how mesenteric lymph exerts its influence on the pancreas, whether via the peripheral circulation or direct lymphatic connections.

Aims. The aim of this study was to determine the nature of the lymphatic connections between the pancreas and intestine.

Methods. Under general anaesthetic, the mesenteric ducts of adult male Wistar rats were cannulated either antegrade near the caecum or inserted retrograde from the thoracic duct. Colloidal carbon, Evans blue dye or polyurethane-based resin was perfused into the lymphatics under direct visualisation to identify connections between the mesenteric duct and pancreas. Using the same cannulation techniques, gadolinium contrast medium was perfused into the lymphatics and images obtained using a 4.7 Teslar magnetic resonance imaging (MRI) scanner.

Results. Lymphatics were well-visualised with the dyes and resin. A dominant lymphatic connection was consistently noted, in all dye and resin studies, between the mesenteric duct and a lymph node located in the head of the pancreas. Other smaller connections were identified parallel and in close proximity to this dominant connection. Both dye and resin were seen to traverse the lymph node and backfill lymphatics that ran into the parenchyma of the pancreas. Contrast enhancement of the mesenteric duct was seen on MRI, with possible enhancement of parts of the pancreas.

Conclusion. For the first time, consistent and direct lymphatic connections were identified between the mesenteric duct and the pancreas through a lymph node in the head of the pancreas. Further research is required to determine whether this is the route by which mesenteric lymph exacerbates acute pancreatitis, and the role of these connections in other critical illnesses.

FP 28.07

BONNET MONKEY MODELS FOR MALNUTRITION-RELATED PANCREATIC DISEASES

Sandhyamani, Samavedam

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Department of Pathology, Trivandrum, India

Introduction. Malnutrition-related pancreatic diseases are common, particularly in developing countries. Their etiology is uncertain owing to lack of definite animal models.

Aims. To conduct histopathological study of diet-induced pancreatic degenerative lesions in bonnet monkeys (Macaca radiata).

Methods. 42 sub-adult monkeys were fed tapioca-starch or cornstarch-based low-protein normal-carbohydrate (LPNC) or low-protein high-carbohydrate (LPHC) or control (normal protein, carbohydrate) diets for 3 or 5 months’ periods.

Results. The pancreas was normal in all the 12 Controls, while 13 animals fed LPNC diets showed marked to severe lobular and acinar cell atrophy. In 17 animals fed LPHC diets the pancreas showed moderate to marked acinar cell atrophy, marked islet hyperplasia or nesidioblastosis with hypertrophy and mucoid metaplasia of duct epithelium with inspissated secretions within ducts and ductules. Generalized mucoid vasculopathic arteriosclerosis, also affecting the pancreatic vasculature, was seen in all the test animals, more pronounced in those fed LPHC diets for a longer duration.

Conclusions. A primate model of diet-induced pancreatic lesions was established. LPNC diets induce lesions resembling human pancreatic atrophy in certain diabetics. LPHC diets induce lesions similar to chronic pancreatitis (Tropical Chronic Calculus Pancreatopathy with diabetes mellitus). Toxic factors from tapioca were excluded in initiating the lesions, since identical changes were seen with both starches. Future work: The long-term effects of mucoid vasculopathy on the exocrine and endocrine pancreas need to be explored. More importantly, the differential damage and regenerative functions of a (alpha) versus β (beta) cells of pancreatic islets need to be studied in the above experimental models. Appropriate Immuno-histochemical and Biochemical techniques to track insulin ∼ glucagon interactions will help in a better understanding of the pathogenesis of diabetes mellitus.

FP 28.08

TUMOUR GROWTH ASSESSMENT USING MINIMUM SPANNING TREE ANALYSIS IN PANCREATIC, AMPULLARY AND DISTAL BILE DUCT CANCER

Verbeke, Caroline S¹; Menon, Krishna V²; Knapp, Johannes³

¹The Leeds Teaching Hospitals NHS Trust, Department of Histopathology, Leeds, United Kingdom; ²The Leeds Teaching Hospitals NHS Trust, Department of Surgery, Leeds, United Kingdom; ³University of Leeds, School of Physics and Astronomy, Leeds, United Kingdom

Background. The definition of microscopic resection margin involvement (R1) in large bowel cancer (LBC) has been established as tumour cells < 1 mm to the margin. This R1 definition is also used for the reporting of pancreatic head cancer specimens, but has never been validated. The Minimum Spanning Tree algorithm (MSTA) is a computer generated method that analyzes the topology of cancer growth patterns by determining the minimum distance between tumour cells.

Aim. To determine, using the MSTA, whether a similar growth pattern in LBC and cancer arising in the pancreatic head justifies the current R1 definition for reporting of the latter.

Methods. In 10 cases of each LBC, pancreatic (PC), ampullary (AC) and distal bile duct cancer (DBC) a 200x picture was taken in the centre and periphery (at the invasive front) of the tumour as well as half way between both. For each picture, the distances between cancer cells were determined using the MSTA. The average minimum distance was compared between the 3 zones in the 4 cancer groups, as was the tumour cell density.

Results. In all cancer groups, the distance between cancer cells was comparable in the central zone, and larger in the periphery than in the centre of the tumour (p ≤ 0.02). However, this difference between centre and periphery was smaller in LBC than in PC, DBC and AC (p ≤ 0.03). Results were similar for PC and DBC, but differed from those of AC (p ≤ 0.03). On average, the tumour cell density dropped in the periphery of PC to 30% of that in the tumour centre, and only to 83% in LBC (p<.0001), 62% in AC and 40% in DBC (p ≤ 0.01).

Conclusion. Tumour cell growth in PC, DBC and — to a lesser extent — AC is less dense than in LBC. Particularly in the periphery, tumour growth is more dispersed in PC, DBC and AD, and tumour cell density drops to as little as 30% at the invasive tumour front. This difference in tumour growth demands revision of the R1 definition for pancreatic head cancer. The MST algorithm is a useful tool to assess the topology of cancer growth patterns.

FP 28.09

Incidence and characteristics of chronic and lymphoplasmacytic sclerosing pancreatitis in patients scheduled to undergo pancreatoduodenectomy

de Castro, Steve¹; de Nes, Lindsey¹; Nio, Yung²; Velseboer, Daan³; Ten Kate, Fiebo³; Olivier, Busch¹; van Gulik, Thomas¹; Gouma, Dirk¹

¹Academic Medical Center, Surgery, Amsterdam, Netherlands; ²Academic Medical Center, Radiology, Amsterdam, Netherlands; ³Academic Medical Center, Pathology, Amsterdam, Netherlands

Background. The determination of the nature of a pancreatic head mass scheduled to undergo pancreatoduodenectomy can be very difficult. This is important since patients who suffer from pancreatitis do not always require surgery. The aim of the present study was to analyze the incidence of pancreatitis and the signs and symptoms associated with the disease and diagnostic procedures performed.

Methods. A consecutive group of patients who underwent a pancreatoduodenectomy between 1992 and 2005 with histopathologically proven pancreatic adenocarcinoma (PCA) and pancreatitis were analysed.

Results. The incidence of pancreatitis after pancreatoduodenectomy is 63 out of 639 patients who underwent a pancreatioduodenectomy (9.9%). Of these patients, 24 patients (38%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) and 31 patients (49%) had focal chronic pancreatitis. Eight patients (13%) had an intermediate form with characteristics of both. Pancreatic adenocarcinoma occurred in 227 patients (36%). The presence of pancreatitis without a discrete mass on endoscopic ultrasonography (EUS) seemed to have clinical relevance with a positive likelihood ratio of 5.1. Mortality after resection was nil in both groups.

Conclusion. The incidence of pancreatitis is 9.9% for patients scheduled to undergo a pancreatoduodenectomy. Of these patients 38% had LPSP, 13% had a intermediate form and 49% had focal chronic pancreatitis. The determination of the exact nature of a pancreatic head mass remains difficult.

FP 29.01

RELIABILITY OF PREOPERATIVE 3D CT VOLUMETRY AND EFFECT OF MHV INCLUSION ON REMNANT VOLUME IN RIGHT LOBE LIVING DONOR LIVER TRANSPLANTATION

R, Anand; Kakodkar, Rahul; Kumaran, Vinay; Nundy, Samiran; Soin, Arvinder S

Sir Ganga Ram Hospital, Surgical Gastroenterology & Liver Transplantation, New Delhi, India

Background. Inclusion of the middle hepatic vein (MHV) in right lobe living donor liver transplantation (LDLT) is regarded by many as essential to ensure optimum graft function. However, concern remains regarding increased donor risk. Volumetry by current imaging techniques is associated with an error of 5–36% when compared to intraoperative graft weight. Hence, there is a potential for leaving behind an inadequate left lobe remnant based on preoperative volumetry.

Aim. To study the reliability of preoperative three-dimensional computed tomography (3DCT) volumetry in the prediction of graft weight in LDLT and the effect of inclusion of MHV with the right lobe graft on remnant liver volume.

Method. 23 consecutive right lobe donors were prospectively studied between March and August 2007. All donors underwent preoperative triphasic CT. Graft and remnant volume was estimated to the right and left of a plane passing along the right margin of the MHV. Postoperatively, 20 stable patients underwent a repeat CT scan within 16 hours of surgery for estimation of remnant left lobe volume. The MHV was included with the graft in all cases, ‘coring out’ the MHV from the left side, preserving any significant segment 4a drainage into the MHV.

Results. Median graft weight was 750g (520–969), and GRWR 1 (0.66–1.7). Median preoperative estimated remnant volume was 37% (27–45) of the total liver volume. Preoperative CT volumetry underestimated graft weight in 10 cases (43.5%), overestimated it in 10 (43.5%) and was identical in 3 cases (13%). The mean error ratio was 8.7 + 6.17. Postoperative predicted remnant volume was greater than the preoperative volume in 12 cases (60%), less in 6 cases (30%) and identical in 2 (10%) cases. All donors except 1(5%) had a remnant volume over 30%.

Conclusion. 3DCT volumetry predicts graft volume with reasonable accuracy. Based on the error ratios obtained, inclusion of the MHV with right lobe grafts did not compromise the remnant liver volume estimated to the right of MHV on preoperative CT volumetry.

FP 29.02

PULMONARY AND BLOOD STREAM INFECTIONS IN ADULT LIVER TRANSPLANT RECIPIENTS

van den Broek, Maartje¹; Saner, Fuat²; Olde Damink, Steven W.M.¹; Rath, Paul³; Paul, Andreas²; Nadalin, Silvio²; Broelsch, Christoph E.²; Malagó, Massimo⁴

¹University hospital Maastricht, Department of Surgery, Maastricht, Netherlands; ²University hospital Essen, Dept. of General, Vis ceral and Transplant Surgery, Essen, Germany; ³University hospital Essen, Institute of Medical Microbiology, Essen, Germany; ⁴University College London, Department of Surgery, London, United Kingdom

Background. Infectious complications occur in approximately 50% of cadaveric liver transplant (CLTx) recipients and confer a major risk of mortality after liver transplantation. Theoretically, living donor liver transplant (LDLTx) recipients have lower infection rates as they are better prepared and have shorter ischemic times.

Objective. To assess whether the incidence of pulmonary and blood stream infections in LDLTx recipients differed from their CLTx counterparts.

Methods. To detect the expected difference of 50 percent in the incidence of pulmonary and blood stream infections in favour of the LDLTx recipients (i.e. incidence of 25% in the LDLTx versus 50% in the CLTx group), a minimum number of 55 patients had to be included in each arm of this cohort study. Consequently, the clinical course of 55 LDLTx recipients transplanted between December 2002 and December 2006 was analysed. The 173 CLTx recipients who were transplanted in the same period served as a control group. Patients were treated in a single ICU receiving triple immunosuppression and antimicrobial prophylaxis. Differences in infectious complications were calculated by means of Fisher's exact test. P < 0.05 was considered significant.

Results. Mean MELD-score did not differ between LDLTx and CLTx recipients (14.2 versus 13.3, p = 0.4). Pulmonary infections were experienced by 18% of LDLTx versus 5% of CLTx recipients (p = 0.005) and blood stream infections occurred in 33% of LDLTx versus 21% of CLTx recipients (p = 0.1). One year survival was significantly higher for all recipients who did not experience a pulmonary infection (85% versus 42%, p < 0.001).

Conclusion. LDLTx recipients experienced significantly more pulmonary infections when compared with their CLTx counterparts. There was a trend towards a higher incidence of blood stream infections in the LDLTx group. These differences might be explained by the smaller graft body weight ratio in the LDLTx recipients reflecting the important role of the liver in the innate immune defence.

FP 29.03

ADULT-TO-ADULT LIVING DONOR LIVER TRANSPLANTATION USING EXTENDED RIGHT LOBE GRAFTS

Kim, Ki Hun¹; Lee, Sung Gyu²; Lee, Young Joo²; Park, Kwang Min²; Hwang, Shin²; Ahn, Chul Soo²; Moon, Deok Bog²; Ha, Tae Yong²; Song, Gi Won²; Jung, Dong Hwan²; Ryu, Je Ho²; Park, Jung Ik²; Lee, Hyo Jun²; Ko, Kyung Hoon²; Kim, Kwan Woo²; Choi, Nam Kyu²

¹Asan Medical Center, Department of Surgery, 388-1, Pungnap-dong, Songpa-gu, Seoul, Korea, Republic of; ²Asan Medical Center, Department of Surgery, Seoul, Korea, Republic of

Background. Adult-to-adult living donor liver transplantation(AALDLT) using extended right lobe grafts has become as an treatment method to solve the problem of graft insufficiency since Hong Kong group first successfully performed for a 90-kg man with fulminant Wilson¡^—s disease in May 1996.

Aims. The authors report their experience with adult-to-adult living donor liver transplantation using extended right lobe graft in a single center.

Methods. From March 1998 to June 2007, 1428 AALDLTs were performed at the Asan Medical Center. Among them, 21 AALDLTs using extended right lobe graft were included in this retrospective study. 3 types of techniques for hepatic vein reconstruction have been used to enable the sufficient venous outflow drainage of extended right lobe grafts.

Results. There were 18 male and 3 female. The median age of recipients was 47 years(range, 19–62 years) and median MELD score was 20(range, 9–36). Of 21 patients, 11 had HBV related LC, 7 had HBV related LC with HCC, and 3 had acute liver failure. The median percentage of steatosis was 5%(range, 0–15%), the median graft weight was 605 gm (range, 400–800 gm) and the median GRWR was 0.86%(range, 0.69–1.16%). There were 2 in-hospital mortalities caused by sepsis. The median age of donors was 28 years(range, 16–39 years). There was no donor mortality. As for hepatic vein reconstruction in this study, there were 3 types of techniques in the following order: 14 quilt venoplasties make ¡°common-large opening¡± using GSV and PV of recipient, 4 direct RHV anastomoses and separate reconstructions of MHV with interposition vein graft, and 3 separate RHV and MHV anastomoses without interposition vein graft. Modification of graft procurement technique by preserving S4b hepatic vein was performed in 2 cases.

Conclusions. The extended right lobe graft may provide an alternative option to overcome the small-for-size graft in AALDLT if the meticulous donor hepatectomy and complete donor selection can be performed for donor safety.

FP 29.04

SAFETY OF THE LIVING DONOR IN LEFT PART LIVER TRANSPLANTATION – AN ANALYSIS OF 100 CONSECUTIVE CASES-A SINGLE-CENTER EXPERIENCE

Paluszkiewicz, Rafal¹; Zieniewicz, Krzysztof¹; Grzelak, Ireneusz¹; Pacho, Ryszard²; Hevelke, Piotr¹; Kalinowski, Piotr¹; Krawczyk, Marek¹

¹Medical University of Warsaw, Dpt. of General, Transplant and Liver Surgery, Warsaw, Poland; ²Medical University of Warsaw, 2nd Dpt. of Radiology, Warsaw, Poland

Background. One of the most serious problems faced for living donor is a risk of death or morbidity. The AIM of this study was to assess the risk of harvesting the left part of the liver from the consecutive 100 living related donors.

Methods. Between October 1999 and January 2007 liver segments II and III were harvested from 90 donors and segments II, III and IV from 10 donors. Blood transfusions, complications, length of hospitalization and resection index, regeneration index and postoperative liver function tests on the 7th, 30th day and after 12 month were evaluated in donors.

Results. The strict correlation between CT volumetric assessment and the mass of harvested graft was demonstrated by linear regression analysis (r = 0.56) and Student's t-test (p < 0.04). The mean regeneration index 12 month after resection increased significantly in donors of segments II, III and IV (138.64%±23.98%) as compared with donors of segments II and III (109.93%±18.36%) (p < 0.02). Postoperatively donors manifested adverse effects of surgery including transient elevation of bilirubin and transaminase levels and a decreased prothrombin index. 12 month after harvesting the mean level of all these parameters was within normal limits. No mortality or reoperation was noted in the entire series. Postoperative complications occurred in 7 patients (2 wound infections, 2 postoperative hernia, 2 delayed gastric emptying, 1 bile reservoir) (7%). Blood transfusion was not necessary in any of the procedures. Mean hospitalization time was 8.76± 3.39 days after harvesting II and III and 9.44±1.42 days after harvesting II, III and IV segments (p > 0.05).

Conclusion. Safety is guaranteed when the left lobe or the left lateral segment is harvested for living related liver transplantation.

FP 29.05

RIGHT VERSUS LEFT LOBE LIVING DONOR LIVER TRANSPLANTATION IN ADULTS: DOES SIDE MATTER?

Kakodkar, Rahul; Kumaran, Vinay; Saigal, Sanjiv; Saraf, Neeraj; Nundy, Samiran; Soin, Arvinder Singh

Sir Ganga Ram Hospital, Surgical Gastroenterology & Liver Transplantation, New Delhi, India

Background. While right lobe grafts usually provide enough liver (graft to recipient weight ratio-GRWR >0.8) for adult liver transplantation, they are technically demanding. Left lobe grafts are simpler, but provide enough volume only for small adults. It is not clear whether right and left liver grafts having similar GRWR function equally well after transplantation.

Aim. To compare early outcomes of patients receiving right and left lobe grafts with GRWR >0.8.

Methods. Since Jan 2005, 96 right lobe and 16 left lobe LDLTs with GRWR > 0.8 were performed in adults. Both groups had comparable demographics and MELD scores. Anterior sector outflow of right lobes was routinely reconstructed by including the middle hepatic vein (n = 90) or extending segmental tributaries (n = 6). Intra-operative Doppler confirmed vascular patency in all cases. Warm ischaemia time, post-operative prothrombin time (PT), aspartate transaminase (AST) and bilirubin on days 1,3,7; ICU stay, duration of ascitic drainage and culture-proven sepsis were statistically compared between the two groups.

Results. Mean GRWR was 0.84 (0.8–1.5) for R lobes and 0.82 (0.8–0.92) for left lobes (p = NS). Thirty day recipient mortality was 8.3% (8/96) and 6.6% (1/16) for right and left lobes respectively (p = NS). Apart from 1 patient who had partial portal vein thrombosis requiring anticoagulation and one with RHV stenosis treated with stenting, there were no vascular complications.

	Warm ischaemia	PT 1	PT 3	PT7	AST1	AST3	AST7	Bili 1	Bili3	Bili7	ICU stay	Septic episodes	Ascites
Left lobe	37min	21.3sec	20.8sec	16.5sec	278IU	144IU	92*IU	9.3mg/dL	6.8mg/dL	3.7mg/dL	9.1*days	1.2*	13 days
Right Lobe	49min*	20.5sec	19.4sec	16.1sec	204IU	118IU	78 IU	6.7mg/dL	4.6mg/dL	2.8 mg/dL	6.8 days	0.8	8.1 days*

* statistically significant Conclusion: Although patients with left lobe grafts may eventually fare as well as those with size matched right lobe grafts, they are more likely to have persistent ascites due to residual portal hypertension and require additional ICU stay due to sepsis.

FP 29.06

SIMULTANEOUS ARTERIAL AND BILIARY REPAIR AFTER LIVER TRANSPLANTATION (LT)

Sommacale, Danièle¹; Sibert, Annie²; Dondéro, Fédérica¹; Francoz, Claire³; Paugam, Catherine⁴; Sauvanet, Alain¹; Vilgrain, Valérie²; Goasguen, Nicolas¹; Durand, François³; Belghiti, Jacques¹

¹Hospital Beaujon, HPB Surgery, Clichy, France; ²Hospital Beaujon, Radiology, Clichy, France; ³Hospital Beaujon, Hepatology, Clichy, France; ⁴Hospital Beaujon, Anesthesia, Clichy, France

Aims. The presence of hepatic arterial (HAS) in patients with biliary strictures (BS) following LT is common. The aim of this study is to report 7 patients with BS associated with HAS treated by simultaneous artery and biliary surgical repair.

Method. Among 787 OLT performed from 1991 to 2005, 12 patients (1.5%) experienced BS associated with HAS. Retransplantation was indicated in 5 with intrahepatic biliary stenosis. In 7 cases, with exclusive extrahepatic BS and HAS, simultaneous biliary and arterial repair were considered. Patients, aged from 31 to 60 yrs. Simultaneous biliary and arterial repair was indicated in the presence of biliary duct to duct stenosis in 6 cases and after Roux-en-Y in 1 case. Arterial stenosis were more than 50% of the arterial diameter. Six patients had BS previously treated by plastic prothesis and 2 had HAS previously treated by endovascular stent or pneumatic dilatation.

Results. Arterial repair was the first step of the procedure with a complete resection of the arterial stricture followed by a terminoterminal arterial anastomosis. In 1 case stenosis involved only the right hepatic artery while in the 6 other cases the stenosis was located at the site of the anastomosis. In all cases resistance index was >0.5 on intraoperative doppler ultrasound after reconstruction. Biliary repair included in all cases a Roux-en-Y. There was no postoperative death and morbidity was observed only in 1 patient. No postoperative biliary fistula was observed and the mean hospital length of stay was 16 days. With a mean follow up of 67 months, all patients are alive without graft loss. Recurrent arterial stenosis was discovered in 1 patient and although successfully treated by endovascular stent, he developed biliary stricture 13 months later and was treated by iterative Roux-en-Y.

Conclusions. Results of our series demonstrated that simultaneous biliary and arterial surgical repair is safe and efficient in patients with extrahepatic biliary stenosis associated with arterial stenosis complicating LT.

FP 30.01

LONG-TERM SURVIVAL AFTER PANCRATICODUODENECTOMY FOR ENDOCRINE TUMORS OF THE AMPULLA OF VATER AND MINOR PAPILLA.

PEDICONE, Roberto¹; ADHAM, Mustapha¹; HERVIEU, Valérie²; SCOAZEC, Jean-Yves²; PARTENSKY, Christian¹

¹Edouard Herriot, HPB Surgery and Transplantation, Lyon, France; ²Edouard Herriot, Pathology and Cytology, Lyon, France

Background. Endocrine tumors of the papilla of Vater and minor papilla are exceptional. Accurate indications for surgical management are lacking.

Objective. To report our personal experience and assess the correlation between pathological features and prognosis.

Methods. Clinical charts of 8 patients, 3 male and 5 female, mean age 47.8 years (range: 37–57 years) who underwent a pancreaticoduodenectomy for endocrine tumor of the ampulla of Vater or minor papilla by the senior author (CP) between 1982 and 2003 were reviewed. No patient was lost to follow-up. Mean follow-up was 88 months (range 17–223 months).

Results. Two patients were diagnosed incidentally, two had a Zollinger-Ellison syndrome, three had abdominal pain and one had jaundice. One patient had a Recklinghausen disease. Operative mortality was nil. Mean size of the tumor was 17.4 mm (range: 5–40 mm). Pathological examination of operative specimens demonstrated 7 cases of well-differentiated and one case of poorly differentiated endocrine carcinoma. Immunochemistry, which was performed in 7 patients, was positive for somatostatin in two, for gastrin in one and for calcitonin in one. Seven patients had positive lymph nodes and one also had diffuse liver metastases. At the end of follow-up, five patients were alive and disease-free, one was alive with stable liver metastases and two patients were deceased: one, with undifferentiated tumor, developed diffuse liver metastases and died 17 months postoperatively and the other one, with gastrinoma, died twelve years after surgery from an unrelated cause.

Conclusion. This study demonstrates the frequency of the metastatic spread to lymph nodes and the variable secretory profile of these uncommon tumors. Pancreaticoduodenectomy may offer long term survival in patients with well differentiated tumors, even when positive satellite lymph nodes and liver metastases are present.

FP 30.02

SURGICAL MANAGEMENT OF NON-FUNCTIONING NEUROENDOCRINE PANCREATIC TUMOURS

Spalding, Duncan¹; Rajakulendran, Karthig²; Pai, Madhav²; Williamson, Robin²

¹Hammersmith Hospital, HPB Surgery, Du Cane Road, London, United Kingdom; ²Hammersmith Hospital, HPB Surgery, London, United Kingdom

Introduction. Due to their slow growth and inability to produce hormone-dependent symptoms, non-functioning neuroendocrine pancreatic tumours (NFNEPTs) usually have an indolent natural history. Surgical treatment of these tumours has become increasingly important for symptom palliation and survival. The aim of this study was to assess the role of surgery, adjuvant therapy and outcomes of NFNEPTs based on the experience of a single institution.

Methods. Between 1994–2007, 21 patients were treated for NFNEPTs. Their investigations, surgery, histology and clinical outcome were reviewed retrospectively.

Results. There were 11 men and 10 women of median age 49 (range 26–76) years. Gut hormone profiles were normal in all patients. Contrast-enhanced computed tomography localised the tumour in 20 patients and visceral angiography in 15 of 16. The NFNEPTs were located in the head in 16 patients, body in 2 and tail in 3. Eleven patients underwent curative resection (pancreatoduodenectomy [PD] n = 8, distal pancreatectomy n = 2 and laparoscopic enucleation n = 1) and 10 palliative resection (PD n = 6, total and distal pancreatectomy 2 each). Four patients had concomitant liver resections (curative and palliative 2 each). There were no operative deaths. Seventeen tumours were malignant, 14 expressed chromogranin, 13 neurone specific enolase, 9 synaptophysin, 7 cytokeratin and 6 protein gene product 9.5. Ten patients received adjuvant therapy (chemotherapy n = 2, embolisation n = 2, chemotherapy and embolisation n = 1, α-interferon n = 2, targeted radionuclide therapy n = 1, targeted radionuclide therapy and radiation n = 1). Nine patients have died from disease a median of 43 (range 10–141) months after operation. The 12 survivors, 7 of whom had curative resections, have been followed for a median of 46 (range 24–95) months. Ten patients are asymptomatic but only 5 are free from disease.

Conclusions. Although surgical cure is rare in NFNEPTs, long-term palliation can be achieved with an aggressive surgical approach and adjuvant therapy.

FP 30.03

NEUROENDOCRINE PANCREATIC AND DUODENAL TUMORS

Straka, Vladimír; Straka, Martin; Sabol, Martin; Chvalný, Peter

St. Elisabeth Oncological Institute, Department of Oncological Surgery, Bratislava, Slovakia

Background. Neuroendocrine tumors(NET) of pancreatic and duodenal origin are rare. This study aimed to present surgical experience analysing the postoperative outcome.

Patients and Methods. From 1991 to 2007 51 patients(range of age 19–76 years) underwent surgery for 46 duodenal and pancreatic NET: 44 patients had functioning tumors(20 gastrinomas, 23 insulinomas and 1 VIP-oma). 7 patients had non-functioning tumor associated with clinical symptoms caused by tumor location and size growth(4 duodenal, 3 pancreatic).

Results. The precise topic diagnosis was achieved in only 50% of gastrinomas, 69% of insulinomas and overall in 64% of cases before surgery. A high portion of functioning tumors in the present study were malignant:45.5% (80% duodenal gastrinomas, 40%pancreatic gastrinomas, 21% insulinomas, 1 VIP- oma, 1 carcinoid tumor and 2 non-functioning tumors of pancreas). Eight proximal pancreaticoduodenectomies, 23 distal pancreatectomies and 20 local excisions were performed. In one female right hepatectomy because of pancreatic gastrinoma liver metastases was done simultaneously with distal pancreatosplenectomy. 7 patients had postoperative complications (15%). Pancreatic fistula developed in 4 patie nts (insulinoma subgroup: 1 pancreaticoduodenectomy, 2 local excisions, 1 distal pancreatectomy) that were resolved by conservative treatment in 3 cases and 1 patient required reoperation. We observed 1 delayed gastric emptying and 2 wound infections. Perioperative mortality was 0.0%. During long follow up period 3 patients died (related to tumor progression: 1 non-functiong pancreatic tumor, 2 pancreatic gastrinomas).

Conclusion. Surgical resection is the only curative option for NET. Surgery can be safely caried out in pancreatic surgery centre and good long-term survival is reached. Our cohort of 242 patients with pancreatic resections (175 proximal and 67 distal) include 51 patients( 21.1%) with NET.

FP 30.04

LAPAROSCOPIC RESECTION FOR ENDOCRINE TUMORS IN 28 PATIENTS

RAULT, Alexandre¹; SaCunha, Antonio²; Collet, Denis²; Masson, Bernard²

¹CHU Bordeaux, Service de chirurgie digestive et endocrinienne, Hopital Haut Lévéque, PESSAC, France; ²CHU Bordeaux, Service de chirurgie digestive et endocrinienne, PESSAC, France

Introduction. These last years, advances in laparoscopic surgery allow treating pancreatic endocrine tumors. We report a single institution experience of laparoscopic treatment of pancreatic endocrine tumors. Patients, Method: In a 10 years period, 72 laparoscopic pancreatectomies were performed. Indication for resection was endocrine tumors for 28 of the patients.

Results. Median age was 48 years-old (21 women, 7 men). Indications for resection were: 17 insulinomas(61%), 6 non functional endocrine tumors (21%), 2 glucagonomas (7%), 1 gastrinoma (3.7%), 1 vipoma (3.7%), 1 carcinoma (3.7%). Mean size of tumors was 14mm and 18.5 mm for non functional tumors. Six tumors were located in the pancreatic head (21.5%), 19 in the body and tail (68%). 22 operations (78%) were performed laparoscopically: 13 enucleations, 4 spleno-pancreatectomies, 4 left pancreatectomies, 1 central pancreatectomy. Six patients required a conversion to laparotomy: 4 undetectable tumors, 1 device problem, 1 suspicion of metastatic lesion. Mean hospital stay was 12.7 days. Morbidity rate was 23% (6 pancreatic fistulas, 1 bleeding, 1 wound abcess). Total remission rate after surgery was 89.2% (100% in case of sporadic insulinoma): 1 endocrine carcinoma with metatstatic disease, 1 gastrinoma, 1 nesidioblastoma.

Conclusion. Laparoscopic treatment of endocrine tumors is safe regarding small tumors. Enucleation is feasible with few morbidity. It seems difficult to detect by laparoscopy small tumors and pre-operative exploration is very important.

FP 30.05

RADICAL SURGICAL RESECTION FOR CARCINOID TUMORS OF THE AMPULLA

Hwang, Shin; Lee, Sung-Gyu; Lee, Young-Joo; Kim, Ki-Hun; Ahn, Chul-Soo; Ko, Kyoung-Hoon; Choi, Nam-Kyu; Kim, Kwan-Woo

Asan Medical Center, Univerisity of Ulsan, Department of Surgery, Seoul, Korea, Republic of

Introduction. Ampullary carcinoid tumors are extremely rare.

Patient And Method. The present study describes the clinicopathological features and outcomes for 10 ampullary carcinoid patients who underwent radical resection from 1998 to 2005. During this study period, 294 patients underwent pancreatoduodenectomy for ampullary neoplasms in our institution.

Results. The mean patient age was 58.0±13.4 years, and 7 were male. Initial clinical manifestations were jaundice in 4 patients, non-specific gastrointestinal symptoms in 5, and completely asymptomatic in 1. Standard pancreatoduodenectomy was performed in 3 patients, and pylorus-preserving pancreatoduodenectomy in 7, and there were no major complications. The mean tumor size and volume were 2.1±1.3 cm and 4.1±6.9 mL, respectively. Synaptophysin staining was positive in 10 patients, and chromogranin staining positive in 8. R0 resection was achieved in all 10 patients. Overall and disease-free survival rates were 90% and 80% at 1 year, and 64% and 56% at 3 years, respectively. The liver was the most common site of initial metastasis after curative resection. Univariate analyses revealed that a maximal tumor diameter > = 2 cm and tumor extension beyond the ampulla were risk factors for tumor recurrence.

Conclusion. While the majority of ampullary carcinoids are indolent, this tumor is associated with a relatively poor prognosis. We believe that radical resection, with the aim of complete tumor removal and cure, is the treatment of choice.

FP 30.06

ASSESSMENT OF THE EFFICACY AND TOXICITY OF 131I-METAIODOBENYLGUANIDINE (MIBG) THERAPY FOR METASTATIC NEUROENDOCRINE TUMOURS (MNETS)

Banks, Melissa¹; Poston, Graeme²

¹University Hospital Aintree, Centre for Digestive Diseases, Lower Lane, Liverpool, United Kingdom; ²University Hospital Aintree, Centre for Digestive Diseases, Liverpool, United Kingdom

Background. MIBG is a licensed palliative treatment for patients with MNETs. However its’ role in symptom control in MNETs remains uncertain.

Methods. We retrospectively assessed the consequences of MIBG therapy in 48 patients (30 gastroenteropancreatic, 6 pulmonary, 12 unknown primary sites) with MNETs between 1996 and 2006.

Results. Mean age at diagnosis 57.6 years (range 34 to 81). MIBG was administered on 88 occasions (mean 1.8 treatments, range 1–4). 29 patients had biochemical markers measured before and after MIBG, and 11 (36.7%) showed >50% reduction in levels post therapy. 40 patients had radiological investigations performed post-MIBG, of whom 11(27.5%) showed reduction in tumour size post therapy. 27 (56.3%) patients reported improved symptoms post-MIBG therapy. Overall median survival from diagnosis was 79 months. Kaplan-Meier analysis showed significantly increased median survival of 37 months (p = 0.01) from date of first MIBG in patients reporting symptomatic benefit post-MIBG, but no increased survival from diagnosis. Patients with biochemical and radiological responses didn't show any significant alteration in survival compared to non-responders. 11 (22.9%) patients required hospitalisation due to complications, mostly mild bone marrow suppression.

Conclusions. MIBG improved symptoms in more than half of patients with MNETs, and overall survival was increased in those patients who reported a symptomatic response to therapy.

FP 30.07

LAPAROSCOPIC CENTRAL PANCREATECTOMY: EXPERIENCE OF SIX PATIENTS

SA CUNHA, ANTONIO; RAULT, ALEXANDRE; BEAU, CEDRIC; MASSON, BERNARD; COLLET, BERNARD

CHU BORDEAUX, BORDEAUX, France

Background. Medial pancreatectomy is an alternative technique for benign or low grade malignant tumors of the neck of the pancreas. We describe our experience of laparoscopic central pancreatectomy.

Methods. In 1999, we started a prospective evaluation of laparoscopic pancreatic resection. Until February 2006, 60 patients were included, 6 of whom had a laparoscopic central pancreatectomy. Surgical procedure, postoperative course and follow up were collected.

Results. Laparoscopic central pancreatectomy was achieved in all patients. In one case, we had to perform a laparotomy to find the specimen which had been lost in the cavity during the anastomosis. The median operative time was 225 minutes (range, 180 to 365 minutes). No patient required blood transfusion in the peri-operative period. There was no mortality. Symptomatic pancreatic fistula occurred in two patients (33%). No patient required reoperation or radiological drainage. Oral feeding was resumed in a median of 11 days (range, 9–21 days). The median post-operative hospital stay was 18 days (range, 15–25 days). With a median follow up of 15 months (range, 4–34 months), all patients are alive without exocrine or endocrine insufficiency.

Conclusion. Laparoscopic central pancreatectomy is feasible and safe. Laparoscopic central pancreatectomy may become the standard approach for resection of benign or low-grade malignant tumors of the neck of the pancreas performed by highly skilled surgeons.

FP 30.08

CLINICALPATHOLOGICAL FEATURES OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASIA OF THE BILIARY TRACT: EQUIVALENT TO PANCREATIC PAPILLARY MUCINOUS NEOPLASIA?

Kloek, Jaap¹; van der Gaag, Niels²; Erdogan, Deha²; Rauws, Eric³; Busch, Olivier²; Gouma, Dirk²; ten Kate, Fibo²; van Gulik, Thomas²

¹Academic Medical Center, Amsterdam, Netherlands; ²Academic Medical Center, Department of Surgery, Amsterdam, Netherlands; ³Academic Medical Center, Department of Gastroenterology, Amsterdam, Netherlands

Introduction. Intraductal papillary mucinous neoplasm of the pancreas (IPMN-P) is a rare but well-established entity, in contrast to intraductal papillary mucinous neoplasms of the biliary tract (IPMN-B) of which pathological features and biologic behaviour are largely undetermined. The aim of the present study was to assess the clinicalpathological features of IPMN-B and to compare these with IPMN-P.

Methods. The files of 19 patients who underwent resection (1991–2006) for IPMN-B (7 underwent local bile duct excision, 8 combined with partial hepatectomy and 4 PPPD) were reviewed and compared with 20 consecutive cas es resected for IPMN-P (all PPPD). Clinicalpathological characteristics of all patients were evaluated, resection specimens were reassessed and immunohistochemically screened for expression of a distinct set of tumor markers.

Results. The most common presenting symptom in patients with IPMN-B was obstructive jaundice (63%). The main symptoms in patients with IPMN-P were abdominal pain (35%), jaundice (25%) and acute pancreatitis (20%). Eleven IPMN-B patients (58%) had neoplasms with invasive adenocarcinoma, compared to 4 IPMN-P patients (20%). The 3-year survival rate of patients with IPMN-B was significantly lower than in IPMN-P patients (62% vs. 89%, respectively; p < 0.01). A high expression of MUC1 and P53 was associated with a significantly shorter survival. CK7, CK20 and Dpc4 protein was equally expressed in both groups (77%, 33% and 92%, respectively). Differences in MUC1, MUC2, MUC5AC and CDX2 expression profile distinguished 4 histologically distinct types of tumor in the IPMN-B group (i.e. gastric, intestinal, pancreaticobiliary and oncocytic type), whereas in the IPMN-P group, 3 different types were identified (not any oncocytic type).

Conclusions. Patients with IPMN-B presented more often with obstructive jaundice than in IPMN-P. Pathological characteristics of IPMN-B resembled those of IPMN-P however, IPMN–B was associated with a higher malignancy rate and therefore, worse survival.

FP 30.09

PRIMARY PANCREATIC LYMPHOMA: INCIDENCE, HISTO-PATHOLOGICAL CHARACTERISTICS AND PROGNOSIS DERIVED FROM A 10-YEAR EXPERIENCE.

CHERIAN, THOMAS¹; Manzia, T²; Pascoe, J²; Toti, L²; Bramhall, SR²; Wigmore, SJ²; Mayer, D²; Buckels, JAC²; Mirza, DF²

¹UNIVERSITY HOSPTIAL, BIRMINGHAM, United Kingdom; ²

Background. Lymphoproliferative diseases induced by immunosuppressive therapy in the gastro-intestinal tract is not infrequent. Primary pancreatic lymphoma (PPL) however is a rare form of extra nodal lymphoma of pancreatic parenchyma with most reports limited to single case publications. As PPLs exhibit diverse biological behaviour and often represents disease that may be curable even in advanced stages, we reviewed and report our experience at a high volume tertiary HPB unit.

Method. We conducted a retrospective review of 1551 pancreatic (including peri ampullary) malignancies from 1997 to 2007, identified from a prospectively collected database. We present the findings of our analysis of all cases of PPL, and discuss inducing factors if any, the clinical course, diagnosis, and treatment of these less common neoplasms of the pancreas.

Results. In total there were 14 cases of PPL leading to an incidence of 1% [males 10, median age of 60 years (range 28–86)]. Presenting symptoms included abdominal pain(6), jaundice(9), and weight loss(6). The median follow-up was 23 months (range1–129). In the absence of pre-operative histological diagnosis, five patients (40%) underwent surgery-2 pancreaticoduodenectomy and 3 palliative bypasses. Final tissue diagnosis confirmed 13 non-Hodgkin's lymphomas (NHL = 10; high-grade B-cell lymphoma = 2; Burkitt's = 1) and one Hodgkin's lymphoma in a patient with a past history of nodal Hodgkin's lymphoma. None of our cohort had had past exposure to immunosuppression or radiation. In our institution 5-year survival was 50%, in contrast to ductal pancreatic cancers (5%), with no survival difference between patients who had and did not have surgery. Conclusion Primary pancreatic lymphomas are rare, comprising 1% of pancreatic tumours. The vast majority are non Hodgkin's tumours. They have a good prognosis whether they are treated with surgery or not supporting the need to achieve histological diagnosis even in patients with irresectable pancreatic tumours.

FP 31.01

SURGERY AFTER NEOADJUVANT CHEMOTHERAPY WITH BEVACIZUMAB IN PATIENTS WITH INITIALLY UNRESECTABLE COLORECTAL LIVER METASTASIS. A MATCHED PAIR ANALYSIS

Figueras, Joan¹; Albiol, Maite²; Mahfud, Mahfud²; Lopez-Ben, Santiago²; Codina-Barreras, Antoni²; Falgueras, Laia²; Queralt, Bernardo³; Hernandez-Yague, Xavi³; Guardeño, Raquel³; Ortiz, Rosa⁴; Soriano, Jordi⁵; Codina-Cazador, Antoni²

¹Trueta Hospital Girona, Surgery, Girona, Spain; ²Josep Trueta Hospital, Surgery, Girona, Spain; ³Josep Trueta Hospital, ICO, Girona, Spain; ⁴Josep Trueta Hospital, Pathology, Girona, Spain; ⁵Josep Trueta Hospital, IDI, Girona, Spain

Background. Neoadjuvant chemotherapy with Bevacizumab (Bev) has been reported to be highly effective for initially unresectable liver metastases (LM). However, wound healing complications and bleeding have been described. The primary objective was to determine the development of complications, reoperations and mortality.

Methods. Prospective study. Inclusion Criteria: Stage IV disease with unresectable LM. 26 patients received neoadjuvant chemotherapy with Bev before surgical resection of LM. Median time from last dose of Bev and operation was 61 days range (31–180). These patients were matched to 45 patients previously operated who also underwent neoadjuvant chemotherapy but without Bev. Matching was performed blinded to the patients outcome and according to the following criteria: age, gender, number and size of LM, bilobarity and type of hepatectomy.

Results. There were no differences regarding: Gender (p = 0.075). Median age (p = 0.11). Median CEA & Ca 19.9 levels before surgery (p = 0.3) & (p = 0.2). Rectal cancer (p = 0.35). 43 (61%) patients presented bilobar LM (p = 0.35). 42 (59%) underwent major hepatectomy (p = 0.48). 14 patients (20%) (p = 0.4) underwent simultaneous resection of the primary and LM. Mean number of LM was 5.4(p = 0.15). 35 (49%) patients had more 3 LM (p = 0.34). Mean size was 2.9 cm(p = 0.63). 25 patients (35%) presented extrahepatic resectable disease. Mean postoperative stay was 14 days (p = 0.38). Only 3 patients needed intraoperative transfusion (p = 1). Postoperative mortality was nil in the group of Bev vs 4 (9%) p = 0.15. Sixteen (62%) vs 21(48%) patients experienced postoperative complications p = 0.17. Without differences between groups except for reintervention that was more frequent in patients with Bev 7(27%) vs 3(7%) p = 0.02. In the Cox regression analysis, factor related with reoperation were presence of extraheptic disease (p = 0.01) and use of Bev (p = 0.053).

Conclusion. Chemotherapy with Bevacizumab is safe. Reoperations seam to be related to other factors

FP 31.02

TREATMENT OF COLORECTAL LIVER METASTASES WITH SELECTIVE INTERNAL RADIATION THERAPY: DOES PRIOR CHEMOTHERAPY AFFECT THE RESPONSE RATE?

Stubbs, Richard; Rajekar, Harshal; Croft, Anthony; Mendis, Nishantha

Wakefield Hospital, The Wakefield Clinic, Wellington, New Zealand

Background. Selective Internal Radiation Therapy (SIRT) is a relatively new and effective modality for treating liver tumours including CRC liver metastases. It involves radiotherapy to the tumours as opposed to chemotherapy.

Aim. To determine if the response rate of CRC liver metastases to SIRT is affected by prior exposure of the patient to systemic chemotherapy.

Methods. We have demonstrated that patients in whom CEA values fall by more than 75% in the 2 months following SIRT, have a better survival than those in whom such a CEA fall is not seen (Boppudi S et al Australasian Radiology 2006). We have used this criteria in those with elevated CEA, or a reduction in tumour size on CT, in those with normal CEA, as a measure of response to determine whether the response rate of CRC liver metastases to SIRT is affected by prior exposure to systemic chemotherapy.

Results. 156 patients with CRC liver metastases received SIRT between January 97 and April 2006. This included 98 males and 58 females with a mean age of 60 years. 40 of the 156 patients had received some form of systemic chemotherapy prior to undergoing SIRT (23 oxaliplatin/irinotecan based regimens, 17 capecitabine/5FU based regimes). Tumour response was assessed by CEA levels in 137 patients and by CT scan changes in 14. Evaluation was not possible in the other 5 patients (early death 3 patients, insufficient data 2 patients). Responses were seen in 96 of the 151 patients (64%). Of the 111 who received no prior chemotherapy 72 responded (65%), and of the 40 who received prior chemotherapy 24 (60%) responded. These differences are not significant (p > 0.05). Of the 23 patients who received oxaliplatin and/or irinotecan based regimens, 12 (52%) responded. This difference is statistically significant (p < 0.05).

Conclusion. Response rates of CRC liver metastases to SIRT are high, but are reduced a little in those who have had prior oxaliplatin or irinotecan based chemotherapy regimens.

FP 31.03

RESPONSE TO NEOADJUVANT CHEMOTHERAPY PREDICTS OUTCOME AFTER RESECTION OF HEPATIC COLO-RECTAL METASTASES BETTE R THAN TRADITIONAL CLINICAL RISK FCTORS

Ben-Haim, Menahem¹; Small, Risa¹; Lubezky, Nir¹; Shmueli, Einat²; Nakache, Richard¹; Aderka, Dan³; Klausner, Joseph¹

¹Tel-Aviv Sourasky Mediacal Center, Surgery B, Tel-Aviv, Israel; ²Tel-Aviv Sourasky Mediacal Center, Oncology, Tel-Aviv, Israel; ³Sheba Medical Center, Oncology, Tel Hashomer, Israel

Background. The prognosis of patients following resection of CRC metastases to the liver has traditionally been predicted by clinical risk factors, such as the Memorial Sloan-Kettering Cancer Center Clinical Score (MSKCC-CS, including: number of metastases, size of largest metastases, lymph node status, CEA level and disease-free interval). However, in the era of contemporary neoadjuvant chemotherapy, the clinical scoring system needs re-validation and the role of treatment related factors as prognostic indicators should also be investigated.

Methods. Retrospective study including patients with CRC liver metastases, who received oxaliplatin or irinocetan based neoadjuvant chemotherapy and underwent R0 resection of liver metastases. Patients followed with tumor markers, CT and PET-CT, before, during and after chemotherapy and surgery. The predictive value of the MSKCC-CS and degree of response to chemotherapy (measured by CT and PET-CT), were analyzed by univariate and multivariate analysis and COX regression.

Results. Included are 54 patients, average age, 60 (range 30–86), mean MSKCC clinical score, 2.6 (range 1–5). Response to chemotherapy on CT was found to be a significant predictor of survival on both univariate (p = 0.03) and multivariate analysis (p = 0.03), whereas the MSKCC-CS and response to chemotherapy on PET-CT were not. Time to recurrence was predicted by the response to chemotherapy measured on CT (p = 0.03; p = 0.02) & PET-CT (p = 0.009, p = 0.03) on both univariate and multivariate analysis, respectively, whereas the MSKCC-CS was not (p = 0.30, p = 0.64).

Conclusions. In this cohort of patients treated with neoadjuvant chemotherapy, the outcome was not predicted by the traditional clinical scoring system, but rather by response to chemotherapy as evaluated by CT and PET-CT. This observation should be considered while designing treatment strategy and establishing justification of surgery for patients with CRC metastases to the liver.

FP 31.04

Survival after systemic chemotherapy and liver resection for colorectal metastases; a ten year audit

Lordan, Jeffrey; Karanjia, Nariman D.; Fawcett, William J; Quiney, Nial; Worthington, Tim R.; Remington, Jacky

Royal Surrey County Hospital, Guildford, United Kingdom

Background. Metastatic colorectal carcinoma is a common cause of cancer death. Hepatic resection offers the only potential cure. The aim of this study was to audit the operative morbidity and overall and disease free mortality of metastatic colorectal cancer in a modern tertiary referral unit.

Methodology. All patients who underwent surgical treatment for colorectal metastases over a ten year period were included. Patients were treated with chemotherapy preoperatively for synchronous and early (<2 years) metachronous metastases. Data were collected prospectively. End points were overall and disease free survival, peri-operative morbidity and mortality. Univariate and multivariate analyses were used to identify mortality risk factors.

Results. 283 patients underwent hepatic resections with curative intent. Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1% respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9% respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100, tumour size > 5cm or a segmentectomy had a significantly worse long term outcome. Dukes’ stage had no effect on overall survival.

Conclusions. Morbidity and mortality for hepatic resection for colorectal liver metastases is improving. The 5 year survival of 46% should encourage surgeons to adopt an ever more aggressive approach to treating/referring hepatic colorectal metastases.

FP 31.05

EFFECTS OF PRE-HEPATECTOMY (HPX) OXALIPLATIN (O) ON NORMAL LIVER ARCHITECTURE IN PATIENTS COMING TO HPX FOR COLORECTAL LVER METASTASES (CLM)

Pathak, Samir¹; Poston, Graeme J²; Verghese, Miriam E²; Foster, Christopher S³

¹Royal Liverpool University Hospital, Dept of Surgery, Liverpool, United Kingdom; ²Royal Liverpool University Hospital, Surgery, Liverpool, United Kingdom; ³Royal Liverpool University Hospital, Pathology, Liverpool, United Kingdom

Background. Pre-HPX O is used routinely before HPX for colorectal liver metastases. Concern has been expressed about hepatic sinusoidal obstruction, and post-operative complications in these patients OBJECTIVES-Use of Electron (EM) and light microscopy(LM) to ascertain whether there was any microscopic differences in chemotherapy treated (C), and chemotherapy naive livers (NC). Additional measures such as post-operative stay and complications were also studied.

Methods. Tru-cut biopsies were taken from normal liver at HPX and underwent, both LM with H&E staining and EM with osmium-tetroxide fixation. Hepatic steatosis and sinusoidal dilatation were graded on a linear scale (0–3) on LM.

Results. 32 specimens were analysed in total, 16 in each arm(NC and C). All pre-operative liver function tests were normal, there was no difference between the two groups in post-operative stays or complication rates. LM showed 7 C samples to demonstrate sinusoidal dilatation(grade 1–2) and 4 C samples to show steatosis (grades 1–2). 5 NC samples showed sinusoidal dilatation(grades1–2) and 7 illustrated steatosis (grades 1–2). No nodular hepatic regeneration or perisinusoidal fibrosis/ veno-occlusive disease in either group. EM showed normal intracellular hepatocyte architecture in all NCs, but all Cs showed development of lipofuscin cytoplasmic blebs, marked paucity of mitochondria and loss of uniformly granulated cytoplasm which contained fragmented membranes.

Conclusions. There were no obvious differences in LM appearances. There were real and measurable O related changes to intracellular hepatocyte architecture but these did not relate to biochemical liver dysfunction or increased postoperative complications in this sample.

FP 31.06

MOLECULAR PROGNOSTIC MARKERS IN COLORECTAL CANCER LIVER METASTASES: CD31, CD34, VEGF, PDGF AND EGFR DO NOT PREDICT OUTCOME

Ben-Haim, Menahem¹; Small, Risa¹; Brazowski, Eli²; Shmueli, Einat³; Nakache, Richard¹

¹Tel-Avi Sourasky Medical Center, Surgery B and Transplantation, Tel-Aviv, Israel; ²Tel-Aviv Sourasky Medical Center, Pathology, Tel-Aviv, Japan; ³Tel-Aviv Sourasky Medical Center, Oncology, Tel-Aviv, Israel

Background. The pathological evaluation of biochemical markers in liver metastases can be a potential strategy to select chemotherapy and predict outcome. We evaluated five molecular markers in resected colorectal liver metastases from patients who received neoadjuvant chemotherapy to determine their correlation with outcome.

Methods. Immunohistochemical staining for markers related to angiogenesis and endothelial receptors, including vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), platelet-derived growth factor (PDGF) and endothelial markers, CD31 and CD34. All were from colorectal cancer liver metastases, which were treated with oxaliplatinin or irinocetan based neoadjuvant chemotherapy and bevacizumab followed by R0 resection. Microvessel quantification was performed for CD31 and CD34 staining, and staining intensity grading and percentages were assessed for VEGF, EGFR, & PDGF. Clinical data (demographics, staging, response to chemotherapy and outcome) were extracted from charts. Kaplan Meier survival and Cox univariate and multivariate analysis were performed.

Results. Tumor specimens from 34 patients’ resected liver metastases were examined (18 men, 16 women; mean age 60.3). Mean microvessel counts for CD31, CD34 marginal and central epithelium were 45, 55, and 34, respectively. EGFR stained negatively in all specimens. VEGF and PDGF mean staining intensity were graded as 1.59 and 1.68, respectively, on a scale of 0–3. Findings of the immunohistochemical staining failed to show significance of these 5 markers in predicting disease recurrence and overall survival. There was no difference in patients who did and did not respond to chemotherapy.

Conclusions. These five molecular markers failed to show significance in outcome prediction. Further evaluation of biochemical markers is warranted in the setting of colorectal cancer and hepatic metastases in order to improve case selection for surgery and aid in design of the most appropriate chemotherapy regimen.

FP 31.07

LIVER RESECTION OF COLORECTAL METASTASES IN ELDERLY PATIENTS: IS IT WORTHWHILE AND IS THERE AN AGE LIMIT?

Adam, René¹; Laurent, Christop he²; Poston, Graeme J³; Figueras, Juan⁴; Capussotti, Lorenzo⁵; IJzermans, Jan NM⁶; Colombo, Pierre E⁷; Herrera, Javier⁸; Ruers, Theo⁹; Mentha, Gilles¹⁰; Wicherts, Dennis A¹; de Haas, Robbert J¹; and, LiverMetSurvey¹¹

¹Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; ²Hôpital Saint André, Department of Surgery, Bordeaux, France; ³University Hospital Aintree, Department of Surgery, Liverpool, United Kingdom; ⁴University Hospital Bellvitge, Department of Surgery, Barcelona, Spain; ⁵Ospedale Mauriziano Umberto I, Department of Surgery, Torino, Italy; ⁶Erasmus MC, Department of Surgery, Rotterdam, Netherlands; ⁷Centre Val d'Aurelle-Paul Lamarque, Department of Surgery, Montpellier, France; ⁸Navarra Hospital, Department of Surgery, Pamplona, Spain; ⁹UMC St Radboud, Department of Surgery, Nijmegen, Netherlands; ¹⁰University Hospitals of Geneva, Department of Surgery, Geneva, Switzerland; ¹¹www.livermetsurvey.org

Background. Elderly patients are increasingly submitted to similar treatment strategies as younger patients for colorectal liver metastases (CLM), but a question remains concerning a possible age limit for surgery. LiverMetSurvey is an international multicentre registry that allows evaluation of large cohorts of patients with long-term Results.

Aim. To evaluate the outcome after liver resection of CLM in patients ≥70 years.

Methods. From January 1986 to July 2006, among 3662 patients resected for CLM in 36 centers from 11 countries, 729 (20%) were aged ≥70 years. Of these, 463 (13%) were 70–75 years, 194 (5%) 75–80 years and 72 (2%) ≥80 years. The total cohort of elderly patients was compared to the younger population. Within the elderly group, a multivariate analysis was conducted to determine prognostic factors of survival.

Results. Elderly patients had a higher maximum tumor size (> 50 mm: 28 vs. 23%, P = 0.02), but less multinodular disease (>3 nodules: 11 vs. 23%, P < 0.0001). Hepatectomy was more frequently limited (<3 segments: 53 vs. 43%, P = 0.0002) and curative (94 vs. 91%, P = 0.01). Perioperative mortality within 2 months was increased (4 vs. 2%, P < 0.0001). Overall 5-year survival was lower than that of younger patients (37 vs. 44%, P = 0.001). Within the elderly group, three factors emerged as independently associated to poor survival: synchronous metastases (P = 0.01), bilateral distribution (P = 0.01) and presence of concomitant extrahepatic disease (P = 0.01). Five-year survivals after resection were not different between patients aged 70–75 years (39%), 75–80 years (31%) and ≥80 years (31%) (P = 0.83).

Conclusion. In patients ≥70 years, liver resection for CLM is able to provide a 5-year survival of 37%, with however an increased perioperative mortality. After 70 years, there is no upper age limit to contraindicate surgery and well selected octogenarian patients may hope for similar long-term survival.

FP 31.08

TWO-STAGE HEPATECTOMY FOR IRRESECTABLE COLORECTAL CANCER LIVER METASTASES: A 14-YEAR EXPERIENCE

Adam, René; Wicherts, Dennis A; Miller, Rafael; de Haas, Robbert J; Bitsakou, Georgia; Vibert, Eric; Veilhan, Luc Antoine; Azoulay, Daniel; Bismuth, Henri; Castaing, Denis

Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France

Background. Single curative hepatectomy for multiple bilateral colorectal liver metastases (CLM) may be impossible for patients with an unfavorable distribution of the disease, even in combination with preoperative chemotherapy, portal embolization and local ablation. In a two-stage strategy, compensatory liver regeneration after a first noncurative hepatectomy may enable a second curative resection.

Aim. To assess feasibility, risks and outcomes of two-stage hepatectomy in a large single center experience.

Methods. Between October 1992 and October 2006, 51 patients with irresectable CLM were planned for two-stage hepatectomy, since single resection could not achieve a complete treatment. Feasibility, risks and outcomes were reviewed.

Results. Two-stage hepatectomy was feasible in 35 of 51 patients (69%). Mean age for the 35 successfully treated patients (M/F = 18/17) was 57.5 years. Patients had a mean number of 9.6 metastases with a mean maximum diameter of 50.2 mm at diagnosis. All but one patient (97%) received preoperative chemotherapy, 27 (77%) continued chemotherapy between the two procedures and 26 (74%) also received postoperative chemotherapy. The mean delay between the two liver resections was 4.3 months. Postoperative mortality within 2 months was 0% and 11% after the first and second hepatectomy, respectively. Morbidity rates were also higher after the second hepatectomy (63 vs. 23%, P < 0.01). After a median follow-up of 26.0 months (range: 3.7–130.3), overall 3- and 5-year survivals were 57% and 39%, respectively, from the time of first hepatectomy.

Conclusion. Two-stage hepatectomy can be considered an established potentially curative strategy in the treatment of selected patients with irresectable multiple CLM. Mortality and morbidity rates after the second hepatectomy are however increased, in these patients concomitantly treated by prolonged chemotherapy. Patients that can sustain this aggressive complete strategy experience a 5-year survival of 39% and are provided with a hope of long-term survival.

FP 31.09

TIMING OF LIVER SURGERY FOR SYNCHRONOUS COLORECTAL METASTASES: A CASE-MATCHED STUDY

de Haas, Robbert J; Wicherts, Dennis A; Azoulay, Daniel; Castaing, Denis; Bismuth, Henri; Adam, René

Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France

Background. Surgery is still the only potentially curative treatment for patients with synchronous colorectal liver metastases (CLM). However, no clear data exists regarding the optimal surgical strategy for these patients, mainly because groups of one- and two-stage strategy are not comparable in terms of extent of liver disease.

Aim. To compare simultaneous colorectal and hepatic resection with a delayed strategy in patients with a limited (<3 segments) hepatectomy.

Methods. All patients with synchronous CLM who underwent limited hepatectomy at our hospital were included. Patients treated by a simultaneous colorectal and hepatic resection (S group) were compared to patients treated with a delayed hepatectomy (D group). Subsequently, patients of each group were matched for age, gender, number and distribution of CLM. Short-term outcome, overall (OS) and disease-free survival (DFS), and prognostic factors were determined.

Results. Between 1986 and 2006, 228 patients underwent hepatectomy for synchronous CLM, of whom 55 (24%) underwent simultaneous colorectal resection versus 173 (76%) in whom hepatectomy was delayed. Postoperative mortality (≤ 2 months) was similar between both groups (0% vs. 1%, P = 0.56), however, morbidity was significantly less within the S group (9% vs. 24%, P = 0.02). Five-year OS and DFS were 47% and 24% in the S group, respectively, compared to 52% and 27% in the D group (P = 0.48 (OS) and P = 0.83 (DFS)). After case-matching, 26 patients remained in each group, similar in terms of number, size, and distribution of CLM, confirming these Results. Multivariate analysis revealed 3 poor prognostic factors of survival: female gender,>3 CLM at diagnosis, and maximum size of CLM at diagnosis > 30 mm.

Conclusion. Combining colorectal resection to a limited hepatectomy is a safe procedure for patients with synchronous CLM, with survival rates comparable to a delayed strategy, and even less morbidity. It can be recommended to patients with limited hepatic disease.

FP 32.01

EVALUATION OF PULL-THROUGH ADHESIVE PANCREATOJEJUNOSTOMY (KAKITA□FS METHOD) FOLLOWING PANCREATODUODENECTOMY

KAZUNORI, FURUTA

Kitasato University, SURGERY, 2-1-1 Asamizodai Sagamihara, KANAGAWA, Japan

Objective. To establish the advantage of our technical procedure and outcome of a consecutive series of pancretojejunostomies Summary Background Data: The mortality rate after pancreatoduodenectomy has been reported to be 4% in institutions in which the number of patients is large. Of the complications, leakage of pancreatic fluid, which could be fatal, is important. To prevent pancreatic suture failure, various modifications have been performed in many institutions. Among the surgical procedures, pancreatojejunostomy, which will affect the outcome, is most important. Therefore, a simple anastomotic method that does not cause complications, which can be used by general surgeons, is necessary.

Methods. 343 consecutive patients who underwent pancreatojejunostomy by our pull-through adhesive pancreatojejunostomy were reviewed.

Results. Of the 343 consecutive patients, the complication of pancreatic fistulae was observed in 5 patients (1.46%). I n all 5 patients with postoperative pancreatic fistulae, the leakage of pancreatic fluid was reduced by long-term indwelling of the drains, and recovery was achieved. The exocrine function of the remaining pancreas was examined by the PFD test. The follow-up observation period was 6–120 months (mean, 31.4 months). A PFD level of more than 70% is normal. The mean PFD level of patients was 68.3□}5.93% before and 68.1□}17.3% after surgery. There was no significant difference in the PFD level between before and after surgery, indicating that, following surgery, the exocrine function of the pancreas was maintained at the same level as that before surgery. During the 5-year follow up after discharge following the initial procedure, 10.1% of 46 survival patients developed insulin-dependent diabetes mellitus(IDDM), and during the 10-year follow up, 17.6% of 17 survival patients developed IDDM.

Conclusions. Our pancreatojejunostomy method is simple, safe, and useful. We consider that it is necessary to evaluate the maintenance of pancreatic function during a longer period after surgery.

FP 32.02

RESULTS OF PANCREATICODUODENECTOMY IN PATIENTS WITH PERIAMPULLARY CARCINOMA. PERINEURAL GROWTH MORE IMPORTANT PROGNOSTIC FACTOR THAN ORIGIN OF TUMOR.

van Roest, Margijske HG¹; Gouw, Annette SH²; Peeters, Paul MJG¹; Porte, Robert J¹; Slooff, Maarten JH¹; Fidler, Vaclav³; de Jong, Koert P¹

¹University Medical Center Groningen, Hepato-Pancreato-Biliary Surgery, Groningen, Netherlands; ²University Medical Center Groningen, Pathology, Groningen, Netherlands; ³University Medical Center Groningen, Epidemiology, Groningen, Netherlands

Background. Pancreatic head carcinoma is considered to have the worst prognosis of the periampullary tumors (papil of Vater, distal bile duct or duodenum carcinoma). Several other prognostic factors for periampullary tumors have been identified, e.g. lymph node status, free resection margins, tumor size and differentiation and vascular invasion. The impact of perineural growth in relation to the site of origin of periampullary carcinomas is less well known.

Objective. To study the impact of perineural growth as a prognostic factor in the various tumor types (pancreatic head, papil of Vater, distal bile duct and duodenum carcinoma).

Methods. 205 patients were retrieved form our prospective database of patients with periampullary carcinomas.

Pancreaticoduodenectomy was performed in 121 patients with a periampullary tumor. 64 patients were found not resectable and underwent a bypass procedure. Clinicopathological characteristics were analyzed in a multivariate analysis.

Results. Angioinvasion was found in 29% of the cases, perineural growth in 49% of the cases. Perineural growth was present in 37 of 51 patients with pancreatic head carcinoma, in 7 of 30 patients with papil of Vater carcinoma, in 7 of 19 with distal bile duct carcinoma, and in 8 of 21 with duodenum carcinoma. Overall 5-year survival was 32.6% (median survival 20.7 months). Median survival in tumors with perineural growth was 13.1 months as compared to 36.0 months in tumors without perineural growth. Using multivariate analysis the following unfavorable prognostic factors were identified: perineural growth (RR = 2.90), R1 resection (R = 2.28), positive lymph nodes (R = 1.96) and angioinvasion (R = 1.79). Portal or superior mesenteric vein reconstruction and tumor localization were not of statistically significant importance.

Conclusion. Perineural growth is a more import riskfactor for survival than the site of origin of periampullary carcinomas.

FP 32.03

PANCREATIC FISTULAS AFTER DUODEDOPANCREATOMY: HOW TO PREDICT THE GRAVITY? INTEREST OF AN INTRA-OPERATIVE CLASSIFICATION OF PANCREATIC STUMP.

Ewald, Jacques; Sa Cunha, Antonio; Rault, Alexandre; Collet, Denis; Masson, Bernard

MAISON DU HAUT-LEVEQUE, DEPARTMENT of DIGESTIVE SURGERY, 33600 PESSAC, France

Introduction. Identify the morbidity and mortality risk factors after duodeno-pancreatectomy and estimate the capacity of intra-operative pancreatic stump classification for predicting the risk and the seriousness of pancreatic fistulae.

Methods. A retrospective study of 245 patients who underwent a duodenopancreatectomy with intra-operative classification of the remaining pancreas in three types. 97 (39,6%) patients had a type I pancreas (healthy pancreas and Wirsung diameter < 5 mm), 27 (11%) a type II (delicate IIa or unstitchable IIb) and 121 (40,4%) a type III (sclerous IIIa or atrophic IIIb). 32 (13%) received a neo-adjuvant treatment for pancreatic adenocarcinoma. Through a blind study, we have analysed the pancreas histological characteristics (fibrosis and adipose tissue density) of 35 patients according to the three types (12 types I, 10 types II and 13 types III). Conducting uni or multi-variable analysis, we have looked for the predictive factors of the pancreatic fistula occurrence, its gravity and the mortality.

Results. We have found two predictive factors of pancreatic fistula: the pancreatic stump kind and the absence of neo-adjuvant treatment. Sixty patients (24,5%) had pancreatic fistula. Among them 80% were type II, 25,7% type I and 10,7% type III (p < 0,0001). Fistulae of type II pancreas appeared earlier (p = 0,04) and were more serious: haemorrhage risk of type II was 10 times higher than type I (p = 0,001) and 40 times higher than type III (p = 0,001). The only predictive factor of mortality was the kind of stump: type II mortality (25,7%) exceeded types I or III (1,1%) (p < 0,0001). Only one fistula (3,2%) occurred among the 32 patients who received pre-operative treatment (p = 0,0001).

Conclusion. This classification may be a tool to predict the gravity of pancreatic fistula. It will also enable to adapt the surgical course and the post-operative support related to the pancreatic fistula risk.

FP 32.05

POST-OPERATIVE PANCREATIC FISTULA-CAN BINDING TECHNIQUE SOLVE THE PROBLEM? THE EXPERIENCE FROM A REGIONAL HOSPITAL IN HONG KONG

FUNG, Ting-Pong¹; LAM, Siu-Ho²

¹United Christian Hospital, Department of Surgery, 130 Hip Wo Street, Kwun Tong, Hong Kong, China; ²United Christian Hospital, Department of Surgery, Hong Kong, China

Introduction. Binding technique had been reported to have zero leakage rates for pancreatojejunostomy. However, whether this technique is easily reproducible is not known. The Objective of this study is to review the incidence of pancreatic fistula, defined according to the international study group of pancreatic fistula (ISGPF) between the end-to-side pancreatojejunostomy (end-to-side PJ) and binding technique pancreatojejunostomy (binding PJ).

Method. From 2002 to mid 2007, patients undergoing pancreatoduodenectomy were reviewed. The method of pancreatojejunostomy (PJ), leakage defined by the ISGPF, mortality and re-operative rate were reviewed and compared.

Results. There were 38 cases of pancreatoduodenectomy. 17 cases got end-to-side PJ and 21 cases got binding PJ. According to the ISGPF definition, in the end-to-side PJ group, there were 6 cases of Grade A(66.7%), 1 case of Grade B(11.1%) and 2 cases of Grade C(22.2%) pancreatic fistula. In the binding group, there were 4 cases of Grade A (36.4%), none in Grade B and 7 cases of Grade C (63.6%) pancreatic fistula. 3 cases of the end-to-side group ( 3/17, 17.6%) and 7 cases of the binding group (7/21, 33.3%) ended up with re-operation and total pancreatectomy. 2 out of the 17 cases in end-to-side group and 3 out of the 21 cases in the binding group resulted in mortality.

Conclusion. Although binding technique had been reported to have zero leakage rates, the result seemed not so easily reproducible. In case of leakage, it is more common to have disastrous Grade C pancreatic fistula requiring re-operation.

FP 32.06

TREATMENT STRATEGY FOR PANCREATIC FISTULA AFTER PANCREATO-DUODENECTOMY

Shimoda, Mitsugi; Kita, Junji; Katoh, Masato; Rokkaku, Kyu; Sawada, Tokihiko; Kubota, Keiichi

Dokkyo University School of Medicine, Second Department of Surgery, Mibu, Japan

Aim. Pancreatic fistula (PF) is the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF after PD.

Material and Methods. Between April 2000 and April 2007, 127consecutive patients underwent a PD with pancreaticojejunostomy (PJ). We performed reconstruction after PD using modified Child.

Methods. Pancreatic duct tube was inserted and fixed by 4–0 TF Vicryl and PJ was performed using 4–0 PDS-II. Omentum graft covered in the GDA then 4 drains were put into the PJ from middle line incision. We diagnosed as PF developing in patients with a 1 POD amylase value in drains of more than 10,000 U/L. We have divided patients into 2 groups, PF group and non PF group. Patient characteristics were comparable in both groups. The predicting risk factors selected in the univariate setting were amount of bleeding, operating time, hospital stay, gender, age, with or without DM, with or wit hout hepatic resection or not, p-duct tube size, "soft" pancreas or not and tumor location. Result: Thirty-four of 127 patients had PF, the overall incidence of PF was 26.7%. There were 23 male and 11 female. Mean operating time, bleeding and postoperative hospital stay were 587.9 min., 729.4 ml and 46.0 days, respectively. Thirty of 34 patients were in need of continuous lavage. Four patients had GDA bleeding, 3 had TAE and one had operation. One of the four patients died from liver failure after TAE. PF was more frequent high age (> 65yrs) and soft pancreas, and prolonged hospital stay after surgery (P = 0.03, P = 0.04, P = 0.0001). Amount of bleeding, operating time, gender, with or without DM, with or without hepatic resection, p-duct tube size and tumor location were not significant difference between two groups.

Conclusion. High age is more frequent risk for PF, and PF prolonged hospital stay after PD.

FP 33.01

NO EVIDENCE FOR SUBSTANTIAL SYSTEMIC ACTIVATION OF BLOOD PLATELETS DURING ORTHOTOPIC LIVER TRANSPLANTATION

Pereboom, Ilona TA¹; Lisman, Ton¹; Hendriks, Herman GD²; Porte, Robert J¹

¹University Medical Center Groningen, Hepatobiliary Surgery and Liver Transplantation, Groningen, Netherlands; ²University Medical Center Groningen, Anaesthesiology, Groningen, Netherlands

Background. In hemostatically compromised patient with liver failure, additional substantial hemostatic changes occur during orthotopic liver transplantation (OLT). Platelet function is thought to deteriorate during OLT, as a result of platelet activation and proteolysis of platelet receptors by plasmin following reperfusion, but this hypothesis was never formally tested.

Objective. To study platelet function markers in samples taken during and after OLT.

Methods. Fifteen patients undergoing OLT were included in the study. Samples were taken at induction of anaesthesia, 15 minutes after the start of the anhepatic phase, 15 minutes after reperfusion, at the end of surgery, and at post-operative days 1, 5, and 10. In addition, one sample was taken directly from the venous outflow from the liver immediately after reperfusion. Platelet activation was assessed by measuring activation makers on platelets by flow cytometry, and by measurement of activation products in plasma by ELISA.

Results. No increase in platelet activation as measured by P-selectin and activated áIIbâ3 expression on the platelets was observed during OLT. In fact, these activation markers decreased post-operatively, indicating that the platelets were in a pre-activated state at the start of surgery. No increases in the soluble activation markers cleaved GPV, GPIbá, and á-granule-released beta-thromboglobulin was observed during OLT. Also at 10 days after surgery plasma levels of these makers were comparable to the levels observed at the start of surgery. Significant proteolysis of PAR-1, GPIb and áIIbâ3 was only observed in the sample taken directly after reperfusion, but no proteolysis of these receptors could be observed in systemic blood samples at all time points.

Conclusion. Using flow cytometry and measurement of soluble platelet receptors, we found no evidence for a significant activation of circulating blood platelets during OLT. These data suggest that platelet activation and proteolysis of platelet receptors is not as overt as previously assumed.

FP 33.02

ACTIVE IMMUNIZATION IN PATIENTS WHO UNDERWENT LIVER TRANSPLANTATION FOR HBV-RELATED LIVER DISEASE

Lee, Hae Won; Suh, Kyung-Suk; Kim, Joohyun; Shin, Woo Young; Yi, Nam-Joon; Lee, Kuhn Uk

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. Active immunization has been tried as an alternative strategy of HBV prophylaxis after liver transplantation for HBV-related liver disease because of several disadvantages of conventional prophylactic methods with hepatitis B immune globulin (HBIG) and lamivudine. We described our experience of HBV vaccination to find its problems and future prospects.

Methods. Preliminary study was performed on eight patients who had undergone LT for HBV-related liver disease more than two years before. All patients showed normal liver function without HBV recurrence or other complications before vaccination. High dose of recombinant vaccine (80¥ìg) were intramuscularly administered four times (0-, 5-, 10-, and 25-week schedule). We continued HBIG administration during the study. Additionally, the vaccination results of twelve random cases not included in this study were also investigated.

Results. In only one (12.5%) of eight patients included in preliminary study, HBIG administration could be discontinued (>180IU/L). The others continued to need HBIG to maintain proper anti-HBs level. Of twelve non-study patients, however, six could maintain anti-HBs level without HBIG administration and all of three patients who had received only lamivudine and vaccination because of intolerability to HBIG could maintain good anti-HBs level (>30IU/L) without HBIG although they required repetitive boosters.

Conclusion. High dose HBIG may disturb the production of anti-HBs antibodies and HBV vaccination under lamivudine prophylaxis is seems to be more effective for active immunization. More potent vaccination method than simple high dose recombinant vaccine, such as adjuvant HBV vaccine, may be necessary for successful active immunization.

FP 33.03

QUALITY IMPROVEMENT PROGRAM FOR LIVER TRANSPLANT ANESTHESIA REDUCES BLOOD TRANSFUSION, NEED FOR MECHANICAL VENTILATION AND DURATION OF HOSPITAL CARE

Hevesi, Zoltan¹; Lopukhin, Sergei²; Mezrich, Joshua³; Lee, Minjung⁴; Andrei, Adin-Cristian⁵

¹University of Wisconsin, Madison, United States; ²University of Wisconsin Hospital and Clinics, Anesthesiology, Madison, United States; ³University of Wisconsin Hospital and Clinics, Transplant Surgery, Madison, United States; ⁴University of Wisconsin, Department of Statistics, Madison, United States; ⁵University of Wisconsin, Biostatistics and Medical Informatics, Madison, United States

Background. Continuous quality improvement (CQI) is widely used in various industries. This method is based on repeated data collection to improve the product. Adapting CQI principles to medicine has limitations. Liver transplantation presents a unique challenge for anesthesiology Chairs in allocating the right level of anesthesiology expertise. Different solutions can be found in various institutions, and the variability of care is significant.

Objective. We aimed to determine if a dedicated anesthesia team is a worthwhile investment of resources.

Methods. We describe organizational changes such as a new dedicated liver transplant anesthesia team, increased anesthesia involvement in the transplant service-line functions, new resident rotation, regularly updated evidence-based clinical guidelines and a new liver transplant anesthesia database. We compare blood transfusion, postoperative mechanical ventilation, intensive care duration and length-of-stay (LOS) for patients undergoing liver transplantation before and after implementation of our CQI program.

Results. In 2003, we implemented an anesthesia CQI process that was based on periodic data analysis of liver transplantation cases and sequential enhancement of anesthesia care. During the follow-up period, patient complexity, surgical group-composition and surgical technique were essentially unchanged. We observed significant reductions of the intra-operative blood transfusion requirement, need for postoperative mechanical ventilation, intensive care duration and LOS. 2000–2002 (N = 217) 2005 (N = 87) RBC 14.9 (16.9) 5.2 (5.4)* FFP 28.1 (21.2) 3.4 (4.7)* ICU (day) 4.5 (6.1) 3.0 (4.1)* Vent (day) 2.3 (4.5) 1.3 (3.3)* LOS (day) 23.1 (23.6) 14.0 (10.3)* Mean (Std Dev) *p-value < 0.05.

Conclusions. Our CQI program was associated with an improvement of short-term patient outcomes at a large university hospital. The quality improvement process described here may be a useful model for other similar hospitals attempting to improve liver transplant anesthesia care.

FP 33.04

SEVERITY OF HEPATIC STEATOSIS AND OUTCOME AFTER ORTHOTOPIC LIVER TRANSPLANTATION: AN ANALYSIS OF RISK FACTORS.

Deroose, Jan¹; Zondervan, Pieter²; Kazemier, Geert¹; Metselaar, Herold³; IJzermans, Jan N.M.¹; Alwayn, Ian P.J.¹

¹Erasmus MC, Departments of Surgery, Rotterdam, Netherlands; ²Erasmus MC, Pathology, Rotterdam, Netherlands; ³Erasmus MC, Hepatology, Rotterdam, Netherlands

Background. Macrovesicular steatosis is thought to be an important risk factor for initially poor function (IPF) or even dysfunction after orthotopic liver transplantation (OLT). Due to shortage of grafts severe fatty infiltrated livers have been used with varying Results.

Aim. To evaluate the impact of steatosis in combination with other known risk factors on the outcome of OLT in terms of IPF, survival and hospitalized time.

Methods. We analyzed 185 consecutive OLT 's between 2000 and 2004. The degree of steatosis was determined by histological examination and classified as non (M0), mild (<30%, M1), moderate (30–60%, M2) or severe macrovesicular steatosis (>60%, M3). Recipients were classified as showing primary function or IPF of the transplanted liver based on serum transaminases.

Results. IPF was observed in 34% of M0, 32% of M1, 58% of M2 and 88% of M3 cases (p < 0,001). In multivariate regression analysis, the grade of steatosis, heart beating (HB) vs. non-heart beating (NHB) donor, and duration of cold ischemia time (CIT) were significantly associated with IPF (p < 0,001, p = 0,003 and p = 0,027, resp.). Furthermore, the risk of developing IPF is 40.3% for livers with M3 steatosis, 40.9% for NHB livers and 33.5% for livers with long CIT (>500 minutes). If none of the risk factors are present, the risk of developing IPF is 7,2%, whereas the presence of all risk factors increases the risk to 97,5%. Patients with IPF have a significantly shorter patient survival than those without IPF (p = 0,04). Graft survival was not influenced by IPF (p = 0,07).

Conclusion. Livers with severe steatosis from NHB donors with a prolonged CIT have a risk of 97.5% for developing IPF. Patients with IPF have a shorter survival, these livers should therefore not be used for transplantation. Livers with severe steatosis without other risk factors have an increased risk for developing IPF and should be used for selected recipients. Livers with mild or moderate steatosis are not at risk for IPF and can readily be transplanted.

FP 33.05

LIVING DONOR LIVER TRANSPLANTATION FOR FULMINANT HEPATIC FAILURE

Ikegami, Toru¹; Shimada, Mitsuo¹; Taketomi, Akinobu²; Soejima, Yuji²; Yoshizumi, Tomoharu²; Imura, Satoru¹; Morine, Yuji¹; Kanemura, Hirofumi¹; Maehara, Yoshihiko³

¹The University of Tokushima, Department of Surgery, Tokushima, Japan; ²Kyushu Univeristy, Department of Surgery and Science, Fukuoka, Japan; ³Kyushu University, Department of Surgery and Science, Fukuoka, Japan

Introduction. Living donor liver transplantation (LDLT) has become an accepted treatment for terminal liver diseases.

Methods. Forty-four living donor liver transplantations performed for fulminant hepatic failure (FHF) at Kyushu University Hospital and the University of Tokushima Hospital were reviewed.

Results. The etiologies included hepatitis B (n = 14), hepatitis C (n = 1), autoimmune hepatitis (n = 2), Wilson□fs disease (n = 3), and unknown cause (n = 25). The graft types were as follows: left lobe (n = 34), right lobe (n = 9), and lateral segment (n = 1). The mean graft volume to standard liver volume ratio was 43.5 □} 9.2%. The extubation was significantly delayed in the Grade IV encephalopathy group (73.7 □} 18.2 hours) in comparison to the other Grades (p < 0.01 to Grade I and II, p < 0.05 to Grade III). All other patients except one with a subarachnoid hemorrhage had complete neurologic recovery after transplantation. The 1- and 10-year survival rate were 77.6% and 65.5% for grafts, and 80.0% and 68.2% for patients.

Conclusion. The outcome in LDLT for ALF is fairly acceptable despite severe general conditions and emergent transplant settings. LDLT is now among the presently accepted life-saving treatment of choice for ALF, although new types of innovative medical treatment for this disease entity are still anticipated.

FP 33.06

MODULATION OF ACUTE CELLULAR REJECTION BY HYPERBARIC OXYGEN THERAPY: A STUDY IN A RAT MODEL OF ORTHOTOPIC LIVER TRANSPLANTATION.

Gan, Stephanie; Muralidharan, Vijayaragavan; Christophi, Christopher

University of Melbourne Austin Health, Department of Surgery, Melbourne, Australia

Background. Acute cellular rejection is a common cause of post-transplantation morbidity. HBO therapy has been shown to favourably alter immune responses.

Aim. This study investigates the effect of HBO therapy on rejection in a rat model of liver transplantation.

Methods. Male inbred Dark Agouti and Lewis rats were transplanted to create severe or mild rejection. HBO was administered twice daily for seven days after transplantation, after which the rats were killed. Outcome was assessed by serum biochemistry, histopathology, area of inflammatory cell infiltrate and T cell counts. A survival study in the severe model was conducted for 14 days with HBO and matching controls.

Results. Twice daily HBO therapy in the severe model significantly reduced serum bilirubin (43.5±7.7 µmolL^-1 vs 81.6±11.4 µmolL^-1 p = 0.02), peri-central venous infiltration (118932±12630 µm² vs 53532±6283 µm² p = 0.005) and conferred significant survival benefit with mean survival time of 289±17.2 hours vs 234±5.5 hours (p = 0.01). In the severe model, there was a significant difference in both T cell number and total cell number in the perivenous region (85.72±6.32 vs 123.76±10.33 cells p = 0.002; 197.52±11.31 vs 275.07±19.18 cells p = 0.001). In the mild model there was a significant difference in both T cell number and total cell number in the periportal region (321.46±20.41 vs 384.71±19.56 cells p = 0.004; 550.68±31.62 vs 618.81±26.47 cells p = 0.008), and in the perivenous region (54.47±3.12 vs 67.03±3.02 cells p = 0.001; 95.71±4.29 vs 113.29±5.01 cells p = 0.007).

Conclusion. Twice daily HBO therapy after transplantation reduces inflammatory cell infiltration, in particular T cell infiltrate, and acute rejection with a survival benefit. This may have potential therapeutic implications.

FP 34.01

CURRENT STATUS OF MINIMALLY INVASIVE NECROSECTOMY FOR POST-INFLAMMATORY PANCREATIC NECROSIS.

I.Babu, Benoy; Siriwardena, Ajith

Manchester Royal Infirmary, Hepatobiliary Surgery Unit, Manchester, United Kingdom

Introduction. Blunt (non-anatomical) debridement of necrotic tissue at laparotomy is the standard method of treatment of infected post-inflammatory pancreatic necrosis. Recognition that laparotomy may add to morbidity by increasing post-operative organ dysfunction has led to the development of alternative, minimally invasive methods for debridement. There is a need for consensus regarding optimal approaches and this study reports the current status of minimally invasive necrosectomy (MIN) by different approaches, using standardised reporting methodology for comparison.

Methods. Searches of MEDLINE and EMBASE for the period 1997–2007 were undertaken using OVID with Boolean operators. Only studies with original data and information on outcome were included to produce a final population of 19 studies reporting on 253 patients undergoing MIN with the median (range) number of patients per study being 7 (1–53). MIN was categorised as retroperitoneal, endoscopic or laparoscopic and the following datapoints were selected for comparison: delay from admission to necrosectomy, inpatient stay and procedure-related mortality. Data are presented as medians (range).

Results. The retroperitoneal approach was undertaken in 139 (54.9%) with a median delay from admission of 35 (13–48) days, median in-pt stay of 74 (23–100) days and overall mortality of 17.4 (8–27%). Endoscopic trans-gastric “necrosectomy” was undertaken in 97 with a median inpatient stay of 18 (1.5–49.5) days. The median number of interventions per patient in both these groups was 3. Laparoscopic necrosectomy is reported in 17 patients (with 0% mortality).

Conclusion. These data show that MIN can be undertaken with acceptably low mortality. The retroperitoneal approach has the most published support of the MIN techniques. Despite these techniques being promoted by enthusiasts, no comment for superiority of MIN over percutaneous radiological drainage of pancreatic abscess or contemporary small-incision necrosectomy can or should be made without formal randomised trial.

FP 34.02

SURGICAL TREATMENT OF NECROTIZING PANCREATITIS BY NECROSECTOMY AND CLOSED LAVAGE: OUTCOME IN A 17-YEAR, SINGLE-CENTER SERIES

Kudari, Ashwinikumar¹; Doley, Rudraprasad¹; GSB, Kishore¹; Yadav, Thakur Deen¹; Gupta, Rajesh¹; Kochhar, Rakesh²; Wig, Jai Dev¹

¹PGIMER, General Surgery, Chandigarh, India; ²PGIMER, Gastroenterology, Chandigarh, India

Background. Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 17 years.

Methods. During this time period 214 patients underwent pancreatic necrosectomy. The total series was evaluated separately for treatment period A (1990–1996) treatment period B (1997-J une 2002) and treatment period C (July 2002–May 2007).

Results. Preoperative disease severity did not differ between the groups. The incidence of sterile necrosis was significantly higher during the time period A. Percutaneous drainage was more frequently used during time period B and C. Disease onset-surgery time was more during time period B and C. The analysis of the three treatment periods revealed that during period B and C, there was a decrease in operatively treated patients with sterile necrosis (P<.0005). Mortality was significantly less during treatment period B and C. There was no significant difference in the incidence of locoregional complications among the three groups.

Conclusions. In conclusion, PN is associated with significant morbidity and mortality Over the long time-course of this study, there has been an evolution in the management of patients, with a reduction in the number operated without an objective diagnosis of infected pancreatic necrosis. We have also found in recent years an increased use of percutaneous interventions and a tendency towards delayed surgical intervention.

FP 34.03

ANTI-INFLAMMATORY EFFECTS OF ANTIFACTOR VII IN SEVERE EXPERIMENTAL PANCREATITIS IN THE RAT

Andersson, Roland; Andersson, Ellen; Axelsson, Jakob

Lund University Hospital, Dept of Surgery, Clinical Sciences, Lund, Lund, Sweden

Introduction. Severe acute pancreatitis (SAP) is characterized by an early onset of pronounced pro-inflammatory response. A crosstalk between inflammation and coagulation exist but exactly how this system interact is unclear. In severe sepsis, the use of activated protein C may provide outcome benefits and this regime has also been tried with some effect in SAP in the rat. In general, though the anti-inflammatory properties of anti-coagulation in acute pancreatitis (AP) has not been studied.

Aim. The aim of the present study was to evaluate the effect of active site inhibited factor VII (ASIS) in SAP in the rat and the effect on the inflammatory response.

Method. ASIS was administered intraperitoneally 40 minutes or 3 hours after induction of SAP. SAP was induced by infusion of taurodeoxycholate in the biliary pancreatic duct. The effect was evaluated by measuring levels of myeloperoxidase (MPO; reflecting neutrophil infiltration) in the lungs, ileum and pancreas and determination of interleukin(IL)-6 levels in plasma.

Results. Comparing the treatment groups with administration given 30 minutes or 3 hours after induction of SAP, plasma levels of IL-6 (p = 0.001 and p = 0.009, respectively) as well as MPO levels in lungs (p < 0.001 and p = 0.04, respectively) were significantly lower in both treatment groups as compared to SAP animals without ASIS treatment. Similar tendencies were seen when measuring MPO levels in ileum (p = 0.08 and p = 0.023, respectively) while MPO levels in the pancreas were not affected by ASIS treatment.

Dscussion/Conclusion. Anti-factor VII given as treatment (early and at fulminant onset of disease) after induction of SAP in the rat resulted in a systemic anti-inflammatory effect, evident by decrease in MPO levels in lungs and intestine, and increased levels of IL-6 in plasma. The role of anti-coagulation in the modulation of the inflammatory response require further studies, but may represent a future treatment modality.

FP 34.04

CONSERVATIVE APPROACH IN THE MANAGEMENT OF SAP. EIGHT-YEAR EXPERIENCE IN SINGLE INSTITUTION

Pupelis, Guntars; Zeiza, Kaspars; Plaudis, Haralds

Clinical University Hospital "Gailezers", Surgery, Riga, Latvia

Introduction. Colloid resuscitation, control of the intra-abdominal hypertension (IAH), renal and pulmonary support, improvement of the visceral perfusion in parallel with early enteral feeding and antibiotics on demand are important conditions for prevention of infection and successful management of SAP.

Objective. to review prospectively collected data and summarise our eight-year clinical experience in the management of SAP.

Methods. Data from clinical protocols of 269 SAP patients treated in our institution during the period from 1999–2006 were analysed. Success of the conservative treatment, frequency of the ventilatory support, infection rate, number of surgical interventions, complications and mortality were evaluated, comparing periods from 1999 to 2002 (P 1) and 2003–2006 (P 2).

Results. Overall success rate for conservative treatment was 57%. Improvement of the protocol routine resulted in more successful conservative treatment comparing 51% in P 1 vs. 69% in the year 2006, p < 0,01. Ventilatory support was applied in 6,3% of cases with similar frequency through the periods. Totally 142 patients underwent continuous veno-venouse haemofiltration (CVVH) as a component of fluid resuscitation and IAH control. Application of the CVVH increased significantly comparing P 1 and P 2 comprising 24% vs. 96%, p< 0,005 respectively. Surgical treatment was performed in 38% of cases (P 1) comparing 22% in P 2, p < 0,001. Overall mortality was 19% with drop down to 12% in year 2006.

Conclusion. Conservative approach with colloid resuscitation, early application of CVVH, control of the IAH, early enteral feeding, and selective antibiotic strategy can be successfully applied in the treatment protocol of SAP.

FP 34.05

SOCIAL DEPRIVATION IS A CAUSATIVE FACTOR IN ACUTE PANCREATITIS

Ellis, Matthew P¹; French, Jeremy J²; Charnley, Richard M²

¹Freeman Hospital, Hepato-Pancreato-Biliary Surgery, Newcastle upon Tyne, United Kingdom; ²Freeman Hospital, Department of Surgery, Newcastle upon Tyne, United Kingdom

Background. The aetiology and mortality of acute pancreatitis (AP) are known to be related to lifestyle factors such as alcohol, smoking and obesity. The role of social deprivation has however not previously been reported.

Objective. To carry out a six month prospective observational study of AP in one geographical region covering a population of 3 million.

Methods. All patients with a clinical and biochemical diagnosis of AP were identified. Clinical casenotes were reviewed to confirm the diagnosis, aetiology and outcome of confirmed cases. Age standardised incidence (ASI) and mortality (ASM) were calculated using 2001 census data and the European standard population. To study social deprivation patients were stratified into five quintiles of deprivation based on the index of multiple deprivation (IMD) score.

Results. AP was confirmed in 963 episodes during the study period. ASI was 55.6 per 105 per year. Case mortality was 4.98% (48/963) for all patients and 17.16% (46/228) for patients with severe AP as defined by the Atlanta criteria. ASM was 2.19 per 105 per year. The aetiology of AP was gallstones for 409 (42.5%), alcohol 277 (28.8%) idiopathic for 137 (14.2%) and other aetiology in 140 (14.5%). A significant trend was observed of increasing ASI with increasing levels of deprivation (Pearson correlation, R = 0.943, p = 0.012). There was also a significant trend of increasing proportion of AP secondary to alcohol excess with increasing level of deprivation (R = 0.981, p = 0.003).

Conclusion. A higher incidence of AP was observed than has previously been reported in the UK. More socially deprived individuals have a significantly increased incidence and alcohol aetiology. A moderate decline in case based mortality is observed compared to previous studies although patients with severe AP remain at significant risk of death.

FP 34.06

TIMING OF LAP CHOLE AFTER ACUTE CALCULUS PANCREATITIS

Sinha, Rajeev

MLB Medical College, General Surgery, Jhansi, India

Background. The optimal time for managing cholelithiasis in acute biliary pancreatitis(ABP) is important because of the significant incidence of recurrent attacks during the waiting period. But it still controversial with very few surgeons advising early cholecystectomy as against the more common practice of interval cholecystectomy.

Aim. To analyse the feasibility of Laparoscopic cholecystectomy at the same admission

Methods. 62 consecutive patients of ABP were taken up for the study After grouping by Glasgow modification of Ransons criteria 8 patients with severe acute pancreatitis were excluded from the study. Laparoscopic cholecystectomy(LC) was carried out during the same admission, within 72 hours, in all these 54 patients and the results were then compared with 60 control group patients undergoing elective LC for cholelithiasis.

Results. The average onset of pain to operating time was 64.6 hrs(48–96 hrs), operating time was similar in both groups,16.5 mins and 14.2 mins in the control group. Fibrous adhesions were seen in 6 patients and Calot's triangle dissection was difficult in 2 patients in the test group as opposed to 5 patients with fibrous adhesions and 3 with difficult Calot's triangle in the control group. Discharge time was not much different 3.33 days in the test group and 2.6 days in the control group. None of the groups had any complications.

Conclusion. Early, same admission, LC in patients with mild acute biliary pancrea titis appears to be a viable and better alternative since it prevents the occurrence of interval pancreatitis during the waiting period, reduces the number of noncompliant patients and gives results comparable with those of elective laparoscopic cholecystectomy. Patients with severe acute biliary pancreatitis are however better treated by interval laparoscopic cholecystectomy.

FP 34.07

RESULTS OF INAPPROPRIATE LAPAROTOMY FOR AUTOIMMUNE PANCREATITIS

Cabral, Carmen¹; Lesurtel, Mickael¹; Paye, Francois²; Vullierme, Marie-Pierre³; Lewin, Maite⁴; Couvelard, Anne⁵; Sauvanet, Alain¹; Lévy, Philippe⁶; Ruszniewski, Philippe⁶; Hammel, Pascal⁶; Belghiti, Jacques¹

¹Beaujon Hospital, HepatoPancreatoBiliary Surgery, Clichy, France; ²St Antoine Hospital, Digestive Surgery, Paris, France; ³Beaujon Hospital, Radiology, Clichy, France; ⁴St Antoine Hospital, Radiology, Paris, France; ⁵Beaujon Hospital, Pathology, Clichy, France; ⁶Beaujon Hospital, Gastroenterology, Clichy, France

Background. Autoimmune Pancreatitis (AP) is a rare cause of benign mass lesion of the pancreas that may mimic that of pancreatic carcinoma and lead to inappropriate pancreatic resection.

Aim. To analyze retrospectively presentation and outcome of patients who underwent a laparotomy for AP.

Methods. From 1995 to 2006, 22 patients had pathologic features consistent with AP following laparotomy including pancreaticoduodenectomy (n = 10), splenopancreatectomy (n = 9), pancreatic biopsy (n = 2) and gastrojejunostomy (n = 1). The demographics, pathological and clinical features, and outcomes of these patients were analyzed.

Results. Fourteen males and 8 females (median age: 44 years (20–70)) presented with weight loss (77%), acute pancreatitis (46%), pancreatic pain (46%) and jaundice (41%). Four (18%) patients had a history of autoimmune disease. Preoperative abdominal CT and/or MR imaging were performed in all patients and endoscopic ultrasound in 20 (91%) patients. In 16 (72%) patients, there was a focal enlargement of the pancreas that mimicked pancreatic cancer. Retrospectively, a review of the imaging work up identified features of AP (diffuse pancreatic enlargement, peripancreatic inflammation and narrowing of pancreatic ducts) in 13 (59%) cases. Preoperative biopsies and peroperative frozen sections were performed in 8 (36%) and 20 (91%) patients, and were suggestive of AP in 2 (10%) and 4 (20%) cases, respectively. Nineteen (86%) patients had a presumed preoperative diagnosis of pancreatic carcinoma. Five (23%) patients developed recurrence (median follow-up, 32 months (1–95)) after resection: 3 with cholangitis and 2 with pancreatitis with a median delay of recurrence of 5 months and 36 months, respectively.

Conclusion. AP mimicked pancreas carcinoma in presentation although imaging features of AP were present in almost two third of the cases. In case of atypical pancreatic mass, arguments for AP have to be sought (imaging features, serum IgG4 levels, biopsy or steroid therapy test) to avoid inappropriate laparotomy.

FP 34.08

PANCREATIC ADIPONECTIN RECEPTORS AND STEATOPANCREATITIS

Mathur, Abhishek; Yancey, Kyle W; Wade, Terrence E; Prather, Andrew D; Swartz-Basile, Deborah; Lu, Debao; Lillemoe, Keith D; Pitt, Henry A; Zyromski, Nicholas J

Indiana University, Department of Surgery, Indianapolis, United States

Background. Obesity leads to fat infiltration of multiple organs, including the pancreas. Increased adiposity is associated with an augmented secretion of proinflammatory adipokines including IL-6 and leptin. Additionally, the levels of the anti-inflammatory adipokine adiponectin are decreased. We have recently shown that hyperleptinemic (Lepdb) obese mice have more pancreatic fat, and they develop a more severe pancreatitis, nonalcoholic steatopancreatitis (NASP) compared to lean mice. However, no data are available on the expression of pancreatic adiponectin receptors and the relationship between adiponectin and pancreatitis. Therefore, we hypothesize that obesity and hypoadiponectinemia will decrease adiponectin receptor expression and accentuate NASP.

Methods. Thirty-two lean C57, and 24 obese Lepdb female mice were studied at 12 weeks of age. Sixteen C57 and 8 Lepdb control mice underwent total pancreatectomy only, and pancreatic adiponectin receptor 1 expression was analyzed via PCR. In the remaining 16 mice from each group edematous pancreatits was induced by intraperitoneal injection of cerulein (50µg/kg hourly for 6 hours). Three hours after the last injection, blood and pancreata were collected. Pancreatitis severity was scored histologically using a validated method: the degree of edema, inflammation, and vacuolization were added for a total score. Serum adiponectin and pancreatic tissue levels of interleukin (IL)-6 were measured by ELISA. Data were evaluated via ANOVA and the Tukey test.

Results Results for pancreatic adiponectin receptor 1 expression in the control mice and serum adiponectin, pancreatic IL-6 and histologic score in pancreatitis mice are presented in the table.

Group	Adiponectin R1	Group	Adiponectin (µg/ml)	IL-6 (pg/mg)	Histologic Pancreatitis
C57 Control	1± 0	C57 Pancreatitis	23±4	731±109	4±0.3
Lepdb Control	0.6±0.1*	Lepdb Pancreatitis	12±2*	9867±250*	7±0.4*

*p < 0.01 vs C57

Conclusions. These data suggest that obese, hyperleptinemic mice have 1) decrease pancreatic expression of adiponectin receptor 1 and 2) more severe cerulein-induced pancreatitis. Therefore, we conclude that decreased pancreatic adiponectin receptors exacerbates steatopancreatitis.

FP 35.01

What happens to patients with colorectal liver metastases who have had a complete pathological response to chemotherapy?

Bagia, Jai Seema¹; Coldham, Chris²; Mayer, David¹; Brahmall, Simon¹; Mirza, Darius¹; Wigmore, Stephen¹; Buckels, John¹

¹Queen Elizabeth Hospital, Biringham, United Kingdom; ²Queen Elizabeth Hospital, Liver Unit, Birmingham, United Kingdom

Background. Increasing effectiveness of neoadjuvant chemotherapy for patients with colorectal liver metastases (CRLM) has led to dramatic radiological responses.

Aim. To report the long term outcome of resected patients who are found to have had a complete pathological response to pre-operative chemotherapy.

Methods. Our prospectively compiled database identified 524 patients undergoing liver resection for CRLM between 1997 and 2006. Case notes, radiology, pathology were reviewed in these patients. 30 had no malignancy of which 11 had benign lesions and 19 were negative/no tumor; of these 14 had chemotherapy prior to resection and form our study group.

Results. Pre-resection chemotherapy was as follows: 6 oxaliplatin based regimes; 5 had 5-fu and folinic acid alone; 1 capcitabine only; 1 irenotecan; 1 chemo-radiotherapy. 7 patients had a right sided resection, 3 a left resection and 5 had non-anatomical resections. Pathology reported no viable tumor or necrotic material with no malignant cells in all 14 cases. 3 patients have died with disease recurrence but the remaining 11 are well at follow-up (median 2 yrs).

Conclusion. This small heterogenous group suggests outcome in patients who have chemoresponsive CRLM is good. The question remains as to whether this could be achieved by chemotherapy alone or whether surgery contributes to this result but in the absence of accurate non surgical assessment of complete pathological response surgery continues to have a role.

FP 35.02

RESECTED COLORECTAL LIVER METASTASES. COMPARING THE SHORT AND THE LONG TERM SURVIVORS.

Mira, Paulo; Pinto Marques, Hugo; Santos Coelho, João; Pereira, José António; Paulino Pereira, Jorge; Carvalho, Carlos; Martins, Américo; Barroso, Eduardo

Hospital de Curry Cabral, Centro Hepato-Bilio-Pancreático e Transplantação, Lisbon, Portugal

Background. Prognostic factors (PF) of colorectal liver metastases (CRLM) resection are usually obtained through the analysis of survival curves including all the patients submitted to resection. In this series, the identification of PF is obtained through the analysis of two groups of selected patients-short (STS) and long term survivors (LTS).

Objectives. Definition of two groups of STS and LTS from resection for CRLM and retrospective identification of PF that influenced survival.

Methods. 219 patients were offered a resection for CRLM (April 1996-March 2007). Two groups of patients were selected: STS (<18 months survival; n = 32) and LTS (>48 months survival; n = 24). PF studied by multiple logistic regression analysis (SPSS): gender; age; primary tumor: Dukes, TNM and Node status; adjuvant chemotherapy and duration; pre-operative radiotherapy; colectomy-hepatectomy interval; neoadjuvant chemotherapy: duration and response; CRLM: synchronicity, number, distribution and size; resection: lobectomy or wider; blood transfusions.

Results. Survival was significantly influenced by: rectal primaries (p = 0.028), Dukes C or D (p = 0.067), N positive of primaries (p = 0.045) and response to neoadjuvant chemotherapy (p = 0.003; the strongest factor). Surgical margin <10 mm seemed to have influenced prognosis (not statistically significant).

Conclusions. Patients with CRLM on progression under chemotherapy should not be offered resection. Rectal origin, high Dukes and N positive are predictive of prognosis. Margins > 10mm shoud be preserved.

FP 35.03

COMPLETE PATHOLOGICAL RESPONSE AFTER PREOPERATIVE CHEMOTHERAPY FOR COLORECTAL LIVER METASTASES: MYTH OR REALITY?

Wicherts, Dennis A¹; de Haas, Robbert J¹; Aloia, Thomas¹; Lévi, Francis²; Paule, Bernard²; Guettier, Catherine³; Kunstlinger, Francis¹; Delvart, Valérie¹; Azoulay, Daniel¹; Castaing, Denis¹; Adam, René¹

¹Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; ²Hôpital Paul Brousse, Department of Medical Oncology, Villejuif, France; ³Hôpital Paul Brousse, Department of Pathology, Villejuif, France

Background. Complete clinical response (CCR) of colorectal liver metastases (CLM) following chemotherapy treatment has recently been shown to be of limited predictive value for complete pathological response (CPR) and cure of the disease.

Aim. The objective of this study was to determine predictive factors of CPR as well as its impact on long-term survival.

Methods. From January 1985 to July 2006, 767 consecutive patients with CLM underwent liver resection after systemic chemotherapy. Patients with CPR were compared to patients without CPR.

Results. Twenty-nine of 767 resected patients (4%) presented with CPR (M/F = 16/13, mean age = 54 years). Prior to hepatectomy, CCR was present in 2 of 767 patients (0.3%). None of the patients with CPR had CCR. Patients with CPR had a mean number of 3.3 metastases with a mean maximum size of 29.3 mm at diagnosis. Surgery consisted of 5 major resections (17%) and 24 limited hepatectomies (83%), and had a 0% postoperative (≤ 2 months) mortality rate. After a median follow-up of 52.2 months (range: 1.1 to 193.0 months), overall 3- and 5-year survivals for patients with CPR were 91% and 76%, respectively, significantly higher when compared to operated patients without CPR (61% and 45%, respectively) (P = 0.004). Disease-free survivals at 5 years were 69% and 19%, respectively (P < 0.001). Independent predictive factors for CPR were age ≤60 years, maximum size of metastases ≤ 3 cm at diagnosis, CEA level at diagnosis ≤30 ng/ml and an objective response following chemotherapy. The probability of CPR ranged from 0.2% when all factors were absent to 30.9% when all were present.

Conclusion. The incidence of CPR is 4% in patients with CLM treated with preoperative chemotherapy. However, CPR may occur in almost one-third of patients aged ≤ 60 years with metastases smaller than 3 cm and low CEA values, showing an objective radiological response. CPR is associated with uncommon high survival rates.

FP 35.04

OUTCOME OF POSTHEPATECTOMY MISSING COLORECTAL LIVER METASTASES AFTER COMPLETE RESPONSE TO CHEMOTHERAPY

Goéré, Diane¹; Boige, Valérie²; Malka, David²; Tomasic, Gorana³; Dromain, Clarisse⁴; Ducreux, Michel²; Elias, Dominique⁵

¹Institut Gustave Roussy, Department of Surgical Oncology, Villejuif, France; ²Institut Gustave Roussy, Medical Oncology, Villejuif, France; ³Institut Gustave Roussy, Pathology, Villejuif, France; ⁴Institut Gustave Roussy, Radiology, Villejuif, France; ⁵Institut Gustave Roussy, Surgical Oncology, Villejuif, France

Background. Dramatic responses to chemotherapy are occurring more and more frequently in patients with multiple colorectal liver metastases (LM), leading to resection. In a few patients, some LM vanish on imaging studies, remain undetected during hepatectomy and are left in place, which defined the “missing LM”. The aim of our study was to assess the long-term outcome of such “missing LM”.

Patients. Between January 1999 and June 2004, among 228 patients treated for colorectal LM, missing LM were observed in 16 patients. All the patients were operated within 4 weeks of imaging. Hepatic arterial infusion (HAI) with oxaliplatin was administrated in 12 patients (75%): 7 before hepatectomy and 5 after.

Results. Overall 69 missing LM were diagnosed and left in place. Among the persistent LM resected, a complete pathological response was significantly more observed in the group with preoperative HAI (6/7), than in the group without (2/9, p < 0.02). With a mean follow-up of 51 months [24–90], missing LM did not reappear in 10 patients (62%). Adjuvant HAI was significantly correlated with the definitive eradication of missing LM (p < 0.01), as was not a complete pathological response. The overall 3-year survival rate of these highly selected 16 patients was 94%.

Conclusion. Colorectal LM under chemotherapy that vanish on high-quality imaging studies, remain undetected during hepatectomy and left in place, are definitively cured in 62% of the cases. This excellent result seems to be due to the administration of adjuvant hepatic arterial infusion of chemotherapy and should stimulate new investigations.

FP 35.05

SALINE-LINKED SURFACE RF ABLATION (SLSRFA): A SAFE EFFECTIVE METHOD OF SURFACE ABLATION OF HEPATIC METASTATIC COLORECTAL CANCER (CRC)

Gnerlich, Jennifer¹; Ritter, Jon²; Hawkins, William¹; Linehan, David¹; Strasberg, Steven¹

¹Washington University in Saint Louis, HPB Surgery, St Louis, United States; ²Washington University in Saint Louis, Pathology, St Louis, United States

Backgound. We have published parameters determining safety and efficacy of a SLSRFA device (TissueLink) in a porcine model (Ann Surg 239:518;2004). Depth of ablation was related to power, lesion size and inflow occlusion. The purpose of this study was to determine safety and efficacy of treatment of CRC metastases in a clinical setting.

Methods. After IRB approval the initial portion of the study was conducted in 16 patients to determine if parameters defined in the animal model were clinically applicable. Normal areas of liver were treated with SLSRFA using various diameters and powers for 9 minutes with and without inflow occlusion (1cm/10W; 2cm/15W; 4cm/45W) in patients undergoing resection. In part two of the study, superficial hepatic CRCs were treated at 45W for 9 minutes without inflow occlusion in 7 patients. After resection ablation depth was measured and samples obtained for NADH staining (for cell viability) and H&E staining.

Results. In the initial 16 patients, ablation depth varied from 3mm to 20 mm. Depth was significantly dependent on power, lesion size and inflow occlusion (all p < 0.05) as in pigs. At 45W/4cm diameter, mean ablation depths in normal liver were 10mm and 18mm without and with inflow occlusion. NADH stains showed total cell necrosis to the full depth of ablation. In the study continuation, large tumors showed total cell necrosis to a mean depth of 14 mm from the surface (range 12–15 mm; n = 5). Tumors less than 1cm size showed complete necrosis. Strikingly normal liver tissue was viable immediately adjacent to dead tumor in the deeper parts of the lesions.

Conclusion. SLSRFA rapidly, completely, and safely ablates normal liver to a depth of 1–2 cm. Remarkably it is even more effective in ablating CRC, possibly because CRC metastases are less hydrated than normal liver. SLSRFA is an effective tool for extending resection margins and for ablating superficial small tumors or superficial parts of large tumors perhaps in conjunction with interstitial RFA of the deeper parts.

FP 35.06

SMA-PIRARUBICIN INHIBITS TUMOUR GROWTH BY DISRUPTING TUMOUR MICROCIRCULATION

Daruwalla, Jurstine¹; Greish, Khaled²; Malcontenti-Wilson, Cathy³; Vijayaragavan, Muralidharan³; Maeda, Hiroshi²; Christophi, Chris³

¹Dept Surgery, Austin Hospital, The University of Melbourne, Melbourne, Australia; ²Sojo University, Biodynamics Research Lab, Kumamoto, Japan; ³Austin Hospital, Surgery, Melbourne, Australia

Background. Macromolecular drugs preferentially accumulate in tumours due to the specific characteristics of tumour microvessels. SMA-Pirarubicin is a macromolecular agent that specifically targets tumour blood vessels via the EPR effect. It has been shown to significantly reduce tumour growth and improve survival in a murine model of colorectal liver metastases. Incomplete tumour destruction at the tumour periphery is the ongoing cause of tumour recurrence. The role played by the tumour microcirculation in tumour recurrence is uncertain. This study investigates the pattern of microcirculatory changes and alterations in the ultrastructural properties of tumour vasculature following administration of SMA-Pirarubicin.

Methods. Liver metastases were induced in male CBA mice using a murine derived colon cancer cell line. SMA-Pirarubicin (100 mg/kg) was administered intravenously over three divided doses. Tumour microvasculature was quantified using scanning electron microscopy of microvascular resin casts. Tumour perfusion and permeability were assessed using confocal in-vivo microscopy and evans blue.

Results. SMA-Pirarubicin reduced tumour microvascular index by almost 60% (27%±3.7 compared to the control group 47%±4.4, p = 0.003). Vessel diameter remained unaltered (66 µm±7.3 54 µm±5.5, p = 0.3). Confocal microscopy showed enhanced leakage and intratumoural drug localization 24 hours following treatment. Vascular occlusion beyond the tumour periphery and central tumour necrosis were apparent 24 hours post-drug treatment. Tumour permeability was also enhanced (p = 0.017) with minimal effect on normal liver.

Conclusion. SMA-Pirarubicin selectively accumulates in tumours compared to normal tissue and has a direct effect on tumour microvasculature. The microcirculatory changes coupled with cytotoxicity together inhibit growth of colorectal liver metastases. Growth of residual cells at the tumour periphery is sustained by a rich microvascular network.

FP 35.07

THE ACTIVATION OF APOPTOSIS IN THE LIVER PARENCHYMA AFTER RADIOFREQUENCY ABLATION

Vanagas, Tomas¹; Gulbinas, Antanas²; Pundzius, Juozas¹; Barauskas, Giedrius¹

¹Kaunas University of Medicine Hospital, Department of General Surgery, Kaunas, Lithuania; ²Kaunas University of Medicine, Institute for Biomedical Research, Kaunas, Lithuania

Background. Radiofrequency ablation (RFA) of liver causes destruction of parenchyma that is morphologically defined as the inner zone of tissue necrosis (central zone) and surrounding hyperemic rim (transition zone). The transition zone contains apparently undamaged tissue but exhibits signs of subacute hemorrhage. However, apoptosis may be an ongoing process which further would lead to cell death in transition zone. Discovery and characterization of transition zone with on going apoptosis has important clinical significance, therefore we conducted an experimental study aimed to qualitatively evaluate if the hyperthermia within the transition zone induces apoptosis in a porcine liver model.

Materials and Methods. Nine anesthetized pigs underwent RFA of liver parenchyma. RFA was carried out for 10 minutes. Altogether eleven lesions were produced. One hour after completion of the procedure pigs were sacrificed and the liver with the ablation zones and surrounding normal liver parenchyma were excised. The specimens were further investigated to identify the apoptotic processes. Western blot analysis and immunohistochemistry were used for the detection of active (cleaved) subunit of caspase-3.

Results. Morphologic analysis of the sections of the ablated area stained with hematoxylin and eosin revealed two zones: inner zone of tissue necrosis (central zone) and transition zone. Necrotic tissue with damaged structure of hepatic cells was observed in central zone, whereas the transition zone contained apparently undamaged liver cells with signs of sub acute hemorrhage. Western blot analysis and immunohistochemistry revealed the caspase-3 active (cleaved) subunit immunoreactivity in the transition zone in contrast to normal liver parenchyma.

Conclusion. Our study showed that the active 17-kDa subunit of caspase-3 was detectable in the transition zone during the early period after thermal ablation. Activation of apoptosis in the transition zone after RFA may play a role inducing the sub lethal injury of the liver parenchyma.

FP 35.08

ROLE OF PET-CT IN MANAGEMENT OF PATIENTS WITH COLORECTAL CARCINOMA

Kumari, Saumya¹; Krishna, B. A.²; Singh, Natasha²; Maitra, Riddhika²

¹P.D. HINDUJA NATIONAL HOSPITAL, Nuclear Medicine, and Medical Research Centre, Mumbai, India; ²P.D. HINDUJA NATIONAL HOSPITAL, Nuclear Medicine, Mumbai, India

Background. Recurrence occurs in one third of patients with colorectal carcinoma, within two years of curative resection. Early detection and prompt treatment may lead to disease resolution in upto 25% of these patients while the presence of extrahepatic disease precludes surgery. The existing diagnostic modalities lack the sensitivity and specificity to detect recurrence.

Aim. To evaluate the role of PET-CT imaging in the detection of recurrence, restaging and hence guiding management.

Methods. A total of 71 patients who had earlier undergone surgical resection of the primary colonic/rectal lesion, were included in the study. All of them were suspected to have recurrence based on raised serum CEA levels/symptoms/ abnormal CT scans during follow up and were subjected to PET-CT imaging.

Results. In 36 patients with elevated serum CEA levels and positive CT scans, the PET-CT imaging revealed additional lesions in 7 patients, suggesting upstaging of the disease by 20%. In 15 patients with elevated serum CEA levels and negative CT scans, the PET-CT study detected recurrence site in 11 patients. In 20 patients who had normal serum CEA levels with an abnormal CT scan, the PET-CT study confirmed recurrence in 16 of these patients.

Conclusions. 1. In our study, the sensitivity of PET-CT to detect recurrence was found to be 92%, whereas that of CT alone was 71%.2. The PET-CT study influenced the management in 35% of patients by detecting either recurrence or additional disease sites.

FP 35.09

PROGNOSTIC VALUE OF KI67 AND P21 IN METASTATIC AND NON-METASTATIC COLORECTAL CANCER

Riesener, Klaus-Peter¹; Steffen, Dirk²; Tittel, Andreas²; Schumpelick, Volker²

¹Marien-Hospital Marl, Department of General and Visceral Surgery, Marl, Germany; ²University Hospital, Department of Surgery, 52074 Aachen, Germany

Background. Molecular markers in proliferating tumours have been widely investigated. Nevertheless their role in metastatic spread of colorectal carcinoma is not known. The aim of our study was to identify a possible role of the proliferation marker Ki67 and the CDK-inhibitor p21 in the development of hepatic metastases.

Methods. Group I consisted of 76 patients, who were operated with R0-resections both on their primary tumour and synchronous or metachronous hepatic metastases within five years after the primary operation (metastatic tumour). Group II consisted of 72 patients, who were operated on their primary colorectal carcinoma and were free of recurrence or metastatic spread at least for the following five years (non-metastatic tumour). Immunhistochemistry for Ki67 and p21 were performed in the primary tumours in both groups. Ki67 was analysed quantitatively, p21 was analysed using a score (0 – 6) based on percentage and intensity of its expression in tumour cells.

Results. The groups were comparable concerning age and sex of the patients. The UICC stage was I in 8 patients, II in 25 patients and III in 39 patients of Group I corresponding with 21, 29, and 16 patients of Group II. 50±2,6% of the tumour cells expressed Ki67 in Group I versus 36±2,3% in Group II (p < 0,05). The expression of p21 reached a higher score in Group II (mean 3,6 vs. 2,9, respectively). Focussing on the results of UICC stage II only, the differences between Group I and Group II were evident as mentioned for the entire groups.

Conclusion. Our study shows a close correlation between the expression of the proliferation marker Ki67 and the occurence of metastases in colorectal carcinoma. The CDK-inhibitor p21 was more likely detected in non-metastatic tumours in our series. The combination of high expression of Ki67 and low expression of p21 was observed in 54% of all patients in group I and only 24% in group II indicating an influence of these markers on the ability of metastatic spread in colorectal cancer.

FP 36.01

ENDOSCOPIC ULTRASOUND VERSUS LAPAROSCOPY AND LAPAROSCOPIC ULTRASOUND TO PREDICT UNRESECTABILITY IN THE STAGING OF PANCREATIC HEAD CANCERS

Shah, Ankur¹; Shah, Jayshri²; Pope, IM¹; Norton, Sally³; Finch-Jones, Meg¹

¹Bristol Royal Infirmary, HPB Surgery, Bristol, United Kingdom; ²Frenchay Hospital, Gastroenterology, Bristol, United Kingdom; ³Frenchay Hospital, Upper GI surgery, Bristol, United Kingdom

Background. Pancreatic head cancers (CAHOP) have a poor prognosis, even after a curative resection. There is no single investigation to accurately predict unresectability(UnR). Endoscopic ultrasound (EUS) and staging laparoscopy with laparoscopic ultrasound (LUS) have been used with CT scan to stage CAHOP.

Objective. The aim of this study is to compare ability of EUS against LUS to predict unresectability in CAHOP after a multislice (CT) scan.

Methods. Two studies. Study I-Retrospective review between 2001–2005 of patients who had a EUS or LUS or both. Study II-A prospective blinded study comparing the 2 investigations over 8 months. Both Investigators were blinded to the findings of other investigation (EUS or LUS). Findings were confirmed on histology, or laparotomy or combination of 2 investigation.

Results. Study I- Out of a total of 79 patients referred, 65 patients had LUS, 29 had EUS and 27 had both. Sensitivity, negative predictive value (NPV) and accuracy of LUS(n = 65) was 74%, 72%,83% compared to 55%,50%, and 69% respectively for EUS(n = 29) When both investigations were performed in the same patient(n = 27); the sensitivity, NPV and accuracy were higher for LUS compared to EUS.( 78%, 69%, 85% compared to 50%, 50%, and 66.5% respectively). Study II: 13 patients were enrolled in the prospective study. The positive predictive value for unresectability was 100% for both the investigations. The sensitivity, NPV and accuracy for LUS was 57%, 675, and 77% as compared to 25%, 54.5% and 61.5% respectively. Both investigations were similar in diagnosing the tumour size, vascular invasion and nodal status; however, LUS diagnosed more patients with liver and peritoneal metastases.

Conclusion. As compared to EUS, LUS was more sensitive and accurate in the overall staging of CAHOP. It was rare to pick up vascular unresectability solely based on EUS. In our unit EUS is now selectively used to aid staging of pancreas cancer only after LUS.

FP 36.02

TPS, CA 19-9, VEGF AND CEA AS TUMOUR MARKERS IN PATIENTS WITH OBSTRUCTIVE JAUNDICE OR MASS LESIONS IN THE PANCREATIC HEAD

Sandblom, Gabriel¹; Granroth, Sofie²; Rasmussen, Ib Christian³

¹University Hospital, Dept of Surgery, Lund, Sweden; ²University Hospital, Dept of Internal Medicine, Uppsala, Sweden; ³University Hospital, Department of Surgery, Uppsala, Sweden

Background. Although numerous tumor markers are available for periampullary tumors, including pancreatic cancer, their specificity and sensitivity have been questioned. OBJECTIVE To assess the diagnostic and prognostic values of tissue polypeptide specific antigen (TPS), carbohydrate antigen 19-9 (CA 19-9), vascular endothelial growth factor (VEGF), and carcinoembrynic antigen (CEA).

Methods. Patients with mass lesions in the pancreatic head or obstructive jaundice of unknown etiology admitted to the department of surgery, Uppsala University Hospital, were included in the study. In addition to the investigations routinely undertaken for these patients, serum was obtained and stored in a freezer for later analysis.

Results. Altogether 56 patients were included (30 men and 26 women). Mean age was 63 years (range 35–92 years, standard deviation 13 years). Among these patients, further investigations revealed pancreatic cancer in 20 patients, other malignant diseases in 12 and benign conditions in 24. Median CEA in all patients was 3.4 µg/L (range 0.5–585.0), median CA 19-9 was105 kU/L (range 0.6–1 300 00), median TPS 123.5 U/L (range 15.0–3350) and median VEGF 132.5 ng/L (range 60.0–4317). Area under the curve was 0.747, standard error (standard error [SE] = 0.075) for CEA, 0.716 (SE = 0.078) for CA 19-9 and 0.822 (SE = 0.086) for TPS in ROC plots based on the ability of the tumours to distinguish between benign and malignant conditions. None of the markers significantly predicted survival in the subgroup of patients with pancreatic cancer.

Conclusion. Our study thus shows that the markers may be used as fairly reliable diagnostic tools, but cannot be used to predict survival.

FP 36.03

IMMUNOHISTOCHEMISTRY FOR M2-PYRUVATE KINASE IN FORMALIN-FIXED PANCREATIC TISSUE: A NEGATIVE MARKER FOR PERIAMPULLARY CANCERS?

Aloysius, Mark M¹; Zaitoun, Abed M²; Bates, Timothy E³; Ilyas, Mohammad²; Rowlands, Brian J⁴; Lobo, Dileep N⁴

¹Nottingham University Hospitals, Division of Gastrointestinal Surgery, Wolfson's Digestive Diseases Centre, Nottingham, United Kingdom; ²Nottingham University Hospitals, Division of Pathology, Nottingham, United Kingdom; ³University of Nottingham, Division of Community Health Sciences, Nottingham, United Kingdom; ⁴Nottingham University Hospitals, Division of Gastrointestinal Surgery, Nottingham, United Kingdom

Background. Although elevated serum concentrations of M2-pyruvate kinase (M2-PK) have been found correlate with poor prognosis in patients with periampullary cancer, there are no published studies on tissue expression of M2-PK in pancreatic cancer. AIMS: To characterise the immunohistochemical expression of M2-PK in archived specimens of periampullary cancers, chronic pancreatitis, and normal pancreatic tissue.

Methods. This was an immunohistochemical study on archived pancreatic tissue of 126 consecutive patients undergoing pancreatic resections for cancer and chronic pancreatitis between June 2001 and June 2006. Tissue microarrays were constructed from formalin-fixed paraffin-embedded tissue blocks containing periampullary cancer, chronic pancreatitis and normal pancreatic tissue. Immunohistochemical staining was done with mouse anti-M2-PK monoclonal antibody, (clone DF-4) at an optimal dilution of 1:25. M2-PK expression was quantified with the immunohistochemical score (IHS) which ranged from 0 to 12.

Results. 104 underwent pancreatic resection for cancer and 22 for chronic pancreatitis. A further 77 specimens of chronic pancreatitis tissue were obtained adjacent to areas of cancers. Normal pancreatic tissue was obtained from the resection specimens, adjacent to areas of cancer or chronic pancreatitis in a total of 32 patients. 91 metastatic lymph nodes from 68 patients were also studied. There was a consistent lack of expression of M2-PK (IHS = 0) in all periampullary tumours and metastatic lymph nodes, irrespective of tumour type or differentiation. However, chronic pancreatitis tissue and normal pancreatic tissue around these tumours were found to have a variable expression of M2-PK (IHS = 1 in 21%, IHS = 2–3 in 39%, IHS ≥ 4 in 40%).

Conclusions. Selective lack of immunohistochemical expression of M2-PK in periampullary cancer cells can potentially be used to confirm a diagnosis of periampullary cancer and differentiate between cancer and chronic pancreatitis.

FP 36.04

LAPAROSCOPIC VS. OPEN RESECTION OF INTRADUCTAL PANCREATIC MUCINOUS NEOPLASMS

Gumbs, Andrew A¹; Gayet, Prof. Brice²

¹Institut Mutualiste Montsouris, Digestive Diseases, 42 Boulevard Jordan, Paris, France; ²Institut Mutualiste Montsouris, Digestive Diseases, Paris, France

Background. Required resection margins for noninvasive intraductal papillary mucinous neoplasms (IPMNs) are a controversial issue. Over a 10-year period we have resected IPMNs from the entire pancreatic gland with minimally invasive techniques and compared our survival and complication rates with open controls to see if any difference in resection margins and outcomes could be observed.

Methods. Data were collected retrospectively, including our first cases of advanced laparoscopic resections. Five-year Kaplan-Meier curves were calculated and statistical analysis was performed using the log rank and Student's T test for continuous variables. Chi square and Fisher's exact tests were used for analyzing categorical variables.

Results. From March 1997 to Febuary 2006, we operated on 22 patients with noninvasive IPMNs, of which 9 (41%) were operated on laparoscopically and 13 (59%) using open techniques. Three patients underwent laparoscopic duodenopancreatectomy, compared to five in the open group. All resection margins were negative, but two patients required total pancreatectomy, both of which were performed laparoscopically. One of these was converted to open (11%) because of difficulty in reconstructing the biliary anastomosis. The overall complication rates were 56% for the laparoscopic group and 85% for the open group. Twenty-two percent of the laparoscopic group required reoperation and 11% required percutaneous drainage, compared to 15 and 23% in the open group, respectively. All patients are alive after a mean of 20 months (range = 2–43) in the laparoscopic group and 37 months (range = 1–121) in the open one (p > 0.05).

Conclusions. Laparoscopic resection of noninvasive IPMNs of the entire pancreatic gland has similar complication and survival rates as open procedures. As a result, the laparoscopic approach is appropriate for noninvasive IPMNs of the entire pancreatic gland; however, larger cohorts are needed to see if any approach has superior outcomes. Because of these favorable results, studies are currently underway to see if the minimally invasive approach is also appropriate for invasive IPMNs.

FP 36.05

RISK FACTORS OF GRADE C PANCREATIC FISTULA AMONG PATIENTS WITH PANCREATIC FISTULA AFTER PANCREATO-DUODENECTOMY

Fuks, david¹; Piessen, Guillaume²; Huet, Emmanuel³; Tavernier, Marion⁴; Nunes, Bertrand⁵; Zerbib, Philippe⁵; Mauvais, Francois⁶; Chiche, Laurence⁴; Salame, Ephraim⁴; Segol, Philippe⁴; Michot, Francis⁷; Scotte, Michel⁷; Triboulet, Jean-Pierre⁸; Mariette, Christophe⁸; Pruvot, Francois Rene⁵; Verhaeghe, Pierre⁹; Regimbeau, Jean-Marc⁹

¹universitary hospital, digestive surgery, Amiens, France; ²University Hospital C Huriez, Department of digestive and oncological surgery, France, France; ³University Hospital, Department of Digestive Surgery, Rouen, France; ⁴University Hospital Clemenceau, digestive surgery, CAEN, France; ⁵University Hospital C Huriez, Department of Digestive and Transplantation, Lille, France; ⁶Hospital Beauvais, Department of surgery, Beauvais, France; ⁷University Hospital C Nicolle, digestive surgery, Rouen, France; ⁸University Hospital C Huriez, Department of digestive and oncological surgery, Lille, France; ⁹University Hospital, Department of digestive and oncological surgery, Amiens, France

Background. Pancreatic fistula (PF) is the most common postoperative complication following pancreatoduodenectomy (PD). A recent definition (ISGPF) allows grading PF according to severity. Most PF are treated conservatively (Grade A), but in a few patients, PF can require interventional procedures (Grade B) or be life-threatening and needs reoperation in emergency (Grade C). The aim of this study was to evaluate the risk factors of Grade C PF among patients with PF after PD.

STUDY DESIGN. Between 2000–2006, 680 consecutive patients underwent a PD in 4 Digestive Surgery Department (Lille, Amiens, Rouen, Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity (Bassi et al.). To identify possible risk factors of Grade C PF, we reviewed records of 111 (16.3%) patients with postoperative PF and compared patients with Grade C PF vs Grade A-Grade B PF.

Results. Median age was 59 years (22–87). 50.4% PD were performed with pancreaticogastrostomy and 55 with pancreaticojejunostomy. Overall mortality was 2% (n = 13/680). Grade C PF occurred in 36 (32%) patients (mortality 36.1%). Seven (19.4%) had percutaneous drainage for intra-abdominal collection and all had reoperation. The major indication for reoperation was haemorrhage (n = 18). Grade C PF increased postoperative LOS (46 vs 29 days, p < 0.001). Univariate analysis showed that peroperative soft pancreatic parenchyma (p 0.01) and transfusion >2 blood units (p 0.0036) were significant factors of Grade C PF. Multivariate analysis identified only soft pancreatic parenchyma as risk factor of Grade C PF (p = 0.05). The presence of a soft pancreatic parenchyma in patient with PF increased by 5.4 the risk of Grade C PF.

Conclusion. Thirty percent of patients will have grade C PF if PF appeared after pancreato-duodenectomy, and among them mortality was 30%. The presence of a soft pancreatic parenchyma in patient with PF increased by 5 the risk of grade C PF.

FP 36.06

VALIDATION OF A NOMOGRAM FOR PREDICTING SURVIVAL AFTER RESECTION FOR ADENOCARCINOMA OF THE PANCREAS SHOWS NO EFFECT OF ADJUVANT THERAPY

de Castro, Steve; Biere, Surya; Lagarde, Sjoerd; Olivier, Busch; van Gulik, Thomas; Gouma, Dirk

Academic Medical Center, Surgery, Amsterdam, Netherlands

Background. Nomograms are statistically based tools that provide the overall probability of a specific outcome. They have shown better individual discrimination than the current TNM staging system in numerous cancer models. The pancreatic nomogram combines individual clinicopathological and operative data to predict disease-specific survival at 1, 2, and 3 years from initial resection. A single European institution database was used to validate a proposed pancreatic adenocarcinoma nomogram.

Methods. The nomogram was validated by an external patient cohort from a pancreatic adenocarcinoma database at Academical Medical Center which included 263 consecutive patients operated on between January 1985 and December 2004. During this period adjuvant therapy was not given regularly but incidentally in clinical trials.

Results. Of the 263 patients, 256 (97%) had all variables documented. At last follow-up, 35 patients (13%) were alive, with a median follow-up time of 27 months (range, 3 to 114 months). The 1-, 2-, and 3-year disease-specific survival rates were 61%, 30%, and 16%, respectively. The nomogram concordance index was 0.61. The calibration analysis of the model showed that the predicted survival did not deviate significantly from the actual survival. This nomogram was developed by the Memorial Sloan-Kettering Cancer Center on 555 patients and validated by Massachusetts General Hospital on 424 patients. When both centers where compared to the AMC cohort, the patient characteristics where similar while adjuvant therapy was used significantly less often in the AMC.

Conclusion: The pancreatic cancer nomogram provides an accurate survival prediction when applied to an external patient cohort. The concordance index was similar to the two major US centers while the adjuvant therapy was used significantly less often. Thus adjuvant therepy has no impact on this nomogram and overall survival.

FP 36.07

SYNERGISTIC EFFECTS OF ERLOTINIB IN COMBINATION WITH GEMCITABINE IN PANCREATIC CANCER

Nagakawa, Yuichi¹; Tsuchida, Akihiko¹; Tohyama, Yasutaka²; Saito, Hitoshi¹; Ozawa, Takashi¹; Kasuya, Kazuhiko¹; Ikeda, Takahisa¹; Aoki, Tatsuya¹

¹Tokyo medical university, Department of Surgery, Tokyo, Japan; ²Tokyo Uni versity of Pharmacy and Life Science, Department of Pharmacy, Tokyo, Japan

Background. It has been reported that the combination treatment of the epidermal growth factor receptor (EGFR) blocker (erlotinib) and gemcitabine is effective as compare to gemcitabine treatment alone in pancreatic cancer. However, the mechanism of synergistic effects of erlotinib in combination with gemcitabine is not fully understood. In this study, we examined the relationship between the anti-tumor effects of gemcitabine and EGFR-related signal pathways after erlotinib treatment, and influences of cell cycle and apoptosis by combination treatment of erlotinib and gemcitabine.

Methods. Five pancreatic cancer cell lines (AsPC-1, BxPC-3, HPAC, MIA PaCa-2, PANC-1) were used. Activation of EGFR-related signal pathways after erlotinib treatment were determined by Western blotting. Cell cycle was analyzed by FACS scan.

Results. We confirmed that erlotinb arrested cells in G1 phase and increase of expression of the p21(Waf1/CIP1) and p27(Kip1) and that gemcitabine arrested cells in S phase. Therefore, we hypothesized that gemcitabine followed by erlotinib would be superior to the opposite order because gemcitabine requires entry into S phase to produce cytotoxy. The schedule of gemcitabine followed by erlotinib caused arrest of cells in S phase. This schedule caused decreased pAKT and pMAPK, and increased apoptosis compared with gemcitabine alone. The schedule of erlotinib followed by gemcitabine also caused suppression of pAKT and pMAPK but arrested cells in G1.

Conclusions. These findings suggest that the schedule of gemcitabine followed by erlotinib may increase the therapeutic index over gemcitabine alone.

FP 36.08

NEW ABLATIVE THERAPY FOR LOCALLY ADVANCED PANCREATIC MALIGNANCY

Naik, Saleem; Varshney, Subodh; Sewkani, Ajit; Purohit, Dipak; Singh, Vikrant; Mishra, Pratik; Sharma, Sandesh

Bhopal Memorial Hospital and Research Centre, Surgical Gastroenterology, Bhopal, India

Background. Unresectable pancreatic cancer has a dismal prognosis. Palliative surgery and chemo-radiotherapy have not produced significant improvement in survival. We evaluated the saftey and the efficacy of radiofrequency ablation for cytoreduction of unresectable tumors of the pancreas.

Material and Methods. Radiofrequency ablation was performed in six patients with histologically proven unresectable cancer of the pancreas: Three females (40–72 years) of age (mean 60 years). The sizes of the pancreatic tumors were 5.0 to 8.0 cm (mean 6.5 cm), respectively. Five pateints underwent radiofrequency ablation during an open operation while one pateint had percutaneous CT guided radiofrequency ablation. Endobiliary stenting for obstructive jaundice was done in all the patients.

Results. Partial necrosis (up to 3 cm) of the tumour was achieved in all cases. There was no major morbidity or mortality. Median survival post procedure was 14 months. Self limiting minor complications occurred in two patients.

Conclusion. Radiofrequency ablation is a local ablative method used with increasing frequency and may be used safely for cytoreduction in locally advanced inoperable pancreatic malignancies. Further studies are required to ascertain whether this can improve survival/quality of life alone or in combination with other therapies.

FP 36.09

PHASE I STUDY OF ORAL FLUOROPYRIMIDINEl ANTICANCER AGENT (S-1) WITH CONCURRENT RADIOTHERAPY IN PATIENTS WITH UNRESECTABLE PANCREATIC CANCER

SHINCHI, HIROYUKI¹; MAEMURA, KOSEI¹; NOMA, HIDETOSHI¹; MATAKI, YUKOU¹; KURAHARA, HIROSHI¹; MAEDA, SHINICHI¹; UENO, SHINICHI¹; SAKODA, MASAHIKO¹; KUBO, FUMITAKE¹; AIKOU, TAKASHI¹; TAKAO, SONSHIN²

¹Kagoshima University Graduate School, Department of HBP Surgery, Kagoshima, Japan; ²Kagoshima University Graduate School, Frontier Science Research Center, Kagoshima, Japan

In this phase I trial, we evaluated the safety of S-1, a novel oral fluoropyrimidine anticancer agent, combined with external-beam radiotherapy (EBRT) to determine the maximum tolerated dose and dose-limiting toxicity (DLT) in unresectable pancreatic cancer patients. Patients had histologically proven unresectable locally advanced or metastatic pancreatic cancer. S-1 was administered orally twice daily. EBRT was delivered in fractions of 1.25 Gy×2 per day, totaling 50 Gy per 40 fractions for 4 weeks. S-1 was given at 5 dose levels: 60 mg/m²/day on days 1–7 and 15–21 (level 1), 1–14 (level 2), and 1–21 (level 3a) and 80 mg/m²/day on days 1–21 (level 3b) and 1–28 (level 4). We studied 17 patients: dose levels 1 (4 patients), 2 (4 patients), 3a (3 patients), 3b (3 patients), and 4 (3 patients). One patient in level 1 (grade 3 vomiting) and two patients in level 4 (grade 4 neutropenia and grade 3 anorexia) showed DLT. No DLT was seen for levels 2, 3a, and 3b. Clinical effects by computed tomography included 5 partial responses (35%), 11 cases of stable disease, and 1 case of progressive disease. CA19-9 levels of less than half the starting values were observed in 8 of 16 (50%) patients. S-1 at a dose of 80 mg/m²/day given on days 1–21 is safe and recommended for phase II study in patients with locally advanced and unresectable pancreatic cancer when given with external beam radiotherapy.

FP 37.01

LAPAROSCOPIC LIVER SURGERY: LESSON LEARNED FROM A CONSECUTIVE SERIES OF 110 PATIENTS.

Belli, Giulio; Fantini, Corrado; D'Agostino, Alberto; Cioffi, Luigi; Limongelli, Paolo; Russo, Gianluca; Belli, Andrea

S.M. Loreto Nuovo Hospital, Department of General and HPB Surgery, Naples, Italy

Background. Recent reports showed that a mininvasive approach in liver surgery could obtain reduced operative blood loss, fewer early postoperative complications and earlier recovery with oncologic clearance and a survival rate similar to open surgery but it is necessary a careful selection of patients and a wide experience in both hepatic and laparoscopic advanced surgery.

Objective. The authors report their experience, the evolution of the technique and their Results.

Methods. From 2000 to 2006 110 laparoscopic procedures for benign and malignant hepatic diseases were carried out in 101 patients. For tumors the selection criteria were: a small (size < 5 cm), exophytic or subcapsular tumor located in the left or peripheral right segments of the liver (II-VI segments, Couinaud); a well-compensated cirrhosis (Child-Pugh A); and an ASA score lower than 3.

Results. There were 90 malignant tumors (81.8%) and 20 benign lesions (18.2%). HCC was the main indication for treatment (67/110) and HCV related cirrhosis was present in all these patients. Four of the 110 procedures (3.6%) were converted to laparotomy; a conversion to hand assisted technique occurred in 1 patient. In 8 patients with HCC on cirrhosis a liver resection was associated with a radiofrequency ablation (RFA). Non anatomic (40) and anatomic (36) resections, laparoscopic RFA (22) and marsupialitations for liver cysts (12) were done. The mean operative time was 131 min. One cirrhotic patients with HCC died in third postoperative day for an acute distress respiratory syndrome while another cirrhotic patient with a small HCC in VIII segment was reoperated for an uncontrollable and persistent bleeding by laparotomy. The morbidity was 15%. No port site or local recurrences occurred in patients with malignant lesions.

Conclusions. Our data confirm that laparoscopic liver resection, in experienced hands, is a safe and effective technique for appropriately selected patients.

FP 37.02

LESSONS LEARNT FROM 230 LAPAROSCOPIC LIVER RESECTIONS

Hatzifotis, Michael¹; Patel, Bhavik¹; Bryant, Richard¹; Shaw, Ian¹; Martin, Ian²; Hopkins, George³; Fielding, George³; Nathanson, Leslie³; O'Rourke, Nicholas³

¹Royal Brisbane Hospital, HPB Surgery, Brisbane; ²Wesley Hospital, HPB Surgery, Brisbane; ³Royal Brisbane Hospital, HPB Surgery, Brisbane, Australia

Introduction. Laparoscopic liver resection allows minimal access treatment, with all its ensuing benefits, in a selected group of patients.

Methods. We would like to reflect on our experience of 230 laparoscopic liver resections.

Results; These include 29 major resections, 60 sectionectomies, 141 minor resections. Only very rarely are procedures hand-assisted. Forty-five percent of resections were for benign pathology, and 55% were for malignant pathology. The average operating time was 138 minutes. Margins were involved in five patients, and within 1cm in 11% of patients. Average blood loss was 482mls. The overall morbidity was 13%. The 30 day mortality was 1.3%.

Discussion. Overall approximately 20% of all of our liver resections are attempted laparoscopically. However all left lateral sectionectomies are performed laparoscopically. Patient selection is based upon position of the lesion within the liver. Major hepatectomies can be attempted only if the lesion is well clear of the plane of transection. Non-anatomic resections when attempted laparoscopically must be done so with caution because of the risk of positive margins as the surgeons inate fear of encountering large blood vessels may compromise oncologic clearance. This is particularly so in dome lesion where, because of the angles of laparoscopic approach, a large surface area of parenchyma may have to be dissected. Encountering major bleeding during laparoscopic liver resection often requires rapid conversion to an open approach. We have found laparoscopic ultrasound helpful, and understanding of resection planes using ultrasound guidance improves with experience. The evolving technology for parenchymal transection and hemostasis make laparoscopic liver surgery an exciting frontier.

FP 37.03

ONE HUNDRED LAPAROSCOPIC LIVER RESECTIONS: AN OPTIMAL APPROACH TO AVOID BLEEDING AND TRANSFUSION

Haddad, Luciana B P; Scatton, Olivier; Randone, Bruto; Andraus, Wellington; Massault, Pierre-Philippe; Soubrane, Olivier

Cochin Hospital, Liver Department, Paris, France

Background. The laparoscopic approach has been developed for liver resections in several centers, and many authors have confirmed the feasibility and safety of this approach in selected patients. The purpose of the present study was to analyze patients that underwent laparoscopic liver resections with special concern to bleeding and transfusion.

Methods. From February 1997 to June 2007, we performed 100 liver laparoscopic resections, including those performed for living donation. Outcomes, perioperative bleeding, need for transfusions were studied.

Results. The resections involved 47 women and 53 men, with a mean age of 42.5±13.5. Indications for hepatectomy were benign lesions in 28 patients, malignant tumors in 33 and living donation in 39 patients. Seventy-five resections involved 2 or more segments. The mean operative time was 253±91.6 min (range, 60–540). The mean operative blood loss was 120±127.6 ml (range 10–1000ml). No transfusion was required in resections completed by laparoscopy. The procedure was completed laparoscopically in 83 patients. In the case of conversion, decision was not made in emergency situation or life-threatening bleeding. Mortality was nil. Postoperative complications occurred in 23 patients, more often in patients converted (p = 0.001). The factors related significantly with conversion were: cirrhosis, BMI, Pringle maneuver necessity, hospital and intensive care stay and morbidity. Perioperative blood loss was significantly higher in patients converted (82.3±153.8 versus 306.3±362.4, p < 0.001).

Conclusion. This study confirms that liver resection by laparoscopy is feasible and safe. Dual surgeon expertise is needed, both in hepatobiliary and laparoscopic surgeries. Laparoscopic liver procedures should have the same technical principles than opens liver surgeries. This policy and precocity in conversion provide better outcome in such cases.

FP 37.04

FEASIBILITY OF LAPAROSCOPIC PORTAL VEIN LIGATION PRIOR TO MAJOR HEPATECTOMY

Are, Chandrakanth¹; Iacovitti, Simonetta²; Crafa, Francesco²

¹Eppley Cancer Centre, University of Nebraska Medical Centre, Divsion of Surgical Oncology, Dept of Surgery, Omaha, United States; ²MG Vannini Hospital, Department of Surgery, Rome, Italy

Background. Portal vein embolization is increasingly performed as the initial step in two-stage hepatectomy. Patients noted to have bilobar disease at laparoscopy are considered for embolization, if suitable, at a subsequent stage.

Aim. The aim of this study was to assess the feasibility of portal vein ligation by the laparoscopic approach at the time of staging in suitable patients.

Materials and Methods. A retrospective review was performed to identify patients that underwent laparoscopic portal vein ligation. The demographic, clinical, radiographic, operative and volumetric details were collected to determine the feasibility of portal vein ligation.

Results. A total of 9 patients underwent portal vein ligation as part of a two stage procedure in preparation for subsequent major hepatectomy. With a median age of 67 yrs, the diagnoses included: colorectal metastasis (5 patients), cholangiocarcinoma (3 patients) and hepatocellular carcinoma (1 patient). The ligation involved the right portal vein in all and was performed with silk ligature (7 patients) and clips (2 patients). Volumetric data was available in six patients which showed a mean increase from 209.1 cc±97.76 to 495.83 cc±301.91 (increase by 137%) In 2 patients, inadequate hypertrophy mandated later embolization by percutaneous technique. Five patients underwent subsequent major hepatic resection as planned. The remaining four patients were noted to have progression of disease that precluded the planned procedure. There were no complications associated with PVL.

Conclusions. Laparoscopic portal vein ligation is feasible and can be safely performed at the time of staging. In selected patients it may be considered as an alternative to subsequent embolization.

FP 37.06

LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY WITHOUT MOBILIZATION OF THE LIVER OR INFLOW OCCLUSION AS ROUTINE APPROACH IN NON-CIRRHOTIC PATIENTS.

Sainz Barriga, Mauricio; Dezza, Maria Clara; Berrevoet, Frederik; de Hemptinne, Bernard; Troisi, Roberto

Ghent University Hospital Medical School, Hepatobiliary Service, Ghent, Belgium

Introduction. Laparoscopic liver resection is increasingly performed for benign and tumoral lesions. Surgical technique is evolving due to the increased experience and the development of resecting devices.

Materials and Methods. Between October 2002 and August 2007, 59 (8.4%) out of 702 liver resections were performed laparoscopically and 22 (37%) were left lateral sectionectomy (LLS). In the last 18 cases, surgical technique consisted in avoidance of mobilization of the left liver and intermittent inflow occlusion. Linear staplers and harmonic scalpel were routinely used.

Results. Mean patient age was 50±16 years (range 29–76). Surgery was performed for 7 (39%) malignant lesions and for 11 (61%) benign tumors. The mean operating time was 125 min (range 90–210). The mean blood loss was 120 ml (range 50–230). No patient had underlying liver cirrhosis and no conversion to laparotomy was recorded. All patients are alive after a median follow-up of 14 months (range 3–59). No biliary leaks were recorded and the total hospital stay was 3.6 days (range 3–6). Occurrence of a new colo-rectal liver metastasis was noticed in 1 patient 12 month after laparoscopic LLS.

Conclusion. According to this experience, laparoscopic left lateral sectionectomy without inflow occlusion and mobilization of the liver is a safe procedure and could be considered as a routine approach in non-cirrhotic patients.

FP 37.07

LAPAROSCOPIC RIGHT HEPATECTOMY –A SINGLE CENTRE EXPERIENCE USING MODIFIED ANTERIOR APPROACH

Chinnusamy, Palanivelu; Palanisamy, Senthilnathan; Ramakrishnan, Parthasarathi; Palanivelu, Praveen Raj; Suviraj James, John; Muthukumar, Rangarajan; Rangasamy, Senthikumar

Gem Hospital, Gi Surgery, Coimbatore, India

Aim. The aim of this study is to establish feasibility, safety and advantages of laparoscopic right hepatectomy.

Material and Methods. Between March 2001 and April 2007, we operated on 18 cases, the indications being hepatocellular carcinoma, focal nodular hyperplasia, secondaries liver and giant hemangioma. Case selection was based on patient and lesion characteristics. Non obese patients with no or minimal co morbid conditions were selected and all were non cirrhotic. There were 13 males and 5 females. Preoperative evaluation includes functional assessment, CT scan abdomen and MRI (selected cases). General Anaesthesia was used in all cases. We have adopted a new technique called laparoscopic modified anterior approach by a single surgeon. The sequence of steps will be portal dissection and inflow control, parenchymal division and right hepatic vein division(out flow control). We used Pringle maneuver only in selected cases.

Results. The mean operative time was 230 minutes and blood loss 310 mls. We used hand port in 3 cases because of bulkiness of the tumor. There were no conversions. Blood transfusion was necessary in 9 of the cases. Postoperatively patients were mobilized on second day and mean hospital stay was 6 days. Two patients developed bile leak postoperatively, one requiring ERCP and stenting. Other complications include ascites (n-1) and pleural effusion (n-1). Follow up ranges between 3 months and 4 years and two patients have since then died of the disease.

Conclusion. Laparoscopic right hepatectomy is feasible, oncologically sound and offers the advantages of minimal access approach, but is a major undertaking which requires adequate skill in open and laparoscopic liver surgery aided by varied advanced instrumentation.

FP 37.08

LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY-IS IT THE GOLD STANDARD YET?

Hatzifotis, Michael¹; Patel, Bhavik¹; Bryant, Richard¹; Shaw, Ian²; Martin, Ian³; Hopkins, George¹; Fielding, George⁴; Nathanson, Leslie¹; O'Rourke, Nicholas¹

¹Royal Brisbane Hospital, HPB Surgery, Brisbane, Australia; ²Prince Charles Hospital, HPB Surgery, Brisbane, Australia; ³Wesley Hospital, HPB Surgery, Brisbane; ⁴ROYAL BRISBANE HOSPITAL, HPB, BRISBANE

Introduction. We describe our simplified technique which avoids any formal dissection of inflow or outflow. The left lobe is mobilized completely and separated from the liver using multiple firings of a linear stapler device. Our usual preference is the EndoGIA 60mm Vascular device (Tyco) in one, two or occasionally three layers for bulky livers.

Methods. We would like to report on our series of 60 consecutive laparoscopic left lateral sectionectomies.

Results; The average procedure time was 93 minutes. Average blood loss was 124ml. There were 3 conversions. Final pathology revealed malignancy in 45% cases. Average length of hospital stay was 4 days. Our overall morbidity was 10%. There was one post operative death.

Discussion. This approach offers the benefits of laparoscopic surgery. We have adopted the laparoscopic approach as our preferred method for resection of the left lateral section of the liver. We believe it to be the gold standard for left lateral sectionectomy.

FP 37.09

LAPAROSCOPIC LIVER RESECTIONS: INITIAL EXPERIENCE IN A UNIVERSITY HOSPITAL SETTING

Stoot, Jan; Van Dam, Ronald; Olde Damink, Steven; Bemelmans, Marc; Dejong, Kees

University Hospital Maastricht, Department of Surgery, maastricht, Netherlands

Background. Laparoscopic liver resections are gaining popularity world wide, but experience in the Netherlands is still limited. This study was conducted to assess the feasibility and safety of laparoscopic liver surgery for left sided leasions.

Methods. Patients treated with laparoscopic liver resections in the years 2003 to 2007 were included using a prospectively collected database. This group was matched with a group of patients undergoing the same type of liver resection as an open procedure. Primary outcomes were complications. Secondary outcomes were conversion, blood loss, length of operation, and length of stay. Data were analysed according to the intention to treat principle.

Results. The laparoscopic approach for left lateral resection (bisegmentectomy 2 and 3) was performed in nine patients (group I, two male, seven female) with a median age of 53 [range 26–82] years. In the open group, nine patients were matched for the same type of resection (group II, five male, four female, median age 63 [range 32–77] years). There were two minor complications in the laparoscopic group compared with two moderate complications in the open group. In the laparoscopic group there were 2 conversions (22.2%) due to tumour size and close relation with the liver vein. The median blood loss was 100cc [range 50–750] in the laparoscopic group versus 500cc [range 250–750] in the open group. The median operation time in group I was 120 [range 106–261] minutes compared to 167 [range 97–229] minutes in group II. The median length of stay was 7 [range 4–10] days in group I versus 6 [4–10] days in group II.

Conclusion. Left lateral resection of liver tumours is feasible and safe using laparoscopic approach, but does not necessarily lead to reduced hospital length of stay. It may be appropriate to consider this as the standard approach in young females with benign liver tumours in the not too distant future.

FP 38.01

THE PROTEOMIC ANALYSIS OF BILE: METHODOLOGY AND POTENTIAL APPLICATION

Bonney, Glenn K¹; Craven, Rachel A²; Melcher, Alan F²; Selby, Peter J²; Banks, Rosamonde E²; Prasad, K Rajendra³

¹St James' University Hospital, Department of Hepatobiliary and Tranpslantation, Beckett Street, Leeds, United Kingdom; ²St James' University Hospital, Cancer Research UK Clinical Centre, Leeds, United Kingdom; ³St James' University Hospital, Department of Hepatobiliary and Tranpslantation, Leeds, United Kingdom

Cholangiocarcnioma is a malignant tumour of the bile duct epithelium of the liver with a rising incidence worldwide. However, there remains a lack of sensitive and specific biomarkers for the disease. Bile, a biological fluid directly draining the liver, may contain higher concentrations of biomarkers than those found in the general circulation. The proteomic analysis of bile in disease pathogenesis (i.e. malignancy and gallstone disease), drug metabolism and biomarker discovery has received recent interest. However several technical challenges arise in its analysis with its high salt content, and the presence of bile pigments and lipids necessitating the development and evaluation of processing Methods. Therefore there remains a need for an accurate method to quantify proteins and process bile prior to such analyses. Here we describe a protocol developed for standard processing of bile prior to proteomic analysis. Modified Bradford and BCA assay failed to demonstrate a linear trend on serial dilution. Densitometric scanning of Coomassie stained 1D SDS PAGE gels quantified against a serial dilution of albumin-depleted serum was the most consistent and reproducible assay for protein quantification. For sample clean-up, TCA precipitation for desalting and concentration was shown to give good results with near 100% protein recovery on 1D PAGE and increased number of spots with better focussing on 2D PAGE compared to TCA/Acetone precipitation and commercially available 2D Clean-up kit or Zeba columns. Delipidation by fast centrifugation (18000g) also improved the focussing on 2D PAGE without loss of protein species. Based on these results a reproducible method for protein quantification and processing of bile for proteomic analysis has been developed. We have generated a master map of bile and are currently carrying out comparative analysis of bile samples from patients with benign versus malignant disease.

FP 38.02

SEGMENTAL ISCHEMIA OF THE LIVER – A NEW MODEL IN THE PIG

Winbladh, Anders¹; Sandström, Per¹; Gullstrand, Per²; Svanvik, Joar²; Trulsson, Lena²

¹University hospital, Linköping, Surgical department, Linköping, Sweden; ²Sweden

Background. Pringle′s manoeuvre used during liver surgery induces an ischemia-reperfusion injury (IRI), which might negatively affect the liver postoperatively. The degree of oxidative stress and apoptosis/necrosis could possibly predict liver failure. Previous experimental models have used clamping of the whole or half the liver, but that causes pooling of blood in the gut which might aggravate the injury to the liver. Further, these models depend on tissue and blood sampling and uses sham operated animals as controls.

Objective. To avoid these problems, we have with the aid of microdialysis (MD), developed a new model with segmental ischemia to study these phenomena.Method.: Eight pigs received MD-catheters placed in liver segments IV and V. After 60 minutes all circulation to segment IV was closed with a clamp. Reperfusion was initiated by releasing the clamp after 80 minutes of ischemia. Segment V had undisturbed circulation and functioned as control. Reperfusion was followed for 220 minutes with dialysate sampled every 20 minutes. Blood and tissue samples were taken once an hour.

Results. The pigs were circulatory stable. Lactate/pyruvate ratio (31 to 3358), lactate (2.8 to 7.4 mM), glycerol (23 to 883 µM) and glucose (4.0 to 15.4 mM) were all significantly raised during ischemia in segment IV compared to segment V, but these values normalized after reperfusion. Serum levels of AST increased significantly, whereas ALT and LDH were unchanged. Histology from segment IV shows infiltration of leukocytes in the portal zones and swelling of cells which is not seen in segment V. Markers of oxidative stress (e.g. glutathione levels) are under analysis.

Conclusion. Total vascular clamping of one liver segment causes minimal systemic effects, but microdialysis technique reveals local anaerobic metabolism during ischemia but no significant changes after reperfusion. This experimental model is suited for studying IRI in vivo, and make temporal histological correlations.

FP 38.03

ESTABLISHMENT OF ALTERED GI MOTILITY IN OBSTRUCTIVE JAUNDICE AND ITS MODULATION BY TINOSPORA CORDIFOLIA- AN IMMUNOMODULATOR

Kantharia, Chetan¹; Rege, Nirmala²; Prabhu, Ramkrishna²; Bapat, Ravindra²; Supe, Avinash²

¹Kemh & Seth Gs Medical College, Surgical Gastroenterology, Parel, Mumbai, India; ² Hospital & Seth Gs Medical College, Clinical Pharmacology, Mumbai, India

Introduction. GI dysmotility has never been considered as an important clinical feature of OJ.

Objective. To assess GI Motility in experimental study and in patients with OJ using objective parameters and if found altered, to evaluate the effect of Tinospora cordifolia, an immunotherapeutic agent.

Methods. Experimental study Percentage gastric emptying (GE) following a semisolid test meal was studied in normal (Grp1), sham operated (Grp2) and cholestatic rats (Grp3). Duration of cholestasis was 4 weeks. Cholestatic rats (n = 30) were then divided into 3 groups and given therapy for next 7 days Group A: distilled water, Group B: aqueous extract of Tinospor a cordifolia (100 mg/kg) and Group C: metoclopramide (1.36 mg/kg). On 8th day% GE was assessed. Clinical study This study was extended in patients with OJ (n = 10) and normal volunteers (n = 10), and orocaecal transit time (OTT) was measured Patients of OJ were treated with Tinospora cordifolia (1.5 gm/day) and OTT was assessed before and after therapy.

Results. Experimental In Group1% gastric emptying was 85±9.65%. Surgical stress (Grp2) did not alter%GE. The% GE of rats with cholestasis was significantly decreased (10.27±13.22%, p < 0.01). Further reduction was seen when these animals were left untreated (-4±14.23%). Therapy with Tinospora cordifolia significantly improved%GE (59.37±20.17%, p < 0.01) but not with metoclopramide. Clinical The OTT was found prolonged in patients with OJ (8.25±1.67 hrs) compared to normal volunteers (5.85±1.7, p < 0.05). Therapy with Tinospora cordifolia significantly reduced the OTT (6.5±2.1hrs.) compared to basal values (9.25±2.36 hrs, p < 0.05). Symptoms suggestive of GI dysmotility disappeared.

Conclusion. Gastroparesis and reduction in GI motility is observed in cholestasis. Tinospora cordifolia is found to improve the altered motility and thus impart better quality of life.

FP 38.04

ALTERED AQUAPORIN-9 (AQP9) EXPRESSION AND LOCALIZATION IN HUMAN HEPATOCELLULAR CARCINOMA (HCC) AND ADJACENT LIVER

McKillop, Iain¹; Banks, Peter²; Heniford, B Todd³; Lincourt, Amy⁴; Russo, Mark⁵; Palilonis, Molly⁴; Iannitti, David³

¹University of North Carolina at Charlotte, Biology, Charlotte, NC, United States; ²Carolinas Medical Center, Pathology, Charlotte, NC, United States; ³Carolinas Medical Center, Surgery, Charlotte, NC, United States; ⁴Carolinas Medical Center, Surgical research, Charlotte, NC, United States; ⁵Carolinas Medical Center, Medicine, Charlotte, NC, United States

Background. Aquaporins (AQPs) represent transmembrane proteins that form channels allowing rapid water movement along an osmotic gradient. Aquaporin 9 is expressed on the basolateral membrane of hepatocytes and plays a role in bile production as well as cell apoptosis. This study evaluates AQP9 expression and localization in human hepatocellular carcinoma (HCC) and adjacent liver.

Methods. 18 human HCC specimens (14 male, 4 female) and adjacent liver were obtained. Immuno-fluorescent histochemitry (IFHC) was performed using an anti-AQP9 and F-488 labeled secondary antibody. DAPI staining was included for nuclear identification and localization purposes. Samples were blind scored the data and correlated to patient pathology.

Results. Of seven HCCs arising in “normal” liver, 4 had no AQP9 expression in the tumor while having strong AQP9 staining with normal zonal distribution in the adjacent liver. In 2 of the remaining samples (both female) equal staining was observed in the tumor and adjacent liver but no zonal localization within the liver lobules. In the final sample, membrane localization and zonal distribution was observed in the normal liver and extensive staining with membrane localization was detected in the tumor. In the micronodular cirrhosis patient group (n = 7), the HCCs stained weakly for AQP 9 while the adjacent cirrhotic liver AQP 9 was detected at the plasma membrane with loss of zonal distribution. In the remaining samples AQP9 detection did not demonstrate a consistent pattern of staining relative to membrane localization or zonal distribution in tumor or adjacent liver.

Conclusions. These data demonstrate decreased AQP9 expression in HCC cirrhotic and non-cirrhotic livers. Additionally, micronodular cirrhosis is associated with loss of zonal distribution of AQP9. These data may improve our understanding of how changes in AQP expression relate to HCC progression in terms of decreased normal liver function and potentially, in the increased resistance to apoptosis in transformed hepatic cells.

FP 38.05

MICROWAVE ABLATION COMBINED WITH INTRA-TUMORAL INOCULATION OF DENDRITIC CELLS INDUCE SPECIFIC IMMUNITY AGAINST HEPATOCELLULAR CARCINOMA

Yin, Xiaoyu; Wang, Zhu; Lu, Mingde; Hou, Xun; Kuang, Ming; Liang, Lijian

The First Affiliated Hospital, Department of Hepatobiliary Surgery, Guangzhou, China

Background. Microwave or radiofrequency ablation has been widely used for treatment of hepatocellular carcinoma (HCC), but post-ablation recurrence still remains a major challenge. Induction of specific immunity may represent a promising approach to prevent tumor recurrence.

Aims. To investigate the efficacy of microwave ablation combined with intra-tumoral inoculation of dendritic cells (DCs) in inducing specific immunity against HCC in vivo.

Methods. C57BL/6 bone marrow-derived DCs were grown in vitro for 6 days with use of murine recombinant GM-CSF and IL-4. C57BL/6 mice were inoculated subcutaneously with Hepa1-6 cells to establish subcutaneous HCC, and randomized into control group, group receiving intratumoral inoculation of DCs (DC group), group receiving microwave ablation of tumor (MWA group), and group receiving microwave ablation of tumor plus intra-tumoral injection of DCs (MWA + DC group). Immunohistochemical staining was employed to evaluate intra-tumoral infiltration of CD4+ and CD8+ lymphocytes. Cytotoxicity of splenocytes against Hepa1-6 was evaluated using MTT method. Tumor growth and animal survival in each group were compared.

Results. Immunohistochemical staining illustrated that MWA + DCs group had a markedly greater number of CD4+ and CD8+ T lymphocytes inside tumor tissue as compared control group, DC group and MWA group (p < 0.05). Splenocytes from MWA + DCs group had a remarkably higher specific cytotoxicity against Hepa1-6 at E/T ratio of 40 and 100 than those from control group, DC group and MWA group (p < 0.05). Tumor regression rate was significantly higher in MWA + DCs group as compared with control group, DC group and MWA group (p < 0.05). Fifteen week survival rate was significantly greater in MWA + DCs group than other three groups (p < 0.01).

Conclusions. Intra-tumoral inoculation of DCs following MWA could effectively elicit specific anti-tumoral immunity in vivo. It represented as an effective approach for preventing tumor recurrence after MWA.

FP 38.06

ASSESSMENT OF HEPATIC FUNCTION DURING LIVER REGENERATION: COMPARISON BETWEEN^99mTc-GSA SCINTIGRAPHY AND^99mTc- MEBROFENIN HEPATOBILIARY SCINTIGRAPHY

de Graaf, Wilmar¹; Bennink, Roelof J.²; Maas, Adrie¹; de Bruin, Cora²; van Gulik, Thomas M.¹

¹Academic Medical Center, Department of Surgery/Surgical Laboratory, Amsterdam, Netherlands; ²Academic Medical Center, Department of Nuclear Medicine, Amsterdam, Netherlands

Background. In living donor liver transplantation, liver regeneration is mandatory for the clinical outcome of donor and recipient. Reliable assessment of liver function during regeneration is therefore crucial. ^99mTc-mebrofenin hepatobiliary scintigraphy (HBS) and ^99mTc-GSA scintigraphy with SPECT have been introduced for assessment of liver function. The uptake of ^99mTc-mebrofenin is equivalent to the uptake of indocyanine green. ^99mTc-GSA scintigraphy can be combined with SPECT, enabling assessment of both liver function and functional liver volume (FLV). There is no study comparing these methods in a standardized model.

Aim. To compare ^99mTc-GSA scintigraphy with ^99mTc-mebrofenin HBS for assessment of hepatic function in regenerating rat livers.

Methods. Rats (n = 60) were allocated to 2 protocols. Hepatic function was determined by ^99mTc-GSA scintigraphy with SPECT or ^99mTc-mebrofenin HBS on day 1, 3, 5 and 7 after 70% partial hepatectomy (PHX) (n = 6 each timepoint). A group (n = 6), undergoing no resection served as controls. Conventional liver volume (CLV), FLV, ^99mTc-GSA uptake and ^99mTc-mebrofenin uptake were expressed as percentage of baseline values.

Results. CLV measured 1 day after 70% PHX was 60.3% of baseline level and further regenerated from 71.4% at day 3 to 76.7% and 76.4% at day 5 and 7. During the regeneration process, there was no difference between CVL and FLV. One day after 70% PHX, ^99mTc-mebrofenin uptake (46.1% from baseline) and ^99mTc-GSA uptake (44.5%) were significantly lower than CLV. At day 5 and 7, there was no difference between ^99mTc-mebrofenin uptake and CLV. ^99mTc-GSA uptake however was still significantly lower compared to CLV and ^99mTc-mebrofenin uptake.

Conclusion. Functional regeneration is impaired compared to volumetric regeneration in the early phase of regeneration. Hepatic ^99mTc-GSA uptake as a liver function test underestimates hepatic regeneration in comparison to liver volume and ^99mTc-mebrofenin uptake in the final phase of liver regeneration.

FP 38.07

THE PATHOLOGICAL EXAMINATION OF GASTRIC MUCOSA IN CHILDREN WITH H. PYLORI —POSITIVE AND —NEGATIVE EHPVO

Prasad, Kaushal K¹; Thapa, Babu R¹; Sharma, Arun K¹; Nain, Chander K¹; Singh, Kartar¹; Negi, B²

¹Postgraduate Institute of Medical Education & Research, Department of Superspeciality of Gastroenterology, Chandigarh, India; ²Postgraduate Institute of Medical Education & Research, Dept. of Radiology, Chandigarh, India

Background. The basic histopathological finding in gastric mucosa is chronic gastritis in patients with Helicobacter pylori-infection.

Aims. We aimed to assess the pattern of gastric mucosal lesion in children with Helicobacter pylori-infection and extrahepatic portal venous obstruction (EHPVO), and to determine whether EHPVO contributed to the severity of the gastritis.

Methods. We retrospectively enrolled 70 patients with EHPVO, and consisted of 30 children with (Group A: 18 male; 12 female; mean age, 10.38±0.64 years) and 40 children without H. pylori-infection (Group B: 27 male; 13 female; mean age, 11.43±0.66 years), who made up the control group. In all patients, diagnostic upper endoscopy was performed, and gastric biopsies were taken for histological examination and diagnosis of H. pylori. The gastric damage was classified according to the modified Sydney System.

Results. H. pylori were not found in gastric mucosa without histological changes. The prevalence of chronic superficial gastritis (13.33% versus 35%, p = 0.04) was significantly low in group A than group B. The prevalence of follicular gastritis (60% versus 42.50%, p = 0.15) and lymphocytic gastritis (10% versus 12.50%, p = 0.74) was similar between the two groups. There was a significant increase in grade of inflammation (1.63±0.10 versus 1.33±0.07, p = < 0.02), activity (0.47±0.12 versus 0.03±0.02, p = < 0.001) atrophy (0.23±0.09 versus 0.03±0.02, p = < 0.05) and edema (1.03±0.09 versus 0.63±0.09, p = < 0.001) on histologic examination in group A than group B. The number of intraepithelial lymphocytes, number of lymphoid follicles, intestinal metaplasia and microvessel congestion was similar between the two groups.

Conclusions. Helicobacter pylori-infection in children with EHPVO may identify cases with chronic active gastritis. The gastric histological pattern in children with EHPVO appears to be independent of H. pylori-infection. The role of H. pylori-infection in the pathogenesis of congestive gastropathy seems to be unlikely.

FP 38.08

BILE LEAKS REDUCTION AFTER ADULT SPLIT LIVER TRANSPLANTATION USING A HAEMOSTATIC SPONGE (TACHOSIL®)

Toti, Luca; Manzia, Tommaso Maria; Lenci, Ilaria; Attia, Magdy; Buckels, John AC; Mayer, A David; Mirza, Darius F; Bramhall, Simon R; Wigmore, Stephen J

Queen Elizabeth Hospital, Liver Unit, Birmingham, United Kingdom

Background. Bile leaks are a frequent complication of adult split liver transplantation. We compared surgical complications in patients who had the cut surface of the liver treated with a fibrin-collagen sponge (Tachosil) and patients in whom the cut surface of the liver was treated with fibrin glue.

Methods. Two consecutive cohorts of 16 patients undergoing adult right lobe split liver transplant were compared. In the first cohort the liver was treated with fibrin glue and in the second the liver surface was treated with Tachosil fibrinogen-thrombin-collagen sponge patches. Blood usage and post operative complications were documented.

Results. Blood usage in both groups was equal. Patients in whom the cut surface of the liver was treated with Tachosil had significantly fewer bile leaks (1 of 16) compared with those where fibrin glue was used on the cut surface (7 of 16). There were some differences in biliary anastomotic techniques used in the two groups but 7 of 8 leaks arose from the cut surface with only 1 anastomotic leak.

Conclusions. Using a fibrinogen-thrombin-collagen sponge patch such as Tachosil may reduce bile leaks from the cut surface of adult right lobe split liver transplants.

FP 39.01

IMPACT OF RESECTION MARGIN STATUS ON SURVIVAL FOLLOWING RESECTION FOR PANCREATIC, AMPULLARY AND DISTAL BILE DUCT CANCER

Gomez, Dhanwant¹; Menon, Krishna V¹; Smith, Andrew M¹; Verbeke, Caroline S²

¹The Leeds Teaching Hospitals NHS Trust, Department of Surgery, Leeds, United Kingdom; ²The Leeds Teaching Hospitals NHS Trust, Department of Histopathology, Leeds, United Kingdom

Background. We have recently reported a high R1 rate (85%) for pancreatic cancer (PC) following the use of a rigorous, fully standardized protocol (SP) for pathological examination.

Aims. To determine whether the R1 rate is consistently high using the same SP in a larger prospective series, and to compare clinicopathological features and survival data between PC, ampullary (AC) and distal bile duct (BDC) cancers.

Methods. Patients undergoing potentially curative resection (pancreaticoduodenectomy) for PC, AC or BDC between January 2003 and April 2007 were identified from the Pathology database. Clinicopathological and survival data were analyzed.

Results. 84 patients were identified (PC = 28, AC = 24, BDC = 32). PCs and BDCs were locoregionally advanced cancers (≥75% of cases pT3N1L1V1) with a high R1 rate (PC: 82%, BDC: 72%). AC, even if T-stage corrected, was significantly different from PC and BDC in terms of smaller tumour size, lower R1 rate (25%) and less frequent vascular and perineural invasion (p < 0.001). There was no difference in clinicopathological factors between the R1 and R0 group in PC, whereas lymphovascular invasion and lymph node positivity rate were higher in the R1 group of AC (p≤ 0.050), and pN1-stage, lymphatic permeation and lymph node positivity rate more common in R1 resected BDCs (p≤ 0.038). One and 3 year survival rates were 68% and 17% for PC, 83% and 83% for AC, and 71% and 30% for BDC, respectively. On univariate analysis, resection margin status was the only adverse prognostic factor in patients with PC (p = 0.024), while there were no prognostic factors that affected overall survival in AC and BDC.

Conclusion. Resection margin status is a significant prognostic factor in PC.

FP 39.03

PANCREATIC CANCER PATIENTS SURVIVING FIVE OR MORE YEARS AFTER SURGERY

Baba, Hiroyuki¹; Honda, Goro²; Kurata, Masanao²; Tsuruta, Koji²; Okamoto, Atsutake²

¹Shuwa General Hospital, Surgery, Kasukabe, Japan; ²Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Surgery, Tokyo, Japan

Background. Although various trials of multidisciplinary treatment approach have been made, pancreatic cancer still remains to be a dismal disease. However, we have experience some patients with good prognosis after surgical resection. AIM We tried to define its character by retrospective review for future treatment strategy.

Method. 140 pancreatic cancer patients, surgically treated from 1975 to 2004 at Tokyo Metropolitan Komagome Hospital, were investigated. They were all pathologically proven as pancreatic cancer and their charts were briefly reviewed. Patients who survived five or more years were targets for this study.

Results Ten patients (six males, four females; average age 64.8 years old) lived more than five years after surgical resection. Nine of them had Whipple procedure and the other had distal pancreatectomy. Five patients received intraoperative radiotherapy (IORT). Maximum tumor diameter averaged 23.3 mm. Only two patients were symptom free. Jaundice was the most common symptom (six patients, 67%). Pathologically, tumor existed within the pancreatic parenchyma. Only one patient had microscopic invasion to the retroperitoneum. Lymph node involvement was found in six patients, two of them being pN2. Survival of node negative patients verses positive were 121 months to 112 months. Adjuvant therapy was routine for all patients, however, regimen varied. Gemcitabine was the first choice for patients after 1999.

Conclusion. Small tumors within the pancreatic parenchyma are candidates for good prognosis. However, it is not sufficient. Interestingly, IORT, adjuvant therapy and node involvement were not factors for long survival.

FP 39.04

POST RADIOCHEMOTHERAPY LEVELS OF SERUM CA19-9 PREDICT RESECABILITY FOR PATIENTS WITH LOCALLY ADVANCED PANCREATIC ADENOCARCINOMA.

Sa Cunha, Antonio; WAGNER, TRISTAN; RAULT, ALEXANDRE; COLLET, DENIS; MASSON, BERNARD

CHU BORDEAUX, BORDEAUX, France

Background. Locally advanced pancreatic adenocarcinoma may be downstaged by Radiochemotherapy (RCT) to allow for surgical resection. However restaging CT was less accurate following RCT for predict resecability. Serum levels of CA19-9 have been shown to correlate with both recurrence and survival in patients with pancreatic cancer.

Aim. The purpose of this study was to determine whether post RCT CA19-9 levels ca n predict resecability for patients with locally advanced pancreatic adenocarcinoma.

Methods. From January 2003 to December 2006, 33 patients with radiographically locally advanced pancreatic adenocarcinoma, pathologically confirmed, have received RCT. Patients with tumor response or stabilization at restaging CT-scan underwent a surgical exploration to determine whether the tumor was resectable. All patients had pre and post RCT CA19-9 levels. Data were analysed according to 2 post RCT serum CA19-9 levels: CA19-9 < 200, and CA19-9 > 200.

Results. At restaging CT-scan, six patients had tumor progression (mean CA19-9 level of 1004 UI/ml), 23 patients had tumor stabilization (mean CA19-9 level of 515 UI/ml) and 4 patients had tumor response (mean CA19-9 level of 72.5 UI/ml). Twenty seven patients (23: tumor stabilization and 4: tumor response) were surgically explored. 18 patients had CA19-9 levels< 200 UI/ml and 9 had CA19-9 levels> 200 UI/ml. Twelve patients were found to be unresectable due to unsuspected distant metastatic disease or persistent malignant arterial encasement on frozen. Fifteen patients underwent pancreatic resection. Surgical margins were negative in 12 patients (80%). Resecability rate was 72% (13/18) in patients with CA19/9 levels <200 and 22% (2/9) in patients with CA19/9> 200 (p0.035).

Conclusion. In patients with locally advanced pancreatic adenocarcinoma, post RCT CA19-9 value of less than 200 UI/ml are strong predictor of resecability. This study shows that CA 19-9 levels should be included in post RCT restaging in patients with pancreatic adenocarcinoma.

FP 39.05

THE EFFECT OF CELECOXIB ON PANCREATIC CANCER IN VITRO

Andersson, Roland; Aho, Ursula; Tingstedt, Bobby; Zhao, Xia

Lund University Hospital, Dept of Surgery, Clinical Sciences, Lund, Lund, Sweden

Background. Among factors underlying the aggressive nature of pancreatic cancer (PC), tissue expression of cyklooxygenase-2 (COX-2) might play a role, as well as the transcription factor nuclear factor kappa B (NF-KappaB), frequently activated in PC and decreasing apoptosis, as well as increased expression of epidermal growth factor receptor (EGFR), stimulating metastases development.

Aim. The aim of the present study was to evaluate the effect of a selective COX-2 inhibitor on PC in vitro.Method.: The cell lines PANC-1, AsPC-1 and BxPC-3 were then stimulated with serum (10% fetal calf serum). Celecoxib was used for cell incubation. The effect was evaluated by measuring cell proliferation, apoptosis, expression of EGFR and NF-KappaB activation.

Results. Incubation with celecoxib for 24 and 48 hours, respectively, resulted in a significant decrease in proliferation in PANC-1 (p = 0.008 and p < 0.001, respectively), BxPC-3 (p = 0.035 and p< 0.001, respectively) and AsPC-1 (p = 0.001; 48 hours). A significant increase in apoptosis was noted in PANC-1 cells after 24 and 48 hours (p = 0.044 and p < 0.001, respectively) and in BxPC-3 after 24 hours (p = 0.002). Celecoxib resulted in significantly decreased expression of EGFR in PANC-1 and BxPC-3 after 24 hours (p = 0.007) and p = 0.005, respectively). A decreased expression of EGFR in AsPC-1 cells was noted after 24 and 48 hours (p = 0.033 and p = 0.003, respectively). Celecoxib decreased the activation of NFKappaB in all cell lines studied.

Discussion/Conclusion. Incubation with celecoxib resulted in decreased proliferation and increased apoptosis especially in cell lines generally considered COX-2 positive (PANC-1 and BxPC-3). Celecoxib decreased expression of EGFR and the activation of NF-KappaB in all cell lines. The study implies that COX-2 might have an important role in the proliferation of PC and the use of COX-2 inhibitors might play a potential role in future palliative treatment.

FP 39.06

MANAGEMENT OF CELIAC ARTERY STENOSIS IN PATIENTS ELIGIBLE FOR PANCREATODUODENECTOMY

de Nes, L.C.F.; van der Gaag, N.A; Idu, M.M.; Busch, O.R.C.; van Gulik, T.M.; Gouma, D. J.

Academic Medical Center, Department of Surgery, Amsterdam, Netherlands

Background. Since an increasing number of elderly patients are considered for pancreatoduodenectomy (PD), the likelihood of encountering advanced vascular comorbidity such as celiac artery/trunk stenosis (CAS) increases. CAS results in retrograde perfusion of the hepatic artery via the gastroduodenal artery (gda) and carries a high risk of liver ischemia when, during PD, the gda is divided.

Aim. To evaluate incidence and management of CAS in patients eligible for pancreatoduodenectomy (PD).

Methods. Records of 1070 patients who underwent an explorative laparotomy during Jan-1992/Sep-2007 on the suspicion of a pancreatic/periampullary tumour, were analyzed for the occurrence of CAS. Management was evaluated.

Results. Twelve patients with CAS were identified (1.1%, 12/1070). CAS was diagnosed preoperatively in 3 patients on radiological imaging and in 8 patients intraoperatively [clamping of gda resulted in disappearance of hepatic artery pulsations]. In 1 patient CAS became apparent after PD and the development of liver abscesses. A PD was performed in 6 patients with concomitant hepatic artery/aortic bypass and in 2 patients with sparing of the gastroepiploic artery and postoperative radiological intervention. Resection was deferred in 4 patients. Reperfusion of the hepatic artery was successful in all cases. Postoperatively 1 of the patients that underwent reconstruction died due to complicated course after pancreatojejunostomy leakage, while 1 patient underwent reoperation for anastomotic leakage and had liver ischaemia due to an obstructed bypass.

Conclusion. CAS is a hazardous condition in patients requiring PD, since misdiagnosis results in postoperative liver ischemia. Awareness of this risk is mandatory in any patient assessed for PD. In patients with CAS who are found to be resectable, PD combined with hepatic artery/aortic bypass is advised.

FP 39.07

CLINICO-EPIDEMIOLOGICAL CHARACTERISTICS OF MUCIN-PRODUCING NEOPLAMS OF THE PANCREAS: ANALYSIS OF 557 CONSECUTIVE CASES

Stefano, Crippa¹; Fernandez-del Castillo, Carlos²; Bassi, Claudio¹; Finkelstein, Dianne³; Roberto, Salvia⁴; Thayer, Sarah P²; Dominguez, Ismael²; Falconi, Massimo⁴; Capelli, Paola⁵; Mino-Kenudson, Mari⁶; Zamboni, Giuseppe⁵; Lauwers, Gregory⁶; Partelli, Stefano⁷; Pederzoli, Paolo⁴; Warshaw, Andrew L²

¹University of Verona, Department of Surgery, Verona, Italy; ²Massachusetts General Hospital, Surgery, Boston, USA Minor Outlying Islands; ³Massachusetts General Hospital, Department of Biostatistics, Boston, USA Minor Outlying Islands; ⁴University of Verona, Surgery, Verona, Italy; ⁵University of Verona, Pathology, Verona, Italy; ⁶Massachusetts General Hospital, Pathology, Boston, USA Minor Outlying Islands; ⁷University of Verona, Surgery, Verona, USA Minor Outlying Islands

Background. Mucin-producing neoplasms of the pancreas (MPNPs) include mucinous cytic neoplasms (MCNs), intraductal papillary mucinous neoplasms involving the main pancreatic duct (MD-IPMNs) or its branch-ducts (BD-IPMNs). In the past MCNs and BD-IPMNs were frequently confused, and a clear distinction between BD-IPMNs and MD-IPMNs is lacking as well.

Aim. To evaluate clinico-epidemiological characteristics and prognosis of a large series of MPNPs.

Methods. Analysis of 577 patients with resected, histologically confirmed MPNPs.

Results. 168 patients (30.2%) had MCNs, 159 (28.5%) BD- IPMNs, 230 (41.3) MD-IPMNs [149 (26.8%) combined IPMNs, 81 (14.5%) “pure” MD-IPMNs]. Patients with MCN were significantly younger than those with BD-IPMNs (44.5 vs 66 years), were almost exclusively women (Female: 95% in MCNs, 57% in BD-IPMNs and 44% in MD-IPMNs); the lesion preferentially involved the distal pancreas in MCNs (97%) and the head in BD-IPMNs (58.5%) and MD- or combined IPMNs (64% and 66%). IPMNs were more likely to be symptomatic than MCNs. Adenoma was found in 73% of MCNs, 44% of BD-IPMNs, 8% of combined IPMNs and 11% of MD-IPMNs. The rate of invasive cancer was 11% in MCNs and BD-IPMNs and 42% and 48% in combined- and MD-IPMNs. MD-IPMNs and combined IPMNs had the same sex-ratio, rate of malignancy, rate of symptomatic patients, and tumor site, and these parameters were significantly different when compared with BD-IPMNs. Neoplasms were incidentally discovered in 35% of BD-IPMNs, 19% of combined IPMNs and 13% of MD-IPMNs. 5-year disease specific survival was 100% for patients with noninvasive MCNs, BD-IPMNs and combined-IPMNs; 95% for patients with noninvasive MD-IPMNs; 58%, 56%, 51%, 64%, for invasive MCNs, BD-IPMNs, MD-IPMNs, and combined-IPMNs.

Conclusions. MPNPs encompass different neoplasms with specific features. MCNs and BD-IPMNs are two distinct diseases. BD-IPMNs show significant differences if compared with MD- and combined-IPMNs. BD-IPMNs should be considered a specific disease itself.

Free Video Abstracts

FV 1.01

APPLEBY OPERATION WITH PREOPERATIVE CELIAC ARTERIAL EMBOLIZATION FOR LOCALLY ADVANCED DISTAL PANCREATIC CANCER

Miyazaki, Akinari; Cho, Akihiro; Yamamoto, Hiroshi; Nagata, Matsuo; Takiguchi, Nobuhiro; Kainuma, Osamu; Soda, Hiroaki; Gunji, Hisashi; Ikeda, Atsushi; Matsumoto, Ikuko; Nimura, Yoshinori; Mikami, Tomoko; Ryu, Munemasa

Chiba Cancer Center Hospital, Gastroenterological surgery, Chiba, Japan

Background. Appleby operation consists of an en bloc resection of the stomach, the body and tail of pancreas and the spleen with celiac artery divided. This procedure is useful for an advanced cancer of pancreas body and tail with celiac trunk invasion.

Objective. We report Appleby operation with preoperative celiac arterial embolization.

Methods. A case report of 72 year-old male with a locally advanced distal pancreatic cancer derived from intraductal papillary mucinous neoplasm. Computed Tomography showed that the celiac trunk was involved but the superior mesenteric artery was intact. We performed Appleby operation two days after transcatheter celiac arterial embolization with coils.

Results. The operation time and intraoperative bleeding was 210 minutes and 400g. There were no remarkable complications and the length of hospital stay after operation was 14days. The surgical margin was free of tumor pathologically.

Conclusions. We performed Appleby operation more safely due to the preoperative celiac arterial embolization.

FV 1.02

PANCREATICODUODENECTOMY AND PORTAL VEIN RESECTION WITH RECONSTRUCTION USING AN INTERPOSITION GRAFT OF LEFT RENAL VEIN IN PDAC

Choi, Dong Wook; Paik, Kwang Yeol; Lee, Hyung Geun; Ryu, Dong Do; Heo, Jin Seok; Choi, Seong Ho

Samsung Medical Center, Surgery, Seoul, Korea, Republic of

Introduction. For pancreatic ductal adenocarcinoma in head portion, Pancreaticoduodenectomy is treatment of choice, although complete resection may require venous resection We experienced the technique of using the left renal vein as a conduit for venous reconstruction during pancreaticoduodenectomy.

Methods. 44-year old man was evaluated for abdominal pain. CT scans demonstrated pancreas mass in uncinate process with SMV invasion at the splenoportal junction. Under the impression of PDAC, exploratory laparotomy was carried out. Dissection of the gastrocolic trunk was difficult, because of inflammatory adhesion existed. Hepatoduodenal ligament was dissected and multiple lymph node were enlarged. After Kocher maneuver, paraaortic node was not enlarged and cleared. Portal vein was invaded at the splenoportal junction level and impossible to dissect from the main tumor; therefore, segmental resection and end-to-end anastomosis was performed. Splenic vein was ligated and distal portal vein stump and 1st jejunal branch opening were united for anastomosis. After end-to-end anastomosis, proxinmal jejunum was discolored by anastomotic site tension. We decided the procedure that using the left renal vein as an interposition graft for venous reconstruction. The left gonadal vein was preserved and left renal vein was harvested about 2cm length. Then re-anastomosis was performed using graft. Jejunal edema and discoloration was improved. Then pancreaticojejunostomy, choledochojejunostomy, gastrojejunostomy were proceeded in order. Operation time was 8hr 40min and estimated blood loss was 800ml. Postoperative 7th day, Renal DMSA scan and Doppler USG revealed decreased left renal function. The patient was discharged on 16th post operative day.

Results. Pathologic diagnosis was ductal adenocarcinoma with moderate differentiation and the stage was IIB (T3N1M0).

Conclusions. The left renal vein provides an additional choice for an autologous graft during pancreaticoduodenectomy with venous resction

FV 1.03

HANGING MANOEUVRE TO FACILITATE THE RETROPERITONEAL DISSECTION DURING PANCREATICODUODENECTOMY

PESSAUX, Patrick¹; ROSSO, Edoardo²; OUSSOULTZOGLOU, Elie²; JAECK, Daniel²

¹Hopital de Hautepierre, Centre de Chirurgie Viscérale et Transplantation, Avenue Molière, Strasbourg, France; ²Hopital de Hautepierre, Centre de Chirurgie Viscérale et Transplantation, Strasbourg, France

Background. Malignant periampullary tumours often invade into retroperitoneal peripancreatic tissues and a positive resection margin following pancreaticoduodenectomy is associated with a worst survival. Among the different steps of pancreaticoduodenectomy one of the most difficult, bloody, and less codified is the resection of the retroperitoneal margin (RM) Aim of the study: The aim of this video was to describe a surgical technique that allows for a precise and reproducible identification of the RM and for an optimal control of bleeding.

Methods. A liberal Kocherization exposes the origin of the SMA just superior to the point at which the left renal vein crosses the aorta. A large right-angled dissector is passed along the superior mesenteric artery from its origin on the aorta up to its emergence in the mesentery. At tape is seized with the right-angled and passed around the RM. The assistant lift upward the tape exposing the RM (hanging manoeuvre) facilitating de dissection of the RM from the superior mesenteric artery. Bleeding may be easily controlled by further lifting of the tape leaving to the surgeon “two” hands for selective and definitive hemostasis with fine sutures.

Conclusion. The hanging manoeuvre for pancreaticoduodenectomy allows a complete, safe, and reproducible resection of the RM and may contribute to increase the number curative resections (avoids the « point of no return » of the classical operation and early identification of non respectability). This method also accomplishes adequate lymphadenectomy and easier identification and safeguarding of a replaced right hepatic artery, if present.

FV 1.04

HEPATIC ARTERY RECONSTRUCTION IN PANCREATICO- DUODENECTOMY BY DIRECT ANASTOMOSIS UTILIZING PANCREATICODUODENAL ARTERY.

Hoshino, Takanobu; Ishida, Takashi; Odaka, Akio; Hashimoto, Daijo

Saitama Medical University, Medical Center, Hepato-pancreato-biliary Surgery, Kawagoe-city, Japan

Objective. To present technical aspects and advantages of hepatic artery (HA) reconstruction by direct anastomosis utilizing pancreaticoduodenal artery (PDA) as a useful option in pancreaticoduodenectomy.

Methods. Pancreaticoduodenectomy was performed in a patient with complete obstruction of celiac trunk. A 69-year-old female patient, complaining of jaundice, was admitted with diagnosis of cancer of either pancreas head or CBD. Angiography demonstrated complete obstruction of celiac trunk, because of arteriosclerosis, and marked dilation of the arcade between inferior and superior PDAs. Blood flow of HA turned out to be supplied only from superior mesenteric artery (SMA) via arcades of PDAs. Therefore, it was mandatory to perform HA reconstruction to safely complete pancreaticoduodenectomy.

Operation. Intraoperative findings revealed no tumor exposure on the surface of pancreas or CBD. There was no tumor invasion to adjacent tissue and no lymph node swelling, either. Therefore, we decided to utilize the arcade of PDAs for HA reconstruction. Anterior arcade of inferior and superior PDAs was carefully dissected and freed, first, by ligating and dividing small branches communicating to pancreas head. Following complete dissection of the anterior arcade of PDAs, we performed reconstruction of HA by end-to-end anastomosis between gastroduodenal artery and dilated anterior inferior PDA (4 mm in diameters for both arteries). After adequate blood flow of HA (through this vascular anastomosis) was confirmed, the rest of pancreaticoduodenal resection followed by biliary and alimentary tract anastomoses were completed in usual fashion.

Results. Postoperative course was uneventful, and no complication, including vascular problems such as anastomotic occlusion or leakage, was observed. This patient is still alive, free of disease, at four years three months following surgery.

Conclusion. HA reconstruction utilizing PDAs appears to be one of the useful options when adequate diameters of the arteries are available.

FV 1.05

PANCREAS SPARING-DUODENECTOMY FOR LOW-GRADE MALIGNANCY OF THE DUODENUM

Ikuko, Matsumoto¹; Cho, Akihiro¹; Miyazaki, Akinari¹; Ikeda, Atsushi¹; Gunji, Hisashi²; Soda, Hiroaki¹; Kainma, Osamu²; Takiguchi, Nobuhiro²; Nagata, Matsuo²; Yamamoto, Hiroshi¹; Ryu, Munemasa¹

¹Chiba Cancer Center, Gastroenterological Surgery, Chiba, Japan; ²

Introduction.Pancreas sparing- duodenectomy (PSD) is an organ-preserving surgical procedure suitable for patients with pre or low-grade malignanies of the duodenum. The surgical technique is challenging due to the close anatomical relationship between the pancreatic head and the duodenum. We herein present a case with early cancer of the papilla Vater which was successfully resected using PSD.

CASE. A 54-year-old man was referred for treatment of a tumor of the ampulla of Vater. Although endoscopic biopsy did not confirm malignancy, the patient underwent PSD under the p resumptive diagnosis of adenoma or cancer in adenoma of the papilla Vater. After cholecystectomy, a stenting tube was inserted from the cystic duct into the duodenum, acting as a landmark. The ligament of Treitz is dissected, and the proximal jejunum is transected with the gastrointestinal stapler. Dissection between the infra-ampullary duodenum and the pancreatic head proceeded to the major papilla. The common duct of the bike and pancreatic ducts was encircled both extra-duodenally and extra-pancreatically. Then, common duct and supra-ampullary duodenum were divided. Reconstruction was accomplished by end-to-end duodenojejunostomy with inplanting the bile and pancreatic ducts in the jejunum. He had compications of bile leakage and delayed gastric emptying, however they got well spontaneously.

FV 1.06

PANCREATOGENOUS ADULT HYPERINSULINEMIC HYPOGLUCEMIA SYNDROME

Pekolj, Juan¹; Fernandez, Diego L²; Bregante, Mariano²; Salceda, Juan³; Mazza, Oscar²; Ardiles, Victoria²; de Santibanes, Eduardo⁴

¹Hospital Italiano Buenos Aires, HPB and Liver Transplant Unit, Buenos, Argentina; ²Hospital Italiano Buenos Aires, HPB and Liver Transplant Unit, Buenos Aires, Argentina; ³Hospital Italiano Buenos Aires, HPB and Liver Transpant, Buenoa Aires, Argentina; ⁴Hospital Italiano Buenos Aires, HPB and Liver Transplant Unit, Buenos Aires

Background. Insulinoma and Nesidioblastosis constitute an important cause of pancreatogenous adult hyperinsulinemic hypoglucemia syndrome. Both can be managed through miniinvasive surgery.

Objective. To show two PAHH Syndrome cases resolved by laparoscopic approach.

Population and Methods. A 26 year-old female and a 54-year-old female with PAHH syndrome are presented here. CT scan did not show any tumor in either of them. Angiography showed an insulinoma on tail of pancreas in the second case. The 48-hour fast test was positive in both cases. Calcium stimulation was positive in splenic artery and in splenic and gastroduodenal artery in the first? case.

Results. Both patients were approached by laparoscopy. The first case was resolved through a laparoscopic spleen-preserving distal pancreatectomy. The second case was resolved performing a laparoscopic distal pancreatosplenectomy. Patients were discharged at day 5 and 6, respectively, without postoperative complications. Post-operative 48-hour fast test was negative. Hypoglucemia and diabetes were not observed in the follow- up.

Conclusion. PAHH syndrome should be surgically managed. Laparoscopic surgery allowed us to resolve both cases satisfactorily. Symptoms were controlled without any complications and without hypoglucemia or diabetes in the follow-up.

FV 2.01

EXTENDED LEFT HEPATECTOMY THROUGH ANTERIOR APPROACH FOR HEPATOCELLULAR CARCINOMA ARISING FROM THE CAUDATE LOBE

Kim, Hong-Jin; LEE, DS; YUN, SS

Yeunganm University Hospital, Surgery, Daegu, Korea, Republic of

Background. Hepatocellular carcinoma arising from caudate lobe is rare, and it's prognosis is poor. We performed extended Lt. hepatectomy through anterior approach for huge hepatocellular carcinoma arising from caudate lobe and would like to present it.

Method. Seventy three-year old male patient was admitted for incidental Lt. lobe huge mass of liver. when serum hemoglobin was 13.7g/dL, platlet was 196K/uL, albumin was 3.7g/dL, Total bilirubin was 1.02mg/dL, AST 45U/L, ALt 13U/L, PT 12.9s, and HBsAg was negative, HBeAb was positive., AntiHCV was negative, aFP was 18542, PIVKA-2 was above 2000U/mL. ICG R15 was 16.6%. whole abd. CT scan shows an about 12cm-sized heterogenous huge mass in Lt. lobe of liver. It arising from caudate lobe and compressing the Lt. lobe of liver. Lt. hepatic vein and Lt. portal vein was not visualized due to compression. We used anterior approach. Lt. heapatic artery and portal vein was ligated and transsected first, and liver parenchyme was dissected with Rt. lobe and Lt. lobe. by color demarcation line. After anterior approach was performed, caudate lobectomy was performed carefully.

Results. Pathologic diagnosis was hepatocellular carcinoma, and its largest diameter was 12cm, vascular invasion and capsule invasion was notified, thus the stage was IVa(T4N0M0). 1 month later, his follow up CT scan and angiography shows that there was no recur or distant metastasis. 3 months later, serum aFP and PIVKA-2 level was normalized.

Conclusion. Anterior approach could be a good strategy for huge HCC arising from caudate lobe.

FV 2.02

CHOLANGIOCARCINOMA IN PROXIMITY OF THE CAVO-HEPATIC CONFLUENCE: RIGHT HEPATECTOMY EXTENDED TO THE POSTERIOR PORTION OF SEGMENT 4

Nuzzo, Gennaro; Giuliante, Felice; Ardito, Francesco; Vellone, Maria; Giovannini, Ivo

Catholic University-School of Medicine, Hepato-Biliary and Digestive Surgery Unit, Rome, Italy

Background. Intrahepatic cholangiocarcinoma accounts for about 10% of primary liver tumours. Although there is often late diagnosis with low resectability rate, liver resection remains the only therapeutic option. Large resections are frequently required.

Objective. The video shows the case of a 69-yr old male patient with a 9-cm tumour completely invading liver segments 6 and 7. CT-scan and magnetic resonance showed close proximity of the tumour to the whole retro-hepatic portion of the cava and caval infiltration could not be totally excluded. Superiorly the tumour was also in close proximity of the right cavo-hepatic confluence, and inferiorly in proximity of the right postero-lateral portal pedicle without infiltration.

Method. A right hepatectomy extended to the posterior portion of segment 4 was performed. To achieve complete vascular control, and be prepared for a total vascular exclusion, the supra- and infra-hepatic vena cava were isolated and prepared, with interruption of the right adrenal vein. The posterior wall of the tumour was progressively detached from the anterior wall of vena cava, proceeding from below upwards, with the interruption of several dorsal veins and of the right dorsal caval ligament, therefore obtaining an extra-parenchymal preparation of the right hepatic vein. The parenchymal transection was carried out by Kelly-clasia and wet bipolar forceps, without clamping of the hepatic pedicle.

Results. The recovery was normal, with uneventful postoperative course.

FV 2.03

RE-HEPATECTOMY AFTER RIGHT HEPATECTOMY FOR COLORECTAL METASTASIS

Regimbeau, jean-marc¹; Fuks, david²; Degremont, raphael¹; de Dominicis, florence¹; Mauvais, françois¹

¹hospitalo-universitary hospital, digestive surgery, Amiens, France; ²hospitalo-universitary hospital, digestive surgery, Amiens

Right hepatectomy for colorectal liver metastasis is, basically, the major resection the most frequently carried out after wedge resection. It represents 30 to 45% of liver resection. Some of the patients, who have had a right hepatectomy, will recur with new liver metastasis. They will become possible candidates for a rehepatectomy, for it has been validated in terms of survival. We are presenting you a video of a rehepatectomy for a metastasis recurrence occurring in the low part of the IVth segment, after a right hepatectomy. This localisation necessitates a hilar cholangiocarcinoma like resection, including a main bile duct resection. We are proposing you a classification of intrahepatic recurrence after right hepatectomy.

FV 2.04

EXTENDED LEFT LOBECTOMY WITH PRESERVATION OF THE INFERIOR RIGHT HEPATIC VEIN FOR A CHOLANGIOCARCINOMA INVOLVING THE HEPATO-CAVAL CONFLUENCE

Dalla Valle, Raffaele

University of Parma, General Surgery, Parma, Italy

Background. After an extended hemihepatectomy adequate venous drainage of the remaining liver is required in order to preserve hepatic function. Most liver tumours involving the confluence of the hepatic veins are considered unresectable because hepatic venous outflow after resection would be compromised. In 10–25% of people, the inferior right hepatic vein presents large calibre. Thus the superior hepatic veins may be sacrified and hepatic function preserved if a large inferior right hepatic vein is present.

Technique. The video describes a case of cholangiocarcinoma involving the dome of the liver, all the three hepatic veins and the portal pedicle to the VIII segment. The patient was a 78 old years woman in good general conditions and liver function. At the CT scan she had a large inferior right hepatic vein draining the posterior liver sector. The patient was treated by an extended left hepatic lobectomy with resection of the main right, left and middle hepatic vein and preservation of the inferior right hepatic vein. The video also shows the technical solution (an omental flap like an hammock fixed to the diaphragm) adopted to preserve a good venous drainage of the residual posterior sector hampered by the kinking of the inferior hepatic vein. The patient is still alive after 18 months of follow-up but a recent CT scan showed three distant liver metastasis actually treated with chemotherapy.

Conclusions. This case confirms that a hepatic lesion involving the dome of the liver, apparently unresectable can turn resectable if an alternative venous drainage is p resent. In these cases a pre-operative search for an inferior right hepatic vein is mandatory and is easily accomplished by ultrasound and computerized tomography.

FV 2.05

ISOLATED COMPLETE RESECTION OF CAUDATE LOBE MAINLY BY LEFT APPROACH

PENG, Shu You; LIU, Yiing Bin; LI, Jiang Tao

Second Affiliated hospital/zhejiang university, Department of surgery, Hangzhou, China

Introduction. Caudate lobe resection especially isolated complete resection(ICR) is still a serious challenge to many of the HPB surgeons. The choice of an appropriate approach is important to the success of ICR.

Objective. Among the 5 different approaches, left approach alone is seldom used for ICR especially when the tumor is huge. This video is to demonstrate the feasibility of left approach in such situation.

Methods. A 37-year-old lady complaint of upper abdomen discomfort for 2 mo CT scan showed a huge hemangioma 10×6cm. Isolated complete resection of caudate lobe was planned.

Results. During operation a huge hemangioma was confirmed. Left lobe was fully mobilized. Separation started from upper pole of the caudate lobe which was detached from the IVC. With the use of a special instrument, Peng¡^—s Multifunctional Operative Dissector (PMOD) to isolate and divide several short hepatic veins, quite a long segment of IVC was separated from the upper part of the caudate lobe. The separation then restarted from the lower left portion of the caudate. With all the short hepatic veins on the left side divided, the Spiegelian lobe was completely detached from the IVC followed by complete detachment of the paracaval portion. Dissection being carried on from left to right, we now came to the right side of the IVC, along which all he short hepatic veins were isolated and divided. The caudate process was then divided and the stump was pushed to the left. The caudate portal triads began to be dissected and divided one by one. the tumor was detached from its base, segment VI and VII using the transection technique called Curettage and Aspiration Dissection technique. Operation time 190 min. Blood loss 300ml.

Conclusion.1 Left approach is feasible for isolated complete resection of caudate lobe even when the tumor is huge in size. 2 PMOD is useful in carrying out precise and delicate dissection such as isolation of short hepatic veins and transection of liver parenchyma as well.

FV 2.06

LIVER HANGING MANOEUVRE APPLIED IN ISOLATED COMPLETE RESECTION OF CAUDATE LOBE

PENG, Shu You¹; LIU, Ying Bin¹; CAI, Xiu Jun²

¹second affiliated hospital/zhejiang university, Department of Surgery, Hangzhou, China; ²Sir Run Run Shaw hospital/zhejiang university, Department of Surgery, Hangzhou, China

Introduction. Liver Hanging Maneuver(LHM) has been used frequently for right lobe resection ever since it was described by Belghiti in 2001 for right lobe resection. It has rarely been used for caudate lobe resection.

Objective. Among 152 cases of caudate lobe resection that we performed, LHM was applied in 5 cases. This video is to show the feasibility and advantage of using LHM in caudate lobe resection.

Methods. A 50-year-old lady complaint of upper abdomen discomfort for 3 mo HBsAg(+), AFP(−) CT scan showed a mass in the caudate lobe, so did the sonography but it was unable to rule out malignancy. It was decided to remove the tumor.

Results During exploration a large hemangioma was found occupying the entire caudate lobe. The liver was fully mobilized and both supra and infrahepatic IVC taped. Caudate process was raised up. An index finger was inserted between the caudate process and the IVC to start developing the retrohepatic tunnel toward the inter-hepatic-venous fossa which had been dissected previously. When the finger tip appeared at the fossa, a catheter was inserted to follow the withdrawing finger until it appeared at the lower opening of the tunnel. The catheter then became a sling to lift the liver forward. With a special instrument, Peng¡^—s Multifunctional Operative Dissector (PMOD), dissection becomes easy. After all the short hepatic veins on the left side were divided the hanging catheter could be swung to the left and became a sling to control the common trunk. Short hepatic veins on the right were totally divided and the caudate portal triads were identified and divided one by one. The hemangiom was then carefully detached from the left and middle hepatic vein and gradually separated from segment VI and VII.

Conclusion.1 LHM is feasible and useful in isolated complete resection of caudate lobe.2 PMOD is very helpful in carrying out precise and delicate dissection. 3 The layer of liver parenchyma encasing IVC might not necessarily be a hindrance to caudate lobe resection

FV 2.07

APPLICATION OF LIVER HANGING MANEUVER FOR HEPATIC RESECTION FOR HCC: REPORT OF TWO CASES

Nanashima, Atsushi; Sumida, Yorihisa; Nagayasu, Takeshi

Nagasaki University Graduate School of Biomedical Sciences, Division of Surgical Oncology, Nagasaki, Japan

Background. Surgical factors such as blood loss, operation time and surgical margins are significant prognostic factors in patients with HCC. The liver hanging maneuver (LHM) proposed by Belghiti is widely used for hemihepatectomy to reduce blood loss and time required for transection. We evaluated feasibility of the procedure and its application for various anatomic resections of the liver.

Methods. We compared surgical parameters in 9 patients who underwent LHM (LHM group) for hemihepatectomy with those of 37 patients without LHM (non-LHM group). We also describe two cases in whom LHM was applied for other anatomic resections.

Results. Time required for hepatic transection was significantly shorter in LHM group than in non-LHM group (37 vs. 48 min, p = 0.04). CASE 1. A 60-year-old man had two HCCs in segments 5 and 8. He was scheduled for anatomic resection of right paramedian sectoriectomy. The space between vena cava and infra-hepatic caudate process was dissected and two small tubes for LHM were passed through this space. At hepatic hilum, the space between Glisson□fs pedicle and hepatic parenchyma was dissected and tubes were placed through (1) the space between right paramedian and right lateral Glisson□fs pedicles, and (2) the space left to right paramedian Glisson□fs pedicle. Hepatic transection was performed by pulling-up at two resected planes, Cantlie line and a line along right hepatic vein simultaneously. This made a □gdouble LHM□h possible. CASE 2. A 72-year-old male was found to have 25 cm-in-size of HCC in the right liver, which compressed hepatic veins and vena cava. The vena cava was not involved by HCC and a tube could be placed. Although large tumor compressed left lateral sector, right trisectoriectomy was easily performed with LHM at the plane of the falciform ligament.

Conclusion. LHM can be applied for various anatomic resections. LHM is useful for appropriate transection plane, shortening time required for hepatic transection and reducing blood loss.

FV 2.08

MODIFIED TWO-SURGEON TECHNIQUE FOR LIVER PARENCHYMAL TRANSECTION USING'TISSUELINK' AND'CUSA'.

Deshpande, Rahul; Efthimiou, Evangelos; Khan, Aamir; Mudan, Satvinder

Royal Marsden Hospital, Dept. of GI Surgery, London, United Kingdom

Background. Although various techniques for parenchymal transection have been described, none has been proven to be conclusively superior to the others.

Methods. A modified technique using precoagulation with'Tissuelink' followed by parenchymal division with'CUSA' was used for parenchymal transection for 40 liver resections. The details of the technique are described in the accompanying video presentation.

Results. The mean operating time for the hepatotomy and the blood loss during the procedure are comparable to other techniques. No inflow occlusion is used during the procedure. No other devices such as argon diathermy are needed.

Discussion. This technique uses precoagulation of parenchyma and vessels, thereby also providing a good resection margin. It can be universally used for all kinds of liver resections. It is a good teaching tool, demonstrates the intrahepatic anatomy clearly and can be safely performed even with an inexperienced assisstant.

Conclusion. Our technique provides for a safe alternative method for liver parenchymal transection.

FV 2.09

EX-VIVO HEPATIC TRISECTIONECTOMY AND LIVER AUTOTRANSPLANTATION IN A PATIENT WITH AN OTHERWISE UNRESECTABLE FIBROLAMELLAR HEPATOCELLULAR CARCINOMA

Gondolesi, Gabriel; Andriani, Oscar; Gonzalez-Campaña, Ariel; Rowe, Carlos; Silva, Marcelo; Podesta, Luis Gustavo

Fundacion Favaloro/Hospital Universitario Austral, Liver Unit, Buenos Aires, Argentina

Background. Ex-vivo hepatic resection with liver auto-transplantation (ATx) was conceived to allow treatment for otherwise unresectable malignancies and to expand the role of controlled liver surgery. Giant fibrolamellar hepatocellular carcinoma (HCC) presenting extrahepatic disease (ED) do not qualify for chemotherapy or transplantation; when feasible, liver resection is the only treatment option remaining in the se patients.

Aim. To present a video of the surgical approach used to treat a patient with extended fibrolamellar HCC considered unresectable and to show clinical, radiological and surgical findings used to plan the surgical strategy.

CASE. A 28 year old female with a two year history of weight loss and non specific abdominal discomfort. Abdominal US performed after 6 months follow-up identified a liver tumor with a central scar. After repeated biopsies, a fibrolamellar HCC was diagnosed and systemic chemotherapy initiated. One year later the patient was referred to us for TACE. Re-evaluation work-up included: αFP, chest and head CT as well as bone scintigraphy, all negative. An MRI showed a 16×14 cm right lobe lesion compressing the retro-hepatic cava and displacing the left hepatic vein. Two extra-hepatic lesions were identified. ED resection was followed by total hepatectomy with preservation of the vena cava and transient porto-caval shunt. Ex-vivo resection and engraftment were completed without the need for vascular graft and with duct to duct biliary reconstruction over a T-tube.

Conclusion. Refinements of classical surgical procedures used for liver transplantation allow referral centers to offer salvage procedures in advanced cases generating challenging clinical scenarios.

FV 2.10

LESSENS LEARNED FROM 150 CASES OF LAPAROSCOPIC LIVER RESECTIONS

Wakabayashi, Go; Nitta, Hiroyuki

Iwate Medical University, Department of Surgery, Morioka, Japan

Backgroud/Aims. Despite advances in laparoscopic techniques, laparoscopic liver resection has not come into widespread use yet. However we have accumulated 150 patients since 1995, who underwent laparoscopic partial liver resection, laparoscopic left lateral sectionectomy, and laparoscopy-assisted major hepatectomy. Bleeding control, which is a basic element for liver resection, needs to be better accessed by methods suitable for laparoscopic surgery in order to perform safer laparoscopic liver resection. The aim of this study is to establish safer technique and significance of laparoscopic liver resection.

Methods. We analyzed initial results from the point of operative techniques and indications for laparoscopic liver resection at our institute. Laparoscopic liver resections have been successfully performed by application of hilar blood flow control technique, automatic suturing devices, and radiofrequency precoagulation method.

Results. One hundred and fifty adult patients with primary or metastatic liver cancer and other diseases underwent laparoscopic partial liver resection(92 patients), laparoscopic left lateral segmentectomy(24), and laparoscopy-assisted lobectomy(34) between 1995 and 2006. Two conversions occurred because of bleeding. There were three post-operative bile leakages, but no post-operative bleeding, nor other major complications.

Conclusions. Laparoscopic liver resection can be safely performed and it can be categolized into surface resection, wedge resection, left lateral sectionectomy, and laparoscopy-assisted lobectomy, although its indications remain restricted. For a safer laparoscopic liver resection, an efficient bleeding control technique such as automatic suturing devices and radiofrequency precoagulation method is needed during parenchymal transection of the liver.

FV 3.01

RADIOFREQUENCY-ASSISTED LAPAROSCOPIC HEPATECTOMY IN CIRRHOTIC LIVER (PARTIAL SEGMENT V RESECTION FOR HEPATOCELLULAR CARCINOMA)

Cugat, Esteve¹; Herrero, Eric¹; Garcia, Maribel¹; Rivero, Joaquin¹; Perez, Noelia¹; Rodriguez, Aurora²; Marco, Constancio¹

¹Hospital Mutua de Terrassa, General and HPB Surgery, Terrassa, Spain; ²Hospital Mutua de Terrassa, Anesthesia, Terrassa, Spain

Introduction. Laparoscopic approach for liver resection has demonstrated to be a safe procedure in selected cases, also in cirrhotic patients, with a comparable morbidity rate than in open resections. It represents a relatively new option for the treatment of hepatocellular carcinoma (HCC) on cirrhosis, probably because of the intraoperative difficulties related to the treatment of this pathology and the problems related to the minimally invasive approach.

Case Report. We present a 74 years-old male with liver cirrhosis, VHC positive serology, A child. In ultrasonography control a 3 cm solid lesion in segment V next to the gallbladder was found. MRI findings strongly suggested the diagnosis of hepatocellular carcinoma. The patient underwent a laparoscopic limited resection including part of the segment V using radiofrecuency ablation device (Habib®) for the liver transection. No postoperative complications occurred. Pathological findings were consistent with HCC.

Discussion. Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients. The laparoscopic approach may enable liver resection in patients with evidence of portal vein hypertension with controversial indication in open surgery. Lower rate of liver decompensation has been reported after laparoscopic procedures. We believe that a minimally invasive approach can minimize the postoperative morbidity rate, and it may represent a new therapeutic strategy for cirrhotic patients. A part from this the development of new techniques and instrumentations is one of the the main factors in the evolution of the laparoscopic liver resections. In this case the radiofrecuency assisted laparoscopic liver resection has demonstrated to be safe in cirrhotic liver, in terms of vascular control during the transection. More cases are needed to determine whether the operating room time and the overall hospital stay might be diminished with this procedure and also to determine the impact on the overall costs.

FV 3.02

LAPAROSCOPIC LIVER RESECTION OF HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENT

Herrero, Eric; Cugat, Esteve; Rivero, Joaquin; García, Maribel; Perez, Noelia; Marco, Constancio

Hospital Mutua de Terrassa, Terrassa, Spain

Introduction. Laparoscopic approach for liver resection has demonstrated to be a safe procedure in selected cases, also in cirrhotic patients, with a comparable morbidity rate than open resections. It represents a relatively new option for the treatment of hepatocellular carcinoma (HCC) on cirrhosis, probably because of the intraoperative difficulties related to the treatment of this pathology and the problems related to the minimally invasive approach.

Case Report. We present a 74 years-old female with liver cirrhosis known since March 2002, VHC positive serology, A child with portal vein hypertension. In ultrasonography control a 2 cm subglissonian solid lesion in segment II/III was found. MRI and CT scan findings strongly suggested the diagnosis of hepatocellular carcinoma. The patient underwent a laparoscopic limited resection including part of the segment II and III. No blood transfusions were needed. No postoperative complications occurred, neither ascites, nor jaundice, nor encephalopathy. Definitive pathological findings were consistent with hepatocellular carcinoma over cirrhotic liver, with a safe resection margin.

Discussion. Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients with compensated liver function, and laparoscopy for surgical treatment of hepatic diseases is at an early stage. The laparoscopic approach may enable liver resection in patients with cirrhosis and evidence portal vein hypertension with controversial indication in open surgery. Lower rate of liver decompensation has been reported after laparoscopic procedures. We believe that a minimally invasive approach can minimize the postoperative morbidity rate, which is still too high in this group of patients, and it may represent a new therapeutic strategy for cirrhotic patients.

FV 3.03

LAPAROSCOPIC LEFT LATERAL SECTORECTOMY FOR COLORECTAL CANCER METASTASES

Herrero, Eric; Cugat, Esteve; Rivero, Joaquin; Garcia, Maribel; Marco, Constancio

Mutua de Terrassa, Terrassa, Spain

Introduction. Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the right liver. The immediate benefits seem to be those of any miniinvasive surgery: reduced trauma to the abdominal wall, early mobilization, shorter hospital stay, and better cosmetic Results.

Case Report. We present a 76-year-old male who underwent colorrectal resection for carcinoma 2 years before (pT3N0M0). CEA elevation was detected. An abdominal CT scan was performed showing 2 liver metastases in segments II and III. No extra hepatic disease was reported after complete study with thoracic CT scan and PET. The patient underwent surgery on May 2006. A left lateral segmentectomy (segments II and III) was performed by laparoscopic approach. Pathological findings were consistent with metastasic colorrectal adenocarcinoma in the 2 resected nodules with safe resection margin.

Discussion. The recent rapid developments of innovative laparoscopic instruments and improvements in surgical skill have made laparoscopic-assisted liver resection possible. Extensive experience in laparoscopic and hepatobiliary surgery is mandatory in carrying out liver resection through the minimal access approach. In appropriatel y selected patients, laparoscopic liver resection is feasible and safe, and achieves acceptable survival among individuals with hepatic malignancy. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations. Finally, the use of the haemostatic and sealant materials, widely used in open surgery, presents technical variations in its use in laparoscopic surgery, just as is we show in this video.

FV 3.04

TOTALLY LAPAROSCOPIC CENTRAL HEPATECTOMY

Gumbs, Andrew¹; Gayet, Brice²

¹Institut Mutualiste Montsouris, Digestive Diseases, 42 Boulevard Jourdan, Paris, France; ²Institut Mutualiste Montsouris, Digestive Diseases, Paris, France

Introduction. Since the first report of a laparoscopic liver resection in 1992, laparoscopic resection of peripheral hepatic segments has become increasingly more common in the surgical treatment of both benign and malignant tumors. The minimally invasive approach to major hepatectomies, however, is still only being currently performed in highly specialized centers. This is principally because of concerns for gas embolism and difficulty in controlling major hemorrhage via the laparoscopic approach. This video will demonstrate the relevant technical maneuvers in the performance of a totally laparoscopic central hepatectomy.

Method. This video will illustrate the pertinent issues regarding instrument selection, trochar placement, intra-operative monitoring and steps necessary to perform central hepatectomy using totally laparoscopic techniques. The principal steps of this procedure include: control of hepatic inflow, division of hepatic parenchyma, control of hepatic outflow, mobilization of the liver and specimen removal.

Conclusion. Minimally invasive techniques for central hepatic resections are feasible, and high volume centers that specialize in these procedures can have results similar to historical open series. Totally laparoscopic central hepatectomy should currently only be performed by surgeons with expertise in laparoscopy and hepatobiliary surgery.

FV 3.05

LAPAROSCOPIC RIGHT HEMIHEPATECTOMY WITH EXTRAHILIAR PEDICLE DISSECTION

Jarufe, Nicolas¹; Boza, Camilo²; Sanhueza, Marcel²; Guerra, Juan Francisco¹; Martinez, Jorge¹

¹P. Universidad Católica de Chile, Digestive Surgery, Santiago, Chile; ²P. Universidad Catolica de Chile, Digestive Surgery, Santiago, Chile

The development of the laparoscopic surgery has permitted to incorporate this technology to the surgical treatment of different pathologies. The use of laparoscopic approach for liver resections has remained limited for selected patients with left-sided and right-peripheral lesions requiring limited resection. This video shows a laparoscopic formal right liver resection (segments V, VI, VII and VIII) with pedicle dissection, extrahepatic right hepatic vein section and liver parenchymal-transection, in a 73 years old male with 2 methachronic colorectal metastases in the right lobe of the liver. He had a laparoscopic right colectomy performed 6 moth before liver surgery.

FV 3.06

LAPAROSCOPIC RIGHT POSTERIOR SECTORECTOMY FOR LIVER METASTASES

Herrero, Eric; Cugat, Esteve; García, Maribel; Rivero, Joaquin; Marco, Constancio

Hospital Mutua de Terrassa, General Surgery, Terrassa, Spain

Introduction. Laparoscopy has become an established approach for many procedures, and its advantages are well-known. Recent developments of innovative laparoscopic instruments and improvements in surgical skills have made laparoscopic-assisted liver resection possible. However, it is usually limited to selected patients in which the lesion is located in the left lobe or peripheral right segments.

Case Report. We present a 76 years-old male who underwent a colorectal resection for a cecum carcinoma on May 2004 (pT3N0M0). Six moths later, a routine CT-scan showed a liver lesion about 2.5cm between segments VI–VII. A PET-scan was performed in order to discard other extrahepatic lesions. The patient underwent surgery on January 2007, by a laparoscopic approach. The intraoperative ultrasonography showed only one 3cm tumor between segments VI-VII. A right posterior sectorectomy was performed. Pathological findings were consistent with metastasic colorectal adenocarcinoma with a safe resection margin.

Discusion. This new technical approach for liver resection is safe and feasible, and considered as a routine procedure for some authors, but its use in malignant tumours is still controversial. In our opinion, the procedure should be performed by an experienced surgical team in hepatobiliary and laparoscopic surgery, following the same oncologic rules than open resectional therapy, including radical R0 resection and a free surgical margin. Laparoscopic ultrasound should be routinely used to achieve complete staging and an adequate margin. Acceptable morbidity and mortality rate, with comparable results to conventional surgery have been reported. Extensive experience in conventional liver surgery and advanced laparoscopic surgery, and also the availability of all requested technology are indispensable prerequisites.

FV 3.07

UTILITY OF THE RADIOFRECUENCY-ASSISTED LAPAROSCOPIC HEPATECTOMY IN NORMAL LIVER (LEFT LATERAL SECTORECTOMY)

Cugat, Esteve¹; Herrero, Eric¹; Rivero, Joaquin¹; Garcia, Maribel¹; Perez, Noelia¹; Rodriguez, Aurora²; Marco, Constancio¹

¹Hospital Mutua de Terrassa, General and HPB Surgery, Terrassa, Spain; ²Hospital Mutua de Terrassa, Anesthesia, Terrassa, Spain

Introduction. Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the right liver. The immediate benefits seem to be those of any miniinvasive surgery: reduced trauma to the abdominal wall, early mobilization, shorter hospital stay, and better cosmetic Results.

Case Report. We present a 47-year-old male with previous history of acute cholangitis and abnormal hepatic blood test. A cholangio-MRI was performed showing segmentary dilatation of intrahepatic biliary ducts in segment II and III secondary to an stenotic process without clear suspicion of malignancy. The patient underwent surgery on March 2007. A left lateral sectorectomy (segments II and III) and cholecistectomy was performed by laparoscopic approach using radiofrecuency ablation device (Habib®) for the liver transection. Pathological findings were consistent with sclerosant cholangitis without malignancy. The postoperative course was uneventful.

Discussion. The recent rapid developments of innovative laparoscopic instruments and improvements in surgical skill have made laparoscopic-assisted liver resection possible. Extensive experience in laparoscopic and hepatobiliary surgery is mandatory in carrying out liver resection through the minimal access approach. In appropriately selected patients, laparoscopic liver resection is feasible and safe, and achieves acceptable survival among individuals with hepatic malignancy. The evolution of laparoscopic hepatectomies will probably depend on the development of new techniques and instrumentations. In this case the radiofrecuency assisted laparoscopic liver resection has demonstrated to be safe and useful in normal liver, in terms of vascular control during the transection. More cases are needed to determine whether the operating room time and the overall hospital stay might be diminished with this procedure and determine the impact on the overall costs.

FV 3.08

TOTALLY LAPAROSCOPIC RIGHT POSTERIOR SECTIONECTOMY AND MILES' OPERATION

Han, Sung-Sik¹; Choi, Hyo Seong²; Kim, Seong Hoon¹; Park, Sang-Jae¹; Park, Joong-Won¹

¹National Cancer Center, Center for Liver Cancer, Goyang-si, Gyeonggi-do, Korea, Republic of; ²National Cancer Center, Center for Colorectal Cancer, Goyang-si, Gyeonggi-do, Korea, Republic of

We describe a case of totally laparoscopic Miles¡^— operation with right posterior sectionectomy of the liver. A 60-year-old woman presented with lower rectal cancer 1cm above anal verge and 3cm sized synchronous liver metastasis in segment 6 and 7. After dividing the right posterior Glisson¡^—s pedicle, the liver parenchyme was transected. Using the intraoperative ultrasonography, 1.5cm tumor free margin was obtained successfully. The resected specimen was delivered through perineal wound after Miles¡^— operation without additional laparotomy for specimen retrieval. The patient was discharged on postoperative day 14 without any complications.

FV 4.01

LAPAROSCOPIC LEFT LATERAL SEGMENTECTOMY IN NORMAL AND CIRRHOTIC LIVERS-USE OF ENDOSTAPLERS

patel, bhavik; O'rourke, Nicholas

royal brisbane and womans hospital, brisbane, Australia

Introduction. Laparoscopic liver resection is becoming more popular and left lateral segmentectomy is probably the simplest of all laparoscopic liver resections. However, it is not withouth its technical difficulties.

Objectives. We aim to demonstrate our tips and techniques for this procedu re, in both normal and cirrhotic livers, by means of an edited video.

Results We have performed more than 70 laparoscopic left lateral segmentectomies over a 7 year period. The experience we have gained from this has allowed us to produce a high quality edited video, which highlights the important aspects of this procedure. The video demonstrates important technical considerations to avoid tumor spillage, ensure clear margins and secure haemostasis. We have performed this procedure in patients with cirrhotic and normal livers. We have had mortality in a patient with child B liver cirrhosis who died of liver failure on day 14.

Conclusions. Laparoscopic left lateral segmentectomy is safe and feasible in both normal and cirrhotic livers. Endoscopic vascular staplers provide haemostasis and permit a controlled resection

FV 4.02

LAPAROSCOPIC LIVER RESECTION

de Santibañes, Eduardo¹; Pekolj, Juan¹; Salceda, Juan²; Fernandez, Diego¹; Bregante, Mariano¹; Bregante, Mariano¹; Ardiles, Victoria¹

¹Hospital Italiano de Buenos Aires, HPB & Liver Transplant Unit, Buenos Aires, Argentina; ²Hospital Italiano de Buenos Aires, HPB & Liver Transplant Unit, Buenos Sires, Argentina

Background. The development of laparoscopic surgery during the last years has also reached liver resections. We present a single case of an incidental liver tumor treated with a laparoscopic approach.

Material and Method. Our case is a 48- year- old man, with a history of steroids oral intake, who presented a liver tumor located in left lateral segment of the liver. The patient underwent a laparoscopic liver resection with an uneventful 4- day post-operative course.

Conclusions. The laparoscopic approach for liver tumors has become an important tool, being also a safe indication for lesions located in the anterior and lateral sectors of the liver. Laparoscopic surgical techniques can reproduce every single step of open surgery such? as intra-operative ultrasound and Pringle maneuver. Laparoscopic liver resections performed by well- trained surgeons are safe and effective procedures for selected patients.

FV 4.03

LAPAROSCOPIC RESECTION OF LEFT LATERAL SEGMENT (LEFT LATERAL SECTIONECTOMY)

Alkari, Bassam; Owera, Anas; Ammori, Basil

Manchester Royal Infirmary, Department Of Surgery, Manchester, United Kingdom

FV 4.04

LAPAROSCOPY-ASSISTED LIVER LOBECTOMY USING GLISSONEAN PEDICLE TRANSECTION

Cho, Akihiro¹; Yamamoto, Hiroshi²; Nagata, Matsuo²; Takiguchi, Nobuhiro²; Kainuma, Osamu²; Souda, Hiroaki²; Gunji, Hisashi²; Miyazaki, Akinari²; Matsumoto, Ikuko²; Arimitu, Hidehito²; Nagao, Yoshiko²; Ryu, Munemasa²

¹Chiba Cancer Center Hospital, Chiba, Japan; ²Chiba Cancer Center Hospital, Division of Gastroenterological Surgery, Chiba, Japan

Although many reports have described laparoscopic minor liver resections, major hepatic resection, including right or left lobectomy, has not been widely developed because of technical difficulties. This article describes a new technique for performing laparoscopy-assisted right or left hepatic lobectomy using hilar Glissonean pedicle transaction. Laparoscopic mobilization of the right or left hepatic lobe is performed, including dissection of the round, faliciform, triangular and coronary ligaments. The right or left Glissonean pedicle is encircled and divided laparoscopically. A parenchymal dissection is then performed though the upper median or right subcostal incision, through which the resected liver is removed. We successfully performed this procedure in 8 patients without blood transfusion or serious complications. Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transaction can be feasible and safe in highly selected patients.

FV 4.05

TOTALLY LAPAROSCOPIC EXTENDED LEFT HEPATECTOMY

Gumbs, Andrew¹; Bar-Zakai, Barak²; Gayet, Brice³

¹Institut Mutualiste Montsouris, Medical and Surgical Department of Digestive Disea, 42 Boulevard Jourdan, Paris, France; ²Institut Mutualiste Montsouris, Department of Digestive Diseas, Paris, France; ³Institut Mutualiste Montsouris, Medical and Surgical Department of Digestive Disea, Paris, France

Introduction. Laparoscopic resection of peripheral hepatic segments has become increasingly more common in the surgical treatment of both benign and malignant tumors. The minimally invasive approach to major hepatectomies is still only being currently performed in highly specialized centers. This video will demonstrate the relevant technical maneuvers in the performance of a totally laparoscopic extended left hepatectomy including resection of segment I. Common pitfalls and areas of concern will also be discussed.

Method. This video will illustrate the pertinent issues regarding pre-operative patient selection, necessary minimally invasive equipment, trochar placement, intra-operative monitoring and steps necessary to perform a left hepatectomy including control and resection of the middle hepatic vein and the left aspect of segment VIII using totally laparoscopic techniques. The techniques for removal of segment I will also be demonstrated. The five principal steps of this procedure include: mobilization of the liver, control of hepatic inflow, division of hepatic parenchyma, control of hepatic outflow and removal of the specimen.

Results. At our institution a total of 3 extended left hepatectomies have been performed with totally laparoscopic techniques. These procedures included left hepatectomies with the addition of resection of the middle hepatic vein and complete or partial resection of segments V and VIII. Complications included bile leak in one patient that responded to endoscopic placement of biliary stents. Out short and long-term results have been similar to our open historical controls. No mortalities have been observed.

Conclusion. Minimally invasive techniques in left hepatic resections are feasible, and high volume centers that specialize in these procedures can have results similar to historical open series. Totally laparoscopic extended left hepatectomy should currently only be performed by surgeons with expertise in laparoscopy and hepatobiliary surgery.

FV 4.06

TOTALLY LAPAROSCOPIC LEFT LATERAL HEPATIC LOBECTOMY USING LIGASURE® DIATHERMY FOR HYDATID LIVER DISEASE

Efthimiadis, Christopher¹; Cosmidis, Christopher¹; Grigoriou, Marios¹; Anthimidis, George¹; Poursalidis, John²; Fahantidis, Epaminontas²; Basdanis, George²

¹Interbalkan Medical Center, Thessaloniki, Greece; ²Aristotle University, Thessaloniki, Greece

Background. Treating patients with hydatid disease of the liver is an uncommon but often difficult task for the surgeon. Surgical intervention is considered the gold standard in the treatment of the disease either in the form of resection or as drainage procedures. Minimally invasive techniques have emerged allowing drainage laparoscopically or with the use of percutaneous catheters under ultrasonographic or CT guidance. Despite the advantages of minimally invasive techniques in some cases with complicated Hydatidosis hepatectomy is both safer and more effective in controlling the disease. Laparoscopic liver resection in conjunction with the use of the Ligasure® atlas™ diathermy system minimizes the morbidity of the procedure making it an even more attractive option in complicated cases.

Aim/Objective. We present the case of a 50 year old woman with a large hydatid cyst involving segments II and III and communicating with the intrahepatic billiary tree that we treated with totally laparoscopic left lateral hepatic lobectomy using the Ligasure® atlas™ diathermy system with excellent Results.

FV 5.01

SIMULTANEOUS PANCREATICODUODENECTOMY, RIGHT TRISEGMENTECTOMY AND RIGHT HEMICOLECTOMY FOR GALL BLADDER CARCINOMA

Are, Chandrakanth¹; Iacovitti, Simonetta²; Crafa, Francesco²

¹Eppley Cancer Centre, University of Nebraska Medical Centre, Division of Surgical Oncology, Dept of Surgery, Omaha, United States; ²MG Vannini Hospital, Department of Surgery, Rome, Italy

Background. Simultaneous pancreaticoduodenectomy and major hepatectomy is a infrequently performed procedure AIM: We report a case of simultaneous pancreaticoduodenectomy, right trisegmentectomy and right hemicolectomy for gall bladder carcinoma.

Materials and Methods. A 67 year female patient that presented with abdominal pain and belching. She underwent a CT scan and MRI that showed a mass arising from the gall bladder that involved hepatic segments IV, V and VI, the pylorus, head of pancreas and hepatic flexure. Upper endoscopy showed evidence of pyloric stenosis and colonoscopy revealed evidence of infiltration of hepatic flexure. Her Ca 19-9, CEA and CA 125 were 1369 u/ml, 57.2 ng/ml and 40 u/ml respectively.

Results. The patient underwent diagnostic laparoscopy that showed no evidence of peritoneal spread, following which she underwent placement of pyloric stent and right portal vein embolization. Her nutritional status had improved after four weeks and repeat imaging demonstrated hypertrophy of left lateral segment. She was taken to the operating room for pancreaticoduodenectomy, right trisegmentectomy and right hemicolectomy. The proximal and distal points of transection for right hemicolectomy were divided with Endo-GIA stapler. The portal vein and superior mesenteric vein were dissected free following which the neck of the pancreas was divided. The inflow and outflow to the right lobe of the liver were isolated and divided. The patient required repair of the left portal vein and the superior mesenteric vein. An end to end pancreaticojejunostomy and end to side hepaticojejunostomy were performed and decompressed with internal/external stents. An ileostomy was fashioned and a feeding jejunostomy tube was placed. The operative time was eight hours with an estimated blood loss of 600 cc. The final histopathology revealed gall bladder carcinoma. (T4 N0 MO).

Conclusion. We present a case of simultaneous pancreaticoduodenectomy, right trisegmentectomy and right hemicolectomy for advanced gall bladder carcinoma.

FV 5.02

RIGHT HEPATECTOMY EXTENDED TO SEGMENT 1 FOR HILAR CHOLANGIOCARCINOMA

Nuzzo, Gennaro; Giuliante, Felice; Ardito, Francesco; Vellone, Maria; Giovannini, Ivo

Catholic University-School of Medicine, Hepato-Biliary and Digestive Surgery Unit, Rome, Italy

Background. Radical surgery for hilar cholangiocarcinoma involves resection of the biliary confluence with right or left hepatectomy according to the extension of the tumour, and resection of the caudate lobe which is frequently infiltrated, at least microscopically.

Objective. The video shows the case of a 57-yr old male patient who developed obstructive jaundice one month before referral. CT-scan and magnetic resonance demonstrated a 2-cm tumour interrupting the main and the right secondary biliary confluence (Bismuth type 3 A), and a right percutaneous biliary drainage was inserted. The patient was then referred in poor condition with sepsis and persistent jaundice. With left percutaneous biliary drainage the patient condition improved, and four weeks later he underwent surgery.

Methods. After bilateral subcostal incision extended to the xifoid, the hepatic pedicle was prepared, confirming in the hilum a nodular mass infiltrating the right hepatic artery. The liver was mobilized, the retro-hepatic vena cava was prepared interrupting several dorsal veins, from below upwards. The caudate lobe was prepared from the right and the left side. The right dorsal caval ligament and the Arantius ligament were interrupted. Extraparenchymal isolation and preparation of the right hepatic vein and common venous trunk was carried out. Right hepatic vein, right portal branch and right hepatic artery were interrupted extraparenchymally. The left hepatic duct, and the common bile duct just above the pancreas, were also interrupted. A right hepatectomy was then performed, with en-bloc resection of caudate lobe and biliary confluence, by Kelly-clasia and wet bipolar forceps, without hepatic pedicle clamping. Frozen section on left hepatic duct was negative, and a Roux-en-Y left hepatico-jejunostomy was performed.

Results. Early recovery was normal. After discharge, readmission was needed because of hemobilia from a small pseudoaneurysm of the left hepatic artery, which was treated by embolization.

FV 5.03

HEPATIC RESECTION COULD BE APPLICABLE TREATMENT IN KLATSKIN TUMORS INVOLVING THE SECONDARY CONFLUENCE ON THE RIGHT AND THE LEFT INTRAHEPATIC DUCT

Hwang, Ho Kyoung; Kim, Jae Keun; Park, Joon Seong; Cho, Shin Il; Yoon, Dong Sup; Chi, Hoon Sang; Kim, Byoung Ro

Yonsei University College of Medicine, surgery, Seoul, Korea, Republic of

Introduction. Hilar cholangiocarcinoma is a relatively rare tumor, Klatskin tumors are usually categorized as by Bismuth-Corlette Classification and the treatment options are primarily either curative or palliative bypass surgery, or non surgical therapy or liver transplantation. A type IV tumors involving the secondary confluence on the right and the left side generally considered unresectalble. We recently had the patient who underwent successful radical hepatic resection for Klatskin type IV tumor.

Methods. The 62-year old male had medical history of hypertension. He had undergone abdominal CT scan, there was Klatskin's tumor extending to the bilateral 2nd order branches, type IV and multiple small lymph nodes in Left paraaortic space and aortocaval space. We performed left hemihepatectomy and caudate lobectomy. We took isolation technique for identifying and dividing left portal triad. Pringle¡^—s maneuver was used. Liver parenchyma was dissected with harmonic scalpel(ethicon, USA). The left hepatic vein was identified and divided with endo GIA 60mm (Autosuture, USA). Left bile ductoplasty was performed after identification of negative resection margin. Roux- en Y hepaticojejunostomy was performed. The specimen of liver, weighing 977gram, There was periductal infiltrative lesion measuring 2×1.5cm.

Results. The operative time was 900 min. The postoperative periods were uneventful except wound infection, with discharge on days 14. The pathologic diagnosis was adenocarcinoma (well differentiated) at bifurcation of right and left hepatic ducts with frequent perineural invasion and with extension to liver parenchyma, distal portion of right hepatic duct and common hepatic duct with clear resection margin and there was no lymph node metastasis.

Conclusion. Hepatic resection could be considerable management option for Klatskin tumor involving the secondary confluence on the right and the left IHD, though further studies are needed for improving the outcome.

FV 5.04

HEPATIC RESECTION AND TRANSDUODEAL BILE DUCT RESECTION AND PANCREATIC DUCTREPOSITIONING FOR BILIARY PAPILLOMATOSIS

Yoon, Dong Sup; Kim, Jae Keun; Hwang, Ho Kyoung; Park, Joon Seong; Cho, Shin Il; Chi, Hoon Sang; Kim, Byoung Ro

Yonsei University College of Medicine, surgery, Seoul, Korea, Republic of

Introduction. Biliary papillomatosis is a rare biliary pathology. Concomitant intrahepatic and extrahepatic involvement was notified about 40%. Some authors believe that local resection is an acceptable form of treatment with comparable outcomes and a markedly decreased morbidity and mortality compared with too excessive major resection for non-malignant lesion. We recently had the patient who underwent successful radical hepatic resection and transduodenal complete bile duct resection with pancreatic duct repositioning for concomitant intrahepatic and extrahepatic biliary papillomatosis.

Methods. The 67-year old male had medical history of pulmonary tuberculosis and pneumoconiosis. He had undergone abdominal CT scan and MRCP, there was Intraductal papillary tumors mainly involving hilar portion and EHD. On PTCS, there was multiple nodular papillary masses with mucin in the left IHD and confluence of bile duct. The result of biopsy on confluence of bile duct was adenocarcinoma, moderately differentiated and pathology of biopsy on distal CBD was tubular adenoma with low-grade dysplasia. The patient underwent left hemihepatectomy and caudate lobectomy. longitudinal duodenotomy was made. The mucosa was incised superior to the ampulla until bile duct was encountered. The dissection was continued until the bile duct was completely excised and pancreatic duct opening was exposed. The pancreatic duct was identified, followed by direct mucosa-to mucosa repositioning with absorbable 4–0 sutures between the orifice and the duodenum. Roux en Y hepaticojejunostomy was performed.

Results. The postoperative periods were uneventful. The pathologic diagnosis was adenocarcinoma at confluence of bile duct and left IHD and tubular adenoma with high-grade dysplasia at distal CBD.

Conclusion. The hepatic resection and transduodenal complete bile duct resection with pancreatic duct repositioning could be considerable management option for concomitant intrahepatic and extrahepatic biliary papillomatosis with severe co-morbidity

FV 5.05

RIGHT TRISECTIONECTOMY WITH CAUDATE LOBECTOMY AND PORTAL VEIN RESECTION FOR HILAR CHOLANGIOCARCINOMA

Choi, Dong Wook¹; Paik, Kwang Yeol¹; Chung, Jun Chul²; Lee, Hyung Geun¹; Ryu, Dong Do¹; Heo, Jin Seok¹; Choi, Seong Ho¹

¹Samsung Medical Center, Surgery, Seoul, Korea, Republic of; ²Soon Chun Hyang Bucheon Hospital, Surgery, Bucheon, Korea, Republic of

Background. Bile duct resection and major hepatectomy is considered as standard treatment for hilar cholangiocarcinoma (HC). We performed right trisectionectomy with caudate lobectomy and portal vein resection for HC and would like to present it.

Methods. Sixty two-year old man was evaluated for incidental detection of AST/ALT increase and suspicious of HC. CT scans demonstrated a type IIIa HC with portal vein invasion at the hilar bifurcation and the volume of left lateral section was 440 ml (32.7%). Under the impression of HC, exploratory laparotomy was carried out. We used bilateral subcostal skin incision with median extension. After verification of no distant metastasis, the above-mentioned operation was planned to achieve a curative resection. Dissectio n of the hepatoduodenal ligament was first initiated to ascertain vascular invasion and to clear lymph nodes. Portal vein was invaded at the bifurcation level and impossible to dissect from the main tumor; therefore, segmental resection and end-to-end anastomosis was conducted after control of several small portal vein branches to the caudate process and the Spigelian lobe. During the mobilization of the right hemiliver, the right hepatic vein was divided using Endo-GIA¢ç. Through further dissection of small hepatic veins from the caudate lobe and the Arantius duct, the whole liver was mobilized from the vena cava. Then liver parenchymal dissection was performed using CUSA and the middle hepatic vein was also divided with Endo-GIA¢ç. Finally, the left hepatic duct was divided at the peripheral level of the confluence of B2 and B3. Hepaticojejunostomy was performed with interrupt sutures using 5.0 Vicryl. The patient was discharged on 9th post operative day without significant complication.

Results. Pathologic diagnosis was ductal adenocarcinoma with moderate differentiation at the common hepatic and intrahepatic duct and the stage was IIA (T3N0M0).

Conclusions. We believe that this technique would be helpful for HC with portal vein invasion

FV 5.06

LEFT TRISECTIONECTOMY WITH CAUDATE LOBECTOMY AND PANCREATODUODENECTOMY FOR HILAR CHOLANGIOCARCINOMA

Choi, Dong Wook¹; Paik, Kwang Yeol¹; Chung, Jun Chul²; Lee, Hyung Geun¹; Ryu, Dong Do¹; Heo, Jin Seok¹; Choi, Seong Ho¹

¹Samsung Medical Center, Surgery, Seoul, Korea, Republic of; ²Soon Chun Hyang Bucheon Hospital, Surgery, Bucheon, Korea, Republic of

Background. Bile duct resection and major hepatectomy is considered as standard treatment for hilar cholangiocarcinoma (HC). We performed left trisectionectomy with caudate lobectomy, bile duct resection and pylorus-preserving pancreatoduodenectomy for HC and would like to present it.

Methods. Fifty six-year old female patient was admitted for suspicious HC with ENBD performed at an outside hospital. Preoperative radiologic findings suggested type IIIb HC and left trisectionectomy with caudate lobectomy was planned with intent of a curative resection. We used bilateral subcostal incision with median extension and explored abdominal cavity to examine distant metastasis. First of all, the hepatoduodenal ligament was dissected to clear lymph nodes and to ascertain vascular invasion, and the CBD was divided near the pancreas. The resection margin of the distal bile duct was positive for tumor in frozen biopsy. After division of hepatic artery and portal vein to the left hemiliver and the anterior section of the right hemiliver, several small portal vein branches to the caudate and the Spigelian¡^—s lobe were also controlled. Next the right hemiliver and the caudate lobe were mobilized through division of small hepatic veins to the IVC and the Arantius duct. The left hemiliver was also mobilized and the left hepatic vein was divided using Endo-GIA¢ç. Liver parenchyma was transected between right anterior and posterior section along with the right hepatic vein and bile duct was divided at the confluence level of B6 and B7. Additional PPPD was carried out due to positive resection margin of the distal bile duct. Hepaticojejunostomy was performed with interrupt sutures using 5.0 Vicryl.

Results. Pathologic diagnosis was ductal adenocarcinoma (Bismuth type IIIb) with moderate to poor differentiation at the common hepatic and intrahepatic duct and the stage was IIB (T2N1M0).

Conclusion. We believe that this technique could be a helpful option for HC.

FV 6.01

THREE-PORT LAPAROSCOPIC SUBTOTAL DISTAL PANCREATECTOMY

Jacobs, Michael

Providence Hospital, Surgery, Wayne State University School of Medicine, Southfield, United States

Backround. Laparoscopic distal pancreatectomy and pancreatic enucleations are preferred techniques for benign diseases and cystic tumors. The application of LDP for malignancy is debatable. In more than 400 reported cases of LDP and Len, four or more port entry incisions were used. The three port technique is a further advancement in minimally invasive surgery of pancreas.

Objective. To demonstrate the feasibility of laparoscopic subtotal distal pancreatectomy using the three-port technique.

Methods and Results. A 46-year old female was evaluated for weight loss. Examination was unremarkable. A CT-scan showed a 4-cm mass in the tail of the pancreas. A laparoscopic subtotal distal pancreatectomy using three-ports was performed. The operating time was less than 3-hours, the blood loss less than 200-mL, and length of stay was 3 days. Histopathology showed invasive moderate- to poorly-differentiated ductal adenocarcinoma of pancreas. The margins of resection were negative. There were no perioperative complications.

Conclusion. In addition to the usual benefits of laparoscopic distal pancreatectomy, the three-port technique can be applied to lesions requiring subtotal resection without compromising the oncologic principles. A shorter recovery enables the patient to begin adjuvant therapy sooner.

FV 6.02

HAND-ASSISTED LAPAROSCOPIC WHIPPLE OPERATION FOR AMPULLA OF VATER ADENOCARCINOMA

Tsui, David; Tang, C N; Lai, Eric; Li, Michael K W

Pamela Youde Nethersole Eastern Hospital, Surgery, Hong Kong SAR, Hong Kong

Introduction. Whipple operation is a highly complex operation for periampullary tumor and tumor in the head of pancreas. With the advent of laparoscopic surgery, laparoscopic resection can be considered for selected cases. We would like to present a case of hand-assisted laparoscopic Whipple operation for ampulla of Vater adenocarcinoma.

Method. A 52-year old lady presented initially with anaemia. Upper endoscopy showed ampulla tumor. Biopsy confirmed adenocarcinoma. Computed tomography (CT) of abdomen showed ampulla tumor with involvement of head of pancreas without evidence of vessel encasement or dissemination. Hand-assisted laparoscopic Whipple operation was performed using 4-port approach (including 1 handport at right upper quadrant measuring 7.5cm long).

Result. The surgery was completed in 270 minutes with operative blood loss of 150ml. Post operative recovery was well and the patient was discharged on day 8. She came back at 2 weeks post operation for vomiting. No major collection was shown on CT abdomen and upper endoscopy revealed intact anastomosis. She was treated conservatively and discharged. There was no tumor recurrence upon a follow up period of 14 months.

Conclusion. Laparoscopic Whipple operation is technically feasible in selected patients. The use of hand-assistance provides a good tactile sensation for the surgeon and thus facilitates the whole procedure.

FV 6.03

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH SPLENECTOMY

Herrero, Eric; Cugat, Esteve; García, Maribel; Rivero, Joaquin; Marco, Constancio

Hospital Mutua de Terrassa, General Surgery, Terrassa, Spain

Introduction. Laparoscopic distal pancreatectomy is a safe procedure, with minimal morbidity, rapid recovery, and short hospital stay. In appropriate cases, spleen preservation is feasible. The most frequent cause of post-operative morbidity is the pancreatic leak but it could be usually managed conservatively. We present a case of surgical treatment of a mucinous cystadenoma of the pancreas by laparoscopic approach. The intervention consisted in a laparoscopic distal pancreatectomy with associated splenectomy.

Case Report. A 45-year-old woman was admitted in emergency by upper abdominal pain referred to the back occasionally associated with vomiting. Abdominal CT scan reported a cystic tumour of 4.8×4.6 cm. in the pancreatic body suggesting a mucinous cystadenoma of the pancreas. The patient underwent distal pancreatectomy with splenectomy by laparoscopic approach. The pathological findings were consistent with mucinous cystadenoma of the pancreas without lymph node involvement. No complications occurred during the postoperative period.

Discussion. Surgical resection is indicated in potentially malignant pancreatic cystic neoplasms. Differentiating serous and mucinous cystadenoma from pseudocysts may be difficult preoperatively, so tumours of the pancreas that cannot be confirmed to be serous cystic neoplasm should be resected as the possibility of pancreatic cancer, mucinous cystadenocarcinoma, or mucinous cystadenoma with malignant potential exists. At present, laparoscopic surgery has proven to be beneficial in patients with cystic pancreatic neoplasms. In experienced hands, this minimally invasive approach reduces postoperative hospital stay and expedites recovery. However, the incidence of pancreatic fistula following distal resection is not any less than in open surgery. The use of sealant materials in the pancreatic resection margin may decrease the incidence of fistula after distal pancreatectomy. Its use in laparoscopic surgery differs technically of that in open surgery as we show in this video.

FV 6.04

LAPAROSCOPIC WHIPPLE'S PANCREATICO-DUODENECTOMY

Alkari, Bassam¹; Ammori, Basil²

¹Manchester Royal Infirmary, Department Of Surgery, Oxford Road, Manchester, United K ingdom; ²Manchester Royal Infirmary, Department Of Surgery, Manchester, United Kingdom

FV 6.05

SURGICAL TECHNIQUE OF DISTAL PANCREATECTOMY WITH EN BLOC CELIAC AXIS RESECTION FOR LOCALLY ADVANCED PANCREATIC BODY CANCER

Hirano, Satoshi¹; Kondo, Satoshi²; Tanaka, Eiichi²; Shichinohe, Toshiaki²; Suzuki, On²; Sagawa, Noriaki²; Ichimura, Tatsunosuke²; Hashida, Hideaki²; Suzuoki, Masato²

¹Hokkaido University, Surgical Oncology, Graduate School of Medicine, Sapporo, Japan; ²Hokkaido University, Surgical Oncology, Sapporo, Japan

Introduction. Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis. Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body.

Objective. To demonstrate the surgical technique of DP-CAR and evaluate its clinical efficacy.

Methods. Preoperative coil embolization of the common hepatic artery was routinely used to enlarge the collateral pathways and prevent ischemia-related complications. The procedures routinely included en bloc resection of the celiac, common hepatic, and left gastric arteries, the celiac plexus and ganglions, the nerve plexus around the superior mesenteric artery, a part of the crus of the diaphragm and the Gerota□fs fascia, the left adrenal gland, the retroperitoneal fat tissues bearing lymph nodes above the left renal vein, the transverse mesocolon covering the body of the pancreas, and the inferior mesenteric vein. Resection of the portal vein and the middle colic vessels was optional.

Results. Since 1998, 23 patients underwent DP-CAR. The postoperative morbidity rate was 48% and no hospital death was encountered. Postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients. The median survival time was 21.0 months.

Conclusions. DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The complete relief from the pain contributes to excellent postoperative quality of life.

FV 6.06

SURGICAL PROCEDURE AND CLINICAL RESULTS OF LAYER-TO-LAYER PANCREATICOJEJUNOSTOMY IN CONSECUTIVE 70 CASES

Hayashibe, Akira; Kameyama, Masao

Bell Land General Hospital, Surgery, Sakai city, Japan

Background. Pancreatic anastomotic leakage remains a major troublesome complication in pancreatic surgery. So various technical modifications regarding the pancreatic anastomosis have been attempted to decrease anastomotic leakage. We have performed Layer Cto-Layer pancreaticojejunostomy and obtained extremely favorable results.

Patients and Methods. During 1999–2007, 70 patients (33 female, 37 male) underwent Layer Cto-Layer Pancreaticojejunostomy. The mean age was 65.0 years (range 33–84). Surgical procedure of Layer Cto-Layer Pancreaticojejunostomy. The jejunal serosa was resected a little smaller than a size of the pancreatic stump. Then jejunal mucosa was exposed. The dorsal part of the jejunal seromuscular layer and the dorsal part of the pancreatic capsular parenchyma of the stump were sutured with seven to eight stitches of 4–0 non absorbable thread to leave no dead space. A small hole in the exposed jejunal mucosa with the same diameter as the pancreatic duct was made. The anastomosis between the posterior wall of the pancreatic duct (ductal mucosa) and the posterior wall of the jejunal mucosa were performed (Layer-to-Layer anastomosis). The anterior wall of¡¡the pancreatic duct (ductal mucosa) and the anterior wall of the jejunal mucosa were sutured in the same manner(Layer-to-Layer anastomosis). The ventral part of the jejunal seromuscular layer and the ventral part of the pancreatic capsular parenchyma of the stump were sutured.

Results. Mean post-operative hospital stay was 32.3 days. Morbidity rate due to early postoperative complication was¡¡9.0% (pneumothorax in 1, pulmonary embolism in 1, gastric ulcer in 1, wound infection in 3), with no pancreatic anastomotic leakage.

Conclusions. There were low complication rate and no pancreatic anastomotic leakage in consecutive 70 patients,¡¡who underwent Layer Cto-Layer Pancreaticojejunostomy. We consider that Layer Cto-Layer Pancreaticojejunostomy is extremely safe, reliable and favorable for pancreatic anastomosis.

FV 7.01

TYPE I CHOLEDOCAL CYST. LAPAROSCOPIC RESECTION AND HAND SEWN LAPAROSCOPIC ROUX EN Y BILIARY RECONSTRUCTION

Jarufe, Nicolas; Escalona, Alex; Guerra, Juan Francisco; Martinez, Jorge

Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Chile

The development of laparoscopic surgery has allowed incorporating this technology to the surgical treatment of diverse pathologies. Todani's type I choledocal cyst are rare in adults. The most optimal treatment consists of its complete resection and the drainage of the normal biliary duct to the intestine through a Roux en Y reconstruction. This video shows a resection of a type I choledocal cyst in a 32 years old woman with previous cholecistectomy. The video demonstrates the procedure, technique and biliary reconstruction in a Roux en Y loop with hand sewn laparoscopic hepatico-yeyunal anastomosis.

FV 7.02

BILIO-ENTERIC RECONSTRUCTION ACCORDING TO HEPP-COUINAUD TECHNIQUE

Nuzzo, Gennaro; Giuliante, Felice; Vellone, Maria; Ardito, Francesco; D'Acapito, Fabrizio; Giovannini, Ivo

Catholic University-School of Medicine, Hepato-Biliary and Digestive Surgery Unit, Rome, Italy

Background. Major bile duct injury at cholecystectomy may involve critical problems, which include early diagnosis and treatment, treatment of secondary complications, and choice of a biliary reconstruction offering the best long-term oucome. Our preference is for the Hepp-Couinaud operation.

Objective. The video shows this type of reconstruction in a 29-yr old female patient, referred with obstructive jaundice after laparoscopic cholecystectomy, with complete stenosis of the common bile duct (Bismuth type 3).

Method. The Hepp-Couinaud operation was performed at day 16 after cholecystectomy, with a preoperatively positioned percutaneous biliary drainage in place. The video details the main surgical steps: right subcostal incision extended to the left; identification of structures of the hepatic pedicle, and of surgical clips on the transected biliary stump; careful access to the hilar plate, lowering of the hilar plate with identification and preparation of the biliary confluence and the left hepatic duct; incision of the biliary confluence and of the left hepatic duct to obtain a 3-cm wide anastomosis; preparation of a 70 cm jejunal loop for Roux-en-Y bilio-enteric reconstruction; final anastomosis with a posterior and an anterior monolayer row of interrupted reabsorbable sutures.

Results. The postoperative course was uneventful.

FV 7.03

LAPAROSCOPIC CHOLECYSTECTOMY IN TWO PATIENTS WITH SITUS INVERSUS TOTALIS

Rajasekar, Arthanari

Sri Gokulam Hospital, Department of Surgical Gastroenterology, 3/60 Meyyanur Road, Salem, India

Background. Laparoscopic cholecystectomy is one of the commonest laparoscopic procedure performed through out the globe. Occasionally patient with situs inversus will require, laparoscopic cholecystectomy. We discuss the surgical difficulties encountered and how they were overcome in two such cases. Case Presentation: A 34 years female patient a known case of situs inversus presented with features of biliary colic. Ultrasonography of the abdomen confirmed cholelithiasis and thickened gallbladder wall. Another 56 years female patient, a known case of situs inversus presented with features of chronic calculous cholecystitis, ultrasonography of the abdomen showed a contracted gallbladder with gallstones. Laparoscopic cholecystectomy was performed in both patients without any complications. All the laparoscopic theatre equipments were placed on the left side of the patient. The ports were inserted in the usual way on theleft side (10mm port subumblical, 10mm port left subcoastal along midclavicular line, 5mm port left subcoastal more laterally and 5mm epigastric port). The epigastric port was used to retract the hartman's pouch and the medial most subcoastal port for dissection and the lateral most subcoastal port was used to retract the fundus.

Conclusion. Laparoscopic cholecystectomy can be performed safely in situs inversus patients, however care must be taken to re-arrange the equipment setup in theatre and to reorganize the mirror image anatomy.

FV 7.04

POST LAPAROSCOPIC CHOLECYSTECTOMY BILIARY STRICTURE WITH PORTAL BILIOPATHY- A SURGICAL CHALLENGE!

KANCHUSTAMBAM, SUBBA RAO¹; sainath, Brundavan²; samal, subhash³; puppala rao, padma⁴

¹APOLLO HEALTH CITY, HPB& LIVER TRANSPLANT SURGERY, HYDERABAD, India; ²apollo health city, HPB and Liver transplant surgery, hyderabad, India; ³apollo health city, gastroenterology and hepatology, hyderabad, India; ⁴apollo health city, anesthesiology, hyderabad, India

Introduction. Benign biliary stricture following laparoscopic cholecystectomy is not an uncommon problem. Portal biliopathy is another benign entity related to portal hypertension induced bile duct changes and presenting as cholangitis and choledocholithiasis due to biliary obstruction. Patient presenting with both problems is a difficult and challenging for the treating team. Here in we present case that has portal hypertension and post cholecystectomy biliary stricture and how we managed surgically.

Materials and Methods. 24yrs female had a Lap cholecystectomy when she was 17yrs. She presented with cholangitis two yrs later. Since then she was managed by placing stents (5 times) across a tight stricture at common hepatic duct as well as right hepatic duct. Left duct stones extracted twice. CT abdomen revealed right lobe atrophy with left lobe hypertrophy with portal vein replaced by portal cavernoma with two stents in situ. Endoscopy demonstrated grade 3 varices.

Operative Findings. There were dense adhesions between omentum and porta. Multiple clips around the cystic duct and bile duct area were found along with large collaterals. Tight stricture was found at the junction of cystic duct and common hepatic duct along with dilated left duct and pin hole at the opening of right duct.

Procedure. 1st stage –mesocaval shunt using right internal jugular vein 2nd stage – roux en y hepaticojejunostomy.

Conclusion. Portal biliopathy along with cholecystectomy induced biliary stricture is a challenge to the surgeon. It can be managed safely in staged procedure.

FV 7.05

POST CHOLECYSTECTOMY MIRIZZI SYNDROME ¡V LAPAROSCOPIC MANAGEMENT

Lo, Xina; Lee, K.F.; Ng, Wilson W.C; Fok, K.L.; Ng, Nancy C.; Mak, Nerissa O.S.; Wong, John; Lai, Paul B.S.

The Chinese University of Hong Kong, Department of Surgery, Hong Kong, Hong Kong

Background. Cystic duct remnant after cholecystectomy occasionally enlarged and have new form stones within, but this usually occur years after the primary surgery and that most of them present as incidental findings or pain and rarely have biliary obstruction as a feature.

Case Report. We report an unusual case of a 45 years old gentleman who had an uneventful laparoscopic cholecystectomy elsewhere for symptomatic gallstones two months before presentation. He was referred for further management of persistent right upper quadrant pain and deranged liver function of obstructive pattern after operation. He had ERCP done at the primary hospital and was told to have impacted common bile duct stone but could not be removed endoscopically. Subsequently further ERCP was performed in our hospital and a 2cm stone was found to be impacted at an enlarged cystic duct remnant, which was also compressing against the common duct, causing Mirizzi syndrome. Stone removal failed once again despite successful cannulation of the cystic duct remnant and a stent in common bile duct was inserted for drainage. Laparoscopy with original aim for cystic duct remnant excision was performed. Cystic duct remnant was found to be relatively small. The stump was opened with the culprit stone milked out and then repaired. Patient¡∣s liver function normalized soon after the operation and his pain was much improved. He was discharged on post operation day 2. Three weeks after operation, the stent inserted was removed via ERCP and he had remained asymptomatic.

Conclusion. This case demonstrated that in experienced hands and with good pre-operative assessment, laparoscopic approach is a safe and effective way to tackle post-cholecystectomy cholelithiasis within cystic duct remnant, and previous surgery does not prohibit subsequent laparoscopic intervention.

FV 7.06

Mirizzi Syndrome Laparoscopic Treatment

Pekolj, Juan; Fernandez, Diego L; Salceda, Juan; Bregante, Mariano; Pfaffen, Guillermo; Ardiles, Victoria; de Santibañes, Eduardo

Hospital Italiano Buenos Aires, HPB and Liver Transplant Unit, Buenos Aires, Argentina

Background. Mirizi′s Syndrome is a rare complication of a long standing cholelithiasis. Many surgical approaches of varing complexity have been advocated for treatment. Minimally invasive surgery has been used for many other procedures and it could be feasible to resolve different types of this syndrome. Objetive: to show two Mirizzi′s Syndrome type II cases resolved by laparoscopic approach.

Population and Methods. Case one is a female 73 year-old patient with abdominal pain and jaundice; Ultrasound showed a cholecystitis with a gallstone impacted at the infundibulum and intrahepatic duct dilatation. Case 2 is a male 82 year-old with abdominal pain and jaundice; the CT scan and MRI showed gallbladder dilatation with a gallstone and intrahepatic duct dilatation.

Results. Both patients were approached by laparoscopy, first case was resolved doing a subtotal cholecistectomy and laparoscopic closure; second case II was resolved performing a laparoscopic hepaticojejunostomy; Both patients were discharged at 3 and 4 day respectively without postoperative complications.

Conclusion. Mirizzi′s syndrome sometimes can be anticipated on the basis of preoperative staging, and often is diagnosed or confirmed during the procedure. Subtotal cholecystectomy and simple closure with secure intraperitoneal drain appears to be a safe option for these patients, also a hepaticojejunostomy could be performed when the closure is not safe because the local conditions.

FV 8.01

GIANT HEPATIC HEMANGIOMA: LAPAROSCOPIC ENUCLEO-RESECTION

Pret, Francesco; Nitti, P; Dalla Serra, G; Sebastiani, R; De Luca, R; Prete, F

University of Bari School of Medicine, Department of Surgery, Bari, Italy

Background. Hepatic hemangiomas (HH) are candidates to surgical treatment when symptomatic, rapidly growing, suspect for malignancy or complicated. Enucleation is an alternative option to the formal hepatic resection. We present the laparoscopic enucleation of a giant HH.

Patient and method. The patient is a 29-year-old woman, with a 10-cm HH of the left lobe causing subcontinuous epigastric pain exacerbated by physical activity. By laparoscopy with four ports, after preparing for an eventual Pringle manouver, we incise the Glisson capsule near the mass margin, and identify the narrow cleavage between the compressed parenchyma and the angioma capsule. An accurate dissection is performed along this plane, up to close and section the vessels of the so-called hilum of the angioma. When the enucleation is almost complete another small nodule isseen posteriorly, and a small portion of hepatic parenchyma is resected.

Results. The postoperative recovery was uncomplicated and our patient discharged in V postoperative day. Histology revealed HH and a small focus of nodular hyperplasia.

Comment. The enucleation of HH reduces the sacrifice of liver parenchyma. Size and location of HH influence the decision towards the most appropriate treatment. In selected cases enucleating a large HH is feasible by laparoscopy and well tolerated.

FV 8.02

SURGICAL TREATMENT OF RECTAL CANCER WITH BILATERAL, MULTIPLE LIVER METASTASES. STAGED HEPATECTOMY WITH PORTAL EMBOLIZATION

Figueras, Joan¹; Codina-Barrera, Antoni¹; Lopez-Ben, Santi¹; Albiol, Maite¹; Farres, Ramon²; Pardina, Berta³; Codina-Cazador, Antoni²

¹Department of Surgery, Division of hepato-biliary-pancreatic surgery, Girona, Spain; ²Department of Surgery, Division of colorectal surgery, Girona, Spain; ³Hospital Trueta, Department of anesthesiology, Girona, Spain

Surgery represents the only chance of cure for patients with colorectal liver metastases (CLM). However, most patients with synchronous CLM will present with huge multiple unresectable disease. Those patients considered unresectable can be rescued and made resectable by neo-adjuvant chemotherapy. Synchronous CLM can be treated either simultaneous (the primary tumor and the liver metastases in the same operation) or sequential surgical procedures. In recent years important advances have been made in surgical treatment of colorectal liver metastases (Portal embolization, staged hepatectomy and thermal ablation). However, the timing of surgery and applied strategy is still not well defined.

Clinical Case We present a patient with obstructing rectal cancer and synchronous 11, huge, multiple, bilateral CLM. An expandable metallic wall stent was introduced to relieve obstruction in the primary and upfront aggressive systemic chemotherapy (Folfiri + Bevacizumab) 8 cycles was initiated. As significant radiological downsizing of CLM was achieved, we proceed with the staged surgical treatment. Our strategy in the first stage was metastasectomy of 3 CLM in the left liver and radiofrequency ablation of another CLM, as well as lymphadenectomy, intraoperative right portal embolization, and resection of the primary was also performed. Two months later a right hepatectomy (2nd stage) was performed with the “extraglissonian approach” stapling of the right pedicle and using the “hanging manoeuvre”. The histopathology confirmed a pT3, pN1 rectal adenocarcinoma, as well 11 CLM and one positive hilar pedicle lympha node. Adjuvant chemotherapy was continued with the sa me schema used preoperatively. Eighteen months after the 2nd staged hepatectomy the patient is alive and disease free.

Conclusion. This clinical case demonstrates that surgical R0 resection can be achieved in patients with rectal cancer and multiple, huge, bilateral CLM even in the presence of extrahepatic disease.

FV 8.03

LIVER RESECTION IN PATIENTS WITH UNILATERAL BILE DUCT CYST TYPE V (CAROLI′S DISEASE)

Lendoire, Javier; Kohan, Gustavo; Quarin, Carlos; Raffin, Gabriel; Duek, Fernando; Barros Schelotto, Pablo; Imventarza, Oscar

Hospital Dr Cosme Argerich, Liver Transplantation Unit, Buenos Aires, Argentina

Liver resection is the best curative option for patients with unilateral symptomatic Caroli′s disease. First case is a 71 year old male whose initial symptom was right upper quadrant pain. CT scan and MRI cholangiography demonstrated left dilated intrahepatic ducts with hepatolithiasis. Surgical approach was done by a midline incision. Intraoperative ultrasound confirmed the unilateral involvement of the biliary tree. A left lateral sectionectomy, cholecistectomy and bile duct exploration was performed. Patient was discharged at 7th postoperative day. Second case is a 39 year old female that presented with episodes of cholangitis that respond to medical treatment. A previous cholecistectomy was performed 4 years ago. Diagnostic imaging showed dilatation of the left bile duct with hepatolithiasis. The surgical approach was a subcostal incision with midline extension. No differences with previous imaging were found on the intraoperative ultrasound. Left hepatectomy was performed. Patient was discharged at the 5th postoperative day. No patient required blood transfusion. There was no recurrence at follow up in both patients. Comments: In our series of 11 patients with Caroli′s Disease a predominance of males with unilateral and left localization was found.

FV 8.04

RECONSTRUCTIO OF MIDDLE HEPATIC VEIN TRIBUTARIES DRAINING SEGMENT V AND VIII OF RIGHT LIVER GRAFT WITH RECIPIENT'S OWN MIDDLEHEPATIC VEIN

Tashiro, Hirotaka; Itamoto, Toshiyuki; Ohdan, Hideki; Amano, Hironobu; Oshita, Akihiko; Ishiyama, Kohei; Asahara, Toshimasa

Hiroshima University, Surgery, Hiroshima, Japan

Background. A right liver graft lacking the middle hepatic vein can cause congestion of the anterior segment in living donor liver transplantation. Various solutions designed to overcome this problem have been reported, including a right liver graft with the reconstruction of the middle hepatic vein tributaries using various interposition vein grafts.□@Method: The recipient hepatectomy was completed with preservation of middle hepatic vein tributaries. In the right-liver living donor transplantation, the middle hepatic vein tributaries draining segments V (V5) and VIII (V8) of a right lobe graft were reconstructed with the recipient□fs own middle hepatic vein. When the recipient□fs middle hepatic vein is too short for reconstruction of the V5, the recipient□fs right or left hepatic vein which was harvested ex vivo from recipient liver was used as an interposition graft between the V5 of the liver graft and the recipient□fs middle hepatic vein.

Results. These techniques were used in 11 branches of V8 and 11 branches of V5 among 16 patients. The 2-month patency rate of the V8 and V5 reconstructed were 100% and 88%, respectively. All liver transplant patients that underwent these operations are alive.

Conclusions. The use of the recipient□fs own middle hepatic vein is a suitable option for reconstructing middle hepatic vein tributaries (V8 and V5) in right-liver living donor transplantation.

FV 8.05

DISSECTION OF THE SUPERIOR MESENTERIC ARTERY (SMA) AS THE FIRST STEP OF PANCREATICODUODENECTOMY.

Dargan, Puneet; ADHAM, Mustapha; PARTENSKY, Christian

Edouard Herriot Hospital, Department of HPB Surgery, Lyon, France

The video demonstrates dissection of the SMA as the first step of pancreaticoduodenectomy. The patient had a space occupying lesion in the head of the pancreas. Preoperative investigations included angio-MRI which showed a replaced right hepatic artery originating from the SMA. After a bilateral sub costal incision, the hepatic flexure of the colon is mobilized. The Kocher's manoeuvre is performed with full mobilization of the duodenopancreas beyond the left margin of the aorta. The origin of the SMA is progressively dissected free and encircled by sectioning the right nervous mesenteric hemi-plexus. Common hepatic duct is also encircled and satellite lymph nodes are resected and sent for frozen section. The right abnormal hepatic artery is encircled and dissection is continued towards its origin from the SMA with resection of lymph nodes which are also sent for frozen section. The retropancreatic segment of SMA is progressively freed by sectioning the pancreaticodudoenal superior and inferior arteries. The portal vein and mesenterico-portal junction are progressively exposed by careful dissection from the SMA. At our Institute pancreaticoduodenectomy is performed with the SMA approach. The advantages of the technique include a radical relevant lymphadenectomy, prevention of point of no return at any time during the procedure and facilitation of preservation of a replaced right hepatic artery and resection of the portal vein when indicated.

FV 8.06

ROBOTIC MICRODISSECTION OF THE HEPATIC HILUM

Jaydeep, Palep

"Misericordia" Hospital, International School Of Robotic Surgery, Via Senese 169, Grosseto, Italy

Robotic assisted surgery overcomes the limitations of standard laparoscopy techniques by giving us 3D stable vision, accuracy of dissection and a fixed operating field which transforms the procedure in to a bench-like microsurgery. The main advantages being the improved quality of dissection of the portal pedicle avoiding a Pringles manouver and the possibility to recognise accurately the anatomical variants which help avoid bile duct and vascular injuries. In this video we have shown three examples of difficult hilum dissections dealt with robotic surgery.

FV 8.07

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH SPLEEN PRESERVATION

Jureidini, Ricardo¹; penteado, sonia²; Abdo, Emilio E²; Sorbello, Mauricio²; Cunha, Jose EM²; Cecconello, Ivan²

¹University of sao Paulo, Gastroenterology, Sao Paulo, Brazil; ²

Division of pancreatic parenchima, vein and artery are difficult procedures during laparoscopic surgery and demand the use of expensive devices. Further, some authors attribute higher incidence of pancreatic fistulae to its division with stapler. To avoid these problems we developed an approach to the splenopancreatic area by dividing the short gastric vessels, the splenocholic ligament and the connective tissue behind the pancreas. After this laparoscopic dissection we perform a small median laparotomy (10 cm) to extract from the cavity the spleen, tail and body of the pancreas. The splenic artery and vein can be easily divided in conventional manner. The pancreatic parenchima is also transected with a sharp blade and the pancreatic duct and vessels can be gently ligated. This Laparoscopic assisted approach is a technically simple procedure for the treatment of distal pancreatic lesions and reduces its costs.

FV 8.08

SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY

Rao, Prashant¹; Rao, Sonali¹; Rane, Abhay²

¹Mamata Hospital, Mumbai, India; ²East Surrey Hospital, Redhill, United Kingdom

Since the advent of Laparoscopic Surgery in the 1980's, laparoscopic cholecystectomy has rapidly become the gold standard for the treatment of symptomatic cholelithiasis. In the last decade, surgeons have pushed the frontiers of technology to apply the laparoscopic technique to various abdominal surgeries. Standard laparoscopic techniques for cholecystectomy have consisted of the four port technique with various modes of triangulation in the French or the American technique. Traditionally laparoscopic ports work on the concept of one instrument per port and this has necessitated the use of four ports and four incisions for the completion of the procedure. Innovative surgeons have tried reducing the ports and have reported cholecystectomies using three and in some cases even two ports. Recently the pressure to perform NO SCAR surgery has culminated in the reporting of a few cases of natural orifice surgery. There has been no reported case of transabdominal single port cholecystectomy using three standard laparoscopic instruments and their modifications. The development of the R port of Advanced Surgical Concepts has made this possible. The R port is an innovative port that allows the ingress of three instruments through a single port. Using the single R port through the umbilicus makes this surgery almost scarless. After all the umbilicus is an embryonic natural orifice. We present a video of one in a series of a few single port cholecystectomies done using the R port through the umbilicus. We used bent instruments, the Endo-eye and modified clip appliers to prevent the chopsticks effect of three instruments through a single port. The video depicts how the instruments were modified to make the procedures feasible and the difficulties encountered and how they were overcome, besides demonstrating the technique of single port surgery. Single port laparoscopic cholecystectomy appears to be a feasible procedure and can be done in a scarless fashion through the umbilical cicatrix without the need for extra ports.

Free Poster abstracts

PP 1.01

JUVENILE HEPATOCELLULAR CARCINOMA ASSOCIATED WITH FAMILIAL POLYPOSIS COLI

Oida, Takatsugu¹; Mimatsu, Kenji¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. It is well known Familial adenomatous polyposis (FAP) patients develop malignant tumors in colon and rectum, but also in other organs such as thyroid grand, adrenal grand, duodenal papilla, stomach and so on. The other hand, juvenile hepatocellular carcinoma (HCC) without hepatitis infection is rare. Extracolonic malignancy on liver such as HCC associated with FAP is extremely rare. Therefore, we present a case of a 23-year-old man who had HCC after total colorectomy for FAP.

Case Report. A 23-year-old man was admitted to our hospital with hepatic tumor. No abnormality was found by physical examination and laboratory functioning data were within the normal range. Virological study revealed hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb) and hepatitis C virus (HCV) were negative. Serum level of alpha-fetoprotein (AFP) was normal range, and paraneoplastic syndrome (PNS) did not exsit. He underwent total colorectomy five years ago due to FAP. Family history were as follows. His mother underwent sigmoidectomy due to sigmoid colon cancer and his sister also underwent total colorectomy due to FAP. Ultrasonograpy (US) revealed hypoechoic solid mass measureing 40 mm on the surface of segment 7–8 in the hepatic right lobe. Magnetic resonace imaging (MRI) showed the tumor with a low signal intensity on a T1-weighted image and a slightly high intensity on a T2-weighted image. Hepatic arteriograhy revealed tumor vessels and pooling. Under Pringel maneuver, partial hepatic resection was carried out. Pathological examination of surgical specimen revealed a 4.0 □∼4.0 □∼3.3 cm tumor, showed moderately differentiated hepatocellular carcinoma.

Conclusion. It is suggested that HCC is one of the manifestation of oncogenicity in FAP.

PP 1.02

PROGNOSTIC FACTORS OF CURATIVE RESECTION IN HEPATOCELLULAR CARCINOMA: AN ANALYSIS OF 163 PATIENTS CONCERNING THE SIGNIFICANCE OF BODY MASS INDEX.

Okamura, Yukiyasu; Maeda, Atsuyuki; Ishii, Hiromichi; Kanemoto, Hideyuki; Matsunaga, Kazuya; Uesaka, Katsuhiko

Shizuoka Cancer Center Hospital, Hepato-Biliary-Pancreatic surgery, Sunto-Nagaizumi, Shizuoka, Japan

Background. The incidence of obesity has been increasing in Japan as well as Western countries. Epidemiological studies have shown that obesity is a risk factor for carcinogenesis of hepatocellular carcinoma (HCC). Although many reports showed some prognostic factors related to the survival of patients following curative resection for HCC, no documentation concerning the impact of obesity on survival have not been presented to date. In this study we analyzed how obesity affected the survival of HCC after surgery.

Patients and Methods. One hundred sixty-three patients who underwent curative hepatectomy for HCC in our hospital between September 2002 and June 2007 were enrolled in this study. The twenty preoperative, operative, and pathologic variables were analyzed retrospectively to identify the factors that might significantly affect the disease-free survival and overall survival. The body mass index (BMI) factor was assigned to three groups: BMI less than 19, BMI 20 to 25, BMI more than 25.

Results. The cumulative overall three-year survival rate was 76.3% and the disease-free rate was 31.8%. Multivariate analysis identified four independent prognostic factors for overall survival: tumor grade (poorly differentiated), BMI (less than 19), blood transfusion(+), and satellite nodule(+), and five independent risk factors for tumor recurrence: UICC-Stage(IIIA, B), microscopic vessel invasion(+), cirrhosis(+), satellite nodule(+), and past history of HCC treatment(+).

Conclusion. Present data showed that the cumulative overall survival rate after curative hepatectomy for HCC, but not the disease-free survival rate, was significantly lower in patients whose BMI were less than 19. This data suggested that low BMI was a new prognostic factor for HCC after surgery. Since our number of patients and follow up period are still limited, further study is needed.

PP 1.03

TREATMENT OF RUPTURED HEPATOCELLULAR CARCINOMA

Kuboi, Youichi¹; Oida, Takatsugu¹; Mimatsu, Kenji¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukase, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background and Aim. Spontaneous rupture is a life-threatening complication of hepatocellular carcinoma (HCC). Liver failure is the main cause of death. Debates still remain on the most appropriate treatment in such patients because of the high operative mortality of emergency surgery and the high risk of rebleeding and less satisfying mid- and long-term results of non-operative procedures like angiographic embolization. The objective of this study was to evaluate the outcome of different treatment strategies.

Patients and Method. A retrospective study of 25 patients with ruptured of HCC was conducted. Three patients underwent emergency surgery and 19 patients urgent transcatheter arterial embolization (TAE) and 3 patients conservative therapy at the onset.

Results. Two of 3 patients of conservative therapy, chemoembolization was performed, and these patients survived 3 and 4 months of each. The other one was died. All cases of urgent TAE, hemorrhage was stopped, 8 of them were performed the surgery. They tolerated the operation, 3 month, 6 month, 1-year rates of survival were 63%, 50%, 13%. Remaining 11 cases were underwent non-surgical procedure, chemoembolization was performed in 6 patients and conservative therapy was in 5 patients. Hepatectomy was performed in 3 cases at onset, although, one patient died from hepatic failure after the surgery, remaining 2 cases were tolerated the surgery and survived 6 month and 28months of each.

Conclusion. Urgent TAE is should be a first step pf procedure, after controlling hemorrhage, only the case with good liver function should be undergo hepatectomy with minimally invasive surgery.

PP 1.04

REDUCTION SURGERY FOR MULTIPLE HEPATOCELLULAR CARCINOMA WITOUT SUFFICIENT HEPATIC FUNCTIONAL RESERVE

Oida, Takatsugu¹; Mimatsu, Kenji¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background and Aim. Resection of hepatocellular carcinoma (HCC) has become a safe operation with low operative mortality, and is the most effective treatment of HCC. However, intrahepatic recurrence after surgical resection for HCC is very common. Aggressive treatment of HCC increases patients□f survival, but frequently, patients are not suitable for surgery because of the multifocality of the tumor. Resectability depends on the number and location of the tumors and the volume of the functional remnant liver. We evaluated the efficacy of the reduction surgery with intraoperative radiofrequency ablation (RFA) for HCC patients without sufficient hepatic functional reserve, and with multiple intrahepatic lesions including intrahepatic metastasis and multicentric recurrence.

Patients and Method. Ten patients were underwent surgical reduction combined with RFA. Preoperative hepatic function reserve was evaluated by converted the indocyanine green retention rate at 15 min (ICG R15). All of the patients□f ICGR15 were over 18%, and the mean IGG15 was 21%. Two patients of them underwent resection of S6 + 7 segmentectomy with RFA, 4 patients S6 segmentectomy with RFA, 1 patient S8 segmentectomy with RFA,1 patient S7 + 8 segmentectomy with RFA,1 patient S2 + 3 segmentectomy with RFA,1 patient S2 + 3 +8 segmentectomy with RFA.

Results. There were no operative death. No surgical complications related to the procedure were observed. The 1-, 2-, 3-, 5-year survival rates were 80%, 60%, 30%, 30%.

Conclusion. Rescection combined with RFA provides a surgical option for the patients who is traditionally unresecrtable HCC, and may be increased long-term survival. Further progresses may improved the efficacy and extend the indications of surgical procedure in HCC.

PP 1.05

LAPARPSCOPIC HEPATECTOMY WITHOUT PRINGLE MANEUVER; Using LIFTING METHOD TO PREVENT PORTSITE AND PERITONEAL METASTASIS

Aramaki, Osamu¹; Oida, Takatsugu²; Kanou, Hisao²; Kuboi, Youichi² ; Amano, Sadao³; Kawasaki, Atushi²

¹Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background/PURPOSE: Laparoscopic liver resection has not become widespread due to technical problems, risk of air embolism, and possible tumoral spread, port site and peritoneal metastases. We provide a report of our procedure for laparoscopic partial hepatectomy preventing air embolization, port site and peritoneal metastases.

Methods. We performed laparoscopic partial hepatectomy in seven patients. For preventing air embolization, lifting method was performed. All patients were no required Pringl maneuver. Before parenchymal transecton of liver, we dicided the resection line at 2cm distant from tumoral edge by laparoscopic ultrasonography. The monopolar microwave coagulator(MC) needle was inserted along the resection line repeatedly. The average out put was 60W, and the duration was 40s. After the coagulation of the resection line by MC, parenchymal transaction was perfomed by ultrasonically activated coagulating shears(US). Left hepatic vein was sutured.

Results. Air embolism was not observed and blood infusion was no required in all patients. No port site or peritoneal metastases were observed.

Conclusion. Laparoscopic liver resection with MC and US is useful procedure preventing port site and peritoneal metastases without Pringl maneuver under lifting method.

PP 1.06

HEPATOCELLULAR ADENOMA WITH MALIGNANT TRANSFORMATION: A CASE REPORT

Jacobs, Michael¹; Malladi, Subramanyam²

¹Providence Hospital, Surgery, Wayne State University School of Medicine, Southfield, United States; ²Providence Hospital, Surgery, Southfield, United States

Background. Liver cell adenomas are rare benign tumors. Their incidence has increased since the introduction of oral contraceptives. The treatment of these lesions remains controversial. Some authors believe that liver cell adenomas are potentially premalignant lesions and could degenerate into a hepatocellular carcinoma. There are very few documented reports of this transformation.

Objective. We report a case of hepatocellular carcinoma arising from a hepatocellular adenoma.

Methods. and Results. A 54-years old female was referred to our institution for the evaluation of a liver mass detected by a CT scan. The patient had history of right upper quadrant pain for 6-months. Past medical history was significant for osteoporosis for which she received hormonal replacement therapy for 8 years. CT scan showed a solid mass lesion arising from right lobe of liver. MRI showed an exophytic lesion from liver with a pseudo-capsule and a central stellate scar. T1 weighted images showed intensity similar to liver. T2 weighted of the mass were hyper intense except for the scar. The alpha-fetoprotein level was normal. The patient was prepared for surgery based on the large size of this symptomatic mass. Intra-operatively the mass was found to be arising from the segment 5 and 6 of the liver. The left side of the liver was unremarkable. Cholecystectomy and partial right hepatectomy with resection of segments 5 and 6 was performed. Histopathology showed a hepatocellular carcinoma arising from a hepatocellular adenoma. The resection margins were free of tumor. Two years after the surgery the patient is symptom free and repeat CT scan has not showed any recurrence.

Conclusion. Malignant transformation of a hepatocellular adenoma is a rare phenomenon but it does occur. Close and prolonged follow up is necessary for all hepatic adenomas if a decision is made to forego surgical resection.

PP 1.07

IS THE OURCOME OF SURGICAL RESECTION OF HEPATOCELLULAR CARCINOMA LOCATED IN THE CAUDATE LOBE WORSE THAN THAT IN SEGMENT IV?

Jeng, Kuo-Shyang

Mackay Memorial Hospital, Surgery, Taipei, Taiwan

Background.

Surgical resection of HCC originating from caudate lobe of the liver is known as a challenging problem to surgeons because of the difficult anatomical location and a worse prognosis. Centrally located HCC, especially originating from Segment IV, is also a technique demanding in resection. The HCC in the two locations are similar in complexity.

Aims. To compare the late outcome of our surgical patients of than two group.

Methods. We compare a consecutive 36 patients with HCC located in caudate lobe and 24 patients with HCC originating from segment iv and analyze the demographic data, pathologic data, the course of operation, and postoperation surgical morbidity and the late outcome including recurrence, recurrence free interval, survival and death between the two groups.

Results. The significant differences of demographic data between the two groups include gender (p = 0.020), hepatitis (p = 0.018), AFP value (p = 0.009). The significant pathologic parameters include vascular invasion (p = 0.018) and encapsulation (p = 0.042). There is no significant difference of recurrence (p = 0.094) and its related death (p = 0.825).

Dicussion and Conclusion. From our study, the late outcome has no statistically significant difference between two groups. We recommend aggressive resection fro HCC located in caudate lobe is advisable if it is feasible.

PP 1.08

PROGNOSTIC FACTORS OF 10-YEAR SURVIVORS AFTER INITIAL TREATMENT FOR HEPATOCELLULAR CARCINOMA, DETERMINED IN 713 JAPANESE PATIENTS

TATENO, Taro¹; Ueno, Shinichi²; Sakoda, Masahiko²; Kubo, Fumitake²; Hiwatashi, Kiyokazu²; Shinchi, Hiroyuki²; Mataki, Yukou²; Kurahara, Hiroshi²; Natsugoe, Shoji²; Aikou, Takashi²

¹Kagoshima University, Surgical Oncology and Digestive Surgery, Graduate School of Medical and Dental Sciences, Kagoshima, Japan; ²Kagoshima University Graduate School of Medical and Dental Sciences, Surgical Oncology and Digestive Surgery, Kagoshima, Japan

Background. Hepatocellular carcinoma (HCC) is a relatively common malignant tumor worldwide, accounting for almost one million deaths annually. In the past two decades, some newly developed therapeutic options have been applied with varying degrees of success: i.e., hepatectomy, transcatheter arterial chemoembolization, and percutaneous ablation therapy. In recent years, liver transplantation also has been applied to patients with small HCC(s).

Objectives. To clarify the prognostic factors for long-term survival by studying the clinical factors of 10-year survivors after initial treatment for HCC and to discuss the timing of liver transplantation for HCC patients with hepatitis C virus (HCV) infection.

Methods. 713 Japanese patients who received over 10 years observation after initial treatment for HCC were selected. Differences in clinical factors between 10-year survivors and the remainder were studied. The multiple logistic regression model was used for multivariate analysis.

Results. Significant differences were noted between the groups in age, tumor number, vascular involvement, concordance of Milan Criteria (MC), Japanese tumor-node-metastasis stage, Child-Pugh stage (CP), HCV infection, serum a-fetoprotein level, and modality of initial treatment. Multivariate analysis showed that older age, out of MC, CP-B or -C, and initially treated other than by hepatectomy were independent risk factors for 10-year survival. If patients were within MC and CP-A, the overall 10-year survival rate of the patients initially treated by hepatectomy was 71% and 49% with HCV infection.

Conclusions. Younger patients with HCC within MC and CP-A can expect long-term survival, if surgically resectable. Hepatectomy should be recommended especially to HCC patients with HCV infection, if in these categories.

PP 1.09

SYSTEMATIC SUBSEGMENTECTOMY FOR HEPATOCELLULAR CARCINOMA

Kubota, Keiichi; Kita, Junji

Dokkyo University Hospital, Department of Gastroenterological Surgery, Tochigi, Japan

Systematic subsegmentectomy (anatomical resection) was developed to extirpate the total portal area containing a hepatocellular carcinoma (HCC) and tumor thrombi. During surgery, the portal branch bearing HCC is punctured under ultrasound guidance and 5 ml of indigocarmine dye is injected. The stained area is marked with electrocautery. Recently, a new technique with a fluorescence imaging system using indocyanine green is employed for determining the subsegment. Under Pringle□fs maneuver, the area is extirpated. This technique is applicable to patients with ICG15 less than 30%. Between April 2000 and March 2005, 56 patients with one HCC underwent this procedure without any mortality (Group 1), whereas 39 patients underwent non-anatomical resection (Group 2). The median operation time, bleeding amount and Pringle time of the 2 groups were 272 min and 285 min, 354 ml and 400 ml and 45 min and 39 min, respectively, without any significant differences. 36 of the 56 patients and 32 of the 39 patients had liver cirrhosis. Portal invasion was observed in 8 of the 54 and 7 of the 37, respectively. In Group 1, 15 of the 30 patients with recurrence underwent re-hepatectomy, w hereas 10 of 26 patients of Group 2 underwent re-hepatectomy. Overall 5-year survival rates and disease-free survival rates of the 2 groups were 71.5% and 46.1% and 28.5% and 14.1%, respectively. There was statistically significant difference in relapse-free survival rate between the two groups. In addition, uni-variate analysis showed that CLIP score, septum formation, portal invasion and defferentiation of HCC are significant prognostic factors for relapse-free survival. Although systematic subsegmentectomy is indicated to patients with better liver function, this procedure is considered superior to non-anatomical resection in terms of prolonging relapse-free survival time.

PP 1.10

APPLICATION OF MELD SCORE AND SERUM SODIUM CAN INDICATE THE EXTENT OF HEPATECTOMY FOR HEPATOCELLULAR CARCINOMA ON CIRRHOSIS

Cescon, Matteo¹; Cucchetti, Alessandro¹; Grazi, Gian Luca¹; Ferrero, Alessandro²; Viganò, Luca²; Ercolani, Giorgio¹; Zanello, Matteo¹; Ravaioli, Matteo¹; Capussotti, Lorenzo²; Pinna, Antonio Daniele¹

¹University of Bologna, Liver and Multiorgan Transplant Unit, Padiglione 25, Policlinico Sant'Orsola-Malpighi, Department of Surgery and Transplantation, Bologna, Italy; ²Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy

Background. The usefulness of MELD in indicating the maximum extent of hepatectomy for HCC on cirrhosis with the lowest risk of irreversible postoperative liver failure (IPLF) is unexplored.

Objective. To elaborate a model for end-stage liver disease (MELD)-based system to indicate the extent of hepatectomy for hepatocellular carcinoma (HCC) on cirrhosis.

Methods. 466 hepatectomies performed at two tertiary Italian centers between 1996 and 2006 were studied. Factors significantly affecting IPLF were used to create a decision tree for safe liver resection.

Results. IPLF developed in 23 patients (4.9%). MELD score (categorized as <9, between 9 and 10, and >10; P < 0.05 for all comparisons) and extent of hepatectomy were independent predictors of IPLF. In patients with MELD <9, IPLF rate was 0.4% (1/30 major hepatectomies; 0/197 other resections). In patients with MELD 9 to 10, IPLF rate was 1.2% (1/83) among resections of <1 segment, 5.1% (3/56) among segmentectomies or bisegmentectomies, and 11.1% (2/18) among major hepatectomies. In this category of MELD, serum sodium identified a low risk group (sodium ≥140 mmol/L), not experiencing IPLF (0/80; 11 major hepatectomies), and a high risk group (sodium <140 mmol/L), where resections of <1 segment led to an IPLF rate of 2.5% (1/40) and resections of ≥1 segment led to an IPLF rate >5% (P < 0.05). In patients with MELD >10, IPLF rate was >10% in all types of hepatectomies.

Conclusions. A simple algorithm based on MELD score and serum sodium can indicate the maximum tolerable extent of hepatectomy for HCC on cirrhosis.

PP 2.01

LAPAROSCOPIC LIVER RESECTION: EARLY UK EXPERIENCE

Alkari, Bassam; Owera, Anas; Ammori, Basil

Manchester Royal Infirmary, Department Of Surgery, Manchester, United Kingdom

Background & Aims. Advancements in surgical technique and technology have facilitated safe laparoscopic liver resection in selected patients. The aim of this study is to evaluate the feasibility and outcome of laparoscopic liver resection.

Methods. Patients with lesions situated in the anterior and left lateral segments were selected for laparoscopic resection. Data were collected prospectively.

Results. Between 2003 and 2007, 23 patients (11 males) with a median (range) age of 64 (30–83) years underwent 23 laparoscopic hepatic resections for colorectal metastases (n = 19) and other indications (n = 4). The resections included left hepatic lobectomy (n = 14), bi-segmental resections (n = 3), uni-segmental (n = 3) resections, and metastatectomy (n = 2). All procedures were completed laparoscopically. Estimated median (range) blood loss was 100 (25–500) and one patient received a total of two units blood transfusion. Postoperative complications were encountered in one patient (4.3 per cent), and there were no operative deaths. The median (range) post-operative hospital stay was 3 (1–14) days. The resection margins were clear in 14 of 18 patients with malignant disease; and at a median (range) follow up of 13.5 (5–36) months, 4 patients (22%) had disease recurrence and 16 patients (89%) remain alive.

Conclusions. In selected patients with lesions in the anterior and left lateral segments, laparoscopic liver resection is feasible, achieves adequate cancer resection, and is associated with smooth and rapid recovery. Long-term follow up data are required for oncological Results.

PP 2.02

LAPAROSCOPIC LIVER RESECTIONS IN A MULTIMODAL ‘FAST TRACK’ SETTING

Stoot, Jan; Van Dam, Ronald; Van De Poll, Marcel; Olde Damink, Steven; Bemelmans, Marc; Dejong, Kees

University Hospital Maastricht, Department of Surgery, Maastricht, Netherlands

Background. Laparoscopic surgical procedures have been popularized because of rapid recovery, short postoperative stay and cosmetic aspects. More recently, so-called multimodal Enhanced Recovery After Surgery (ERAS) programs have shown promising results in many open elective surgical procedures with respect to improved recovery and outcome. The added value of a fast track ERAS programme in laparoscopic liver surgery has hitherto not been explored.

Aim. This study was conducted to evaluate the added value of an ERAS programme for laparoscopic liver surgery for left sided lesions.

Methods. Patients treated in an ERAS programme with laparoscopic left-sided liver resections in the years 2005 to 2007 were included. The laparoscopic ERAS group was compared with historical data from consecutive patients using a prospectively collected database of laparoscopic liver resections. Primary outcome was length of stay. Secondary outcomes were complications, conversion, blood loss and duration of operation.

Results. Six patients were treated with laparoscopic liver resections (bisegmentectomy 2 and 3) in the ERAS programme (group I; 1 male, 5 females, median age 54 [range 34–82] years). Three laparoscopic procedures were performed before the ERAS programme from 2003–2005 (group II; 1 male, 2 female, median age 37 [26–70] years). Median length of stay was 6 [range 4–10] days in group I versus 8 [7–9] days in group II. There were two minor complications in the ERAS group compared with no complications in the historical group. There was one conversion in each group. Median blood loss was 75cc [range 50–200] in group I versus 250cc [range 50–750] in group II. Median operation time in group I was 119 [range 113–149] minutes compared to 182 [range 106–261] minutes in group II. There were no deaths.

Conclusion. This first fast track laparoscopic liver resection study ever conducted suggests that a multimodal enhanced recovery programme for laparoscopic liver surgery is feasible and probably reduces median length of hospital stay.

PP 2.03

LAPAROSCOPIC LIVER RESECTIONS

Juan, Pekolj; Salceda, Juan; Fernandez, Diego L; Bregante, Mariano; Mazza, Oscar; Ardiles, Victoria; de Santibañes, Eduardo

Hospital Italiano Buenos Aires, HPB and Liver Transplant Unit, Buenos Aires, Argentina

Background. laparoscopic liver surgery had had an important development in specialized centers, and laparoscopic liver resections are the most complex procedures in this area. Objectivs: to value the results of an initial experience of laparoscopic liver resections. Institution: Specialized HPB Surgery Section in a Private Hospital. Variables to measure: age, sex, pre and postoperative diagnosis, indications for resection, number size and localization of the lesions, procedure performed, pedicle clamping, technique of parenquimal section, operative and clamping time., associated procedures, conversion rate., postoperative stay, morbidity and mortality, long term results in malignant cases.

Results. In 24 patient we indicated laparoscopic liver resection. This is the 5.2% of all our resections in the same period. In 87,5 was by benign lesions, and in 12.5 by malignant tumors. Two patients (8,3%) were converted. The resections were minor in 21 cases and major in 1. Pringle maneuvere was performed in 50% of the cases. Mean operative time was 170 min, and the mean length of stay was 3 days. We had no mortality and only one postoperative bile leak self limited (4.1%). In all malignant patient a safety minimal margin of 1 cm was obtained.

Conclusions. laparoscopic liver resections performed by well trained surgeons, are safe and effective procedures for selected patients with benign and malignant liver lesions.

PP 2.04

SHORT-TERM AND LONG-TERM Results OF LAPAROSCOPIC OPERATIONS ON THE LIVER AT NON-PARASITIC CYSTS

Starkov, Yury; Shishin, Kirill; Solodinina, Elena

A.V.Vishnevsky Institute of Surgery, Endoscopic Surgery, Moscow, Russian Federation

Ninety nine patients with 169 non-parasiti c liver cysts were operated from 1992 till 2007. The age varied from 32 till 78 years (middle age was 63 years). Plural cysts were found at 32 patients and solitary-at 67. The size of liver cysts at this group of patients varied from 4 up to 18 cm (average size-10.6±2 cm (± SE). Complications occurred at 6 patients: 5 had cyst infection and 1- intracystic bleeding. Cyst fenestration and atypical liver resections were performed. The long liquid leakage on drainages within 5–7 days was marked in the postoperative period at 11 patients. The bile leakage from 300 up to 100 cc per day occurred in one case after atypical liver resection for the big cyst of 2, 3 and 4th segments and resolved spontaneously within 1 month. Average duration of the postoperative period was 9 days (from 4 days till 1 month). Liquid congestions in a residual cavity were observed at 4 patients and were successfully treated by a unitary puncture under the ultrasonic control. Long-term results from 1 to 10 years were observed at 45 patients with large cysts. Residual cysts at the operation cite were found in two cases in dorsal segments of the right lobe of a liver. Considering the absence of clinical signs the repeated intervention was not performed. Long-term experience shows, that laparoscopic treatment of non-parasitic liver cysts liver is accompanied by good results with small quantity postoperative complications and low rate of recurrences. Wide excision of protruding cystic walls with deepitelization of a residual cavity is the most widespread and effective operation. Laparoscopic atypical liver resections with excision of thin, partially sclerotic functionally defective sites areas of parenchyma is indicated at big and giant liver cysts. Laparoscopic punction and punction-drainage methods of treatment are auxiliary in addition to cystic excision. They provide radicalism of intervention at patients with plural liver cysts with intraparenchymal or dorsal location.

PP 2.05

METHODS of PARENHIMAL DISSECTION AND THE HEMOSTASIS AT LAPAROSCOPIC OPERATIONS ON THE LIVER

Starkov, Kirill; Shishin, Kirill; Solodinina, Elena

A.V.Vishnevsky Institute of Surgery, Endoscopic Surgery, Moscow, Russian Federation

Today laparoscopic technologies are one of actively developing directions of surgical hepatology, reflecting general tendencies of development of Surgery. The basic real approach to increase the safety of operations is prevention of the possible bleeding which is realized by precise manipulations with application of consecutive or simultaneous various methods of dissection of hepatic tissue and hemostasis on the incision line. Superficial liver areas (2–3 cm from a capsule) usually do not contain large vessels. Optimal tools to incise the parenchyma are ultrasonic scissors which provide reliable hemostasis. The additional hemostasis is achieved using various kinds of electrocoagulation. Methods of contactless coagulation (argonoplasmal, hydrothermal, spray) have obvious advantages. Safe dissection of deep liver areas means topical diagnostics and marking of large vessels by dynamic laparoscopic ultrasound for their précised allocation and their crossing after their clipping or sewing. The sufficient for crossing dissection of vessels from parenchyma is performed by destructor-aspirator, water-jet dissector, instruments or devices as Tissue-Link. The hemostasis is made using various variants of contactless electrocoagulation. Large veins are crossed with vascular staplers. Veins of moderate diameter (up to 3–4mm) can be crossed after processing by the device as LigaSure or clipping. Vascular isolation of a liver is not an obligatory stage of laparoscopic operations. Pringle method can be applied if uncontrolled bleeding occurs at segmentary resections for a period of maintenance of the reliable hemostasis. The experience of laparoscopic liver resections on 29 patients shows, that the combination of various techniques of parenchymal dissection and hemostasis allow to perform safe laparoscopic resections even at patients with a cirrhosis.

PP 2.06

MESOHEPATECTOMY FOR METASTASIS OF COLORECTAL CANCER

Visokai, Vladimir; Lipska, Ludmila; Levy, Miroslav

Thomayer Teaching Hospital, Surgical Department, Prague 4, Czech Republic

The only chance of a long time survival for patients with colorectal carcinoma is a surgical removal of all malignant tissues. TNM classification helps to predict the prognosis, but even patients in a very advanced stage of the disease can profit from an agressive surgical treatment. Large centrally located liver metastases are usually indicated for major liver resection e.g. extended right (segment 4,5,6,7,8)or left (segment 2,3,4.8) hepatectomy, or mesohepatectomy (segment 4,5,8). Mesohepatectomy is leaving the right and left segments in situ, preserving more functioning liver tissue. Mesohepatectomy is a seldom used, technically demanding procedure. A 54–year-old woman was operated for obstructive ileus in 1996. Obstruction was caused by a tumor of descending colon invading abdominal wall and the acute left colectomy with lymphadenectomy was performed. Microscopically 6 lymphatic nodes were positive. Patient was postoperativelly treated with adjuvant chemotherapy. Fifteen months later the patient underwent a resection of central hepatic segments (Couinaud′s segment IV +V + VIII) for metachronous metastasis 8cm large. At present the patient has no signs of recurrence, she has returned back to her normal life. Despite several unfavorable prognostic factors-obstruction, abdominal wall infiltration, number of positive nodes and centrally located metastasis with satelite lesions- the patient has been surviving 10 years since mesohepatectomy.

PP 2.07

AN APPROACH FOR THE SYSTEMATIC RESECTION OF ANTERO-SUPERIOR AREA: EXPOSING GLISSONEAN PEDICLES BY PRIOR DISSECTION OF THE MAJOR HEPATIC FISSURE

Honda, Goro¹; Baba, Hiroyuki²; Kurata, Masanao²; Tsuruta, Koji²

¹Tokyo Metropolitan Cancer and Infectious Diseases Center, Surgery, Komagome Hospital, Tokyo, Japan; ²Tokyo Metropolitan Cancer and Infectious Diseases Center, Surgery, Tokyo, Japan

Introuduction. Most hepatocellular carcinomas (HCC) invade the portal vein and form intrahepatic metastases at an early stage. Therefore, patients with HCC require a systematic resection (SR) of the liver containing the tumor. However, the antero-superior (AS) area is located in the center of the liver and Glissonean pedicles of the AS area are not visible from the liver□fs surface or hilum; therefore, it is difficult to ligate Glissonean pedicles of the AS area precisely before dissection of parenchyma of the liver, though this procedure is the most important step for the SR.

Methods. We performed the SR of the AS area with prior dissecting the major hepatic fissure and exposing Glissonean pedicles of the AS area in 9 HCC patients (8 men, 1 woman; mean age, 58.8 years; age range, 33–68 years; 4 chronic hepatitis B, 5 chronic hepatitis C) between December 1999 and December 2003. Two patients had another tumor involving another area; 1 patient also had an additional partial resection, while the other patient was given intraoperative radio-frequency ablation. We determined operation time, blood loss, postoperative hospital days, postoperative complications and prognosis and investigated the effects of venous congestion (outflow block) on antero-inferior area that are caused by transection of the drainage vein of this area interflowing to middle hepatic vein.

Results. The mean operation time was 311 minutes. The mean blood loss was 905 milliliters. The mean postoperative hospital days was 17 days. Postoperative complications included 4 cases of pleural effusion or ascites; there were no cases of bile leakage. The mean observation period was 46.4 months, and 8 patients (88.9%) had no recurrence. Atrophy of S5 parenchyma was seen on CT 6 months after operation in only 2 patients, but they never developed postoperative hepatic failure.

Conclusion. The SR of the AS area with this approach is considered safer and useful.

PP 2.08

USE OF NOVEL BIPOLAR RADIOFREQUENCY DEVICE FOR OPEN AND LAPAROSCOPIC HEPATIC RESECTION: INITIAL EXPERIENCE AND OUTCOME.

Espat, Joseph; Somasundar, Ponnandai

Roger Williams Cancer Center, Surgical Ocnology, 825 Chalkstone, United States

Background. A wide range of hepatic parenchymal devices is available at present and radiofrequency energy has been increasingly utilized in these technologies. In the present report, hepatic parenchymal trasection performed with the EnSeal device (SurgRx, Redwood, CA) was evaluated for postoperative bile leak, hepatic necrosis, or hemmorrhage.

Methods. Data was extracted from a prospective database of hepatobiliary surgical procedures maintained by the department; patient demographics, procedure, postop complications(< and >30 day) were prospectively collected. 6 total patients underwent hepatic resection with the Enseal bipolar radiofrequency device, (3 colorectal (CRC) metastasis, 1 adenoma, 1 hemagioma and 1 HCC; of these, 2 CRC metastases and the hemangioma were performed laparoscopically.

Results. procedures: 1 hemihepatectomy, 2 left lateral sections, and 3 atypical non-anatomic resections were performed. Estimated blood loss did not differ from standardized instituional historical control ( data not shown). No postoperative bile leaks were identified and no postoperative drainage was required in any of the 6 patients. Similarly. no postoperative hemmorrhage was observed and no patient clinically required transfusion. In the 30 day complication category no parenchymal abscess was noted and no patient demonstrated transection plane necrosis on routine 30 day postoperative imaging.

Discussion. In utilizing new technologies and devices, outcomes for common operations should be equivalent or superior to the standard approach. When evaluated for the specific anticipated and recognized complications of radiofrequency energy, the use of the EnSeal bipolar device performed without evidence of bile leak, abscess formation or change in < or > 30 complication rate.

Conclusion. While the use of a specific technique or device is largely predicated on surgeon preference, in this experience, the device performs to expected outcome standard.

PP 2.09

BILIO-JEJUNOSTOMY: AN OPTION TO TREAT NON RESPONSIVE CHRONIC BILIOMA FOLLOWING TRAUMA TO THE LIVER

Sharma, Pradeep¹; Sharma, ²

¹Bharati Vidyapeeth Medical College & Hospital, ²Department of Surgery, Dhankawadi, Pune, India

Background. Biliomas are one of the sequels following trauma to the liver. Most of the time these bilioma occur due to trauma to the minor biliary radicles. These biliomas respond to repeated aspirations and/or therapeutic ERCP and stenting of the common bile duct. However the biliomas can become recurrent if they involve major biliary radicle. Such large biliomas can also cause pressure atrophy of the liver affecting its functions.

Method. We present herewith a case of chronic recurrent bilioma following intrahepatic transection of the left Hepatic duct which was successfully treated with a Roux – en – Y Bilio Jejunal anastomosis. This was followed by complete disappearance of the bilioma as well as regeneration of the liver. We have not found any such mention in the literature.

Conclusion. Roux-en-Y Bilio Jejunal anastomosis can be a safe and easy option to treat chronic and recurrent biliomas occurring after liver trauma.

PP 2.10

TRANSECTION OF THE LIVER WITH A NEW RF-ASSISTED DEVICE, IN VIVO ESSAY WITH OPEN APPROACH IN A PIG LIVER MODEL

Navarro, Ana¹; Burdio, Fernando²; Berjano, Enrique³; Güemes, Antonio⁴; Sousa, Ramon⁴; Subira, Jorge⁵; Rufas, Maria⁴; Gonzalez, Ana⁶; Burdio, Jose Miguel⁷; Castiella, Tomas⁸; Tejero, Eloy⁴; De Gregorio, Miguel Angel⁹; Grande, Luis²; Lozano, Ricardo⁴

¹Hospital Clínico Lozano Blesa and Fundación Hospital de Calahorra, Department of Surgery, Zaragoza and Calahorra, La Rioja, Spain; ²Hospital del Mar, Department of Surgery, Barcelona, Spain; ³Polytechnic University of Valencia, Department of Electronic Engineering, Valencia, Spain; ⁴HCU Lozano Blesa, Department of Surgery, Zaragoza, Spain; ⁵HCU Lozano Blesa, Department of Urology, Zaragoza, Spain; ⁶Veterinary Faculty, University of Zaragoza, Department of Animal Pathology and Surgery, Zaragoza, Spain; ⁷University of Zaragoza, Dept of Electric Engineering and Communications, Zaragoza, Spain; ⁸HCU Lozano Blesa, Department of Pathology, Zaragoza, Spain; ⁹HCU Lozano Blesa, Department of Interventional Radiology, Zaragoza, Spain

Introduction. In hepatic surgery, both blood loss and transection time have shown to be main determinants of operative outcome. Some methods have been employed in order to reduce intraoperative blood loss. More recently, saline-linked radiofrequency technology has been described and evaluated for transection of the liver, main advantages being: Less blood loss during transection and a shorter transection.

Objective. A new radiofrequency-assisted device specifically designed for tissue thermocoagulation and division of the liver is described and compared with an state-of-the art saline-linked instrument in an in vivo pig liver model.

Material and Methods. The new radiofrequency-assisted device is a hand-held instrument that contains in a single embodiment: a blunt cooled-tip Coagulation System:A blunt uninsulated cooled-tip electrode and a Cutting System attached to the tip. Four pigs (47.6 kg) were usedto perform a total of 8 non-anatomical resections using either our new RF-assisted method (Group A) or saline-linked dissecting sealer –DS 3.0; Tissue Link Medical (Group B). Pringle maneuver was not performed and only these instruments were used for dissection, division and hemostasis. Transection time, Total blood loss, Transection area, Transection speed, Blood loss per transection area, Risk for Biliary leakage (methylene-blue test) and Tissue coagulation depth, were main variables considered and compared between groups.

	Group A	Group B	P*
Transection time (min)	11.95±2.48	21.02±6.61	0.006
Total blood loss (ml)	69.75±73.93	527.00±273.29	0.001
Transection area (cm2)	34.83±6.54	41.01±8.34	N.S.
Transection speed (cm2 /min)	2.97±0.39	2.06±0.51	0.002
Blood loss per transection area (ml/cm2)	1.82±1.56	12.85±6.14	0.001
Tissue coagulation depth (mm)	5.90±1.61	3.37±1.40	0.005

Results. All the pigs tolerated the procedures well and no relevant complications occurred. In group A both blood loss and and blood loss per transection area were lower (p = 0.001 than in group B (69.75±73.93 ml, and 1.82±1.56 ml/cm2 vs. 527.00±273.29 ml and 12.85±6.14 ml/cm2). Transection speed was 2.97±0.39 cm2 /min in group A and 2.06±0.51cm2 /min in group B (p = 0.002).

Conclusions. Our new RF-assisted device has shown to address parenchymal division and hemostasis simultaneously, saving both blood and transection.

PP 2.11

HOW TO PERFORM ANATOMICAL SUBSEGNENTECTOMY USING GLISSONEAN PEDICLE APPROACH

Yamamoto, Masakazu¹; Kotera, Yoshihito²; Ariizumi, Shun-ichi²; Takahashi, Yutaka²; Imai, Kenichirou²; Katagiri, Satoshi²

¹Institute of Gastroenterology, Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan; ²Institute of Gastroenterology, Department of Surgery, Tokyo, Japan

The liver can be divided into three segments according to the secondary Glissonean pedicles at the hepatic hilus. One secondary pedicle has 4 to 6 tertiary branches. The area fed by a single tertiary branch does not correspond to Couinaud□fs segment. We therefore refer to the area fed by a tertiary branch as a cone unit of the liver. We can easily approach the branches in the left segment because the tertiary branches can be seen along the umbilical portion without liver dissection. However, in the right segment, the tertiary branches can not be seen at the hepatic hilus. We therefore should clamp the secondary pedicles at the hepatic hilus and confirm the borderline between the segments. The tertiary branches from near the hepatic hilus can be approached after dissecting the liver parenchyma around the secondary pedicle. However, tertiary branches which originate from deep portions of the secondary branches cannot be approached from the hepatic hilus. Such deep branches can be approached after firstly dissecting the liver parenchyma on the borderline between the segments. We have performed over 2000 anatomical liver resections at our institute since 1980. Over half of these were anatomical resections smaller than one segment of the liver. Any type of anatomical subsegmentectomy can be achieved using this technique.

PP 3.01

RADIOFREQUENCY-ASSISTED LIVER RESECTION: MORE LIVER PRESERVATION, LESS BLOOD LOSS

Kilicturgay, A.Sadýk¹; Ozen, Yýlmaz²; Kaya, Ekrem¹

¹Uludag Universty Medical Faculty, HPB surgey, Bursa, Turkey; ²U.Universty Medical FAculty, HPB Surgery, Bursa, Turkey

Aim. The aim of this study was to assess the feasibility and safety of a novel concept for liver resection using a radiofrequency energy-assisted technique.Method.: Under intraoperative ultrasound (IOUS) guidance, a Cool-Tip RF probe is inserted into the liver parenchyma surrounding the tumor. A zone of coagulative desiccation is created around the tumor ensuring a 1-cm resection margin. Then, using a scalpel, the liver parenchyma is divided, and the tumor is removed with minimal blood loss. RF works by the conversion of RF waves into heat. Coagulative desiccation occurs and results in sealing of blood and biliary vessels.

Results. From January 2005 to July 2007, 127 radiofrequency-assisted liver resection (RF-ALR) (68 female, 59 male, mean age:58.6 (15–78) years old) were performed in our unit. RF-ALR was used in 53 cases with metastatic disease (colorectal, breast, pulmonary), 19 cases with primary liver tumor, 25 cases with liver hydatidozis, 22 cases with hemangioma. 55 of these cases had nonanatomic hepatectomies, 26 of the cases had hemihepatectomies (right or left), and 46 cases had segmentectomies, 7 cases had resection for more than 1 metastasis and 5 cases had reresections. The mean operation time was 145 min (range, 120–290 min), and only 12 (9.7%) patients needed blood transfusion, predominantly those were receiving major hepatectomy. All resections, except one, have been done without inflow occlusion of the liver even in the sirotic cases. Postoperatively, only 4 patients had billiary fistula and absess and right-sided pleural effusion was observed in 17 cases. Elevated AST and ALT levels returned to the normal with in the 2–7 days. There was no mortality.

Conclusion. The technique is safe and feasible, simplifies liver resection and appears to be associated with minimal morbidity and blood lose and maximum liver parenchyma preservation.

PP 3.02

RADIOFREQUENCY-ASSISTED HEPATIC PARENCHYMA RESECTIONS (RFR): IS THERE ANY REAL BENEFITS?

Ribeiro Jr, Marcelo A F¹; Condi, Gustavo¹; Fonseca, Alexandre Z²; Saad, William A¹

¹UNICID, PUC-sorocaba, Hospital Sao Luiz, Surgery, Sao Paulo, Brazil; ²Grajau Hospital, Surgery, Sao Paulo, Brazil

Introduction. Liver resections demand good surgical skills, since it is usually associated with important blood loss, specially in cirrhotic patients with poor coagulation parameters. It has been reported that for each blood unit transfused the risk of disease recurrence and death was increased by 5% and 7%, respectively. Thus, in order to reduce blood loss during surgery, several techniques were developed, including low central venous pressure anesthesia, continuous or intermittent hepatic pedicle clamping or total vascular exclusion. Nowadays, RFR has been often used by offering feasibility and efficacy in reducing those bleedings.

Objective. Analyze radiofrequency as an alternative way for hepatic parenchyma resections.

Methods. Literature systematic review based on Medline from 1997 to 2007.

Results. The authors describe RFR as a promising technique for hepatectomies in comparison to clamps, ultrasonic dissectors or stapling devices due to its capability of reducing the operative time, the postoperative morbidity, mortality and consequently increasing the survival rates. The main advantage achieved was the massive reduction of blood loss at the operative time, which contributes to the patients recover by avoiding common postoperative complications.

Discussion. It is estimated that 20% to 60% of the patients undergoing liver resections require blood transfusions, while the association between bleeding versus poor short survival is well established. Although the RFR was initially used for hepatic tumors resection in cirrhotic patients, it can be used in healthy parenchyma, once the time of application is shortened.

Conclusions. Currently, RFR has been referred as one of the most effective techniques for tumor resections, allowing positive impact in patients surviving rates. Future research must be performed to evaluate the best time of application of radiofrequency and the not totally known consequences of the heat injuries in the intra-hepatic biliary tract.

PP 3.03

GIANT LIPOMA OF HEAD OF PANCREAS- A CASE REPORT

Malladi, S.V. Subramanyam; Malladi, S.V. Subramanyam; Chang, Yeon-Jeen; Mittal, Vijay; Jacobs, Michael

Providence Hospital and Medical Centers, Surgery, Southfield, United States

Background. Mesenchymal tumors represent only 1 to 2% of all pancreatic tumors. Pancreatic lipoma was first described by Bigard and since then only five cases have been reported with histological confirmation.

Objective. We report a case of massive pancreatic head lipoma that mimicked a liposarcoma and required a pancreaticoduodenectomy.

Methods and Results. A 59-year-old male with a history of severe sinusitis, gastroesophageal reflux, and early satiety, was found to have an intraabdominal mass on a computer tomography scan of the thorax. The patient was not jaundiced and did not have evidence of pancreatitis. CAT scan of the abdomen revealed a 12 cm fat containing mass replacing the pancreatic head with areas of soft tissue density and internal striations suspicious for liposarcoma. MRI confirmed the above findings. The patient was prepared for surgery. Intraoperatively, a large fat containing mass was seen directly arising from pancreatic parenchyma, effacing the duodenum, and indistinguishable from the pancreas proper. On the inferior aspect of the pancreatic body a separate lipomatous mass was found, and its excision was necessary to identify the pancreatic neck and body. Intraoperative ultrasound revealed a 6 cm area of increased density in the central aspect of the pancreatic head mass, finding suspicious for liposarcoma. A Kausch-Whipple procedure was performed. Histopathology showed extensive replacement of the head of pancreas with mature adipose tissue extending into the pancreatic margins. Clear-cut pancreatic parenchyma was not detected, suggesting a massive lipoma of the head of pancreas.

Conclusion. Giant lipomas of the pancreas are rare tumors. Their clinical presentation is variable, however, resection is indicated if they are symptomatic or if they cannot be differentiated from malignancy.

PP 3.04

INFERIOR VENA CAVA LEIOMYOSARCOMA: A SURGICAL CHALLENGE

Andraus, Wellington¹; Medeiros, Raissa²; Azevedo, Mauricio A²; Haddad, Luciana B P¹

¹University of São Paulo School of Medicine, Department o f Gastroenterology, São Paulo, Brazil; ²

Background. Leiomyosarcomas of the inferior vena cava is a rare tumor. These tumors are seen more frequently in middle-aged women and have a favorable prognosis once completely resected.

Objective. The aim of this study is to relate a case of a patient successfully treated for extensive leiomyosarcoma of the vena cava with pancreas invasion.

Case Report. A 40-year-old woman presented with upper abdominal pain and progressive jaundice. Physical examination revealed only jaundice and obesity. Laboratory tests showed bilirrubine of 12 mg/dl, alkaline phosphatase of 1220 mg/dl and gama glutamil transferase of 367mg/dl. Computed tomography showed a high-density image in pancreas head and vena cava “thrombosis”. Laparotomy was performed and a large caval mass involving the renal veins, caudade lobe and pancreas head was seen. Vena cava, renal veins and all liver was dissected and repaired. Pancreas and duodenum was divided. Caudade lobe was divided of the liver. Vena cava was ligated 2 cm under hepatic veins and 5 cm under the renal veins, that was also cutted and all tumor was ressected in bloc. Venous reconstruction was undertaken only for the renal veins, using a PTFE prosthesis for a reno-renal vein anastomosis. A double loop reconstruction was used for pancreas and biliary tree. Pathologic examination confirmed a leiomyosarcoma with free surgical margins. The postoperative course was uneventful and the patient was discharged on postoperative day 12. The venous flow through the renal veins became normal, as confirmed by later Doppler ultrasound.

Conclusion. Treatment of inferior vena cava leiomyosarcoma remains a technical challenge. When complete caval obstructin is present, caval resection without any caval anastomosis is possible. Hepatic and pancreatic associated resection can be performed. Colateral vessels of left renal vein are often present in such cases, and the renal-renal vein anastomosis is an option to preserve the right renal vein drainage.

PP 3.05

DOES THE METHOD OF CLOSURE OF THE STUMP OF PANCREAS AFTER DISTAL PANCREATECTOMY AFFECT POSTOPERATIVE FISTULA RATE?

Gandhi, Manish¹; Bedi, Manmohan²; Ramesh, Hariharan¹

¹Lakeshore Hospital & Research Center, GI Surgery, Cochin, India; ²

Background. Postoperative pancreatic fistulas are common following distal pancreatectomy regardless of technique used Aim: to analyse whether the technique of pancreatic stump closure affected the postoperative fistula rate

Patients and Methods. 39 patients who underwent distal pancreatectomy for neoplasms were studied. Patients with chronic pancreatitis or those where drainage procedures were added were excluded. There were 19 males and 20 females (ages 27 to 69, median 46). Patients were grouped into three: a) sutured closure (closure with 0000 Prolene suture with duct closure) (n = 16); b) external pancreatic fistula using a 5/6 French tube (n = 9); and c) stapled closure using Endo GIA 60 or Echelon 60 stapler (n = 14). Fistula rates, hospital stay, readmission rate and other complications Parameter Sutured Ext drainage Stapled (group a) (group b) (group c) P value Number 16 9 14 Duration of drain placement (median) 8 5 4 <0.05 Hospital stay (days, median) 11 6 7 <0.05 Intra abdominal abscess 4 0 0 Readmission 2 2 0 Fistula 6 0 1 <0.05 Conclusion: Stapled closure had the lowest incidence of postoperative fistula and the lowest hospital stay.

PP 3.06

DIAGNOSIS AND TREATMENT OF HEMOSUCCUS PANCREATICUS: DEVELOPMENT OF ENDOVASCULAR MANAGEMENT

Lermite, Emilie¹; REGENET, Nicolas²; TUECH, Jean-Jacques³; MUCCI, Stéphanie⁴; LADA, Paul⁴; Arnaud, Jean-Pierre⁴

¹Chirurgie viscérale. CHU, Angers, France; ²CHU nantes, chirurgie viscérale, Nantes, France; ³CHU, Chirurgie viscérale, Rouen, France; ⁴CHU, chirurgie viscérale, Angers, France

Objectives. The purpose of this study was to analyze the diagnostic and therapeutic features of hemosuccus pancreaticus.

Methods. We reviewed our experience with management of 17 patients admitted to surgery or gastroenterology units for hemosuccus pancreaticus between 1981 and 2005. We studied symptoms, contribution of established morphological examinations (upper digestive endoscopy, computed tomography, and selective digestive angiography), and treatment.

Results. Fifteen men and two women with a mean age of 57 years presented hemosuccus pancreaticus. All the men had a history of chronic alcoholic pancreatitis. Thirteen patients (76.5%) presented overt digestive bleeding (5 melena, 2 hematochezia, 2 melena with hematochezia, and 4 hematemesis). The inaugural sign was anemia in 2 patients and epigastric pain another 2 patient. An upper digestive endoscopy was performed in 15 patients and visualized hemosuccus pancreaticus directly in 9 patients. Arteriography was performed in 16 patients (94.1%) and made the diagnosis in 14 (87.5%). Surgery was performed in 9 patients, after embolization in 2 patients. Embolization was performed in 9 patients and effective in 7 patients. Therapeutic abstention proved successful in 1 patient. There were no death and no recurrent bleeding.

Conclusions. Hemosuccus pancreaticus is a rare cause of digestive bleeding. Upper digestive endoscopy and angiography during active bleeding can provide the diagnosis. Most cases can be managed by angioembolization. However, in patients with recurrent bleeding or failed embolization, emergency surgery is required.

PP 3.07

MANAGEMENT OPTIONS IN SPLANCHNIC ARTERY PSEUDOANEURYSMS-A CRITICAL ANALYSIS AT A TERTIARY CARE REFERRAL CENTER

Johnson, Mariaantony1; Surendran, Rajagopal²

¹Govt. Stanley Medical College Hospital, SURGICAL Gastroenterology, Chennai, India; ²Govt. stanley Medical college hospital, surgical gastroenterology, shennai, India

Background. Haemosuccus Pancreaticus and Haemobilia are rare causes of obscure gastrointestinal bleeding.

Objective. To evaluate the safety, efficacy and clinical outcome of non-surgical and surgical treatment options for pseudoaneurysmal bleeding from visceral arteries with an intent to setup management guidelines.

Methods. Retrospective analysis of 16 patients treated for bleeding visceral artery Pseudoaneurysms (PAs) from 1998 to 2005.11 patients had bleeding PAS complicating pancreatitis, post-traumatic in two following blunt liver injury, and post-operative in 3 patients, following laparoscopic cholecystectomy in two and whipple's Pancreatoduodenectomy in one.

Results. Computed tomography revealed the bleeding PA in 53.8% (n = 7/13) patients and conventional angiography gave the correct diagnosis in 81.8% (n = 9/11). The mean (range) size of the P.A was 5.45 (2–10) cm. Angiography was undertaken in 11(68.75%) with Transcatheter angiographic embolization (TAE) attempted in 9 (81.8%) and achieving temporary hemostasis in 6(66.6%). Technical failure occurred in 3 (33.3%), secondary intra-abdominal sepsis in one(11.1%), rebleeding in one patient, respectively and were successfully treated by elective operation. Morbidity and rebleeding in the angiographic intervention group were 11.1% each respectively. Surgical morbidity was 41.6% with no rebleeding. No mortality in either group. Follow-up data was available for 14 patients without any recurrence of pseudoaneurysm or bleeding after a mean (range) follow-up of 26.3 (45–59) months.

Conclusion. TAE should be considered as the first line treatment of choice in all patients presenting with pseudoaneurysmal bleed after adequate resuscitation. Surgery should be reserved only for (i)actively bleeding lesions unsuitable for angioembolization with significant haemodynamic instability(ii)non-availability or failure of embolization(iii)secondary complications such as extrinsic compression or sepsis. Operation and TAE play complementary management roles.

PP 3.08

RADIO FREQUENCY ABLATION (RF) OF THE PANCREAS â_“ EFICIENCY AND SAFETY. AN EXPERIMENTAL STUDY IN A PORCINE MODEL.

Felekouras, Evangelos¹; Pikoulis, Emmanouil¹; Papalois, Apostolis¹; Agrogiannis, Georgios²; Pavlakis, Emmanouil¹; Prassas, Evangelos¹; Papaconstantinou, Ioannis¹; Petrou, Athanasios¹; Geranios, Aggelos¹; Bastounis, Elias¹

¹Laiko General Hospital, First Department of Surgery University of Athens, Athens, Greece; ²Laiko General Hospital, Pathology Department University of Athens, Athens, Greece

Background. The aim of our experimental study was to investigate the safety and efficacy of radiofrequency ablation of pancreatic tissue in a porcine model.

Material. Two groups of 6 animals were operated under general anesthesia. RF energy was applied to a pre-marked area of pancreatic head on the right side of portal vein. In group A, portal vein cooling during ablation was external, and in group B internal.

Method. Under full monitoring (PiCCO®) portal vein was catheterized via splenic vein with a pulmonary artery catheter, the tip being positioned to t he level of the hepatic pedicle. Ablation time was 12 min, using a 2 cm intra-cooling RF needle (TYCO®). The head of the pancreas was isolated and the needle electrode placed in it parallel and in proximity (0,5 cm) to the right side of the portal vein. Cooling was effective, as the intraluminal temperature of the vein never exceeded the core temperature. Blood tests were taken prior to operation and day 10, 20 and 30 postop. Euthanasia followed by necrotomy was performed to all animals. The entire pancreas was excorporated and undergone pathological study. The collected data were cautiously interpreted.

Results. All the animals suffered diarrhea and significant weight loss during the first week postop. Three out of them died during the 3rd week; the cause was ileus and kahexia in one, duodenum perforation in another, or generalized sepsis (multiple small liver abscesses) in the third. Two animals presented portal vein thrombosis, one presented mass formation in distal pancreas, were in another 2 a significant atrophy of the entire pancreas observed. Formation of abscesses in the sub skin fat tissue was estimated in 8 animals. Serum tests confirmed severe pancreatitis in all animals. Pathology of the pancreatic specimens is in process.

Conclusion. Radiofrequency ablation of the pancreas carries high postoperative morbidity and noteworthy mortality. Our experiment did not demonstrate safety and efficacy of the method.

PP 3.09

OUTCOME AND MANAGEMENT OF RUPTURED PANCRETICO-DUODENAL ARTERY ANEURYSMS

Lee, Minjae¹; Gerstman, Michelle¹; Burton, Paul¹; Lyon, Stuart²; Usatoff, Val¹; Evans, Peter¹

¹The Alfred Hospital, Monash University, Department of Surgery, Melbourne, Australia; ²The Alfred Hospital, Department of Surgery, Melbourne, Australia

Background. Pancreatico-duodenal artery aneurysms are an uncommon form of splanchnic artery aneurysm. Patients frequently present after rupture with major intra-abdominal haemorrhage or unexplained collapse and are associated with a high mortality rate. Diagnosis and management of this condition has proven to be challenging despite the use of advanced diagnostic and interventional modalities.

Methods. A retrospective review was conducted on reported cases of Pancreatico-duodenal artery aneurysm rupture at a tertiary institution.

Results. Five recent cases of pancreatico-duodenal artery aneurysm rupture were identified. Two of the cases resulted in patient mortality due to haemorrhage.

Conclusion. The risk of Pancreatico-duodneal artery aneurysm rupture is not associated with the size of the aneurysm. However due to the high resultant mortality associated with rupture, accurate diagnosis and expedient management of this condition is crucial. Therapeutic embolisation has evolved as the preferred management technique for most foregut aneurysms as they are not easily amenable to surgical intervention in the emergent setting. High-resolution Computed Tomography angiography and selective embolisation have improved the diagnostic and therapeutic options available for the treatment of this condition. Therefore the use of urgent Computed Tomography angiography is advocated in all patients with unexplained retroperitoneal or intraperitoneal haematoma. This can be followed by targeted embolisation with concurrent intensive monitoring and resuscitation. Nevertheless, should the advanced interventional radiology techniques fail then surgical intervention is the only remaining option.

PP 3.10

NONOCCLUSIVE SMALL BOWEL NECROSIS IN ASSOCIATION WITH FEEDING JEJUNOSTOMY AFTER ELECTIVE UPPER GASTROINTESTINAL SURGERY

Spalding, Duncan¹; Behranwala, Kasim²; Straker, Peter²; Thompson, Jeremy²; Williamson, Robin³

¹Hammersmith Hospital, HPB Surgery, Du Cane Road, London, United Kingdom; ²Royal Marsden Hospital, Department of Surgery, London, United Kingdom; ³Hammersmith Hospital, HPB Surgery, London, United Kingdom

Introduction. Nonocclusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population, and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals.

Methods. The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of an FJ for benign or malignant disease between 1997–2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ).

Results. Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no significant difference in incidence between routine NCJ (n = 5, 1.16%) and selective TJ (n = 1, 1.06%). Median rate of feeding at time of diagnosis was 105 (range 75–125) ml/h, and diagnosis was made at a median of 6 (range 4–18) postoperative days. All patients developed abdominal distension, hypotension and tachycardia in the 24 hr before re-exploratory laparotomy. Five patients died and one patient survived.

Conclusions. The understanding of the pathophysiology of NOSBN is too limited to recommend that enteral nutrition be withheld from patients except in those at high risk with an open abdomen, planned repeat laparotomies, or significant bowel oedema. Patients should be fully resuscitated before initiating enteral feeding and feeding interrupted in the face of haemodynamic instability, significant abdominal distension or feeding-related pain.

PP 3.11

NEW HIGH SPEED RADIOFREQUENCY SYSTEM IN THE LIVER ABLATION: A PRELIMINARY REPORT

Yao, Peng; Chu, Francis; Daniel, Steve; Morris, David

University of New South Wales, Department of Surgery, Sydney, Australia

Background. Radiofrequency ablation (RFA) is a relatively safe procedure proving local heating of the tissue and subsequent thermal necrosis of the tested tissue. RFA has been broadly used for unresectable liver tumours, however there are many important residual problems associated with currently available standard RFA. Current probes are only easily able to treat tumors of approximately 3 cm and often take over 20 minutes to produce a single 5 cm diameter sphere of ablatable tissue. High local recurrence and tract seeding is also the major drawback.

Aim. We have developed new high speed radiofrequency system for the liver ablation.

Methods. Study was approved by the local authority and patients were given consent preoperatively. 14 patients underwent tumor ablation followed by the surgical resection. After surgery the ablated tissue was opened and analysed, the ablation size was measured. The total ablation time was also recorded.

Results. No perioperative morbidity and mortality occurred. Three different size ablations were studieded: 3.5 cm diameter, 5 cm diameter, and 7 cm diameter. The average ablation size was 3.6±0.1 cm, 5.0±0.3 cm and 6.9±0.3 cm respectively, the ablation time was 3 min, 5 min and 12 min respectively.

Conclusion. We have shown that this high speed radiofrequency system is safe, effective, and requires only a small fraction of the time.

PP 4.01

MULTIMODALITY THERAPY FOR LARGE INOPERABLE HCC

Purohit, Dipak¹; Naik, Saleem²; Varshney, Subodh²; Sewakani, Ajit²; Sharma, Sandesh²; Singh, Vikrant²

¹Bhopal Memorial Hospital and Research Centre, Surgical Gastroenterology, Bhopal, India; ²Bhopal Memorial Hospital and Research Center, Surgical Gastroenterology, Bhopal, India

Background. Only a small proportion of patients with HCC are able to undergo surgical resection. Following resection, overall 5-year survival rates range from 35–50%. Even with curative resection, intrahepatic reccurence occurs in upto 70% of cases. We report 3 year survival of four pateints for large HCC (size 8–12 cms) in pateints with Child C cirrhosis and Hepatitis B or C viral infection, treated with multimodality therapy for the HCC and retroviral therapy for hepatitis.

Material and Methods. Four pateints (three male and one female), aged 58–70 years, 3 had Hepatitis B and 1 had Hepatitis C infection, all were Child C status and had large HCC (size 8 to 11 cms) on presentation. These pateints were considered inoperable due to large size of tumour and large size and poor liver function. They were managed by various multimodality ablative techniques and supportive care. Supportive treatment were given to improve the Child's status in the form of FFP, Albumin and retroviral therapy for viral hepatitis (HBV received Adefovir 10mg OD, Hep C on low dose PegINF, 2 patients with Hep B and HCC were also given LAR Sandostatin 20mg IM every 4 weeks). The modalities used were TACE( 1 to two sessions) followed by Radiofrequency of residual tumour. The pateints were assessed with cross sectional imaging in pre and post procedure and were followed up with tumor markers, USG, CECT or contrast enhanced MRI and routine labarotory parameters. RESULT The tumour showed 60–100% reduction in size and th e Child's status improved from Child's C to B in 3 patients and to Child's A in one patient. We report 100% 3 yr. survival in all four pateints (Ranging 3.0 to 5.5 yrs). Two pateints are still alive at 36 and 42 months.

Conclusion. Aggressive multimodality management by TACE/RFA and treatment of the underlying viral hepatitits and supportive care can increase the survival some of pateints with large inoperable HCC.

PP 4.02

ADJUVANT THERAPY FOR THE RESECTABLE HEPATOCELLULAR CARCINOMA

Shen, Feng; Li, Jun

Eastern Hepatobiliary Hospital/Second Military Medical University, Shanghai, China

Introduction. The multiple well-selected therapies following liver resection might yield longer survival for the HCC patients.

Aim and Method. To decrease the recurrent rate of HCC patients after liver resection, multiple therapies were applied, including TACE and combined therapies for portal vein tumor thrombus (PVTT).

Results. (1) The data of our 823 patients who underwent curative resection was analyzed. Multivariate analysis suggested that adjuvant TACE was a significant and independent negative predictor of the tumor recurrence, the recurrence rate of patients who received this treatment (n = 126) was significantly lower than that of patients who did not received it (n = 697). Our data also indicated the significant role of adjuvant TACE in terms of anti-tumor effect occurred within two years after liver resection, which might increase the survival within two years of surgery (1st year was 81.5% vs 67.8%, 2nd year was 70.7% vs 54.4%, 3rd year was 52.3% vs 43.9% and 5th year was 42.5% vs 35.0%). (2) In our 917 cases of HCC, 797(86.9%) had PVTT if all portal vein system was included and 139(15.2%) had gross PVTT. The patients with resectable HCC and gross PVTT received tumor resection and PVTT resection or aspiration. The three years disease free survival was better in resection (71.2%) than in aspiration (21.0%). Also TACE, LA (laser ablation) and PPVC were performed in our hospital for eliminating the gross PVTT. 65 cases of HCC with gross PVTT were treated with LA, TACE and PPVC respectively. The regression of PVTT and the reappearance of portal vein flow detected by color Doppler US were used as evaluating criterion for the efficacy of therapy. LA showed a better role in the elimination of gross PVTT (P < 0.05).

Conclusion. The combination of adjuvant therapies might yield more benefit for patients in terms of recurrence prevention. The further progress depends on the well-planned combination of multiple treatments and reasonable sequential arrangement of these strategies.

PP 4.03

RADIOFREQUENCY ABLATION OF PRIMARY AND METASTATIC LIVER TUMORS-125 CASES EXPERIENCE

Ribeiro Jr, Marcelo A F¹; Chaib, Eleazar²; Sala, Mariana³; Vulcano, Juliane C³; Yamashita, Renato H³; Saad, William A⁴

¹PUC- Sorocaba, UNICID and Hospital São Luiz, Department of Surgery, São Paulo, Brazil; ²University of Oxford, Nuffield Department of Surgery, Oxford, United Kingdom; ³UNICID, Department of Surgery, São Paulo, Brazil; ⁴HCFMUSP, UNICID and PUC-Sorocaba, Surgery, Sao Paulo, Brazil

Background. Radiofrequency ablation of primary and metastatic liver tumors has been shown to be one of the promising new modalities to treat or to palliate liver tumors. It can be used in nodules until 3–4 cm of diameter, by laparotomy, laparoscopy and percutaneouslly.

Aims. The authors will present a serie of 125 cases, 59 females and 66 males with a mean age of 60,8 years, in which the radiofrequency ablation has been used either by laparotomy or percutaneouslly to treat 192 lesions.

Results. In the present series the group was composed of 47 cases of hepatocellular carcinoma, 61 metastases of colorectal cancer, 06 cases of neuroendocrine tumors, 04 cases of breast cancer metastasis, 04 cases of cholangiocarcinoma, 01 case of hepatic metastasis of leiomyosarcoma, 01 case of pancreas cancer metastasis and 01 case of kidney cancer metastasis. The mean number of lesions treated were 1,5 per case with a average size of 3,69cm per lesion. The following liver segments were compromised: Seg I (10), Seg II (7), Seg III (7), Seg IV (43), Seg V (11), Seg VI(14), Seg VII (53) and Seg VIII (47). The morbidity was 25,6% and the mortality was 3,2%. In 13,6% of the cases we were able to find recurrence after the procedure, with a mean time of 10,5 months. In association with RFA were performed at the same procedure ethanol injections, nodulectomies, left lateral segmentectomies and others.

Conclusion. RFA is safe, can be used in patients with a poor hepatic function (Child B and C), as a bridge to liver transplantation, given to the patients a chance to stay disease free or at least controlled while waiting for the new organ. For the metastatic diseases it does not substitute surgery but can be used in patients who do cannot be operated, can also be used associated with other modalities like surgery, transarterial chemoembolization and after recurrence and can give to the patient a chance to remain disease free.

PP 4.04

REPEAT TRANS-ARTERIAL CHEMOEMBOLIZATION FOR UNRESECTABLE HEPATOCELLULAR CARCINOMA: INSTITUTIONAL EXPERIENCE

Damrah, Osama¹; Pai, Madhava¹; Lapenga, Alex²; Tait, Paul²; Habib, Nagy¹; Canelo, Ruben²; Jiao, Long²

¹Hammersmith Hospital-Imperial College London, London, United Kingdom; ²Hammersmith Hospital, London, United Kingdom

Introduction. Trans-arterial chemoembolization is a widely used method of treatment for patients with unresectable hepatocellular carcinoma (HCC), but its efficacy remains debated. The aim of this study was to assess the outcome of trans-arterial chemoembolisation (TACE) in the management of unresectable hepatocellular carcinoma.

Methods. Between January 2002 and May 2006, patients with unresectable hepatocellular carcinoma who had lipidol chemoembolization (lipidol plus doxorubicin) were reviewed. Both patient and tumour characteristics, results of chemoembolization including complications and survival were collected for analysis.

Results. A total of 66 TACE procedures were performed in 26 patients consisting of 2.5±1.5 treatment per patient. Cirrhosis was present in 22 patients (47%). Twelve patients had Okuda Score II and III (46%) with multifocal disease present in 20 patients (77%). The mean tumour size was 6.1±4.2 cm (range, 1.7–17.5 cm). Eight patients had TACE twice (31%), 3 patients 3 (11.5%) and 4 (11.5%) times respectively, 3 patients 5 (11.5%) and 1 patient 6 (4%) times respectively. Post embolisation syndrome was common (76%). Other complications included liver abscess (n = 1) and liver failure (n = 2). The median follow-up time was 26.5 months. Four patients (15%) died at the follow-up from tumour progression (n = 3) and gastrointestinal haemorrhage (n = 1). The overall median survival rate was 26.5 months. Patients who had repeated TACE had a better median survival compared with those treated with single TACE (28.5 vs. 9.5 months).

Conclusion. Repeated TACE is an effective therapeutic option for patients with unresectable HCC.

PP 4.05

EFFECTS OF THE SELECTIVE CYCLOOXYGENASE-2 INHIBITOR ON THE INVASION OF HUMAN HEPATOCELLUAR CARCINOMA CELLS

jiansheng, li¹; ZhengDong, Fang²

¹Anhui Provincical Hosptial, general surgery, hefei, China; ²Anhui Provincical Hosptial, Department of General Surgery, hefei, China

Abstract Introduction. Tumor cyclooxygenase-2 (COX-2) expression is known to be associated with enhanced tumor invasiveness. Recent studies show that up-regulation of cyclooxygenase-2 (COX-2) in human cancer cells induces activation of matrix metalloproteinases (MMPs) and increase of metastatic potential. In this study, we investigate the effects of nimesuli, a selective cyclooxygenase inhibitor, on the invasion of human hepatocelluar carcinoma cell line SMMC-7721 and on the expression and enzymatic activity of MMPs.

Methods. SMMC-7721 cells were treated with nimesuli (25,50,100,200, 400∣Ìmol/L)and control group, MTT reduction assay was used to evaluate the inhibitory rate;Transwell chamber assay was performed to determine its effect on the invasion of SMMC-7721 cells; the expression of MMPs mRNA and enzymatic activity of SMMC-7721 cells were evaluated by RT-PCR and gelatin zymography, respectively.

Results. The inhibitory rate of nimesuli on SMMC-7721 cells proliferation increased as incubated time and nimesuli concentration increasing;Compared with that in control group, Nimesuli could down-regulate the expression of MMPs mRNA and enzymatic activity(Nimesuli 25,50,100,200L, 400∣Ìmol/L vs control: MMP-2 mRNA 0.968£-0.545£-0.330£-0.158£-0.083 vs 1.063£»MMP-9 mRNA 1.005£-0.758£-0.465£-0.208£-0.103 vs 1.075 £-P£¼0.05);the inhibitory rates of SMMC-7721 cells that penetrated polycarbonates in experiment group(7.8%£-08.0%£-35.6%£-53.6%£-61.4%)was less than control group(P£¼0.01). CONSLUSION: The selective cyclooxygenase inhibitor, ni mesuli, can inhibit the growth and invasion of SMMC-7721 cells. Its possible mechanism may be involved in down-regulation of MMPs.

PP 4.06

MAJOR ANATOMICAL VARIANTS WITH SURGICAL VALUE FOR LIVER RESECTION AND TRANSPLANT. STUDY ON CORROSION CASTS

MATUSZ, PETRU

University of Medicine and Pharmacy "Victor Babes", Department of Anatomy, Timisoara, Romania

Introduction. The segmental character of liver parenchyma is admitted since Rex (1888). Most descriptions are based on the intraparenchymal distribution of afferent pedicle elements (portal hepatic vein – PHV, proper hepatic artery – PHA, and the intrahepatic biliary ducts system – IHBDS).

Matherial and Method. On a study material of 100 liver corrosion casts we analyzed the major anatomical variants of intraparenchymal distribution of the afferent pedicle elements. The corrosion casts were made by injecting with plastic the vasculo-ductal systems, followed by parenchyma corrosion with hydrochloric acid.

Results. The PHV trunk presents variations of ramification in 4% cases (2% trifurcations and 2% atypical bifurcations). In 9% cases there are 3 lateral branches (in 2% cases two superior lateral branches and in 7% two inferior lateral branches). In 1% cases the medial branch gives birth to 4 segmental branches. In 8% cases the anterior branch is absent as a morphologic entity, the segmental branches arising directly from the right branch. The posterior branch has, in 22% cases, a supplemental segmental branch. The proper hepatic artery presents, in 1% cases, only the right branch. In 16% cases, the medial branch arises from the right branch. In 14% cases we found an anastomotic arterial network in contact with the anterior aspect of the PHV bifurcation. The left hepatic duct receives, in 19% cases, the lateral, medial and posterior branch; the posterior branch crosses the plane of the main portal fissure. In 21% cases the right hepatic duct is absent as a morphologic entity.

Conclusions. Knowledge of these aspects of variants of intraparenchymal distribution of the elements from the afferent pedicle is important in case of surgical procedures of the hepatic parenchyma.

PP 4.07

RELIABILITY OF INTRAHEPATIC MICRODIALYSIS IN MONITORING OF SMALL MOLECULES IN THE LIVER

Isaksson, Bengt¹; Jersenius, Ulf¹; Ravn, Anna²; Iwata, Takashi²; Jorns, Carl²; Nowak, Greg²

¹Karolinska University Hospital Huddinge, Division of Surgery, Stockholm, Sweden; ²Karolinska University Hospital Huddinge, Division of Transplantation Surgery, Stockholm, Sweden

Introduction. Intrahepatic microdialysis has potential of being a standard monitoring method in surveillance of liver during and after resection and transplantation. Four small molecules, glucose, glycerol, lactate and pyruvate give information about the metabolic state of the liver. Today, 20kD cut off membranes are used for collection of those molecules. However, use of membranes with 100kD cut off would allow us to monitor bigger molecules such as cytokines. The aim of this study was to assess whether 20kD and 100kD intrahepatic microdialysis catheters can be used equally concerning the recovery of glucose, glycerol, lactate and pyruvate.

Methods. Six female pigs were used in the experiment. Four microdialysis catheters were inserted in the liver of each pig, two catheters of 20kD and two of 100kD cut off. A Ringer-like solution was pumped through the 20kD catheters and one of the 100kD catethers at a flow rate of 0,3 µl/min. The other 100kD was pumped with Voluven at the same flow rate. Samples were collected at 40 minute intervals and analysed for glucose, glycerol, lactate and pyruvate.

Results. All fours parameters were stable during the monitoring time. There were no differences regarding intahepatic glucose and glycerol across groups. Regarding lactate and pyruvate we observed a tendency of higher lactate and pyruvate monitored with 100kD catheters. However, there were no differences between catheters with the same cut off.

Conclusions. Our results showed that 20kd and 100kD intrahepatic catheters can be used equally regarding the monitoring of small molecules such glucose and glycerol. The placement of the catheters in different liver lobes gives the same results. Microdialysis is an easy and reproducible method to directly monitor the liver and replacement of routinely used 20kD catheters with 100kD catheters, could give us a chance to monitor bigger molecules such as cytokines.

PP 4.08

EFFECTS OF PRINGLE′S MANOUVRE ON INTRAHEPATIC METABOLISM DURING LIVER RESECTION

Isaksson, Bengt¹; Jersenius, Ulf¹; Ungerstedt, Johan¹; Lundell, Lars¹; Permert, Johan¹; Nowak, Greg²

¹Karolinska University Hospital Huddinge, Division of Surgery, Stockholm, Sweden; ²Karolinska University Hospital Huddinge, Division of Transplantation Surgery, Stockholm, Sweden

Introduction. Careful evaluation of liver function is vital for planning of the surgical strategy to minimize morbidity and mortality in extensive liver surgery. With microdialysis (MD) it is possible to continously monitor metabolic alterations in the liver. A clinical study of intrahepatic metabolic effects of Pringle′s manouvre (PM) during liver resection was done.

Methods. Eleven consecutive patients who underwent liver resections were investigated. Intrahepatic placement of the MD-catheter in segment 4 was done immediately after laparotomy. Serial samples of the dialysis fluid were collected every 10 minutes, before, during, and after a 20-minutes period of PM. Glucose, lactate, pyrvate (markers of ischemia), and glycerol (marker of membrane damage or lipolysis) were alalyzed and the lactate/pyruvate-quotient was calculated (sensitive marker of ischemia).

Results. During PM intrahepatic glucose increased from 7.1±0.7 to 12.9±1.7 mM. During initial reperfusion, glucose further increased to 15.7 ±2.5 mM, and thereafter decreased. PM also resulted in an increased lactate/pyruvate-ratio (from 3.4±0.5 to 9.0±2.3). During reperfusion the lactate/pyruvate-ratio was normalized. Intrahepatic pyruvate was unchanged during PM, but increased during reperfusion (from 99±18 to 151±23 µM), indicating increased perfusion. During PM, both intrahepatic glycerol and lactate were increased (from 50±6 to 139±28 µM, and from 2.4±0.3 to 6.5±08 mM, respetively): Both lactate and glycerol continued to increase during initial reperfusion.

Conclusions. PM for 20 minutes was associated with severe intrahepatic metabolic alterations with increased glucose (glycoenolysis), lactate/pyruvate-ratio (anaerobic metabolism), and glycerol (cellular membrane damage). Microdialysis enables continous monitoring of intrahepatic metabolism during liver surgery. The method is easy to use and safe for the patient.

PP 4.09

SURGICAL EXPERIENCE WITH FUNCTIONAL AND NON-FUNCTIONAL HPB NEUROENDOCRINE TUMORS

Chhabra, Deepak¹; Joshi, Shashank²; Lad, Prashant¹; Navadgi, Suresh³; Shah, Rajiv¹; P, Jagannath¹

¹Lilavati Hospital and Research Centre, Dept. of Surgical Oncology, Mumbai, India; ²Lilavati Hospital and Research Centre, Dept. of Endocrinology, Mumbai, India; ³S. L. Raheja Hospital, Dept. of Surgical Oncology, Mumbai, India

Background. Neuroendocrine tumors (NETs) of the gastro-entero-pancreatic system present with different biological behaviors. Surgery is curative and plays an important role in palliation.Aims And Objectives. To determine difference in surgical outcomes of functioning and non-functioning hepato-pancreato-biliary (HPB) NETs.

Methods. 43 patients of NETs (March 2003 to March 2007) were retrospectively reviewed. Tumors were classified as per functional status and WHO classification system. Factors evaluated for disease-specific mortality were: age, sex, functional status, surgical procedure, pathologic characteristics, disease-free and overall survival.

Results. 43 patients (19 females, 24 males) included 21 functional and 22 non-functional tumors. Mean age was 50 + 1 years. Functional tumors included 15 Insulinomas, 3 gastrinomas, 2 glucagonoma and 1 calcitonin secreting tumor. 23 (54%) tumors were malignant and dominated by non-functional tumors (n = 19). 20(46%) tumors were benign, majority of which were functional (n = 17). Biologically, 18 patients had low grade and 5 patients had high grade malignant tumors, 19 tumors were benign and 1 was of uncertain behaviour. 84% (n = 16) of non-functional pancreatic tumors were malignant. 33 patients underwent surgery: 25 pancreatic resections, 3 hepatic resections, 2 enucleations, 1 triple bypass and 1 RFA. 1 patient was inoperable. 88% (n = 29) patients had curative resection. At median follow up of 30 months, 29 surgical patients (88%) are alive and no patient with benign tumor died because of NET. Significant difference in survival was observed in surgical vs. non surgical patients. There was no significant difference in the surgical outcomes for functional or non-functional tumors. Disease free survival was 79.5% and overall survival was 72%.

Conclusions. Surgical resection should be advocated for NETs. Non-functional tumors should be considered potentially malignant and treated with aggressive surgery. Definitive surgical resection is a predictor of survival in NETs.

PP 4.10

ADULT HEPATOBLASTOMA: REPORT OF A CASE.

Morales, Dieter¹; Garcia de Polavieja, M²; Figols, FJ²; Casanova, D²; Arruabarrena, A²; Madrazo, C²; Palacios, A²; Yagüe, E²; Naranjo, A²

¹University Hospital "Marqués de Valdecilla", Department of Surgery, Santander, Spain; ²

Introduction. Hepatoblastoma is most common primary malignant hepatic neoplasm in children. Median age at diagnosis is one year and mostly present by three years. This is a rare case report of a female patient with hepatomegaly diagnosed as hepatoblastoma.

Case Report. 28 year old female with history of A hepatitis at childhood. She was was addressed to our hospital with upper right abdominal mass and pain for one month. Blood samples, cultures and hepatic tests were normal. Ct scan showed a mass of 15 cms with necrosis at left hepatic lobe (figure 1). Magnetic resonance imaging showed a tumor at left involving segments III–IVb with necrosis. Diferencial diagnosis with adenoma and fibrolamelar carcinoma was done. A laparotomy was performed finding a big mass at III–IV b. intraoperative ultrasonography confirmed the finds and a segmentectomy of II, III, IV was performed. All abdominal cavity was normal. Postoperative period was uneventful. Histology demonstrated embrionary Hepatoblastoma (Fig. 2,3,4,5).

Conclusions. 1.-Hepatoblastoma is an uncommon tumor in adults. 2.- Surgery is the only effective treatment in this kind of tumors despite the use of systemic chemotheraphy or hepatic chemoembolithation.

PP 5.01

MANAGEMENT OF NECROTISING PANCREATITIS-INFECTED OR NONINFECTED-AN INDIAN EXPERIENCE WITH RETROSPECTIVE CORELATION WITH APACHE II SCORING

Trivedi, Dilip¹; Trivedi, Mayuri²; Walawalkar, Rajeev²

¹Sir H N Hospital, Mumbai, India; ²Sir H.N Hospital, mumbai, India

Aim. To study the outcome of protocolised management of infected/noninfected necrotizing pancreatitis and correlate the outcome of the treatment with Apache II scoring for judging the prognosis in the prospective study in future.

Method. 67 cases of infected and noninfected pancreatic necrosis were analyzed retrospectively with the apache II scoring criteria. All the patients were investigated as per the protocol and the decision to start the conservative or surgical method was taken as per the protocol. Some of the patients needed 1- 4 surgical explorations. Necrosectomy and open cholecystectomy if the patients' condition permitted was done as surgery of choice in patients of gallstone pancreatitis. In pancreatitis due to other etiology Cholecystectomy was not mandatory. The outcome and the complications like secondary bleeding and pancreatic fistula were analyzed. Various combinations of broad spectrum antibiotics were used depending on the culture antibiotic sensitivity reports of the pus from pancreatic necrosectomy. All the patients were given enteral feeding in both the groups. In persistent infection prophylactic proximal diversion of stool was used in 8 cases. Intensive care monitoring, respiratory support and TPN were used judiciously whenever the need arose. The total mortality was 22%. Long term follow-up was available in 60% of the patients and the duration of long term follow up was from 1 to 8 years.

Conclusion. Protocolised management of necrotizing pancreatitis in a tertiary care hospital with experienced team of doctors definitely improved the results of necrotizing pancreatitis compared to an individual surgeon managing this kind of patients occasionally. Apache II scoring will definitely indicate the severity of necrotizing pancreatitis and give an indication of the likely prognosis in a given situation. Pancreatic fistula is one of the dreaded complications which are difficult to manage. As reported in literature we also feel that gallstone pancreatitis probably has a better prognosis and outcom

PP 5.02

HOSPITAL CASELOAD IS A RISK FACTOR FOR MORTALITY IN PATIENTS WITH ACUTE PANCREATITIS

Ellis, Matthew P; French, Jeremy J; Charnley, Richard M

Freeman Hospital, Hepato-Pancreato-Biliary Surgery, Newcastle upon Tyne, United Kingdom

Background. Acute pancreatitis is associated with a significant risk of mortality. Although specialist referral for selected patients is recommended in international guidelines there is little data on the influence of hospital-related factors on mortality.

Objective. To conduct a comprehensive assessment of the risk factors for mortality in an observational study of AP in 18 hospitals within a geographical area of population 3 million.

Methods. Extensive prospective data collection of clinical, radiological and laboratory data. Multivariate logistic regression analysis was used to assess the independent relationship of potential patient- and hospital-related risk factors to observed mortality.

Results. Complete data was obtained from all 963 confirmed episodes of AP which occurred during the study period, of which 228 (23.68%) were severe according to the Atlanta criteria. Case mortality was 4.98% (48/963) for all patients and 17.16% (46/228) for patients with severe AP. Independent risk factors for mortality in the adjusted model were older age (likelihood ratio, p < 0.001), iatrogenic aetiology (p = 0.018), and low hospital caseload (p = 0.012). A bimodal distribution of mortality against time to first intervention was observed, the optimal window of opportunity for intervention occurring in weeks 3–5 of admission. A non-significant trend of higher mortality was observed following procedures which were carried out in non-specialist centres (36.4%, 8 fatalities) than in the specialist centre (17.6%, 3 fatalities).

Conclusion. Severe AP continues to present a significant risk of mortality. This large population-based study has, for the first time, identified that low hospital caseload is associated with higher mortality in acute pancreatitis. Formulation of precise guidelines for the specialist referral of selected groups are therefore needed.

PP 5.03

AUTOIMMUNE PANCREATITS: STILL A CHALLENGING DIAGNOSTIC PROBLEM

Massani, Marco¹; Caratozzolo, Ezio²; Recordare, Alfonso²; Bassi, Nicolò²

¹Regional Hospital, IV Dpt surgery, Treviso, Italy; ²

Background. Acute pancreatitis is an inflammatory condition with an high incidence of morbidity that frequently represents a life threatening problem. Over the last few years, thanks to radiological and biochemical improvement, the number of idiopathic pancreatitis is decreased. The diagnosis of autoimmune pancreatitis is now day quite common and is accepted that treatment is based on medical therapy. But some reports of unnecessary duodenopancreatectomy are still published.

Methods. In a cohort of 1026 patients with proven acute pancreatitis we retrospectively reviewed our experience. We have considered 4 patients (0,38%) with autoimmune pancreatitis. Three of whom (75%) had a complete response to steroid therapy, one pt. relapsed (33,33%), the other one needs a duodenopancreatectomy after one month of high dose steroid therapy due to the persistence on cephalic mass mimicking an adenocarcinoma.

Discussion. The diagnosis of autoimmune pancreatitis is possible when we find the typical radiological apparency, with the so called sausage pancreas with the irregularly narrowing pancreatic duct, and with high level of IgG and IgG4 with presence of autoantibody revealed at biochemical test. Sometime FNAC is helpful showing interlobular fibrosis with infiltration of lymphocyte and IgG4 positive plasmacyte. Treatment should start as early as possible with steroid's high dose associated with antiproteases. Sometime the diagnosis remain unclear and surgery has to be considered, only in these situation, an option.

Conclusion. our data suggest that even in high volume center, the correct diagnosis of autoimmune pancreatitis could still be difficult and that sometime is possible only after “unnecessary” duodenopancreatectomy.

PP 5.04

METHODOLOGICAL PROBLEMS ASSOCIATED WITH THE L-ARGININE-INDUCED EXPERIMENTAL PANCREATITIS MODEL: EVIDENCE FOR NON-PANCREATITIS RELATED MORTALITY

Jamdar, Saurabh¹; Jeziorska, Maria²; Nirmalan, Mahesh²; Siriwardena, Ajith³

¹Manchester Royal Infirmary, Manchester, United Kingdom; ²University of Manchester, Manchester, United Kingdom; ³Manchester Royal Infirmary, Surgery, Manchester, United Kingdom

Background. This investigation evaluates the degree of pancreatic injury using three commonly utilised concentrations of L-arginine administered in the L-arginine-induced experimental pancreatitis in the rat.

Methods. Adult male rats were divided into four groups at random as follows: control (n = 7); 250 mg L-arginine per 100g body weight (n = 6); 300mg/100g (N = 6), 400mg /100g(n = 6). Pancreatitis was induced by intra-peritoneal injection of L-arginine in pH-buffered sterile 0.15M saline. At 48 hours, all animals were sacrificed. Plasma was taken for lipase, amylase and haematological indices and pancreata were fixed in formalin and stained with haematoxylin and eosin. Pancreatic injury was assessed using a histological injury scoring system. Data are presented as median (range) with analyses being undertaken by non-parametric Mann-Whitney U-test accepting significance at the P < 0.05 level.

Results. The serum lipase in control animals was 5.5 (3–8) units/ml. In comparison, lipase was significantly elevated in animals administered both 250 mg/100g bodyweight (12 [7–16] units/ml) (P = 0.02) and 300mg/100g bodyweight (10 [7–16] units/ml) (P = 0.03) of L-arginine. There was no difference in lipase levels between the 250mg and the 300mg groups (P = 0.79). Histological injury scores were significantly increased in animals receiving 250mg/100g body weight and 300mg/100g body weight of L-arginine when compared to control. Animals receiving 400mg/100g body weight of L-arginine died several hours after administration of L-arginine, subsequent histology demonstrated almost no features of pancreatic injury but confirmed chemical peritonitis.

Conclusions. There is a concentration dependent increase in the degree of pancreatic injury in the L-arginine-induced experimental pancreatitis model. At high concentrations mortality secondary to chemical peritonitis is a feature.

PP 5.05

UPPER ABDOMINAL COMPARTMENT SYNDROME (UACS) IN NECROTIZING SAP. TWO DIFFERENT STRATEGIES.

Plaudis, Haralds; Zeiza, Kaspars; Pupelis, Guntars

Clinical University Hospital “Gailezers”, Surgery, Riga, Latvia

Introduction. Inflammatory fluid collections localised above the transverse colon can severely affect pulmonary, renal and cardiovascular function due to UACS. However urinary bladder measurements of the IAP can be inconsistent with clinical picture.

Objective. To demonstrate two cases of the UACS in necrotizing SAP with different treatment strategies.

Methods. Case report.

Results. Patient 1. Necrotizing SAP developed in 37 year old male patient after alcohol abuse. Serum lipase 1924 U/L, SIRS, asymmetric distension and pressure pain of the upper abdomen, liver and metabolic dysfunction were present on admission. Pulmonary, renal and haematological dysfunction was observed two days later. CRP reached 656 mg/L. Urinary bladder IAP measurements reached 14 mm Hg on day 8. Five–organ system MODS due to UACS persisted despite laparocenthesis, ICU support therapy and continuous veno-venouse haemofiltration (CVVH). Surgical decompression and necrosectomy was performed on day 12. Repeated laparotomy and ileostomy was necessary to manage colon fistula and retroperitoneal infection. Patient recovered after 5 month treatment. Patient 2. 55 year old male patient suffered necrotizing SAP after alcohol abuse. Serum Lipase activity was 3000U/L on admission. Renal, liver and haematological dysfunction developed in 24 h. CVVH was started. Maximal CRP reached 444 mg/L on day 3. Pulmonary, neurological and metabolic dysfunctions marked progression of MODS few days later. Moderate elevation of the IAP reaching 15 mmHg was observed. Resolution of MODS was evident on day 8. Hospital stay was 22 days without need for surgical intervention.

Conclusion. Routine urinary bladder measurements of the IAP can be inconsistent with the magnitude of the physiologic consequences in the presence of UACS during the course of necrotizing SAP. Timely complex ICU treatment including early CVVH can prevent progression of UACS and MODS.

PP 5.06

MANAGEMENT OF BLEEDING PSEUDOANEURYSMS IN COMPLICATED PANCREATITIS

Ðileikis, Audrius; Beiða, Virgilijus; Zdanytë, Elena; Jurevièius, Saulius; Strupas, Kæstutis

Vilnius University hospital Santariðkiø klinikos, Abdominal surgery, Vilnius, Lithuania

Background. Development of pseudoaneurysms and haemorrhage in patients with pancreatic diseases is a rare but life-threatening condition.

Methods. We presented the data of 28 patients treated at the Abdominal Surgery Center of Vilnius University Hospital Santariðkiø Klinikos for bleeding peri/intrapancreatic pseudoaneurysms in the period from 1995 to 2006.

Results Sonoscopic duplex scanning provided for accurate determination of pseudoaneurysms in 6 (54.5%) of 11 patients. Spiral CT angiography determined correct diagnosis in 13 (92.8%) of 14 patients while common CT scan with intravenous contrasting in 5 (50%) out of 10 patients. Transcatheter angiography was performed for 16 patients resulting in accurate diagnosis of pseudoaneurysm for 11 patients (68.7%). Transcatheter embolization of the impaired blood vessel was successfully performed for 6 (54.5%) patients during angiography. Most frequently pseudoaneurysms developed in a. lienalis 12 (42.8%) and in a. pancreatoduodenalis 11 (39.3%). Seven patients (25%) with unstable hemodynamics and continued bleeding were operated on immediately as emergencies. 22 (78.6%) patients had pancreas resection performed, 4 (14.2%) underwent arterial ligation with pseudocyst drainage, 1 (3.6%) patient undervent transcatheter embolisation and debridment afterward and another one (3.6%) underwent transcatheter embolization only. There was one case (4.5%) of recurrent bleeding following pancreas resection, and two patients (50%) had recurrent hemorrhage after arterial ligation and pseudocyst drainage.

Conclusions. Spiral CT angiography is considered to be the most accurate diagnostic method in determining peri/intrapancreatic vascular pseudoaneurysms. Transcatheter angiography and embolization is not always possible. We consider embolization alone to be insufficient in case pseudoaneurysm has already formed in the long chronic process and ruptured since the main cause conditioning the development of pseudoaneurysm-pancreas irreversibly changed due to inflammation-remains not eliminated.

PP 5.07

AN IMPROVED SURGICAL PROCEDURE IN PATIENTS WITH SMALL DUCT AND DISTAL CHRONIC PANCREATITIS

Aramaki, Osamu¹; Oida, Takatugu²; Mimatsu, Kenji¹; Kawasaki, Atushi¹; Kuboi, Youichi¹; Kanou, Hisao¹; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Social Insurance Yokohama Central Hospital, Suregery, Yokohama, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Introduction. Small duct chronic pancreatitis has been regarded as a classical indication for more extensive resection. We proposed herein a new strategy for surgical treatment of small duct chronic pancreatitis based on the resection of the tail of the pancreas combined with a caudal pancreatojejunostomy pancreaticoplasty and sphincteroplasty.

Patients and Methods. Between 1996 and 2006, patients with severe pain who were diagnosed with small duct pancreatitis (main pancreatic duct < 7 mm) underwent the procedure. There are 6 major surgical steps: (1) A Kocher maneuver, (2) mobilizing the spleen and the tail of pancreas, (3) the resection of the tail of the pancreas, (4) Termino-lateral pancreaticojejunostomy (5) transduodenal sphincteroplasty, (6) transduodenal pancreaticoplasty.

Results. No complications or mortality associated with the surgical procedure were observed in the immediate postoperative period. Follow-up ranged from 6 to 100 months and complete symptom control was achieved in all patients.

Conclusion. In small duct and distal pancreatitis, our procedure is a safe, minimally invasive, and effective.

PP 5.08

POLYMORPHISMS OF THE MCP-1 AND HSP70-2 GENES IN KOREAN PATIENTS WITH ALCOHOLIC CHRONIC PANCREATITIS

Lee, Sang Hyub¹; Kim, Yong-Tae²; Ryu, Ji Kon²; Jeong, Ji Bong²; Lee, Kyeung-Yeup²; Yoon, Yong Bum²; Hwang, Jin-Hyeok³

¹Seoul National University Bundang Hospital, Department of Internal Medicine, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea, Republic of; ²Seoul National University College of Medicine, Department of Internal Medicine and Liver Research, Seoul, Korea, Republic of; ³Seoul National University Bundang Hospital, Department of Internal Medicine, Seongnam-si, Gyeonggi-do, Korea, Republic of

Background. Although alcohol abuse is the most common cause of chronic pancreatitis, alcoholic chronic pancreatitis (ACP) develops in only a small number of alcoholics. Genetic factors may influence susceptibility. Monocyte chemotactic protein-1 (MCP-1) ∣¡2518 and heat shock protein 70-2 (HSP70-2) ∣¡1267 G alleles have been reported to be risk factors of severe acute pancreatitis. However, their role in ACP has not been investigated. Our aim was to determine whether their polymorphisms affect the susceptibility and severity to ACP.

Methods. A genetic association study for susceptibility and severity was performed on 79 male Korean ACP patients (49.8¡¾11.2 years) and 82 male controls (52.3¡¾11.2 years). MCP-1 and HSP70-2 genotypes were determined using a fluorescence pola rization detection method.

Results. The distribution of the MCP-1 A/A, A/G and G/G genotypes in ACP patients was 12.7, 49.4 and 38.0%, respectively, and for HSP70-2 they were 22.8, 58.2 and 19.0%, respectively. Genotype distributions were not different in patients and controls (p = 0.93 and 0.41, respectively). In ACP patients, the frequencies of the MCP-1 and HSP70-2 G alleles were 62.7% and 48.1%, respectively, which was not different from those of controls (p = 0.73 and 0.91, respectively). However, MCP-1 G allele revealed the influence on the development of severe ACP, when its frequency was compared between mild to moderate and severe ACP (29.6% vs. 56.0%, p = 0.02).

Conclusions. The MCP-1 and HSP70-2 polymorphisms do not play a major role in the development of ACP in Koreans. However, MCP-1 polymorphism may be associated with the severity of ACP.

PP 5.09

ANTERIOR GASTROTOMY, CYSTGASTROSTOMY, PERCUTANEOUS TRANSGASTRIC RETROPERITONEAL DRAINAGE AND COMBINATION G-J TUBE FOR COMPLEX PANCREATIC PSEUDOCYSTS

Espat, Joseph¹; Saied, Abdul²; Somasundar, Ponnandai²; Hering, Justin²

¹Roger Williams Medical Center, Hepatobiliary Surgery, 825 Chalkstone Ave, Prior 4, Providence, RI, United States; ²Roger Williams Medical Center, Hepatobiliary Surgery, Providence, RI, United States

Background. Various approaches have been used to achieve complete resolution of persistent complex pancreatitis-associated pseudocysts (PAP). Particularly challenging are those PAP located near the pancreatic head. While in recent years endoscopic and/or radiologic drainage has been in vogue; approximately 40–60% of patients will still require an operation. Herein we describe our open operative approach.

Methods. The prospectively maintained departmental hepatobiliary database was queried for the combined procedure codes of “cystgastrostomy, retroperitoneal drainage and combined G-J tybe placement”. Resultant matches were then cross referenced against the electronic medical record for the diagnosis of “alcoholic pancreatitis”. Additionally, the data points of PAC anatomic location, post-operative length of stay(LOS), time to enteral feeding and image confirmed resolution at 90 days was collected.

Results. Over the interval 2003–2006, 17 patients meeting the above criteria were identified; 12 patients had pancreatic body/tail associated collections and 5 demonstrated pancreatic head/neck anatomic location. 17/17 had undergone ERCP with pancreatic duct decompressive stent placement, 13/17 had undergone failed percutaneous radiologic drainage. 17/17 had demonstrated persistent PAC despite interventions. The operative procedure of laparotomy with cystgastrostomy performed via anterior gastrotomy, with placement of a transgrastric peritoneal drain in combination with a G-J tube placed floroscopically past the Ligament of Treitz was performed in all patients. Median post op LOS was 7 days (range 4–13), 100% of patients initiated J-tube enteral feeding 24 hours post procedure, 15/17 patient demonstrated complete resolution of PAC on 90 day imaging (CT).

Conclusion. The described surgical approach is useful for patients with persistent PAP to attain rapid hospital discharge, conversion to enteral alimentation and >85% resolution of PAP.

PP 5.10

CHRONIC PANCREATITIS FOLLOWING ALCOHOL ABUSE.

Liyanage, Chandika¹; Deen, Kemal²; Ariyaratne, Jayantha²

¹Faculty of Medicine, University of Kelaniya, Department of surgery, Sri Lanka, Ragama, Sri Lanka; ²Faculty of Medicine, University of Kelaniya, Department of surgery, Ragama, Sri Lanka

Introduction. Unlike in the west the commonest cause for pancreatitis in Sri Lanka is alcoholism. Chronic pancreatitis is the commonest sequale of acute pancreatitis and gives rise to chronic pain, and pancreatic pseudocysts.

Objectives. To understand the aetiology and the quality of life including the degree of pain and the outcome of interventions on patients with chronic pancreatitis. Methodology: 19 patients who were diagnosed of having chronic pancreatitis were followed up.

Results. 17/19(89%) of the patients had a history of heavy alcohol consumption. 14/17(82%) of these patients had been consuming illicit liquor. One had a history of gallstones and common bile duct stones. One had a history of Caroli's disease and one was diagnosed with an idiopathic stricture. The commonest problem was severe pain which had an average of 6 in the visual analog pain score. 11 (58%) of patients had pancreatic pseudocysts. One spontaneously ruptured. 2 underwent operative cystgastrostomy and one was drained under ultrasound guidance. Others were managed conservatively while monitoring serial ultrasounds. The pain and discomfort significantly regressed in patients who underwent therapeutic interventions for symptomatic psedocysts. 5 patients had intractable pain which required referral to a pain clinic. None had complex pancreatic surgery.

Conclusions. Majority of this cohort had a history of illicit alcohol abuse. It is possible that due to poor standards harmful compounds may be present in local brew. Some patients benefited by surgical interventions. However expertise pancreatic surgical care was not available for these patients. Almost all patients were unable to get along with their vocation which emphasizes the need for proper management of this benign but disabling condition.

PP 6.01

THE DIAGNOSTIC USEFULNESS OF FDG-PET AND DWI-MRI FOR PANCREAS TUMORS

Arakawa, Yusuke

Tokushima University, Tokushima, Japan

Backgrounds. Not only the FDG-PET (fluorodeoxyglicose-positron emission tomography) but also DWI-MRI (diffusion-weighted imaging magnetic resonance imaging) has been reported to be an innovative diagnostic tool for various types of malignancies. The purpose of this study is to evaluate the usefulness of FDG-PET and DWI-MRI for the correct diagnosis of pancreas tumors.

Methods. Sixteen patients who underwent surgical removal of pancreatic tumors were enrolled in this retrospective study. The SUV-max (Maximum standardized uptake values) in FDG-PET and the ADC (apparent diffusion coefficient) in DWI-MRI were used the following analyses. The mean follow-up periods was 1.8years.

Results There were 11 patients with pancreas carcinomas: invasive ductal carcinoma (n = 9), intraductal pancreas mucinous carcinoma (n = 2), and 5 patients with benign tumor: intraductal pancreas mucinous adenoma (n = 2) and insulinoma (n = 2). The mean SUV-max in FDG-PET was significantly higher in pancreatic carcinomas (10.4) than other benign lesion (4.3) (p < 0.05). The mean ADC in DWI-MRI of pancreatic carcinoma (1.97□∼10–3) was significantly higher than benign tumor (2.7□∼10–3) (p < 0.05). Among the 4 patients with lymph node metastases, the detectability of FDG-PET was 0/4 (0%), whereas that of DWI-MRI was 1/4 (25%). No significant difference was observed in the relationship between SUV-max and patient survival or pathological factors.

Conclusions. This study showed the potential usefulness of FDG-PET and MRI-DWI in diagnosing benign or malignant natures in pancreas tumors, although further collection and analysis of cases might be necessary.

PP 6.02

PANCREATIC HEAD MASS: IS A PREOPERATIVE DIAGNOSIS ALWAYS NECESSARY?

Varma, Vibha¹; Thumma, Venu Madhav²; Bheerappa, Nagari²; Sastry, Regulagadda Adikesav²

¹Nizam's Institue of Medical Sciences, Department of Surgical Gastroenterology, Hyderabad, India; ²Nizam's Institute of Medical Sciences, Department of Surgical Gastroenterology, Hyderabad, India

Background. Despite advances in imaging, differentiating a benign and malignant pancreatic head mass is difficult.

Aim. Retrospective clinicopathological study of pancreatic head masses to analyze the etiology and factors influencing final management.

Methods. Pancreatic head masses operated between June 2002 and June 2007 were studied. Standard protocol of investigations included side viewing endoscopy and biopsy where indicated, contrast enhanced computed tomography of abdomen, estimation of Ca 19-9 and endoultrasound (select cases). Frozen done incase of diagnostic dilemma. Good risk patients with operable lesion underwent resection even without a definitive diagnosis.

Results. Thirty five of 75 operated patients of head masses with uncertain diagnosis formed the study group and were divided into: Group I with associated chronic pancreatitis (20), while Group II without chronic pancreatitis (15). In Group I, 10 each had inflammatory head masses and malignancy on final histopathology. Of 8 Whipple's resection for suspected malignancy, 4 proved malignant finally. Two of 5 patients following Frey's procedure were malignant, frozen being negative in both. Rest had bypass procedures, for advanced malignancy (4) or inflammatory mass (3). Frozen was positive in 20% (1/10) patients with malignancy. In Group II, 7 were benign and 8 malignant on final histopathology. Eleven underwent Whipple's resection for adenocarcinoma (5), focal pancreatitis (1), groov e pancreatitis (1), tuberculosis (1), Non Hodgkin's Lymphoma (1), duodenal gastrointestinal stromal tumor (1) and cystic neoplasm (1). Median pancreatectomy was done for cystic neoplasm in one. Others had palliative procedures. Frozen was positive in 43% (3/7) patients with malignancy. No major complications encountered after Whipple's resection.

Conclusion. Definitive diagnosis was not possible in nearly half patients of pancreatic head mass. Inability to distinguish benign from neoplastic disease justifies the use of pancreaticoduodenectomy in appropriate setting.

PP 6.03

CLINICALLY AGGRESSIVE SOLID PSEUDOPAPILLARY TUMOR OF THE PANCREAS

Nagatsuka, Ryousuke; Iki, Katsumichi; Urakami, Atsushi; Saitoh, Ai; Saitoh, Ai; Tsunoda, Tsukasa

Kawasaki Medical School, Gastroentelorogical Surgery, Kurashiki, Japan

Solid pseudopapillary tumors (SPTs) are unusual neoplasms of the pancreas of uncertain histogenesis that occur mostly in young women. Despite its low malignant potential, proximately 15% of patients with SPT develop metastatic disease. Even in the presence of disseminated disease, the clinical cause is usually protracted, and overall 5-year survival is reportedly 97%. We have encountered a case of SPT possessing unusual pathologic features. The patient was a 35-year-old woman who had chemotherapy for malignant lymphoma two years ago. She complained of an increase in abdominal girth, mild abdominal pain, and constipation for a month. Laboratory workup demonstrated normal pancreatic enzyme levels and liver function tests, and serum CEA and CA19-9 were within normal range. Initial imaging evaluation revealed a 7-cm mass in the body of pancreas. No masses were identified in the liver. There was no evidence of lymphadenopathy. Fine needle aspiration of the pancreas was performed with endoscopic retrograde pancreatography and revealed □gpoorly differentiated malignant neoplasm□h. The patient underwent a pancreatic body resection with splenectomy. The postoperative recovery was unremarkable and adjuvant chemotherapy has been performed for three month after operation. The pathologic features of the tumor, which might have been indicative of its aggressive behavior, included a diffuse growth pattern, extensive tumor necrosis, and significant nuclear atypia. Immunohistochemically, the tumor cells were positive for ¿-1-antitrypsin, synaptophysin, neuron specific enolase, CD56, and P53 protein, but were negative for CD10, AE1:AE3, CAM2, and EMA. Markedly increased MIB-1 expression and unusually high mitotic rate (>50%/50 HPF) were also detected in the case. Although precise pathologic criteria suggesting a high risk for aggressive behavior are uncertain, recognition of some of the unusual pathologic features displayed in this case may be useful in the prediction of potentially more aggressive SPTs.

PP 6.04

CANCER CELL DETECTION BY FLUORESCENT IN SITU HYBRIDIZATION FROM PERITONEAL FLUID IN RESECTABLE PANCREATIC CANCER

Han, Sung-Sik¹; Hwang, Dae Wook²; Lee, Seung Eun²; Jang, Jin-Young²; Lee, Dong Soon³; Kim, Sun-Whe²

¹National Cancer Center, Center for Liver Cancer, Goyang-si, Gyeonggi-do, Korea, Republic of; ²Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of; ³Seoul National University College of Medicine, Department of Laboratory Medicine, Seoul, Korea, Republic of

Background. Detecting free tumor cells from peritoneal fluid in patients with pancreatic cancer can be useful for predicting prognosis and choosing the modality of adjuvant therapy. But there are few reports about the method of effective detection.

Objectives. To identify the free cancer cells from peritoneal fluid with cytology and fluorescent in situ hybridization (FISH) technique and to investigate the prognostic significance through clinical correlation.

Methods. The patients who were suspected for pancreatic ductal adenocarcinoma were enrolled. Peritoneal washing was performed right after laparotomy with normal saline and collected and preserved with fixative. Post-operative drain fluid was collected on postoperative 2 day and preserved with fixative. Peritoneal washing fluid and drain fluid were analyzed using Papanicolau¡^—s method and FISH with p53 probe. Immunohistochemistry for p53, CEA, CA19-9 was performed with cell block. Cancer tissue was examined using immunohistochemistry for p53, CEA, CA19-9 and FISH for p53 probe. DNA was extracted from cancer tissue and sequencing was done to find out mutation. Clinico-pathologic correlation with the results of the fluid analysis was performed.

Results. The mean age of the 35 subjects was 61.3 years with a male/female ratio of 2.2:1(24:11). Peritoneal washing fluid was collected in 30 patients. FISH for p53 showed positive rate of 53.3%. Post-operative drain fluid was collected in 35 patients. FISH for p53 showed positive rate of 51.4%. The positive rate of the control group was 0%. Immunohistochemistry and FISH for p53 in cancer tissue showed positive rate of 41% and 89.3% respectively. Clinicopathologic analysis showed that patients with p53 FISH (+) for peritoneal fluid tend to have more metastatic diseases.

Conclusion. FISH method is very useful for detecting free cancer cells from peritoneal fluid in patients with pancreatic cancer. However, further studies of larger scale using various probes are required to investigate the prognostic significance.

PP 6.05

PANCREATIC HEAD LESION: DILEMMAS AND SOLUTIONS

Adhikari, Devbrata¹; Singh, Rajinder²; Patil, Bhushan²; Bhange, Snehal²; Shetty, Tilakdas²; Joshi, Rajeev²

¹T. N. Medical College & B.Y.L Nair Ch Hospital, Dept of General Surgery, A.L Nair Road, Mumbai, India; ²T.N Medical College & B.Y.L Nair Ch Hospital, Mumbai, Dept of Surgery, Mumbai, India

Background. Differentiation between chronic pancreatitis and cancer is difficult in pancreatic head lesions. Focal pancreatitis around small cancers may cause them to be missed and 3% of cases with chronic pancreatitis harbour malignancy.

Objective. To avoid a misdiagnosis and form a diagnostic and therapeutic algorithm.

Method.163 cases with pancreatic head lesions were analyzed between February 1999 to July 2007. Diagnosis was based on clinical assessment, USG, CT, tumour markers, MRI and EUS guided FNAC in select cases. RESULT: 6 cases of cystic tumours and 3 cases of metastatic deposits, all of whom underwent curative resection after definitive diagnosis.1 case of lymphoma underwent chemotherapy. Presumptive diagnosis of mass due to carcinoma or chronic pancreatitis and/or inflammation was made in 123 patients and 13 and 17 patients respectively. 29 of the 123 patients were resectable and underwent pancreatico-duodenectomy. Preoperative tissue diagnosis of carcinoma was confirmed in 18 cases while 10 were confirmed postoperatively.1 resected patient turned out to be chronic pancreatitis. 59 non resectable patients underwent palliative surgical bypass and intra-operative biopsy but malignancy was confirmed in only 38 patients. Of the 30 cases of benign head mass 11 patients underwent Frey's procedure and histopathology confirmed chronic pancreatitis.

Discussion. No diagnostic modality can, in isolation or in combination, accurately differentiate between chronic pancreatitis and cancer. Pre operative tissue diagnosis is desirable but not mandatory provided the clinico-radiological co-relation is strongly indicative.11 out of 29 patients underwent resection without a tissue diagnosis and 1 proved negative, justifying an approach based on the above concept.

Conclusion. Good clinico-radio-pathological correlation, appropriate aggressiveness and resection even without or inspite of negative tissue diagnosis if the clinical setting and imaging is typical, is justified.

PP 6.06

CENTRAL PANCREATECTOMY WITH PANCREATICOGASTROSTOMY: A TECHNIQUE FOR THE RESECTION OF PANCREATIC NECK LESIONS.

Ajit, Sewkani¹; Sandesh, Sharma²; Saleem, Naik³; Dipak, Purohit³; Subodh, Varshney³

¹Bhopal Memorial Hospital & Research Centre, Department of Surgical Gastroenterology, Bhopal, Bhopal, India; ²Bhopal Memorial Hospital & Research Centre, Department of Surgical Gastroenterology, Bhopal, India; ³Bhopal Memorial Hospital & Reseach Centre, Department of Surgical Gastroenterology, Bhopal, India

Background. Central pancreatectomy is a segmental pancreatic resection indicated to remove benign or low-grade malignant tumors of the neck and proximal part of the body of the pancreas. The main advantage of this operation compared with major resections is that it permits to spare normal pancreatic parenchyma; moreover, spleen and upper digestive and biliary tracts are saved. It has been used sparingly because the spectrum of indications is quite narrow. Although historically used for traumatic pancreatic transection and chronic pancreatitis, it currently is reserved for selective management of pancreatic neck lesions that are benign or have low malignant potential.

Case Summary. A 62 years female presented with pain in abdomen with loss of appetite and weight, on routine evaluation found to have mass in body of pancreas. On cro ss sectional imaging a 1.1×1.3 cm mass lesion in proximal body in close proximity with main pancreatic duct was confirmed. Her CA 19-9 and chromogranin A levels were normal. On exploration pancreatic mass in proximal body/neck found which was anterior to superior mesenteric vein and artery. A central pancreatectomy was performed with suture ligation of proximal stump and distal pancreatico-gastrostomy. Frozen section suggestive of serous cystadenoma with free margin.

Conclusion. When technically feasible, central pancreatectomy is a safe, pancreas-preserving pancreatectomy for non-enucleable benign pancreatic pathology confined to pancreatic neck that allows for cure of the disease without loss of substantial amount of pancreatic parenchyma & preservation of exocrine/endocrine functions. Caution is necessary when using central pancreatectomy in the treatment of pancreatic neck lesions. Surgeon experience is of utmost importance in this decision-making process as well as the technical aspects of central pancreatectomy. The precise role of central pancreatectomy in the management of benign or low–malignant potential lesions of the neck of the pancreas remains in evolution.

PP 6.07

INTRAOPERATIVE GLUCOSE MANAGEMENT IN PANCREATIC SURGERY

van Samkar, Gan¹; Stoker, Sharon²; Preckel, Benedikt¹; Hollmann, Markus¹

¹AMC University Hospital of Amsterdam, Anesthesia, Amsterdam, Netherlands; ²University of Amsterdam, Amsterdam, Netherlands

Background. Poor intraoperative glucose control has been associated with worsened hospital outcome in patients undergoing cardiac surgery(1;2). Intensive insulin therapy in critically ill patients has shown beneficial effects, reducing morbidity and mortality(3). Little is known about the effect of glucose control in pancreatic surgery. We retrospectively analyzed if patients undergoing pancreatic surgery experienced hyperglycemic episodes during this procedure and the effect of insulin therapy on glucose levels.

Methods. data were collected from the electronic database: 2004, 2005, 2006 (Whipple operations). Hyperglycemia was defined as > 7.0 mmol/L (126mg/dL). Glucose management, sampling time, frequency, time delay to sample after induction of anesthesia, therapeutic intervention and the result of intervention were scored.

Results. In total, 156 patients underwent pancreatic surgery, from which 63 patients had a normal glucose and 89 patients (57%) were hyperglycemic. In 4 patients, no glucose levels during the operation were recorded. Of the 89 hyperglycemic patients, only 18 patients were treated with Insulin. In only 7 patients Insulin therapy resulted in normoglycemia. In the 69 untreated hyperglycemic patients, 8 patients had glucose levels of >9.0 mmol/L. In 5% of patients, the first glucose sample was taken within 30 minutes after induction of anesthesia. In all others, the delay to first measurement was > 60 minutes. (range: 70 – 300 minutes).

Conclusion. Sampling of glucose levels occurred infrequently and often delayed. The majority of hyperglycemic patients (glucose > 7.0 mmol/L) was not sufficiently treated with Insulin. Only 38% of the treated patients showed normoglycemia. For patients at risk, such as pancreatic surgery, studies should address whether frequent glucose sampling and sufficient treatment of hyperglycemia might improve perioperative outcome. We should sample after induction of anesthesia, and at least at hourly intervals in the case of hyperglycemia or insulin therapy in patients at risk

PP 6.08

TOTAL PANCREATECTOMY FOR INTRADUCTAL PAPILLARY MUCINOUS TUMOURS OF THE PANCREAS

Spalding, Duncan¹; Behranwala, Kasim²; Alaee, Farhang²; Williamson, Robin²

¹Hammersmith Hospital, HPB Surgery, Du Cane Road, London, United Kingdom; ²Hammersmith Hospital, HPB Surgery, London, United Kingdom

Introduction. Total pancreatectomy (TP) is rarely performed for pancreatic ductal adenocarcinoma due to its associated morbidity and poor prognosis. Although increasingly recognised, the correct surgical management of intraductal papillary mucinous tumours (IPMT) of the pancreas remains controversial. Total pancreatectomy is increasingly performed on the basis that these tumours are characterised by extensive intraductal spread and have a favourable outcome even when presenting at an invasive stage. The aim of this study was to assess the role of TP in the surgical treatment of patients with IPMT.

Methods. Pancreatic resections were performed on 10 patients with IPMT between 2001–2005. Histology and the clinical outcome were reviewed.

Results. There were 6 men and 4 women of median age 68 (range 58–75) years. Five patients underwent a pylorus-preserving proximal pancreatectomy (PPPP), one had a Whipples procedure with inclusion of the body of pancreas and 4 had a TP depending on operative and frozen-section findings. Histology revealed benign IPMT (n = 2), invasive mucinous adenocarcinoma (n = 8), positive lymph nodes (n = 4) and positive resection margins (pancreatic intraepithelial neoplasia [n = 2]). There was no operative mortality and morbidity was equivalent between PPPP and TP (27.5% vs 25%). Six patients had adjuvant chemotherapy (gemcitabine and cisplatin). At a median follow-up of 9 (range 7–80) months, one patient had died of recurrent disease at 18 months (PPPP and positive resection margin) and 1 patient had evidence of recurrence at 11 months but was alive and well at 80 months after further chemotherapy (PPPP and negative resection margin). Eight patients have remained disease free.

Conclusions. TP should be considered as an effective treatment for IPMT with extensive involvement in order to achieve complete resection.

PP 6.09

SOLID PSEUDO-PAPILLARY TUMOR OF THE PANCREAS PRESENTING AS HEMATEMESIS

Apostolidis, Stelios; Zatagias, Akis; Papavramidis, Theodossis S; Michalopoulos, Antonis; Papadopoulos, Vassilis N.; Paramythiotis, Daniel; Harlaftis, Nick

AHEPA University Hospital, Aristotles' University of Thessaloniki, 1st Propedeutic Surgical Department, Thessaloniki, Greece

Background. Solid pseudo-papillary tumors (SPTs) of the pancreas are rare and typically present in young female patients. They are slowly growing masses, that may attain large size, and of low malignant potential. Surgical resection is curative in most of the cases

The present case is extremely interesting because it concerns a small SPT of the head of pancreas which present with a episodes of hematemesis.

Case Report. The present case concerns a 71 years old female with a small SPT of the head of the pancreas. The patient presented to the emergency department with an episode of hematemesis but otherwise hemodynamically stable. Emergency gastroscopy revealed a bleeding mass projecting to the duodenum. Fluid, blood and electrolyte resuscitation followed. CT revealed a small mass in the head of the pancreas. A typical Whipple operation was performed. The pathological features of the tumor were compatible with an SPT. The postoperative course of the patient was uneventful and today, a year after the operation, no recurrence of the disease is present.

Conclusion. International literature supports the concept that complete surgical excision offers benefits in almost all patients. SPTs are of low-grade malignancy and are potentially curable by extended resections of the primary tumor mass.

PP 6.10

EVALUATION OF POSTOPERATIVE COMPLICATIONS IN PACREATICODUODENECTOMY AT SHIKOKU CANCER CENTER HOSPITAL

Ohta, Koji; Tanada, Minoru; Kurita, Akira; Takashima, Shigemitsu

Shikoku Cancer Center Hospital, Mastuyama, Japan

We evaluated postoperative complications in pancreaticoduodenectomy. 41 patients underwent pancreaticoduodenectomy between 2001 and 2006 at the Shikoku Cancer Center Hospital. The subjects were 16 pancreatic, 9 bile duct, 4 duodenal, 4 papillary, 1 gastric cancer, and 4 benign tumors including intraductal papillary-mucinous tumor. Pancreaticoduodenectomy(PD) was performed in 27 cases with pancreaticojejunostomy, and pylorus preserving pancreaticoduodenectomy(PPPD) was done in 14 cases with pancreaticogastrostomy. Mean intraoperative blood loss was 1180g in PD and 995g in PPPD. The mean operative time was 441 minutes in PD and 377 minutes in PPPD. No operative mortality was recognized during this period. The postoperative complications in PD were recognized in 11 cases (40.7%), with the most common complications being pancreatic fistula (n = 5), early delayed gastric emptying (n = 2), and bowel obstruction (n = 2). The postoperative complications in PPPD were recognized 9 cases (64.2%), with the most common complications being early delayed gastric emptying (n = 8) and pancreatic fistula (n = 3) Median postoperative length of hospital stay was 29 days in PD and 35 days at PPPD. Pancreaticoduodenectomy can be performed safety. But many complications occurred and prolonged postoperative length of hospital stay.

PP 6.11

EFFECTS OF WIRSUNG-PANCREATICO-GASTRIC ANASTOMOSIS FOLLOWING PANCREATICODUODENECTOMY: A SINGLE CENTER EXPERIENCE

Prete, Francesco; Vincenti, L; Basile, R; Nitti, P; De Renzo, D; Preziosa, G; Prete, F

University of Bari School of Medicine, Department of Surgery, Bari, Italy

Introduction. Management of the pancreatic stump following pancreaticoduodenectomy (PD) is a source of concern among pancreatic surgeons. The ideal choice of anastomosis remains a matter of debate. Aim of the present study is to ascertain the effect of the wirsung-pancreatico-gastrostomy (wPGA) after pancreaticoduodenectomy through a single surgeon's experiences.

Materials and methods. Since 1998 our model of treatment of the pancreatic stump switched from PGA to wPGA. From January 1998 to March 2007, 101 patients were perspectively and consecutively treated with wPGA after PD. After opening only the seromuscular layer of the posterior gastric wall, sparing the mucosa, the inferior border of the pancreatic stump is sutured to the inferior border of the gastric opening. Then a small incision is performed on the posterior aspect of the exposed gastric mucosal layer. A small drain, the distal extremity of which is inserted in the wirsung duct, is anchored to the nasogastric tube (retrieved through the mucosal incision), and then retracted together with it through the stomach. The anastomosis between the pancreatic parenchyma and the muscular layer of the stomach is completed. The wirsung duct drain is removed on the VII–VIII postoperative day. Results The overall mortality (30 days) was 2/101 (1.9%), the overall morbidity (including late morbidity) was 5/101 (4.9%), while the anastomosis-related morbidity and mortality were 0%. Since 2001 there was no perioperative mortality. No pancreatic leakage was reported. The mean postoperative stay was 12 days.

Conclusions. In our experience this technique was a technically reproducible and safe method to prevent complications after pancreaticoduodenectomy.

PP 7.01

HEPATIC TUBERCULOSIS MIMICKIN METASTASES IN A PATIENT WITH COLORECTAL CANCER.

Morales, Dieter¹; Garcia de Polavieja, M²; Carrasco, M²; Figols, FJ²; Madrazo, C²; Casanova, D²; Ortega, C²; Vega, ME²; Naranjo, A²

¹University Hospital "Marqués de Valdecilla", Department of Surgery, Santander, Spain; ²

Introduction. Hepatic tuberculosis is very uncommon and usually its consequence of lung tuberculosis infection. We report the case of a patient with colorectal cancer and hepatic metastases with histological diagnosis of adenocarcinoma and hepatic tuberculosis simultaneously. CASE REPORT 67 year old male with history of radical surgery for colorrectal cancer and two liver metastases at IV, V operated in other hospital. He also had two hepatic metastases at segments VII and VIII didn′t removed at this moment. Histological study showed colorectal adenocarcinoma T4N1M1(hepatic). Postoperative CEA was normal. The patient was included in a Phase III study with chemotheraphy and the CT scan showed two hepatic metastases at segments VII-VIII. He was admitted at our unit for surgery of this hepatic metastases. Pre-operative CT scan showed two hepatic injuries, one of this has decreased its size, with low density without gain of contrast (figure 1). Right hepatectomy was performed and the histological study showed hepatic tuberculosis, but not adenocarcinoma.

Conclusions. 1.-Coexistence of hepatic tuberculosis with colorectal cancer metastases is very uncommon. 2.- Pain, fever and miliar spread is typical of hepatic tuberculosis. 3.- Ultrasonography and CT scan hypoechogenic images without contrast change are typical of hepatic tuberculosis.

PP 7.02

ARTERIAL EMBOLIZATION FOLLOWING PORTAL VEIN OCLUSSION CAN INCREASE RESECTABILITY OF HEPATIC METASTASES FOR COLORECTAL CANCER

Ardiles, Victoria; Bregante, Mariano; Salceda, Juan; Fernandez, Diego; Pekolj, Juan; de Santibañes, Eduardo

Hospital Italiano de Buenos Aires, HPB Surgery and Liver Transplant Unit, Buenos Aires, Argentina

Background.: Portal occlusion has been shown to be an effective method for increasing the resectability of liver metastases from colorectal cancer. However, when the liver parenchyma does not grow enough, it is possible to embolize the ipsilateral hepatic artery in order to increase hypertrophy.

Objective. To analyze our experience in sequential ipsilateral portal and arterial occlusion for the treatment of liver metastases from colorectal cancer. DESIGN: Retrospective cohort study.

Materials and Method. Five men, mean age: 59, with liver metastases from colorectal cancer initially irresectable due to small remnant liver volume. Preoperative portal embolization and IV chemotherapy were performed. As remnant liver volume/patient′s weight ratio was < 0.8, arterial embolization was carried out. Right hepatic artery was selectively embolized. Follow-up was performed with hepatic CT scan.

Results. Hypertrophy of the left lateral segment was observed in all patients. Three patients underwent a right hepatectomy. Because two patients showed disease progression, surgery was not performed. A patient was reoperated on for a hemoperitoneum. Mean ICU stay and hospital stay were 2 and 6 days, respectively. Resected patients are disease-free with a follow-up of 3–12 months.

Conclusions. Arterial embolization following ipsilateral portal occlusion can increase resectability of liver metastases from colorectal cancer.

PP 7.03

HEPATIC LYMPH NODE DISSECTION PROVIDES A SURVIVAL BENEFIT FOR PATIENTS WITH NODAL DISEASE OF COLORECTAL CARCINOMA LIVER METASTASES

Wakai, Toshifumi; Shirai, Yoshio; Sakata, Jun; Korita, Pavel; Takizawa, Kazuyasu; Hatakeyama, Katsuyoshi

Niigata University Graduate School of Medical and Dental Sciences, Division of Digestive and General Surgery, Niigata City, Japan

Background. The issue whether hepatic lymph node dissection is efficacious for nodal disease of colorectal carcinoma liver metastasis is yet to be resolved. The aim of this study was to define the role of hepatic lymph node dissection in the surgical management of patients with resectable colorectal carcinoma liver metastases.

Methods. Seventeen of 130 consecutive patients who had hepatectomy for colorectal carcinoma liver metastases underwent concomitant lymphadenectomy for suspected nodal metastasis. A total of 217 lymph nodes were examined histologically for metastases. The therapeutic value index of hepatic lymph node dissection was estimated by multiplying the prevalence of hepatic lymph node metastases by the 5-year survival rate of patients with hepatic lymph node metastases. The median follow-up time was 98 months.

Results. Overall cumulative 5-year survival rate after resection was 24% (median survival time, 20 months). Lymph node metastases were detected in 10 patients: hepatic lymph node metastases (four patients), distant lymph node metastases (three patients) and both lymph node metastases (three patients). Of the 10 patients with lymph node metastases, two patients survived for 10 years despite the involvement hepatic lymph node. The prevalence and 5-year survival rate for patients with hepatic lymph node metastases were 50% and 29%, respectively. Thus, the therapeutic value index of hepatic lymph node dissection was 14.5.

Conclusions. The application of hepatic lymph node dissection is justified for patients with suspected nodal disease. Hepatic lymph node dissection provides a survival benefit for some patients with nodal disease of resectable colorectal carcinoma liver metastases.

PP 7.04

SEGMENT-ORIENTED APPROACH TO LIVER RESECTION

Kostov, Daniel; Ivanov, Valkan

Naval Hospital, Clinic of General Surgery, Varna, Bulgaria

Introduction. Aims of liver resection are to resect the liver with minimal bleeding and leaving adequate functional liver.

Objective. We present our experience in the rationale and techniques of segment-oriented approach to liver resection and assess the technical and oncologic results of anatomic segmentectomies.

Methods. From 166 liver resection, 64 cases (38%) have included 1, 2 or 3 adjacent segments. There were 18 monosegmentectomies, 7 right posterior sectionectomies (segments 6 and 7), 4 right anterior sectionectomies (segments 5 and 8), 4 right inferior bisegmentectomies (segments 5 and 6), 12 central hepatectomies (segments 4,5 and 8 ±1), 2 central posterior bisegmentectomies (segments 4a and 8), 6 central anterior bisegmentectomies (segments 4b and 5) and 11 left lateral sectionectomies (segments 2 and 3). Indications were hepatocellular carcinoma (n = 4), Klatskin tumor (n = 2), gallbladder carcinoma (n = 2) and liver metastases due to different diseases: colorectal carcinoma (n = 49), mammary carcinoma (n = 2), malignant melanoma (n = 1), gastric carcinoma (n = 2), pancreatic head carcinoma (n = 2). Intraoperative ultrasound had been used to achieve anatomic resection.

Results. Mortality, transfusion, and morbidity rates were 1,5%, 22%, and 24%, respectively. Mean section margin was 7mm (range 1–35mm). Isolated intrahepatic recurrence occurred in 12 patients (18%), and 4 (6%) underwent repeat hepatectomy.

Conclusion. Segment-oriented liver resection is a distinct surgical approach and represents t he complexity of hepatic surgery. This operative procedure is a safe alternative to extensive liver resection in selected patients.

PP 7.05

Title: RELATIONSHIP BETWEEN METACRHONOUS COLORECTAL LIVER METASTASES AND NODE STATUS OF PRIMITIVE TUMOR.

La Greca, Gaetano¹; Sofia, Maria²; Li Destri, Giovanni³; Mosca, Francesco³; Lombardo, Rosario²; Zappalà, Orazio⁴; Fichera, Simona⁵; Puleo, Stefano²

¹University of Catania, Dep Surg Sci Org Transp Adv Tech, Catania, Italy; ²University of Catania, catania, Italy; ³University of Catania, Italy; ⁴Univerity of Catania, Catania, Italy; ⁵University, Catania, Italy

Background/ AIMS: The golden point in colorectal liver metastases should be to establish which patient are at risk to develop liver metastases and what we have to do to find and treat this metastases in a very early stage. Aim of this work is to evaluate retrospectively how positive nodes in colorectal specimen have been predictive for the development of liver metastases in our patients.

Materials andMethods. All patients submitted to R0 resection for colorectal cancer in the period January 1999-December 2003 were considered retrospectively. Age, sex, site of tumor and type of resection, Aster-Coller classification, number of nodes in surgical specimen, ratio of metastatic nodes and disease free interval were considered.The patients were followed-up in order to evaluate the development of liver metastases, in relation to the presence of positive node in the surgical specimen of colorectal resection.

Results. We analysed 221 patients submitted to R0 colonic resection for colorectal cancer: 118 were male and 103 female with a median age of 69.8 years (range 26–89). According with the Aster-Coller classification the patient were 113 in B2 stage and 108 in C stage. In the group of patients in B2 stage 67 are alive without disease after 5 years, the remnants developed liver metastases and/ or other recurrence. The number of examinated nodes in this group of patients, are respectively 11.4 for patients that didn't developed metastases and 14.3 for patients that developed metastases. In the group of patients in C stage 34 patients are free from disease, in this group the positive nodes ratio was 1 N + /3.6 (0.28). In the 72 patients that developed liver metastases the nodes ratio was 1N + /2.7 (0.37).

Conclusions. Our results show that also in patients in B2 stage, liver metastases occur, so only the number of nodes is not enough to predict the development of metastases. Other factors related to biological aspect of the primitive tumor or to immunological status of the patients could influence the liver recurrences.

PP 7.06

EFFECTIVENESS OF FONG'S SCORE AND LAPAROSCOPIC EXPLORATION TO ASSESS THE RESECTABILITY OF METACHRONOUS COLORECTAL LIVER METASTASES.

La Greca, Gaetano¹; Li Destri, Giovanni²; Sofia, Maria¹; Portale, Teresa Rosanna¹; Di Benedetto, Fabrizio¹; Vicari, Salvatore¹; Latteri, Saverio¹; Russello, Domenico¹; Puleo, Stefano¹

¹University of Catania, Catania, Italy; ²Uniuversity of Catania, Castania, Italy

Background/ AIMS:The resectability of liver metastases is usually assessed by imagine techniques, intraoperative ultrasonography or preoperative ultrasound laparoscopic exploration, and the Fong's clinical score can be used to predict the prognosis of patients. Aim of this retrospective study was to establish the effectiveness of the Fong's risk score to predict the rate of resectability and if laparoscopic exploration with ultrasonography can considerably reduce the number of useless laparotomies.

Materials and Methods. in the period January 1997-January 2003 in all patients with colorectal liver metases was calculated the Fong's clinical score and a statistical analysis was performed to evaluate the relation score-resectability, the probability of unless laparotomy in related to the score and the Fong's factor that better predict the resectability. None of the patients was submitted to preoperative laparoscopic exploration.

Results. we have observed 47 patients, eligible for liver resection. The Fong's score was calculated and the patients submitted to liver resection were: all patients with score 0 (100%), 10/14 (76.9%) with score 1, 7/12 (58.3%) with score 2, 4/6 (66.6%) with score 3. No patient had score 4 o 5. The statistical analysis showed a not significant relationship between the level of the score and the resectability (p = 0.4056), but the probability of useless laparotomy in relation to the score range from 0.07 for score 0 to 29.4 for score 2. The best parameter that influence the assessment of not resectability is the CEA. The use of lapascopic exploration could spared 12% of unless laparotomies in the subgroup of patients with score 0–1, and 39% in the subgroup with score 2–3.

Conclusions. our study show that a high Fong's score, especially the CEA positivity should be considered in the evaluation of not resection of colorectal liver metastases. Moreover the preoperative laparoscopic exploration could avoid useless lapatomies.

PP 7.07

SYNCHRONOUS EXTRAHEPATIC DISEASE DOES NOT CONTRAINDICATE HEPATECTOMY FOR COLORECTAL LIVER METASTASES

Yeluri, Sashidhar; Prasad, K Rajendra; Gomez, Dhanwant; Malik, HZ; Lodge, J Peter A; Toogood, GJ

St. James's University Hospital, Department of HPB and Transplant Surgery, Leeds, United Kingdom

Background. The presence of extra hepatic disease (EHD) is traditionally considered to be a contraindication for hepatic resection in patients with colorectal hepatic metastases (CRLM). The aim of the present study is to report the long term outcome following aggressive surgical resection in CRLM patients with synchronous resectable EHD. The secondary aim is to identify prognostic factors that impact on long-term outcome in these patients.

Methods. CRLM patients with synchronous EHD were identified from a prospectively maintained database. Data analysed included demographics, operative and pathological factors. Irrespective of the number of metastasis, each EHD location was counted as one lesion.

Results. 25 patients were included, of which 12 were identified intraoperatively as having EHD. 32 EHD sites were identified in these patients; the most common affected sites being pulmonary and diaphragmatic involvement. 16 patients with EHD underwent simultaneous resection at the time of hepatectomy, whilst 7 patients with distal metastases underwent resection at a later date. 2 patients underwent pulmonary resection for EHD prior to undergoing hepatectomy. Overall morbidity was 19% and there was 1 peri-operative death. The 1, 3 and 5 year overall survival was 83%, 34% and 14%, respectively.

Conclusion. In selected cases, an aggressive approach in resecting EHD may lead to prolonged disease-free and overall survival.

PP 7.08

THE RESULTS OF TREATMENT THE COLORECTAL METASTASES TO THE LIVER BY USING DIFFERENT METHOD.

Musiewicz, Marcin; Ciosek, Jakub; Lampe, Pawel; Mrowiec, Slawomir

Medical University of Silesia, Department of Gastrointestinal Surgery, Katowice, Poland

Introduction. The liver resection is still conventional but radical treatment of metastases of colorectal cancer. In recent years, there has been observed an increasing interest in ablation technique in treatment of nonresection metastases.

Material and Method. 528 patients with liver tumour, who had undergone treatment from January 1990 to June 2005, were studied. 170 patients with colorectal cancer metastases of a liver were included in the study. There were performed: 48 hemihepatectomies, 80 segmentectomies or cone resections, 12 ablation procedures, 13 cannulation of hepatic artery and 17 explorative laparotomy. The final results of resection or ablation were obtained from 134 patients and they were divided into three group: I group including 48 patients after hemihepatectomy, II group including 80 patients after segmentectomy or cone resection, III group including 12 patients who had undergone ablation.

Results. The intraoperative blood loss was highest in case of I group where it was 725 ml (300–3600mI) in comparison with II group with 280 ml (150–2500 mI) and III group with 150ml [0–400ml]. The postoperative complications were observed more often in case of I group-20 [42%] patients than in case of II group 24 [30%] patients and III group 1 [8%] patient. The perioperative mortality was more frequent in case of I group -8.3% [4 patients] in comparison with II group-3,75% [1 patient] and III group-8% [1 patient]. The average duration of hospitalisation after surgery was longer in I group [23 days] than in II group [16 days] and III group [8days]. The three-year survival rate was 37% in case of group I and 31% in case of group II; five-year survival rate was 21% in group I and 25% in-group II.

Conclusions. The result after surgical treatment of colorectal metastases depends on an extent of liver resection. The ablation is a safe alternative method of treatment in the selected group of patients who have not been qualified to a resection procedure.

PP 7.09

MICROWAVE ABLATION IS AN EFFECTIVE METHOD OF TREATING PATIENTS WITH UNRESECTABLE COLORECTAL LIVER METASTASES.

Bhardwaj, Neil¹; Strickland, Andrew D¹; Ahmad, Fateh¹; El abassy, Moshier²; Lloyd, David M¹

¹Leicester Royal Infirmary, Department of Hepatobiliary Surgery, Leicester, United Kingdom; ²Leicester Royal Infirmary, Department of Radiology, Leicester, United Kingdom

There are many thermal methods available to treat unresectable colorectal liver metastases. Microwave tumour ablation (MTA) is fast becoming an acceptable method to destroy these tumours. Other modalities such as cryoablation and radiofrequency suffer from high complication or recurrence rates. AIMS To assess the efficacy of MTA to treat unresectable colorectal liver metastases.

Methods. Twenty-five consecutive patients surviving greater than 1 year post-ablation were included in this study. A total of 80 tumours (mean 21mm; range 8–62 mm) were ablated. All patients underwent pre- and post-operative cross sectional imaging. The majority of patients were treated between 2–4 minutes at 150W by the single insertion of the applicator. Fifteen patients had a concomitant liver resection and MTA and ten had MTA alone.

Results No bile duct injury, abscess formation, bleeding or microwave related complications were observed. Fourteen patients are alive post ablation of whom 7 are disease free (mean f/u 27 months; range 12 – 41), 7 are alive with distal intra-hepatic tumour recurrence (mean f/u 35 months; range 18–48), of whom 1 patient also has local recurrence at the treated site, probably due to their tumour in close proximity to major hilar vessels. Of those with recurrence, 86% of patients are alive more than 2 years post ablation. Eleven patients died; surviving an average of 25 months (range 12–41 months). DISCUSSION MTA is safe, efficient and an effective treatment option for patients with unresectable colorectal liver tumours. The low local tumour recurrence (1.25%) and complication (0%) rate are extremely encouraging and compare favourably to other treatment options.

PP 7.10

LARGE UNRESECTABLE LIVER TUMOURS TREATED SUCCESSFULLY WITH MICROWAVE ABLATION.

Bhardwaj, Neil¹; Strickland, Andrew D²; Ahmad, Fateh²; Elabassy, Moshier³; Lloyd, David M²

¹University Hospital Leicester Royal Infirmary, HPB surgery, 6th floor Balmoral Building, Infirmary square, Leicester, United Kingdom; ²University Hospital Leicester Royal Infirmary, HPB surgery, Leicester, United Kingdom; ³University Hospital Leicester Royal Infirmary, Radiology, Leicester, United Kingdom

Introduction. It has always been a challenge to treat large unresectable liver tumours. Radiofrequency (RF) and cryoablation are often unsuccessful in gaining local control over tumours greater than 3cm. Microwave tumour ablation (MTA) can be a successful alternative as it may be more effective. AIMS To assess the efficacy of MTA to treat unresectable tumours greater than 3cm.

Methods. 17 consecutive patients with either single or multiple unresectable tumours measuring at least 3cm or above were included. All patients underwent pre-operative cross-sectional imaging. A total of 48 lesions were treated, 26 of which were 3cm or greater (mean 3.9cm; range 3–7cm). Fifteen patients had colorectal liver metastases, 1 patients had a HCC and 1 a parathyroid carcinoma metastasis. Most tumours were treated with 150 Watts of power for 2 – 3 minutes by a single insertion of the applicator. All treatments were monitored in real time with IOUS and temperature monitoring. Eight patients underwent MTA alone and nine patients underwent a concomitant liver resection along with MTA. All patients underwent 3 monthly cross-sectional imaging post-operatively.

Results No ablation related complications such as bile leaks, abscess formation or bleeding were reported. Eight patients are alive of whom 4 are disease free (mean 34 months; range 18–41). Four have distal intra-hepatic recurrence of disease (mean 40 months; range 32–48) of whom one also has local tumour recurrence at the ablation site. Nine patients died (mean 19 months; range 12–42) of either hepatic or extra-hepatic disease progression, none had evidence of local recurrence on their latest scan. DISCUSSION All patients treated were initially declared inoperable prior to coming to our centre and over 60% were alive more than 2 years post-ablation. MTA safely produces complete tumour ablation of large liver tumours without the need for multiple insertions of the applicator. The local tumour recurrence rate of 2% compares favorably to RF and cryoablation.

PP 8.01

INFANTILE HEPATIC VASCULAR TUMORS: TREATMENT OPTIONS

Kotru, Anil¹; Kotru, Anil¹; Chapman, William²; Lowell, Jeff³

¹Geisinger Medical Center, Organ Transplantation, Danville, United States; ²Washington University in St Louis, Saint Louis, United States; ³Washington University in Saint Louis, Organ Transplantation, Saint Louis, United States

Hepatic vascular tumors (HVT) are the most common benign liver tumors present in infancy and childhood commonly associated with high output cardiac failure. The most common is infantile hemangioendothelioma, a lesion most often congenital, usually multifocal, frequently symptomatic in infancy and may be complicated by hemodynamic and coagulation disorders. Clinical symptoms are variable and range from asymptomatic forms detected by chance to intractable high output cardiac failure. In addition, hepatomegaly, consumption coagulopathy with anemia, and thrombopenia/hemorrhage (Kasabach-Merritt-Syndrome) as well as cutaneous/visceral hemangiomas can occur -up. Medical treatment consists of steroids, á interferon, and treatment of additional clinical symptoms. Possible surgical procedures are ligature of feeding vessels, hepatic resection, and liver transplantation Apart from established medical and surgical options, the endovascular approach represents an important alternative. In this report, we present our experience with interventional coil occlusion in 3 patients suffering from symptomatic vascular tumors of liver. Methods Three patients suffering from AVM of liver (age range 30–150 days) associated with cardiac failure were treated by endovascular interventions between 1999–2006 Results Signs of heart failure resolved in two patients within 3 weeks intervention. These two patients after a follow up of 72 months and 36 months remain asymptomatic. Third patient who is still remains in hospital after endovascular coil occlusion of hepatic artery has shown remarkable improvement in cardiovascular haemodynamics and hepatic functions. Follow up imaging in these patients showed significant regression of lesions. Conclusion Embolisation of hepatic artery and rest of the collateral arteries feeding these arteriovenous malformations is a safe and effective treatment. Liver transplantation is very rarely performed. We do not recommend endovascular intervention in multifocal

PP 8.02

SUCCESSFUL TRANSPLANTATION OF LIVER GRAFT WITH GRADE III TRAUMA.

Mohanka, Ravi¹; Cruz, Ruy²; Fontes, Paulo²; Marsh, Wallis²; Marcos, Amadeo²; DeVera, Michael²

¹Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, United States; ²Thomas E Starzl Transplantation Institute, Pittsburgh, United States

Background. Liver trauma is usually considered a contraindication for liver recovering. Isolated cases of emergency transplant utilizing injured liver have been reported. We reported a case of liver with intra-parenchymal hematoma which was successfully harvested and transplanted in an elective procedure.

Case Report. A 28-year old man was admitted to emergency department following a road traffic accident. A CT-scan of his abdomen showed a 11cm×7cm×4cm intra-parenchymal hematoma involving segments VI and VII (grade III, AAST organ injury scale). His AST/ALT peaked 264/213 and were 83/158 at the time of organ procurement. Forty eight hours after admission in the hospital, the irreversible nature of his brain injury became apparent and he was declared brain dead. A standard technique was used for liver procurement using 10 liters of aortic and 5 liters of UW solution. The liver was transplanted in a 49-year old patient with end stage liver disease secondary to a hepatitis C induced cirrhosis. The cold and warm ischemia times were 13 hrs 51 min and 28 minutes, respectively. USG was performed on the back-table to evaluate the vessels and hematoma size. Transplant was done using a piggyback technique with venous-venous bypass and standard end-to-end portal vein, hepatic artery and bile duct anastomosis over a T-tube. Solumedrol was used for induction followed by prograf monotherapy. Five days after his transplant a ct-scan was done showing a complete regression of the hematoma. His post-operative course was complicated by severe bile duct stricture, DVT of upper extremities and agitation/confusion requiring change in the immunossupression treatment. The patient was discharged 38 days after transplant.

Conclusion. The presence of grade III liver trauma should not contraindicate liver harvesting and transplantation. Inclusion of this group of patients would potentially contribu te to expand the donor pool.

PP 8.03

RESULTS OF HEMI-RIGHT SPLIT LIVER TRANSPLANTATION WITH OR WITHOUT THE MIDDLE HEPATIC VEIN

Dargan, Puneet¹; ADHAM, Mustapha¹; Dumortier, Jérome²; Abdelaal, Amr¹; Sagnard, Pierre¹; Boucaud, Catherine¹; Boillot, Olivier¹

¹Edouard Herriot Hospital, Department of HPB Surgery, Lyon, France; ²Edouard Herriot Hospital, Department of Hepatology, Lyon, France

Middle hepatic vein preservation for a hemi-right split adult liver transplantation is not consensuel. The aim of this study was to evaluate outcomes of the graft and patient after right split graft with or without the middle hepatic vein. Methods 33 patients received 34 cadaveric right split liver graft between 02/2000 & 05/2006. According to the type of recipient pairs, two adults or adult + pediatric, the middle hepatic vein was kept or not with the right hemi liver. The first group (GI, n = 15) had grafts with only the right hepatic vein, the second (GII, n = 18) had grafts with right and middle hepatic veins. The 2 groups were similar for patients’ demographics, initial liver disease and donor characteristics. In GI and GII, GRWR was 1.2±0% and 1.6±.3% (p < 0.05), and cold ischemia time was 10:55±2:49 hr and 10:47±3:32 hr, respectively (p = NS). Results Post-operative death occurred in 1 patient in each group. Vascular complications included 2 portal vein, 1 hepatic artery, and 1 right hepatic vein anastomotic strictures, all in GI. Biliary complications occurred in 20% and 22% of the patients, in GI and GII, respectively (p = NS). There were no differences between both groups regarding post-operative outcome and blood tests at day 1–15 except for a significantly higher cholestasis in GI. At 1 and 3 years, patients’ survival was 94% for both groups and graft survival was 93% for GI and 90% for GII (p = NS).

Conclusions. Our results suggest that adult right split liver transplantation with or without middle hepatic vein is safe and associated with similar long term

Results. Early liver function recovered more slowly in livers without the middle hepatic vein.

PP 8.04

ALTERNATIVE SURGICAL TECHNIQUE FOR CAVAL PRESERVATION IN LIVER TRANSPLANTATION

Doria, Cataldo¹; Frank, Adam¹; di Francesco, Fabrizio¹; Spaggiari, Mario²; Ramirez, Carlo¹; Ranjan, Dinesh³; Zibari, Gazi⁴; Marino, Ignazio⁵

¹Jefferson Medical College-Thomas Jefferson University Hospital, Surgery, Philadelphia, United States; ²j, Surgery; ³University of Kentucky Medical Center, Surgery, Lexington, KY, United States; ⁴Willis-Knighton/Louisiana State University, Surgery, Shreveport, LA, United States; ⁵Jefferson Medical College-Thomas Jefferson University Hospital, Surgery, Philadelphia

Introduction. The two most commonly used surgical techniques to perform liver transplantation are: standard and piggy-back. The first replaces the recipient's vena cava from the diaphragm to the right renal vein. The latter preserves the recipient's inferior vena cava, and the donor's IVC is anastomosed to a combination of the recipient's hepatic veins. Material and method: We herein describe a modification of the piggy-back technique, where the recipient's hepatic veins were clumped en-bloc without pealing the liver off the IVC. This maneuver was carried out by bluntly developing a surgical plan between the IVC and the hepatic veins; the infrahepatic IVC was, subsequently, tangentially clumped as shown in the figure.

Results. The operative time was reduced by two hours compared with our mean operative time.

Conclusions. Piggy back technique, whenever possible, is considered the technique of choice for liver transplantation, because patients remain more hemodynamically stable. Our modification proved to be safe, effective and allowed a shorter operating time.

PP 8.05

INFERIOR LONG TERM POST LIVER TRANSPLANTATION OUTCOMES IN RECIPIENTS OF ASIAN ORIGIN

Bhati, Chandra; Naidu, Sudeep; Seth, Avnish; Gunson, Bridget; Bramhall, Simon; Buckels, John; Mirza, Darius

Queen Elizabeth Hospital, Liver Unit, Birmingham, United Kingdom

Background. Outcomes in liver transplantation are dependant on donor, operative and recipient factors. Liver disease is common in patients of Asian origin and almost all UK cadaveric donors are Caucasian. These factors may impact on graft availability and outcome.

Aim. We compared outcomes in matched groups of adult Asian and Caucasian recipients of cadaveric liver grafts at a single UK centre.

Methods. Demographics, risk factors, graft availability, survival and mortality data on all adult Asian patients transplanted between 1986 and October 2006 were analysed from a prospective database.

Results. For each Asian recipient (n = 111), one Caucasian transplant recipient (n = 111), matched for age, gender, race, diagnosis, and year of transplantation, was selected from the transplant database. Blood group distribution, MELD, Creatinine, BMI and time on waiting list were also recorded.

	Asian	Caucasian	P value
No	111	111	n/s
Type of graft –Full/Split	103/8	105/6	n/s
Graft failure	50	36	0.017
Total deaths	48	30	0.005
Diabetes	30	15	0.019
Cardiac co morbidity	9	2	0.05
Time on waiting list (Mean)	73 days	43 days	0.01
MELD (Mean)	12	12	n/s
BMI (Mean)	25.02	26.02	n/s
Graft failure in blood group (B + AB)	20/41	9/33	0.041
Death in blood group B + AB	19/41	7/33	0.016

Patient and graft survival by Kaplan-Meier analysis was better in Caucasian patients (Patient survival: 5 and 10 years survival 60% and 50% in Asian versus 77% and 70% in Caucasians; Graft survival: 5 and 10 years survival was 57% and 46% in Asian versus 71% and 63% in Caucasians), with a higher incidence of diabetes and cardiac co-morbidity in Asian patients.

Conclusion. Liver transplant recipients of Asian origin have worse long term outcomes having waited longer for their grafts. The higher incidence of diabetes, cardiac comorbidity and incidence of blood group B may contribute to this

PP 8.06

LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA IN PORTUGAL

Pinto Marques, Hugo¹; Ribeiro, Vitor²; Oliveira, Fernando José³; Costa Maia, José⁴; Barroso, Eduardo¹

¹Curry Cabral Hospital, HepatoBiliaryPancreatic and transplantation Centre, Lisbon, Portugal; ²Hospital de Santo António, Surgery and Transplantation, Porto, Portugal; ³Hospitais da Universidade de Coimbra, Liver Transplantation, Coimbra, Portugal; ⁴Hospital de São João, Surgery, Porto, Portugal

Background. Results of liver transplantation (LT) for hepatocellular carcinoma (HCC) are comparable to those of LT for other diseases. Although it is commonly done in the various liver transplant Centres in Portugal, until now no study analyzed the global results of this therapeutic strategy in our Country.

OBJECTIVES. To evaluate the global results of LT and the impact of sequential LT for the treatment of HCC in Portugal.

Patients and Methods. A Multi-institutional retrospective sudy including the 4 LT Centres in Portugal was done. Between 1993 and 2006, 137 patients were submitted to LT for HCC. There were 122 men and 15 women. Most frequent aetiologies were cirrhosis due to alcohol, HCV and HBV. Forty-seven patients were submitted to preoperative therapy, most frequently transarterial chemoembolization. Sequential LT was performed in 56 patients (41%). The median size of the largest nodule was 4,3 cm and 16 patients had more than three nodules. Eighty patients (58%) fulfilled Milan Criteria and 95 patients (69%) fulfilled University of California – San Francisco (UCSF) Criteria. Kaplan-Meier and Log Rank tests were used for statistical analysis.

Results. Operative mortality was 13,1% (18 patients). Twenty-seven patients (19,7%) relapsed, most frequently in the lung or liver. Overall 5-year survival was 56%, and 10-year survival was 32%. Patients fulfilling Milan Criteria had a 73% 5-year survival. Patients fulfilling UCSF Criteria had a 72% 5-year survival. The most important factors influencing survival were number and size of nodules, as well as the presence of vascular invasion. There was no difference regarding overall or disease-free survival for cadaveric or sequential LT.

Conclusion. In Portugal, results of LT for HCC respecting standard selection criteria are similar to most international series. Expansion of those criteria obtained satisfactory results in our Centres. Sequential LT is a valid option for the treatment of those patients and achieves results that are equivalent to cadaveric LT.

PP 8.07

COMPARISON OF HISTIDINE- TRYPTOPHAN- KETOGLUTARATE SOLUTION (HTK) AND UNIVERSITY OF WISCONSIN SOLUTION (UW) IN ADULT LIVER TRANSPLANTATION

Rayya, Fadi¹; Schoen, Michael¹; Uhlmenn, Dirk²; Hauss, Johann¹; Fangmann, Josef¹

¹University Hospital Leipzig, Clinic for Abdomen and Transplant Surgery, Leipzig, Germany; ²University Hospital Leipzig, Clinic for Abdomen and Transplan Surgery, Leipzig, Germany

Background. A safe and effective preservation solution is a precondition for successful liver transplantation (LTx). This study compares University of Wisconsin (UW) and Histidine- Tryptophan- ketoglutarate HTK solutions in liver transplantation PATIENTS/ Methods. We retrospectively reviewed medical records of 137 primary cadaveric LTx performed between January 2003 and December 2006 at our institution. 68 grafts were harvested using UW and 69 using HTK. Recipients were managed similarly with regard to operative techniques and immunosuppression. Donor data including serum transaminases, serum sodium, ICU stay and assessed macroscopic liver quality were collected. Recipient serum transaminases were collected at postoperative days 1, 7, 14 and 30. Biliary- and vascular complications, patient and graft survival were compared.

Results. Mean serum transaminase levels were slightly higher in the HTK group at day 1 (NS) but were comparable thereafter. Primary non-function occured in 1 patient in each group. 6 patients in the UW and in 7 patients in the HTK group, were retransplanted. Biliary complication rates were similar in the UW and HTK groups (26.5% and 30.8%, respectively). There were 5 (7.2%) arterial complications in the HTK and 2 (2.9%) in the UW group (p < 0.05). Mean follow-up was 25 months. Graft survival at 1, 12, and 36 month was 90%, 78%, 75%, and 90%, 71%, and 71% in the UW and HTK group, respectively. 1, 12, 36 month patient survival was 93%, 78%, 75% and 93%, 78%, 78%, in the UW and HTK group, respectively.

Conclusions. There were no significant differences in graft and patient survival between the two groups. Biliary and arterial complication rates were also comparable. UW and HTK solutions seem to be equally safe

PP 8.08

LIVER TRANSPLANTATION IN JEHOVAH'S WITNESSES

HONORE, Pierre; DETRY, Olivier; DEROOVER, Arnaud

C.H.U. Sart Tilman(ULG), surgery, LIEGE, Belgium

Background. and AIM: In liver transplantation(LT), the use of blood products(red cells, platelets, plasma components) was reduced due to better medical and surgical management, but the interest of transfusion-free LT is debated. The authors developed a transfusion-free LT program for Jehovah's witnesses(JW), and analysed its outcome to evaluate the potential interest of bloodless strategies in LT for the JW and non-JW recipient population.

Methods. Over an 8-years period,17 selected JW underwent 18 LT in the author's department, including 5 right lobe living related LT and one pediatric LT. We analysed herein the outcome of 11 adult patients(5 males,6 females, mean age:50 years) who underwent 12 cadaveric whole LT. They received preoperative erythropoietin(EPO) therapy, with iron and folic acid to increase preoperative haematocrit(Ht). A cell saving system was used during the surgical procedures. No patient was lost to follow-up(mean:44 months).

Results. No blood product was used in the whole follow-up. During the operative procedure a mean of 1,250 ml were scavenged by the cell-saving system, allowing the reinfusion of a mean of 404 ml of concentrated red cells. Due to preparation, Ht level rose from 37.5±1.6% at the first visit, to 43±1.5% just before LT(p < 0.05). Postoperative day 1 mean Ht was35±1.6%,(p < 0.05), and further decreased during the post transplant period(mean lowest Ht:30.7±1.7%, p < 0.05). Mean Ht at discharge was 33.6±1.9%. One patient needed urgent retransplantation due to early hepatic artery thrombosis. No patient experienced complication linked to anemia. Patient and graft survival is 100% and 90% respectively, at follow-up.

Conclusions. These excellent results justify the development of bloodless LT program. They also raise questions on the interst of prospective evaluation of bloodless strategies in non-JW patients undergoing LT, and on the possible protective effects of EPO against ischemia-reperfusion injury and apoptosis

PP 8.09

THE FIRST DOMINO TRANSPLANTATION IN CZECH REPUBLIC

OLIVERIUS, Martin¹; Adamec, Milos¹; Trunecka, Pavel²; Frankova, Sona³; Kieslichova, Eva⁴

¹Institute for Clinical and Experimental Medicine, Transplant Surgery Department, Prague, Czech Republic; ²Institute for Clinical and Experimental Medicine, Department of Hepatogastroenterology, Prague, Czech Republic; ³Institute for Clinical and Experimental Medicine, Department of Hepatogastroenterology, Prague, Czech Republic; ⁴Institute for Clinical and Experimental Medicine, Department of Anestesiology and Intensive Care, Prague, Czech Republic

Background. while there is a worldwide increase in liver transplantation the number of cadaveric donors remains relatively stable. Several new techniques including reduced-, split-, living donor- and non heart beating donor transplantation have been developed to solve this problem. Domino liver transplantation represents an uncommon alternative. AIM(S)/OBJECTIVE(S): Familial amyloidotic polyneuropathy (FAP) is an inherited disorder with the systemic deposition of amyloid fibrils containing mutant transthyretin variants. The liver produces 95% of the mutant form of transthyretin. Successful liver transplantation could eliminate the source of the variant transthyretin molecule, and is now the only known curative treatment. Sequential transplant or domino liver transplant (DLT) allows the transplantation of a patient with chronic liver disease by implantation of a full-size liver derived from a patient with FAP who in turn receives a cadaveric graft. Therefore, it is poss ible to transplant two patients using a single cadaveric graft.

Methods. A 40-yr-old woman with FAP underwent cadaveric liver transplantation, and her liver was used as a domino graft for a 59-yr-old man with pT2NOMO G2 hepatocellular carcinoma. The first procedure was performed as a conventional “end to end cavocaval anastomosis “ while the second one was a "piggy back" procedure.

Results. The surgical outcome was successful. Postoperative course was uneventful with early liver function. Immunosuppression was based on tacrolimus, MMF and steroids.

Discussion and Conclusion. domino liver transplantation is a save procedure which may help in reducing of current organ shortage in some particular cases in the future.

PP 9.01

A NOVEL TECHNIQUE OF MODIFIED DEVINE WITH TWO BRAUN ANASTOMOSES FOR UNRESECTABLE PANCREATIC CANCER

Kawasaki, Atsushi¹; Oida, Takatsugu¹; Mimatsu, Kenji¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background/AIMS: If curative operation of pancreatic cancer is not possible, palliation of cholestasis and eventual duodenal obstruction is mandatory. In these cases with both duodenal and biliary obstruction, the standard approach has been gastroenterostomy plus biliodigestive anastomosis. However, in the case of conventional gastrojejunostomy, the bypass dose not always function effectively. The other hand, with the development of interventional insertion of a biliary stent has taken the place of surgical bypass, but there was a higher prevalence of late complications. We introduced and evaluated our bypass procedure for unresectable pancreatic cancer.

Patients and Methods. Eight patients underwent modified Devine with two Braun□fs amastomoses to treat untesectable pancreatic head carcinoma. 1) Modified Devine Exclusion; The side of anastomosis was determined at greater curvature of the body of the stomach. With a linear stapler, partial ablation, a wide segment near the lesser curvature was left as a drainage route for contents remaining in the oral of the constricted duodenum. The jejunum was anastomosed antecolically to the oral side of the stomach. 2) Braun anastomosis (First Braun□@anastomosis) was performed at the 20 cm below of the gastorojujunostomy. 3) Choledocojujunostomy was performed without stent tube. 4) Another Braun anastomosis was performed between the first Braun□@anastomosis and choledochojejunostomy.

Results. No complications directly related to the procedure occurred. No suction drain was required. Mean survival, hospital stay and out of hospital stay were 5 months, 20 days and 3.5 months.

Conclusion. Modified Devine with two Braun□@amastomoses is a simple and effective technique for unresectable pancreatic carcinoma.

PP 9.02

DIFFERENT TECHNIQUES OF MINIMALLY INVASIVE PANCREATIC NECROSECTOMY

Nagpal, Anish; Haribhakti, Sanjiv

Haribhakti Surgical Hospital, Ahmedabad

Introduction. Infection of pancreatic necrosis is one of the most morbid complication of acute necrotizing pancreatitis. Almost all the patients of infected necrosis of pancreas require surgical intervention. With advances in technology, necrosectomy has become possible with minimally invasive techniques.

Methods. 5 patients of infected pancreatic necrosis underwent necrosectomy by minimally invasive techniques during the period between January 2004 to December 2006. Mean APACHE II score on admission was 14.2 (range from 5–36). 2 patients underwent retroperitoneoscopic necrosectomy, 2 patients underwent hand assisted and one patient underwent total laparoscopic necrosectomy. 2 patients underwent simultaneous cholecystectomy.

Results. 2 out of 5 patients died (one on 5th post-operative day and one on 25th postoperative day just before discharge) while 3 patients developed controlled, self healing pancreatic fistula.

Conclusion. Minimally invasive pancreatic necrosectomy is feasible technique with acceptable results in carefully selected patients by experienced surgeons.

PP 9.03

NEW SUGICAL TECHNIQUE OF LAPAROSCOPIC CYSTGASTROSTOMY FOR PANCREATIC PSEUDOCYSTS; POSTERIOR APPROACH

Aramaki, Osamu¹; Oida, Tkatugu²; Oida, Tkatugu²; Mimatsu, Kenji¹; Kawasaki, Atushi¹; Kuboi, Youichi¹; Kanou, Hisao¹; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Introduction. Internal drainage of acute pancreatic pseudocysts is indicated 6 weeks after the first documentation of pseudocyst. When pseudocysts are located in close contact with the posterior wall of the stomach, they are best drained by pseudocyst-gastrostomy. Laparoscopic treatment of pancreatic pseudocysts allows for definitive drainage with faster recovery. Although, many groups have reported their experiences with an anterior approach, only a few have done with a posterior approach.

Patients and Methods. Five patients underwent laparoscopic cystogastrostomy for pancreatic pseudocysts. The posterior approach was performed by directly visualizing the posterior gastric wall and the pseudocyst, drainaging the cyst with a needle. After a sufficient drainage orifice is made and the cyst contents are thoroughly debrided. The cystogastrostomy was fashioned through an posterior approach with stapling device. Closure of the opening wall was performed by hernia stapler.

Results. Cystogastrostomy was underwent by posterior approach with stapling device in all patients without conversion to anterior approach nor to open surgery. There were no operative complications. No late recurrences have been found at a median follow-up of 49 months.

Conclusion. Laparoscopic csytogastrosotmy by posterior approach with wide internal drainage for pancreatic pseudocyst is safe, feasible and effective procedure, and it no requires the opening of the anterior stomach.

PP 9.04

THE LAPAROSCOPIC APPROACH TO DRAINAGE OF PANCREATIC PSEUDOCYSTS: A SUITABLE APPROACH FOR'ALL COMERS'

Hamza, Numan¹; Alkari, Bassam²; Ammori, Basil J²

¹Manchester Royal Infirmary, HepatoPancreatoBiliary Surgery, Oxford Road, Manchester, United Kingdom; ²Manchester Royal Infirmary, HepatoPancreatoBiliary Surgery, Manchester, United Kingdom

Introduction. Pancreatic pseudocysts (PP) are traditionally managed by laparotomy.

Objective. Our experience with the laparoscopic approach for all comers with PP requiring surgical drainage is presented.

Methods. Between 2001 and 2007, 15 consecutive patients underwent 16 surgical drainage procedures for PP, all of which were attempted laparoscopically.

Results. The median PP size was 13 (range, 6.5–23) cm. The procedures included pseudocyst-gastrostomy (PCG) (n = 13), Roux-en-Y pseudocyst-jejunostomy (n = 2), and an unplanned external drainage due to extensive adhesions (n = 1). The approach to PCG was transgastric (n = 8), endogastric (n = 3) and exogastric (n = 2). Pancreatic necrosis was present in 13 patients of whom 9 required debridement. Three patients underwent a concomitant cholecystectomy. There were no conversions to open surgery. The median operative time was 122.5 (interquartile range, 85–153.75) minutes. There were no postoperative complications and no mortalities. The median postoperative hospital stay was 2 (range, 1–4) days. At a median follow up of 13 (range 1–41) months one patient (6.7%) developed a recurrent PP that was drained laparoscopically.

Conclusions. Laparoscopic drainage of PP is a feasible, safe, an effective alternative to laparotomy for all comers with PP that require internal drainage, and is associated with rapid recovery, short hospital stay and a recurrence rate comparable to open surgery.

PP 9.05

A TAILORED APPROACH TO LAPAROSCOPIC SPLEEN-PRESERVING DISTAL PANCREATECTOMY – OUR INITIAL EXPERIENCE

Das De, Soumen¹; Kow, Alfred Wei-Chieh¹; Lim, Khong-Hee²; Liau, Kui-Hin²; Ho, Choon-Kiat²

¹Tan Tock Seng Hospital, Digestive Disease Center, Dept of General Surgery, Singapore; ²Tan Tock Seng Hospital, Digestive Disease Center, Dept of General Surgery, Singapore, Singapore

Background. ¼ Laparoscopic resection for small lesions of the pancreas has recently gained popularity. We report our initial experience with a tailored approach to laparoscopic spleen-preserving distal pancreatectomy, individualized to the location of the lesion.

Aim. Our aim is to show a tailored approach reduces the removal of excessive normal pancreatric tissue without compromising margins.

Methods. Three patients underwent laparoscopic distal pancreatectomy with spleen-preservation over a two-month period. Surgical techniques and patient outcomes were examined.

Results. All our patients were females, with ages ranging from 31 to 47 years old. Two patients underwent the surgery with a “medial-to-lateral” approach as the lesion was close to the body or proximal tail of pancreas. The third patient had a lesion in the distal tail of the pancreas and surgery was performed in a “lateral-to-medial” manner. This latter approach allowed us to avoid excessive sacrifice of normal pancreatic tissue for such distally located lesions. All patients had preservation of the splenic artery and vein. The first two patients stayed in hospital for 5 days while the third patient stayed for 9 days. There was no significant difference between operative time and intra-operative blood loss.

Discussion. Laparoscopic distal pancreatectomy with preservation of the spleen is a feasible surgical technique with acceptable outcome. We practice a tailored approach to the dissection technique based on location of the lesion. A “medial-to-lateral” approach is indicated for lesions in the body of the pancreas while a “lateral-to-medial” dissection has been shown to be feasible for lesions in the distal tail of the pancreas. We have successfully performed splenic preservation in both approaches, with preservation of splenic vessels, with a successful surgical outcome.

PP 9.06

LAPAROSCOPIC MANAGEMENT OF CYSTIC NEOPLASMS OF PANCREAS-MMHRC EXPERIENCE.

PALANIAPPAN, KUMAR; Chandran, Nivedita; Narashiman, Mohan; Arthanari, Ramesh

MEENAKSHI MISSION HOSPITAL & RESEARCH CENTRE, DEPARTMENT OF SURGICAL GASTROENTEROLOGY, MADURAI, India

Background. Cystic lesions of pancreas are common, and more than 80–90% are pseudo cyst of pancreas. Cystic neoplasms account for 10–15% of cystic lesions of pancreas. The most common cystic neoplasm are serous cystadenoma & mucinous cystadenoma. Accurate pre op diagnosis is essential for optimum surgical management.

Aim. To analyze retrospectively the outcomes of patients admitted with cystic neoplasm of pancreas-specifically at morbidity like pancreatic fistula, abscess etc. TYPE OF STUDY: Retrospective chart analysis. PERIOD OF STUDY: 2000–2007.

Results. Total of 13 patients were admitted with cystic neoplasm of pancreas. 11 females and 2 were males. Age group varied from 17–56 years ( mean 26.3years). 10 patients had serous cystadenoma, 3 cases had mucinous cystadenoma. All underwent laparoscopic procedures. Enucleation was done in 2 patients, distal pancreatectomy with spleenectomy was done in 5 patients, 4 patients underwent distal pancreatectomy with spleen preservation, 2 cases underwent median pancreatectomy. The average operating time was 110–160 min ( mean: 130 min). None of the patients required blood transfusion. The average size of tumor varied from 5–20 cm( mean 8cm). There was no mortality in the present series. 3 patients had post op external pancreatic fistula, which was managed conservatively. Fistula closed spontaneously over a period of 3weeks. The average fistula volume was about 100ml. 2 patients had post op intra abdominal abscess, which was percutaneously aspirated. the average hospital stay was about 6 days (5–17 days).

Conclusion. Cystic neoplasms of pancreas can be managed safely by laparoscopic techniques with accepted morbidity & mortality.

PP 9.07

LAPAROSCOPIC HAND ASSISTED NECROSECTOMY FOR SEVERE GALLSTONE PANCREATITIS

Yoo, Stephen; Tchanque, Catherine N; Chang, Yeon-Jeen; Jacobs, Michael J; Mittal, Vijay K

Providence Hospital and Medical Centers, General Surgery, Southfield, United States

Introduction. Debridement is a key principle for the management of necrotizing pancreatitis. Traditionally, an open laparotomy has been required to address this difficult clinical scenario. Presented here is a case of laparoscopic hand-assisted necrosectomy as a minimally invasive approach to managing complications from severe gallstone pancreatitis.

Objectives. To present a case of laparoscopic hand-assisted necrosectomy for the management of severe gallstone pancreatitis

Presentation. A 28 year-old Hispanic female presented with a case of severe gallstone pancreatits. Her initial hospital course required an ERCP with placement of a biliary stent, as well as complications from ARDS. A laparoscopic cholecystectomy was performed on the same admission prior to discharge. She returned to the hospital 7 days post-discharge with a temperature of 38.9°C. CT scan revealed a retroperitoneal fluid collection along Morrison's pouch and the right paracolic gutter. CT-guided drainage was unsuccessful, and aspiration was positive for Candida glabrata. With failure of conservative means, a laparoscopic hand-assisted necrosectomy was performed. A drainage system was created to irrigate the peritoneum utilizing Jackson-Pratt drains and a 28-French chest tube. The patient was eventually discharged home with the devised drainage system. Subsequent CT scans had shown successful resolution of the infected necrotic fluid collections.

Discussion. With the high mortality associated with necrotizing pancreatitis, aggressive debridement is mandatory. When considering a less invasive surgical option, it must not come at the expense of achieving substandard outcomes. The hand port helped facilitate the necessary and adequate level of necrosectomy, while still limiting the morbidity from a more invasive laparotomy.

PP 9.08

LAPAROSCOPIC DISTAL PANCREATECTOMY

Slepavicius, Algirdas

Klaipeda University Hospital, Abdominal and endocrine surgery, Klaipeda, Lithuania

Background. Laparoscopic distal pancreatectomy for benign conditions was first described in the early 1990s, but it has not become as popular as other laparoscopic surgeries. There are only several case reports and a handful of small series. We present our initial experience in performing laparoscopic distal pancreatectomies.

Methods. From June 2006 to June 2007, three patients underwent laparoscopic distal pancreatectomy in the department of Abdominal end Endocrine surgery of Klaipeda University Hospital. The author performed one distal pancreatectomy with preservation of the spleen and two distal splenopancreatectomies.

Results. Two males and one female in the age range of 69–87 years underwent operations. Splenic preservation was possible in one patient. The tumor diameter ranged from 3.6 cm. to 6.5 cm. The mean operating time was 125 min for distal splenopancreatectomy and 210 min for distal pancreatectomy. All patients were started on a liquid diet on the first postoperative day. The median hospital stay was 6 days. The histologic report showed two insulinomas and one mucinous cystadenoma. There were no pancreatic leaks, deaths, nor readmisions.

Conclusions. Laparoscopic distal pancreatectomy is a safe procedure with rapid recovery and short hospital stay. In appropriate cases, splenic preservation is feasible.

PP 9.09

LAPAROBOTIC APPROACH TO PANCREATODUODENECTOMY

Yiengpruksawan, Anusak¹; Carnevale, Nino²

¹The Valley Cancer Center, Valley Hospital, Ridgewood, New Jersey, United States; ²The Valley Cancer Center, Ridgewood, New Jersey, United States

Background. Pancreatoduodenectomy (PD) is a technically demanding procedure. Although the laparoscopic approach has been performed successfully, technical difficulties may preclude its widespread adoption. With the newly introduced robotic technology, some of these difficulties have been over come.

Objective. We would like to report our recent experience applying this technology to PD and show that the procedure and outcomes may be improved with the laparobotic approach.Method.: We used the daVinci robotic surgical system (Intuitive Surgical, Mountain View, CA, USA) equipped with four arms. Pyloric sparing technique was performed in all cases. The pancreatic remnant was anastomosed to the stomach. Technical details of the procedure and outcomes of the patients were evaluated.

Results. Successful pyloric sparing PD was achieved in two patients with benign pancreatic tumors using a unique approach that takes advantage of the superior vision and dexterity-enhanced instruments inherent in the robotic approach. The operative time were 5 and 7 hours, and the lengths of hospital stay were 5 and 7 days, respectively. No blood transfusion was given. There was one postoperative complication but no death.

Conclusions. Laparobotic pancreatoduodenectomy is feasible and safe in the hands of a highly skill pancreatic surgeon with minimally invasive surgical experience. It warrants further investigation on a large scale multiinstitutional study.

PP 9.10

TREATMENT OF THE SMALL CYSTIC NEOPLASM OF THE PANCREAS

Kubyshkin, Valery¹; Grishankov, Sergey²

¹Vishnevsky Institute of Surgery, Moscow, Russian Federation; ²Moscow, Russian Federation

Background. Cystic neoplasm of the pancreas (CN) is demanded surgical approach usually, but treatment policy of the small cystic tumors is controversial.

Aim. To study clinical and morphological features of the small cystic tumors and determine appropriate treatment one's.

M ethods. Between 1992 and 2006 we treated 52 patients with different CN of the pancreas. 12 patients (23%) had CN less than 3cm in size. Median age was 53 years (varied from 35 to 73). All patients were female. Tumor localization: neck –5 (41.6%), body and tail – 7 (58.4%). We analyzed clinical dates (complains, history of disease, rate of growing), results of US, CT and EUS. All cysts were treated surgically and undergone cross-section morphological examination.

Results. only 1 patient with small CN had clinical symptoms (moderate pain in upper part of abdomen). Rest of the small CN was found incidentally and long time (from 2 to 7 years) has been observed in outpatient's clinics. All small CN increased in size during of observation (rate was 0.5–1cm/per year). Cystic septa were discovered in 10 cases, solid masses in cystic cavity were visualized in 1 case. 1 patient had unilocular cyst. We not perform fine needle aspiration in during EUS routinely. Surgical treatment included – 7 distal pancreatectomy, 3 medial resection and 2 enucleation of CN. Results of cross-sectional histological examination: 7 CN were serous cystadenomas without any malignant changes, 4 CN were mucinous cystadenovas with foci of moderate dysplasia and 1 patient had borderline mucinous CN with severe dysplasia. Malignant tumors we not discovered between all small CN.

Conclusion. Small CN are benign usually but has trended to increase in size and demand constant medical observation because part of them are mucinous with premalignant changes.

PP 10.01

PRENEOPLASTIC LESIONS IN GALLBLADDER CANCER

Saitoh, Ai¹; Iki, Katsumichi¹; Urakami, Atsushi¹; Nagatsuka, Ryousuke¹; Tsunoda, tsukasa²

¹Kawasaki Medical School, Gastroentelorogical Surgery, Kurashiki, Japan; ²

Background. Gallbladder cancer is an uncommon disease except in countries like India, Japan and Chile. The knowledge of the etiology and pathogenesis of this neoplasia is significantly less compared to other malignant tumors. The epithelial lesions involved in gallbladder carcinogenesis are dysplasia and adenomas that represent two biologically distinct carcinogenetic models. Both models were supported by morphological and molecular genetic evidences. However, dysplasia associated or not to gallbladder cancer have not been studied. We presented the possibility of the dysplastic lesion is or not one of precancerous lesion in gallbladder cancer.

Materials and Method. Twelve surgical specimens which histologically diagnosed as gallbladder cancer were used. Tissues were fixed in 10% buffered formalin, embedded in paraffin by conventional methods and stained with hematoxylin and eosin. General rules for surgical and pathological studies on cancer of the biliary tract, 5th edition 2003 Japan, was used to classify macroscopic types of each cases as follows: 1) papillary type, 2) flat type, and 3) nodular type. And we counted atypical lesions, hyperplasia (H), metaplasia (M), and dysplasia (D), which adjacent to neoplastic lesions in each types of gallbladder cancer.

Results. Epithelial hyperplasia, metaplasia, and dysplasia are present in the mucosa adjacent to each cancer type in 13%, 27%, and 62% in papillary type, 25%, 20%, and 54% in flat type, and 13%, 19%, and 69% in nodular type, respectively. And in 18%, 21%, and 61% in total gallbladder cancer examined. The frequency of atypical epithelial lesions was not associated with histologic types of gallbladder cancer. In all cases, dysplasia is observed in the surrounding mucosa of the tumoral lesion.

Conclusions. From the morphological point of view, the dysplasia □∣ carcinoma sequence is the most plausible carcinogenic pathway for gallbladder cancer.

PP 10.02

INCIDENTAL GALLBLADDER CANCER: RADICAL SURGERY OFFERS LONGER SURVIVAL.

Toti, Luca; Attia, Magdy; Manzia, Tommaso Maria; Lenci, Ilaria; Buckels, John AC; Mirza, Darius F; Mayer, A David; Taniere, Philippe; Bramhall, Simon R

Queen Elizabeth Hospital, Liver Unit, Birmingham, United Kingdom

Background. Gallbladder cancer (GBC) is a disease with an increasing incidence. The majority of cases present with advanced incurable disease but increasingly GBCs are being diagnosed incidentally after routine cholecystectomy. Our aim was to retrospectively evaluate our experience of incidental GBC according to surgical approach and TNM staging.

Material and Methods. 180 patients (129 females 72% and 51 males 18%) with GBC were treated in our unit between March 1997 and June 2007. Incidental gallbladder cancer (iGBC) was identified in 39 (22%).

Results. In the iGBC group median age at presentation was 62.3 (range 40–79) years; there were 33 female (85%) and 6 males (15%); 38 were adenocarcinomas, 1 adenosquamous (10 well, 18 moderately, 11 poorly differentiated). The local pathological stage of the tumours was pT1a (1), pT1b (8), T2 (21) and T3 (9). 9 patients had an open cholecystectomy, 14 had a gallbladder bed resection (GBR), 13 had a gallbladder bed resection + extrahepatic biliary duct excision (GBR + EBDE) and 3 had just a laparotomy (LP). The overall 5 year survival in all 180 GBC patients was 14%: 38 patients had a resection with an overall survival of 40%. In the iGBC group overall 5 year survival was 38%. In T1 group overall 5 years survival was 53%, in T2 was 50% and in T3 was 0% (but 1 patient is still alive). In patients who had GBR only and patients who had GBR + EBDE the 5 year survival was 33 and 62% respectively (p < 0,03).

Conclusions. Radical re-operation in patients with incidental gallbladder carcinoma appears to improve survival. Extrahepatic bile duct excision when added to gallbladder bed resection also appears to improve survival.

PP 10.03

COMPARISON BETWEEN TWO METHODS OF PALLIATION FOR JAUNDICE AND PRURITUS IN PATIENTS WITH UN-RESECTABLE NON-METASTATIC GALLBLADDER CANCER

Jain, Sundeep¹; Kalla, Mukesh²; Sharma, Jayant³; Chokrobarty, Sudipto⁴; Sharma, Shyam Sunder⁵

¹S.K. Soni Hospital, Gastrointestinal & Laparoscopic Surgery, Sector 5, Vidhyadhar Nagar, Jaipur, India; ²S.R. Kalla Memorial Hospital, Gastroenterology, Jaipur, India; ³S.K. Soni Hospital, Gastroenterology, Jaipur, India; ⁴S.K. Soni Hospital, Gastrointestinal & Laparoscopic Surgery, Jaipur, India; ⁵S.M.S. Medical College & Hospital, Gastroenterology, Jaipur, India

Introduction. Majority of patients with gallbladder cancer (GBC) in India have un-resectable disease with jaundice and pruritus as their main complaint. Biliary drainage gives significant improvement in morbidity related to cholestasis. OBJECTIVE This study was conducted to compare the results of surgical and endoscopic biliary drainage in the selected group of patient with un-resectable, non-metastatic GBC.

Methods. Data was collected from patients with GBC with obstructive jaundice who underwent biliary drainage by endoscopic stenting (plastic/SEMS) (group I) or segment III bypass (group II) during the period August 2005 to July 2007. Systematic analysis of prospective data was undertaken; patients were analyzed for post-procedure morbidity, mortality and symptom free survival.

Results All patients were matched for demographic features, gallbladder stone association and stage of the disease. The fall in serum bilirubin levels to <4mg% within one month and complete relief from pruritus with in 2–7days was seen in all the patients. There was no difference in procedure related morbidity and mortality. The median hospital stay was 1and 6 days (range of 1–6 and 5–15 days) in the respective groups. Four in group I and one in group II patients had readmission for cholangitis and gastric outlet obstruction respectively, for which stent replacement and gastrojejunostomy was done. The mean symptom free survival in the two groups was 3.1 and 4.5 months (median 2.5 and 3.5 months, range of 1–6 and 1–12 months) respectively. Three patients in group II (30%) survived for more than 6 months with none in group I. Five patients underwent stenting with SEMS. The cholangitis and survival rates were similar with SEMS and plastic stents.

Conclusions. Segment III biliary-enteric bypass can be performed safely and provides better palliation for jaundice and pruritus in patients with un-resectable non-metastatic GBC. There is no advantage of SEMS over plastic stents in these patients.

PP 10.04

SURGICAL MANAGEMENT OF CARCINOMA GALL BLADDER

Khandelwal, Manish¹; Goyal, Ashish²; Khandelwal, Chiranjiva³

¹Broomfield Hospital, Chelmsford, United Kingdom; ²Mahavir Cancer Sansthan, Surgical Oncology, Patna, India; ³IGIMS, GI Surgery, Patna, India

Background. Carcinoma(Ca) Gall Bladder(GB) is common in North India. It is an aggressive disease with poor prognosis. We come across 250–300 cases of Ca GB every year. Most of these are diagnosed by Imaging Studies or FNAC. We lack facilities for endoscopic biliary drainage in our part of the world.

Methods. We retrospectively analysed 255 cases of Ca GB that presented to us from Jan ‘95 to March ‘07. We reviewed the symptoms, stage at presentation, mode of spread, treatment options & mortality.

Results. M:F ratio was 1:2.4. Average age was 47.1 for males and 46 years for females.6 were less than 15 years of age. 25% presented with obstructive jaundice & 20% with gastric outlet obstruction. Calculi were noted in 69% cases. GB fundus was involved in 30%, body in 18% & neck in 16%. Entire GB was involved in 36% cases. Spread of tumor was mainly through direct invasion into liver, bileduct, duodenum & colon.22% cases had only wide spread lymphadenopathy, without liver infiltration. 200(78%) underwent resection.54% of cases were in advanced stage at presentation (36% & 18% in Stage III & Stage IV respectively). Curative resection was done in 37% while palliative resection was done in 63%. Curative surgery included extended cholecystectomy in 31 cases with liver resection & radical lymphadenectomy, 5 cases with bile duct excision & and 2 had pylorus preserving pancreatoduodenectomies. Simple Cholecystectomy done in 10(5.5%) cases (Incidental CaGB, Stage I) were also curative resections. Bypass was done in 48(19%) cases (biliary bypass in 28 & bowel bypass in 20). 13(7.5%) cases were inoperable. The overall mortality was 5.5%.

Conclusion. Surgical treatment is the only curative option. Resection should be done wherever R0 resection is possible. However, debulking surgery & aggressive surgery can have high morbidity & mortality and should be avoided. Areas where endoscopic drainage is not available or technically not possible; palliative resection/bypass can be done with acceptable mortality and offers better quality of life.

PP 10.05

WHAT IS AN ADEQUATE EXTENT OF RESECTION FOR T1 GALLBLADDER CANCERS?

YOU, Dong Do; Lee, Hyung Geun; Paik, Kwang Yeol; Heo, Jin Seok; Choi, Seong Ho; Choi, Dong Wook

samsung medical center, Seoul, Korea, Republic of

Introduction. Simple cholecystectomy offers adequate treatment for T1a cancers, however it remains debatable whether T1b cancers should be treated by simple cholecystectomy or by radical resection.

Objective. The purpose of this study was to analyze clinicopathologic and surgical features and to determine what should be an adequate extent of resection for T1 gallbladder cancers.

Methods. A retrospective analysis was conducted on 52 patients with pathologic stage T1 (27 with T1a and 25 with T1b). Clinicopathological features, extents of resection and survival rates were investigated retrospectively.

Results. No lymph node metastasis, lymphovascular or perineural infiltration was observed in those with T1a disease, but 2 of the 25 patients with T1b disease had lymph node metastasis and one patient had lymphatic infiltration. 21 of the 52 study subjects underwent simple cholecystectomy. No peritoneal dissemination occurred regardless of surgical method (laparoscopy or open surgery). Of the 23 radically resected patients in T1b group, 6 patients underwent cholecystectomy and hepatoduodenal lymph node dissection (CholeLN), and 17 patients underwent CholeLN combined with wedge resection of IVb, V segment of liver, common bile duct resection, or pancreaticoduodenectomy. No difference in locoregional recurrence, metastasis or survival rate was observed regardless of combined resection of an adjacent organ. The overall survival rate for all patients was 96.15% and for T1a and T1b these were 96.3% and 96.0%, respectively.

Conclusion. When early gallbladder carcinoma is suspected as a result of imaging findings, further evaluation of the depth of invasion by endoscopic ultrasonography or intraoperative frozen biopsy is advised. Then if the disease stage is determined to be T1a, laparoscopic or open cholecystectomy alone is curative, and if T1b, cholecystectomy with hepatoduodenal lymph node dissection without combined resection of an adjacent organ is recommended.

PP 10.06

EARLY STAGES OF GALLBLADDER CARCINOMA

Frena, Antonio

Central Hospital of Bolzano, General Surgery, Bolzano, Italy

Background. carcinoma detected at histological examination of the gallbladder after cholecystectomy for gallstone disease or acute cholecystitis is defined as incidental. It is a fairly rare event, but the increase in the number of cholecystectomies performed as a result of the success of the laparoscopic technique has led to a rise in the number of incidental carcinomas detected. Histologically, in most cases, these are pT1 and pT2 carcinomas, i.e., tumours that do not penetrate beyond the muscular wall of the gallbladder.

Aims. up until the ‘nineties it was believed that these carcinomas could be adequately treated by simple cholecystectomy, whereas today the treatment of choice entails a radical second operation. Methodology: this study, conducted at a single institute, constitutes a review of 20 years’ experience: the data base consists of 3072 cholecystectomies with a 0.68% incidence of incidental gallbladder carcinoma.

Results. survival data are carefully calculated in relation to the evolution of surgical treatment over the years, thus making it possible to correlate tumour staging, patient survival and surgical therapy.

Conclusions. the contributions made by literature reports since the ‘nineties have prompted hepatobiliary surgeons to modify their attitudes towards incidental gallbladder carcinoma. Detection of previously unrecognised microinfiltrations of the serosa and of neoplastic involvement of distant lymph-node stations has led to the introduction of the concepts of radical and extended cholecystectomy. Comparison between the historical survival curves of patients treated with simple cholecystectomy and the distinctly better curves of those treated with a radical second operation accounts for the evolution of surgical treatment over the past two decades.

PP 10.07

EFFICACY OF GEMCITABINE/CISPLATIN COMBINED CHEMOTHERAPY FOR GALL BLADDER CANCER

Nakamura, Noriaki; Arii, Shigeki; Tanaka, Shinji; Kudo, Atsushi; Itoh, Kouji

Tokyo Medical and Dental University, Dept. Hepato-biliary pancreatic surgery, Bunkyo-ku Yushima Tokyo, Japan

BackgroundAlthough the first treatment of gallbladder cancer is an operation, still sufficient results are not expected. Furthermore, in unresectable gallbladder cancer, a prognosis is very poor. We will report the gemcitabine/cisplatin (GEM/CDDP) combined chemotherapy we have tried recently.

Material and method 37cases of gall bladder cancer were treated from April, 2000 to July, 2007 in the department of Hepato-biliary pancreatic surgery, Tokyo medical and dental university hospital. The three weeks protocol of the GEM/CDDP chemotherapy tried mainly for the unresected cases was that the CDDP (50mg/mm2) was administrated intravenously on the day 8, GEM (1000mg/mm2) was on the both day 1 and 8 and no treatment was on the day 15. The radiological images and the tumor marker (CEA and CA19-9) were examined

ResultThe number of resected case was 24 (64.9%) among 37 cases.□@The median survival time (MST) was about 12 months and the five-year probability of survival was 31.5%. According to the treatment, although MST of 24 cases of the resected group was about 24 months, in 13 cases of unresected group, about 7.2 month. This difference was significant statistically. Then, the GEM/CDDP treatment was enforced as the chemotherapy against for unresected group. The eight patients were enrolled in this chemotherapy group from December, 2004 to July, 2007. Average age was 70.6 years old. One case was an adjuvant treatment after operation others were clinical stage IVb. Although MST of a GEM/CDDP group is about seven months and the significant difference was not statistically accepted to 3 months of MST in no chemotherapy group before GEM/CDDP treatment trial, extension of MST for about 4 months was seen. In the evaluation of efficacy, the overall response rate was 42.8% (3 out of 7 cases). Adverse events were observed in one case of reduction of blood platelet (Grade3) and 2 cases of leukocytopenia (Grade2).

Conclusion This combined□@chemotherapy had few adverse events and was good response rate(42.8%).

PP 10.08

GALLBLADDER CANCER IN A PATIENT PRESENTING WITH MASSIVE WEIGHT LOSS

Jacobs, Michael; Ahad, Ahmad W.; Patel, Purnal; Jacobs, Michael

Providence Hospital and Medical Centers, Surgery, Southfield, United States

Background. Gallbladder (GB) cancer has an aggressive natural history and carries a poor prognosis. Surgery offers the only possible cure in early stage gallbladder cancer. Unfortunately, symptoms are vague and most diagnoses are made incidentally.

Objective. We report a case of severe weight loss in a patient with GB cancer, whose diagnosis was possibly overlooked due to confounding symptoms.Method. AND RESULT: A 54 year-old female presented to us with a history of vague abdominal pain associated with a 185-pound weight loss that was attributed to diet and exercise following an abdominoplasty. She had intermittent symptoms of abdominal discomfort, pain, bloating and dyspepsia after this procedure. An ultrasound revealed cholelithiasis. A Computer Tomography scan showed a pericholecystic collection that was compressing the GB. Subsequent Magnetic Resonance Imaging study confirmed cholelithiasis, and showed eccentric, focal areas of GB wall thickening that extended into the adjacent hepatic parenchyma and mesenteric fat. CA 19-9 level was elevated with other labs being unremarkable. Surgery w as advised. Intraoperatively, a mass emanating from the GB was found to be penetrating segments 4B and 5 without any other local involvement. En-bloc resection of the GB and segments 4B and medial aspect of 5 was performed. Portocaval, celiac, hepatic and supraduodenal lymph nodes were negative for metastasis. Pathology revealed an invasive poorly differentiated carcinoma with focal squamous differentiation extending to the posterior margins. Postoperative course was unremarkable.

Conclusion. The best prognosis for GB cancer is observed in-situ adenocarcinomas that are resected in completion. Surgically, in-situ cancers can be treated with simple cholecystectomy while any other stage require more extended procedures. In patients with significant weight loss, underlying malignancy should be ruled out with further thorough work-up to allow these patients the best possible outcome.

PP 10.09

MANAGEMENT OF GALLBLADDER CANCER IN A TERTIARY REFERRAL CENTRE

Oniscu, Gabriel C¹; Cornell, Rachel¹; Oniscu, Anca²; Kamel, Hassan²; Garden, James¹; Parks, Rowan W¹

¹University of Edinburgh, Department of Clinical and Surgical Sciences, Edinburgh, United Kingdom; ²University of Edinburgh, Departmetn of Pathology, Edinburgh, United Kingdom

Background. Gallbladder cancer poses a significant treatment dilemma, especially when discovered incidentally.

Aim. This study reviews the management of gallbladder cancer and investigates the role of further surgery after the initial cholecystectomy.

Methods. Demographic, diagnostic and procedural data were obtained from a prospectively collected database for all patients diagnosed with gallbladder cancer between 1996 and 2006. All histology reports and resected specimens were reviewed to ensure uniform and up-to-date staging.

Results. A total of 116 patients were treated. Seventy one patients (61%) were diagnosed incidentally following an initial cholecystectomy of whom 42 (60%) underwent a laparoscopic procedure and one third were tertiary referrals. Of the 71 patients, 21 (29.5%) underwent further radical surgery (16 central liver resection /gallbladder bed excision, 5 radical bile duct excision) 17 (24%) underwent palliative stenting or bypass surgery and the remaining 33 (46%) had chemo/no further treatment). The staging after initial cholecystectomy for those patients that underwent further procedures is shown in the table below. Only 4 of the 26 patients with positive resection margin at the initial surgery underwent further radical surgery. The median time interval between cholecystectomy and further radical surgery was 70 days, with no difference between local and referred patients. Radical surgery (median survival 1002 days) did not lead to a survival benefit compared to cholecystectomy alone (median survival 796 days) (Log Rank, p = 0.69) Of the 45 patients that were not diagnosed incidentally, 50% underwent palliative stenting, 22.5% had a cholecystectomy only and 25% had other palliative procedures. Only one patient (stage IIB) had a subsequent radical bile duct excision.

Conclusion. Gallbladder cancer is often an incidental finding. Further surgery in selected cases is indicated and results in a limited survival benefit.

	IA (n = 4)	IB (n = 20)	IIA (n = 10)	IIB (n = 19)	III (n = 1)	IV (n = 7)
+ve resection margins	1	4	3	13	0	5
Liver resection	0	4	3	4	1	1
Bile duct excision	1	1	0	2	0	0
Stenting	1	1	3	1	0	2
Other palliative surgery	0	2	0	4	0	0

PP 10.10

SYSTEMATIC LITERATURE REVIEW OF NEUROENDOCRINE TUMOURS OF THE GALL BLADDER

Mirza, Tariq A¹; Iype, Satheesh²; Feakins, Roger³; Propper, David⁴; Kocher, Hemant²

¹Barts and the London NHS Trust, HPB Surgery, London, United Kingdom; ²Royal London Hospital, Barts and the London NHS Trust, HPB Surgery, London, United Kingdom; ³Barts and the London NHS Trust, Department of Pathology, London, United Kingdom; ⁴Barts and the London NHS Trust, Medical Oncology, London, United Kingdom

Background. Neuroendocrine carcinoma of gall bladder is a rare condition, often diagnosed incidentally.

Methods. Case reports on neuroendocrine tumours of gall bladder published from 1997 till 2007 were searched on Pubmed. 34 patients of neuroendocrine tumours of gall bladder were found in 26 articles. Primary outcome measures of this systematic review were surgical management, oncological management, histology of the tumour, metastasis and survival.

Results

RESECTABLE = 25

SURGICAL MANAGEMENT Open cholecystectomy = 9 Laparoscopic cholecystectomy = 5 Cholecystectomy with liver resection = 7 Cholecystectomy with biliaryenteric anastamosis = 3 Cholecystectomy with pancreatic resection = 1

ONCOLOGICAL MANAGEMENT Patients given adjuvant chemotherapy and drugs mentioned = 11 Patients given adjuvant chemotherapy and drugs not mentioned = 1 Patients not given adjuvant chemotherapy = 13

SURVIVAL Patients followed up = 21 Patients lost to follow up = 4 Survival range = 3.5 months to 15 years

HISTOLOGY Small cell = 11 Carcinoid tumour = 4 Clear cell = 2 Large cell = 0 Miscellaneous = 8

METASTASIS Metastasis present = 15 Metastasis absent = 7 Not mentioned = 3

UN-RESECTABLE = 9

SURGICAL MANAGEMENT Surgery not performed = 5 Palliative resection and biliodigestive anastamosis = 2 Exploratory laparotomy open and close = 2

ONCOLOGICAL MANAGEMENT Patients given palliative chemotherapy and drugs mentioned = 3 Patients given palliative chemotherapy and drugs not mentioned = 3 Patients not given palliative chemotherapy = 3

SURVIVAL Patients followed up = 6 Patients lost to follow up = 3 Survival range = 5 months to 10 months

HISTOLOGY Small cell = 4 Carcinoid tumour = 0 Clear cell = 0 Large cell = 4 Miscellaneous = 1

METASTASIS Metastasis present = 8 Metastasis absent = 0 Not mentioned = 1

Conclusion. The response to chemotherapy is poor and at present, resectional surgery with adjuvant chemotherapy offers the best hope.

PP 10.11

BOUVERET'S SYNDROME MASQUERADING AS CARCINOMA GALL BLADDER:REPORT OF TWO CASES AND REVIEW OF LITERATURE

Dash, Nihar Ranjan¹; Kumar, Ashok²; Saxena, Rajan²

¹AIIMS, GI Surgery and LTx, New Delhi, India; ²SGPGIMS, Surgical Gastroenterology, Lucknow, India

Background. Bouveret's syndrome (BS) is a rare condition of large gall stone fistulating in to the gastric outlet. The varied presentations, difficulty in diagnosis and changing trends in the management warrants a timely review. We describe two cases of BS that presented like gall bladder cancer (GBC) and discuss the management in the light of literature. Case1. A 75 year lady presented with gastric outlet obstruction (GOO) for 15 days, anemia, hypoproteinemia, and a vague lump in the right hypochondrium. Sonography (USG) and CT showed poorly defined gall bladder (GB) outline with a suspicion of mass lesion. Endoscopy showed an irregular bulging into first part of duodenum with a clot over it. Biopsy was not done. Laparotomy revealed a 5×4×4 cm stone impacted at the cholecystoduodenal fistula. Frozen section, partial cholecystectomy (Pccx), cholangiogram, duodenostomy and gastrojejunostomy (GJ) were done. Case2. A 65 year lady presented with pain abdomen and obstructive jaundice for 2 months, GOO for one month, anaemia and hypoproteinemia. No mass was palpable. Serum bilirubin was 6mg/dl. USG and CT gave an impression of GB neck mass with infiltration into proximal CBD and duodenum. Endoscopy revealed an intraduodenal bulging with old hemorrhage. Laparotomy revealed a 7mm thick-walled GB with stones impacted at the site of a cholecysto-choledocho-duodenal fistula. Pccx, cholangiogram, choledochostomy, duodenostomy and GJ was done.

Discussion. Both the cases had uneventful recovery. Both had xanthogranulomatous cholecystitis. The stones were amorphous type and did not cast any shadow on USG. Case reports of BS do appear every year since its description. In areas common to GBC, BS might confuse the diagnosis and lead to under or over treatment. Endoscopy, lithotripsy and surgery are the modes of management advocated. However we suggest surgical management because of better assessment of malignancy.

Conclusion. BS can masquerade GBC. A high index of suspicion can lead to appropriate management.

PP 11.01

A TEN YEAR STUDY COMPARING RIGHT AND EXTENDED RIGHT HEPATECTOMIES WITH ALL OTHER HEPATIC RESECTIONS FOR COLORECTAL METASTASES

Lordan, Jeffrey; Karanjia, Nariman; Quiney, Nail; Fawcett, William; Worthington, Tim; Remington, Jacky

Royal Surrey County Hospital, Guildford, United Kingdom

Aims. Colorectal cancer metastasises to the liver in 50% of patients who develop the disease. The gold standard treatment and only potential cure is hepatic resection, often accompanied with adjuvant chemotherapy. Many studies have examined factors that predict outcome, but none have compared right sided resections with left or parenchymal sparing resections.

Patients and Method. 283 patients underwent hepatic resection for colorectal metastases from September 1996 to November 2006 and were prospectively studied. The early and late outcomes of those who had right and extended right hepatectomies (RH) were compared with those who had all other types of liver resection (AOLR). Adjuvant therapy and pre-operative assessment were standardized.

Results. The 1, 3 and 5 year overall survival rates in the RH group were 84.1%, 54.3% and 38.9% respectively. The 1, 3 and 5 year overall survival rates in the AOLR group were 95.4%, 65.4% and 53.3% respectively. The difference was statistically significant (p = 0.033). The 1, 3 and 5 year disease-free survival rates in the RH group were 69.5%, 34.4% and 25.5% respectively and 68.4%, 34.9% and 34.9% respectively in the AOLR group (p = 0.455). Operative mortality was 3.9% in the RH group and 0.65% in the AOLR group (p = 0.042). Morbidity was 31.3% in the RH group and 18% in the AOLR group.

Conclusion. Patients undergoing right and extended right hepatectomies for colorectal metastases have a greater operative morbidity and mortality and have a significantly worse overall survival compared to all other liver resections for the same disease.

PP 11.02

A 10 YEAR STUDY OF OUTCOME FOLLOWING HEPATIC RESECTION FOR COLORECTAL LIVER METASTASES – THE EFFECT OF EVALUATION IN A MULTI-DISCIPLINARY TEAM SETTING

Jeffrey, Lordan; Karanjia, Nariman; Quiney, Nail; Fawcett, William; Worthington, Tim

Royal Surrey County Hospital, Guildford, United Kingdom

Aims. Colorectal carcinoma is the second most common cause of cancer death in the western world and nearly 50% of patients develop liver metastases. Many cancers are managed via a multidisciplinary team process. This study compares the long term outcome of patients with metastatic colorectal cancer referred via a multidisciplinary team including a liver surgeon (MDT) with those referred directly to a tertiary hepato-biliary unit.

Patients and Method. This is a prospective study of 331 consecutive referrals made to the Royal Surrey County Hospital over ten years out of which 108 patients were referred via a formal MDT including a liver surgeon while 223 were referred directly. Pre-operative assessment and management were standardised and short and long term data were recorded.

Results. Patients referred via the MDT had 1, 3 and 5 year survival rates of 89.6%, 67.5% and 49.9% respectively and 1, 3 and 5 year disease free survival of 65.4%, 31% and 27.2% respectively. Patients referred directly had 1, 3 and 5 year survival rates of 90.3%, 54.1% and 43.3% respectively and 1, 3 and 5 year disease free survival rates of 70.3%, 37.6% and 27.9% respectively. The difference in overall survival was significant (p = 0.0001), although the difference in disease free survival was not (p = 0.21).

Conclusion. Assessing, managing and referring patients with metastatic colorectal cancer via a multidisciplinary team process including a liver surgeon significantly improves overall survival.

PP 11.03

FAILURE OF CURATIVE SCHEDULE IN PATIENTS WITH POTE NTIALLY RESECTABLE COLORECTAL CARCINOMA WITH SYNCHRONOUS METASTASES.

Cook, marie-cécile; Fuks, david; Bréhant, olivier; Dumont, frédéric; Chatelain, denis; Yzet, thierry; Joly, jean-paul; Dupas, jean-louis; Verhaeghe, pierre; Regimbeau, jean-marc

Hospitalo-Universitary Hospital, Digestive Surgery, Amiens, France

Background. The management of patients with synchronous liver metastases (SLM) depends on primary tumour, the resectability of the metastatic disease and patient's comorbidities. Among all patients with potentially resectable primary colorectal carcinoma (CRC) with SLM, curative resection will be possible in some patients although in others, surgery will never be performed. The purpose of our study was to identify factors of failure of curative schedule in these patients.

Methods. From January 2002 to March 2007, we reviewed over 88 patients with CRC and SLM, data of 45 patients potentially resectable. Two groups were defined: Group 1 when complete metastatic and primary tumour resection was finally performed after one and more surgical stages (n = 31) and Group 2 when curative resection was not possible (n = 14). Clinical, pathologic and outcome data were retrospectively analysed so as preoperative management of SLM (chemotherapy, radiofrequency, portal vein embolization).

Results. Curative resection (Group 1) was performed in 31 (69%) patients with 48% of major hepatic resection. The mortality rate of hepatic resection was 0% although it was 9% for primitive tumour resection (27% of primary tumour were located in rectum). Portal vein embolization was performed preoperatively in 8 patients and radiofrequency ablation was realised in 13 patients. Median follow-up was 21 months. Overall survival was 86% at 1 year and 39% at 3 years. Survival in group 1 was 97% and 57% at 1 and 3 years respectively. Disease free survival was 87% and 40% at 1 and 3 years. Tumoral recurrence occurred in 61% of resected patients. In a multivariate analysis, number of hepatic metastases >3 and complicated initial presentation of primitive tumour were found to be significant and predictors of failure hepatic resection.

Conclusion. Curative resection of SLM may produce a long-term survival thanks to aggressive management. A number of SLM >3 and complicated initial presentation of primitive tumour are predictive factor of failure of curative schedule.

PP 11.04

DIAGNOSTIC ACCURACY OF LIVER-SPECIFIC MRI AS A PREDICTOR OF CHEMOTHERAPY ASSOCIATED HEPATIC CELLULAR INJURY PRIOR TO LIVER RESECTION

O'Rourke, Thomas¹; Rees, Myrddinn¹; Tekkis, Paris²; Lyle, Nicola³; Mustajab, Asmat⁴; Welsh, Fenella¹; John, Timothy G¹; Peppercorn, Delia³

¹North Hampshire Hospital, Department of Hepatobiliary Surgery, Basingstoke, United Kingdom; ²St Mary's Hospital, Imperial College, Department of Biosurgery and Surgical Technology, London, United Kingdom; ³North Hampshire Hospital, Department of Radiology, Basingstoke, United Kingdom; ⁴North Hampshire Hospital, Department of Pathology, Basingstoke, United Kingdom

Background. Hepatic parenchymal injury following chemotherapy for colorectal liver metastases (CRLM) is associated with increased surgical morbidity and mortality. Currently there is no non-invasive preoperative investigation available that reliably predicts this parenchymal damage.

AIM: To evaluate the diagnostic precision of preoperative magnetic resonance imaging (MRI) using two contrast agents (gadolinium and ferocarbotran) for hepatic parenchymal injury prior to hepatic resection for CRLM.

Methods. Preoperative MRI criteria were used to score 37 patients with CRLM by two independent radiologists, blinded to outcomes, for steatosis and ferocarbotran uptake and compared to blinded standardized histopathological endpoints of steatosis, steatohepatitis and sinusoidal dilatation. Sensitivity, specificity, predictive values, diagnostic accuracy and area under the receiver operating characteristic curve were calculated for the MRI sequences.

Results. On histological examination, severe steatosis, steatohepatitis and sinusoidal dilation were evident in 6 (16.2%), 4 (10.8%) and 9 (24.3%) patients respectively. The MRI steatosis score had a diagnostic accuracy for detection of severe steatosis (97.3%, positive predictive value (PPV) = 100%) and steatohepatitis (97.3%, PPV = 80%) but not sinusoidal dilatation (62.2%, PPV = 0). Ferocarbotran-enhanced MRI had a higher diagnostic accuracy for the detection of severe sinusoidal dilatation (78.3%, PPV = 100%).

Conclusion. The present study demonstrated that liver-specific MRI accurately predicted the severity of steatosis and steatohepatitis and less so for sinusoidal dilatation. Liver-specific MRI may play a crucial role in the pre-operative setting in diagnosing chemotherapy-induced hepatotoxicity and timing of liver surgery for colorectal liver metastases.

PP 11.05

IMATINIB MESYLATE COMBINED WITH SURGERY FOR THE TREATMENT OF PERITONEAL AND MULTIPLE LIVER METASTASES FROM GASTRIC GASTROINTESTINAL STROMAL TUMOR

Jain, Sundeep¹; Kalla, Komal²; Maru, Anish³; Kalla, Mukesh⁴

¹S.K. Soni Hospital, Gastrointestinal & Laparoscopic Surgery, Sector 5, Vidhyadhar Nagar, Jaipur, India; ²S.R. Kalla Memorial Hospital, Pathology, Jaipur, India; ³S.K. Soni Hospital, Medical Oncology, Jaipur, India; ⁴S.R. Kalla Memorial Hospital, Gastroenterology, Jaipur, India

Introduction. Imatinib mesylate is the first line of treatment for metastatic GIST. Although the evidence in favor of surgery is growing, it is still considered experimental for the treatment of metastatic GIST.

Methods. We present a case of a middle-aged female with metastatic GIST, treated successfully with the combination of imatinib and surgery. The English literature on the treatment of metastatic GIST is also reviewed. CASE A 35 years old female underwent a subtotal gastrectomy for malignant leiyomyosarcoma in September 1999. She presented to our hospital in November 2005, with malignant ascites, multiple liver metastases and intolerable pain in the right hypochondrium. The presence of C-KIT protein was confirmed in the tissue from liver secondary and imatinib mesylate (400 mg daily) was started. After 2 months of treatment ascites was completely resolved. In February 2006, R0 liver resection was performed for secondaries causing intolerable pain. Postoperative period was uneventful with the hospital stay of 5 days. She was discharged on maintenance imatinib therapy (400 mg daily).

Results Patient was completely pain free at the time of discharge. She is asymptomatic and disease free till date (18 months) after treatment with this combined approach.

Conclusions. The combination of imatinib mesylate and surgery can prove to be curative in selected patients whose disease is responsive to preoperative imatinib therapy. However, more studies with large number of cases are necessary to further evaluate the effectiveness of combination of imatinib and surgery for the treatment of metastatic GIST. Postoperative maintenance imatinib therapy is important to prevent recurrence.

PP 11.06

SUCCESSFUL RESECTION OF HEPATICTUMOR WITH PORTAL TUMOR THROMBI DUE TO GASTRIC CANCER

Kawasaki, Atsushi¹; Oida, Takatsugu¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Mimatsu, Kenji¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. Portal vein tumor thrombus frequently develops in advanced hepatocellilar carcinoma. However, it is extremely rare in gastric cancer, and the prognosis of gastric cancer with extensive tumor thrombus in the portal vein is poor. Obstruction of the portal vein can lead to cavenous transformation of veins, intestinal bleeding and ascites. Removal of the thrombus is the only procedure preventing such situations. We report a rare case of metastatic hepatic tumor from gastric cancer with a tumor thrombus in the portal vein.

Case Report. The patient was a 62-year-old man who underwent gastrectomy due to gastric cancer. At 8 months after the surgery, follow-up ultrasonography and computed tomography revealed a hepatic tumor with a tumor thrombus in the portal vein without metastasis to either the extra-abdominal region or lymph nodes. To prevent cavenous transformation of the veins, intesitinal bleeeding and ascites, we performed right hepatic lobectomy with removal of the tumor thrombus. The pathological findings yielded a diagnosis of metastatic liver tumor from gastric cancer. The patient died of peritoneal carcinomatosis at 1 year after the second operation. The period of survaival after the surgery was short, however, he had maintained a good quality of life for a while.

Conclusion. Extended excision of the liver might be useful for improving the prognosis of such patients with a tumor thrombus in the portal vein from gastric cancer.

PP 11.07

LIVER SURGERY AND MANAGEMENT OF NEUROENDOCRINE HEPATIC METASTASES.

Sapisochin, Gonzalo; Bilbao, Itxarone; Escartin, Alfredo; Dopazo, Cristina; Lazaro, Jose Luis; Olsina, Jorge; Balsells, Joaquin

Hospital Vall D′Hebron, HBP Surgery and Liver Transplant, Barcelona, Spain

Introduction. Compared with most metastatic gastrointestinal tumors, neuroendocrine cancers have a slow clinical progression and survival is prolonged. Liver metastases are the most important predictor of poor survival and resection is believed to be the first-line therapy.

Aims. To asses our experience in liver surgery of neuroendocrine liver metastases.

Results. Between 1989–2006, 695 hepatectomies have been performed in our unit, 9 (1,3%) for neuroendocrine metastases. Mean patients age was 57,5 years (r 38–76);(4 males,5 females). Primary tumor was pancreatic in 7 cases (78%) (4 non-functioning, 1 VIPoma, 1 glucagonoma, 1 gastrinoma); midgut carcinoid in 1 and carcinoid syndrome of uncertain origin in 1. Liver metastases were diffuse in 5 cases, located on the left lobe in 3 and 1 on the right lobe. Preoperative mean size of the biggest lesion was 5±1,5 cm and 78% of them were well delimited. Liver surgery was synchronic with the primary tumor in 5 cases, after the primary tumor was treated in 2 and before the primary tumor was identified in 2. Surgical procedures were 5 minor hepatectomies and 4 major hepatectomies. Four patients required blood transfusion. There was no postoperative mortality or acute liver failure. Eight patients (88%) had progression of their disease after a mean follow-up of 38 months (r 6,5–89). Four of these patients were retreated, with re-hepatectomy, RFA or TACE; 2 of them are now waiting to be retreated. Progression was local in 4 patients, systemic in 2 and both local and systemic in the other 2. Actuarial patient survival rates at 1 and 5 years were 100% and 78% while actuarial patient survival rates free of disease at 1 and 5 years were 89% and 44%.

Conclusions. The relatively slow growth of these tumors makes debulking surgery the first line of treatment and can occasionally result in cure. Surgery must be performed even after progression is diagnosed, since it can increase survival rates. Techniques such as RFA and TACE can be useful for a better oncologycal control of the disease.

PP 11.08

MANAGEMENT OF LIVER METASTASIS FROM GASTROINTESTINAL STROMAL TUMOURS: MULTIMODAL APPROACH

Damrah, Osama¹; Sipos, Peter²; Pai, Madhava¹; Wasan, Hapreet²; Canelo, Rubin²; Habib, Nagy¹; Jiao, Long¹

¹Hammersmith Hospital-Imperial College London, London, United Kingdom; ²Hammersmith Hospital, London, United Kingdom

Introduction. Liver metastasis from gastrointestinal stromal tumours (GIST) is a major determinant of survival. A treatment strategy is crucial to achieve the best survival. A multimodal approach for treatment of GIST liver metastasis is reported here.

Methods. Database of patients with liver metastasis from GIST (n = 13) treated at our unit between January 2002 and June 2006 were reviewed. Treatment modalities included surgical resection, radio frequency ablation (RFA), hepatic artery chemoembilisation (TACE), imatinib mesylate, and selective internal radiation therapy using Yttrium microsphres (SIRTEX). Patient and primary tumour clinicopathological characteristics and the extent of intrahepatic and extrahepatic metastatic disease were recorded.

Results. There were 6 (46%) males and 7 (54%) females with a mean age of 65.5 + 9.7 years (range 45–80). The primary tumour site was the stomach in six patients (46%), terminal ileum three patients (23%), duodenum two patients (15%) and the pelvis in two patients (15%). The mean size of the metastatic liver lesions was 8.03cm +4.33sd. Liver resections were performed in 7 patients. RFAs in 4 patients. In two patients TACE was performed and one patient was treated with SIRTEX. Five patients were treated with imatinib. One patient received 8 therapeutic modalities, 2 patients 7 modalities and one patient received 4 treatment modalities. The more modalities were given the longer survival time was observed. Resection and imatinib treatment significantly improved the survival time in comparison with imatinib treatment alone (p = 0.031). Of all patients who underwent hepatectomy, three patients survived more than 5 years (23%) after the initial hepatectomy. The average survival was 35.14 month.

Conclusion. multimodal approach for patients having liver metastasis from GIST provides better survival rates. Treatment should be patient tailored, and well-conducted prospective studies are needed to further evaluate the different treatment options.

PP 11.09

RESECTION OF A METASTATIC LESION OF LARYNGEAL CANCER IN THE LIVER AFTER LARYNGECTOMY: A CASE REPORT

Yazawa, Naoki; Imaizumi, Toshihide; Furukawa, Daisuke; Fukumitsu, Hiroshi; Okada, Kenichi; Matsuyama, Masahiro; Oida, Yasuhisa; Ishii, Masanori; Dowaki, Shoichi; Sugio, Yoshinori; Tobita, Kosuke; Ohtani, Yasuo; Makuuchi, Hiroyasu

Tokai University School of Medicine, Department of Surgery, Isehara, Japan

We here report a markedly rare case that laryngeal cancer metastasized to the liver after laryngectomy. A 58-year-old male underwent total laryngectomy for laryngeal cancer in November 2004. Pathology revealed moderately differentiated squamous cell carcinoma at stage IV (T4, N2). He received chemoradiation therapy (S-1 and 50-Gy irradiation) postoperatively. In February 2007, abdominal CT demonstrated a low-density mass in 3 cm in diameter in S7 of the liver. Abdominal ultrasonography revealed an iso-echoic mass in 31×30×27 mm with a low-echoic marginal zone. SPIO-MRI showed a high-intensity region in S7 of the liver by T2-weighted image. Upper gastrointestinal endoscopy and barium enema revealed no abnormal findings. Tumor biopsy was done for differentiation from cholangiocarcinoma and liver metastasis of laryngeal cancer was diagnosed. Tumor markers were within the normal range (CEA, 1.9 ng/ml; CA19-9, 25.9 U/ml; and SCC, 1.1 ng/ml). Since there was no local or lymphatic relapse for 2 years and 6 months after laryngectomy and liver metastasis was solitary, surgical indication was determined. Liver S7 subsegmentectomy was carried out in June 2007, and liver metastasis of laryngeal cancer was diagnosed pathohistologically.

PP 11.10

HEPATIC METASTASECTOMY FOR MEDULLARY CARCINOMA OF THYROID

Babel, Nitin; Kumar, Naveen; Chamberlain, Ronald

Saint Barnabas Medical Center, Department of Surgery, Livingston, NJ, United States

Introduction/Aim. Metastatic medullary carcinoma of the thyroid (MTC) is an uncommon surgical problem and usually advanced at presentation. Hepatic metastases from MTC may impair quality of life by hypercalcitonemia-associated diarrhea, pain or liver failure. We report a case of 58 year old male with liver metastases from a primary MTC. We discuss potential role of hepatic resection in these patients with review of pertinent literature.

Methods. A 58 year old male presented with constant, right upper quadrant pain. Laboratory workup was normal. CT scan of abdomen showed a solid 5.9 cm mass in the right lobe of the liver. CT guided biopsy revealed a metastatic non-small cell poorly differentiated carcinoma. Further evaluation revealed a 4.5 cm mass in the left neck. PET evaluation revealed disease limited to the neck and right liver. Fine-needle aspiration of the neck mass confirmed MTC and plasma calcitonin levels were elevated at > 5300 pg/ml (normal < 10 ng/l). MEN syndrome was excluded prior to embarking on surgical treatment.

Results. The patient underwent an R0 total thyroidectomy and central neck dissection, which revealed a 6 cm MTC. Repeat evaluation revealed the liver lesion had increased to 7.5 cm. The patient underwent an R0 right hepatectomy, and RFA of potential smaller lesion on the left lobe of liver. Pathology revealed metastatic MTC.

Discussion. MTC is a well-defined adult neuroendocrine tumor. Currently there are no curative therapeutic options in metastatic MTC. Palliative systemic chemotherapy regimen or TACE, irradiation and somatostatin analogue have been employed but are unproven. Hepatic metastasectomy for metastatic lesions of the liver may play a role in these patients. Amidst this clinical dilemma, and considering our patient's good performance status with radiographically resectable disease, we persued surgical metastasectomy in an effort to achieve maximal tumor control locally. At six months of follow up with calcitonin and radiologic studies there are no signs of tumor recurrence.

PP 12.01

EVALUATION OF HUMAN LIVER REGENERATION AFTER PARTIAL HEPATECTOMY BY HEPATIC EXTRACTION FRACTION CALCULATED WITH^99mTc-MEBROFENIN

Tralhao, Jose¹; Abrantes, Ana²; Cardoso, Dulce³; Figueirinha, Rita²; Lourenço, Candida³; Ponciano, Emanuel⁴; Botelho, Maria F⁴; Castro Sousa, Francisco¹

¹Coimbra University Hospitals, Surgery, Coimbra, Portugal; ²Ibili-Faculty of Medicine, Biophysics/Biomathmatics, Coimbra, Portugal; ³Coimbra University Hospitals, Nuclear Medicine, Coimbra, Portugal; ⁴Ibili-Faculty of Medicine, B iophysics/Biomathematics, Coimbra, Portugal

Liver regeneration after hepatectomy (Hep) is a fundamental parameter of liver response to injury. Much of the investigation on the mechanisms and kinetic of hepatic growth has been done only in partially hepatectomized animals and in hepatocytes primary cultures. The study of the hepatic extraction fraction (HEF) by radioisotopic methods gives information about physiological mechanism of uptake, transport and allows also the excretion quantification of the hepatobiliary system by using 99mTc-IDA derivates. This prospective study aimed to estimate the interest of HEF in the evaluation of human liver regeneration/function of patients with hepatic tumoral disease underwent partial Hep. 22 patients with colorectal metastases (n = 18), hepatocellular carcinoma (n = 2) and others (n = 2) were included. Liver function was assessed after intravenous bolus injection of 99mTc-Mebrofenin that was uptaked by the hepatocytes and eventually excreted via billiary pathway without any change to its chemical structure. The HEF is calculated using deconvolution analysis of first pass curve coming from scintigraphic data. We evaluated the pre-operative HEF and in the 5th day and one month after the hepatic resection. We considered the HEF values of 98.8±0.4% (MED±SD) as normal. For statistical analysis, T-Student test was used. The pre-operative, 5th day or one month after the partial Hep HEF (MED±SD) was 98.33±3.36%, 98.37±3.06% and 97.1±5.37%, respectively. There was not statistically difference between the three evaluations of HEF (ns). These results allow us to say that the human liver regeneration is early enough to normalize the HEF at day 5 after partial Hep, being this evaluation of undoubtedly interest to know the function kinetics and indirectly knowledge about human liver regeneration. Additionally, this fast functional liver recovery has high clinical importance, once more aggressive adjuvant chemotherapy can start much early after surgical treatment.

PP 12.02

CLINICAL SIGNIFICANCE OF PORTAL VEIN EMBOLIZATION BEFORE RIGHT HEPATECTOMY

Nanashima, Atsushi; Sumida, Yorihisa; Sawai, Terumitsu; Nagayasu, Takeshi; Yasutake, Toru

Nagasaki University Hospital, Division of Surgical Oncology, Nagasaki, Japan

Aim. To identify clinical significances of portal vein embolization (PVE) prior to major hepatectomy, we examined clinical parameters and outcome after right hepatectomy in patients who underwent PVE.

Methods. The subjects were 30 patients who underwent PVE (PVE group), and 52 patients (non-PVE), in whom PVE was considered unnecessary, followed by right hepatectomy for hepatobiliary cancer.

Results. Total hepatic volume after PVE (1068±268 ml) tended to increase compared with before PVE (p = 0.059). After PVE, the change in hemi-liver volume was 8.9±6.0%. Increases in hepatic volume of non-embolized left liver before and at 4 weeks after hepatectomy between PVE and non-PVE groups were similar. Changes in hepatic volumes before and after PVE were not significantly influenced by background liver disease. After PVE, the functional liver volume (419±185 cm3) was significantly lower than morphological volume (564±165 cm3) in the embolized liver (p < 0.05). Although preoperative liver function was worse in PVE group compared with non-PVE, serious hepatic complications were rarely observed in PVE group.

Conclusion. Marked changes in hepatic volume were noted after PVE in patients with impaired liver function and those who need large-volume right hepatectomy, especially in functional volume, suggesting that PVE is a useful procedure to prevent post-operative liver failure.

PP 12.03

THE YIN AND YANG OF ISCHAEMIC PRECONDITIONING IN LIVER REGENERATION – PRODUCTION OF REGENERATIVE MEDIATORS IN HUMAN HEPATOCYTES

Gomez, Dhanwant¹; Graham, Anne²; Orsi, Nicholas³; Ekbote, Uma³; Burn, J Lance⁴; Homer-Vanniasinkam, Shervanthi⁵; Prasad, K Rajendra⁶

¹St. James's University Hospital, Department of Hepatobiliary Surgery & Transplant, Beckett Street, Leeds, United Kingdom; ²University of Bradford, Department of Biomedical Sciences, Bradford, United Kingdom; ³St. James's University Hospital, Leeds Institute of Molecular Medicine, Leeds, United Kingdom; ⁴University of Sheffield, Section of Oncology, Sheffield, United Kingdom; ⁵Leeds General Infirmary, Leeds Vascular Institute, Leeds, United Kingdom; ⁶St. James's University Hospital, Department of Hepatobiliary Surgery & Transplant, Leeds, United Kingdom

Introduction. Liver regeneration is crucial following major liver resection and transplantation, particularly in cases of auxiliary and split-liver transplantation. However, the beneficial effects of ischaemic preconditioning (IPC) on liver regeneration following surgery is inconclusive. We aimed to assess the cytokine and growth factor production by human hepatocytes (n = 5) and evaluate the effect of IPC on these mediators in an in vitro hypoxia-reoxygenation (H-R) model mimicking ischaemia-reperfusion injury.

Methods. Confluent culture flasks of hepatocytes were subjected to H-R (1 hour hypoxia + 1 hour reoxygenation), IPC with H-R (10 minutes hypoxia + 10 minutes reoxygenation + 1 hour hypoxia + 1 hour reoxygenation) and compared to untreated controls. Production of interleukin (IL)-1 beta (β), IL-1 receptor antagonist (IL-1ra), IL-6, IL-8, tumour necrosis factor-alpha (TNF-a), transforming growth factor (TGF)-a and granulocyte-colony stimulating factor (G-CSF) were determined over a 48 hour period.

Results. IL-8, G-CSF and IL-1ra were produced by hepatocytes, while IL-1β, IL-6, TGF-a and TNF-a were undetected in all groups. IPC prior to H-R decreased IL-8 and G-CSF production over the 48 hour period compared to H-R alone, in particular, decreased G-CSF levels at the 36 hour time-point (56%). IPC prior to H-R decreased IL-1ra output by 52% and 35% compared to H-R alone after 8 and 12 hours respectively. Although there was a trend for decreased IL-8, G-CSF and IL-1ra production, this was not statistically significant between IPC-treated and non-IPC-treated groups.

Conclusion. Hepatocytes produced pro-regenerative mediators such as IL-8, G-CSF and IL-1ra. Although there was a trend towards decreased production of these mediators, the beneficial effect of IPC in liver regeneration remains inconclusive. The final effect on liver regeneration would depend on the interaction of various liver cells and studies on co-culture models are required.

PP 12.04

ISCHAEMIC PRECONDITIONING VERSUS INTERMITTENT CLAMPING ON HUMAN HEPATOCYTES: EFFECTS ON CYTOKINES AND GROWTH FACTORS INVOLVED IN LIVER REGENERATION

Gomez, Dhanwant¹; Graham, Anne²; Orsi, Nicholas³; Ekbote, Uma³; Burn, J Lance⁴; Homer-Vanniasinkam, Shervanthi⁵; Prasad, K Rajendra⁶

¹St. James's University Hospital, Department of Hepatobiliary Surgery and Transplant, Beckett Street, Leeds, United Kingdom; ²University of Bradford, Department of Biomedical Sciences, Bradford, United Kingdom; ³St. James's University Hospital, Leeds Institute of Molecular Medicine, Leeds, United Kingdom; ⁴University of Sheffield, Section of Oncology, Sheffield, United Kingdom; ⁵Leeds General Infirmary, Leeds Vascular Institute, Leeds, United Kingdom; ⁶St. James's University Hospital, Department of Hepatobiliary Surgery and Transplant, Leeds, United Kingdom

Introduction. Ischaemic preconditioning (IP) with continuous clamping and intermittent clamping (IC) of the portal triad are distinct protective strategies against ischaemia-reperfusion injury (IRI) following liver transplantation and resection. However, their effects on liver regeneration are undetermined. We aimed to evaluate the effects of IP and IC on cytokine and growth factor production by human hepatocytes in an in vitro hypoxia-reoxygenation (H-R) model to mimic IRI.

Methods. Confluent culture flasks of hepatocytes were subjected to H-R (1 hour hypoxia + 1 hour reoxygenation), IP with H-R (10 minutes hypoxia + 10 minutes reoxygenation + 1 hour hypoxia + 1 hour reoxygenation), IC (15 minutes hypoxia + 5 minutes reoxygenation x3 + 1 hour reoxygenation) and compared to untreated Control. Differences in production levels of interleukin (IL)-1 receptor antagonist (IL-1ra), IL-6, IL-8, tumour necrosis factor-alpha (TNF-a), transforming growth factors (TGF)-a and granulocyte-colony stimulating factor (G-CSF) were determined over 48 hours.

Results. The production of IL-6, TGF-a and TNF-a was undetectable. IP prior to H-R decreased IL-8 production over 48 hours compared to H-R alone. In comparison, IC increased the production of IL-8 at the 8, 12, 24 and 48 hour time-points. Both IP and IC decreased the production of G-CSF by 56% and 55% at 36 hours, and by 20% and 15% at 48 hours, respectively. There was no significant difference in IL-8 and G-CSF production between IP- and IC- treated groups. IP prior to H-R decreased IL-1ra output by 52% compared to H-R alone after 8 hours. By contras t, IL-1ra production was significantly increased (56%) by IC at 8 hours (p = 0.019).

Conclusion. IP and IC equally influence the expression of IL-8 and G-CSF in hepatocytes, with IC significantly influencing the release of IL-1ra between 4 to 12 hours. These results suggest that IC could potentially affect the liver regeneration cascade more than IP.

PP 12.06

SYNERJIC PROTECTIVE EFFECTS OF RECOMBINANT HUMAN ERYTHROPOIETIN AND 2-MERCAPTOETHANE SULFONATE ON LIVER ISCHEMIA-REPERFUSION INJURY

Tasar, Pýnar; Özen, Yýlmaz; Kilicturgay, A. Sadýk

Uludag Üniversity, Medical Faculty, HPB Surgery, Bursa, Turkey

Aim. One of the important causes on mortality and morbidity in liver surgery and transplantation is ischemia-reperfusion injury. The protective effects of recombinant human erythropoietin (rhEPO) and 2-Merkaptoethane sulfonate(MESNA), when applied together, on the injury of ischemia- reperfusion has been investigated in this study.

Material and Method. Female Wister- Albino rats have been applied for 30 minutes duration hepatic ischemia and after that for 2 hours long reperfusion. 5 minutes before ischemia 1000IU/kg rhEPO, and 15 minutes before ischemia 150mg/kg MESNA alone and combined were administered intraperitoneally. At the end of the reperfusion, for estimating liver functions, aspartate aminotransferase(AST), alanine aminotransferase(ALT), laktate dehydrogenase(LDH) and gama-glutamyi transferase(v-GT) serum levels were measured. Malondialdehyde(MDA), which is the main indicative of lipid peroxidation in ischemia-reperfusion injury, was measured. Hystological changes in tissues samples taken from rats' liver, were also evaluated.

Results. It is found that plasma ALT, AST, LDH and v-GT levels were very high in control groups. AST and ALT levels -especially for rhEPO group- were in the range of normal limits. In the combined group, which has been given MESNA and rhEPO treatment together, parankimal alterations in liver tissue were less significant and necrosis did not occured.

Conclusion. It is clear that rhEPO treatment is quite more effective than MESNA treatment in order to prevent oxidative injury. The combination of these two agents has opbvious effects biochemically, and significant tissue protection hystologhically in ischemia-reperfusion injury.

PP 12.07

SYNERGEIC PROTECTIVE EFFECTS OF RECOMBINANT HUMAN ERYTHROPOIETIN AND 2-MERCAPTOETHANE SULFONATE ON LIVER ISCHEMIA-REPERFUSION INJURY

Tasar, Pýnar; Ozen, Yýlmaz; Kilicturgay, Sadik

Uludag Universty Medical Faculty, U.Ü. Medical Faculty General Surgery, Bursa, Turkey

Aim: Ischemia-reperfusion injury is a very well knowm cause of morbidity and mortality in major liver surgery. Several agents have, and are being tried to decrease this definitely hazardous clinical problem. In this study the protective effects of the combined application of recombinant human erythropoietin (rhEPO) and 2-Merkaptoethane Sulfonate (MESNA) are investigated. Material and Method: Female Wistar- Albino rats were anesthetized with 5 mg/kg Xylazine hydrochloride (IM) and 60 mg/kg Ketamine hydrochloride (IM). Rats were subjected to 30 minutes duration hepatic ischemia and after that 2 hours reperfusion. The rats of Group-A (control) had ischemia-reperfusion only. Group-B rats were given 1000IU/kg rhEPO, and Group-C rats had 150mg/kg MESNA 5 and 15 minutes before ischemia respectively. Group-D rats were given rhEPO and MESNA with the same doses and timing of Groups B and C. At the end of the reperfusion, aspartate aminotransferase (AST), alanine aminotransferase (ALT), laktate dehydrogenase (LDH) and gama-glutamyl transferase (ã-GT) serum levels were measured for liver function alterations. Malondialdehyde (MDA), which is the main indicative of lipid peroxidation in ischemia-reperfusion injury, was also measured. Hystological changes in tissue samples taken from rats’ livers, were also evaluated under light microscopy.

Results. Plasma ALT, AST, LDH and ã-GT levels were very high in control groups. AST and ALT levels were in the range of normal limits in Groups B, C and D (especially in group B). In the combined treatment group (Group-D) parenchymal alterations in liver tissue were less significant and necrosis did not occured.

Conclusion. It is clear that rhEPO treatment is quite more effective than MESNA treatment in order to prevent oxidative injury. The combination of these two agents has obvious protective effect biochemically, and significant tissue protection hystologically in ischemia-reperfusion injury.

PP 12.08

POSTOPERATIVIE MORBIDITY AND LIVER REGENERRATION AFTER LEFT HEMIHEPATECTOMY IN DONORS HAVING GREATER THAN 50% STEATOSIS

Moon, Deok-Bog¹; Lee, Sung-Gyu¹; Hwang, Shin¹; Kim, Ki-Hun¹; Park, Kwan-Woo¹; Ha, Tae-Yong¹; Ahn, Chul-Soo¹; Song, Gi-Won¹; Jung, Dong-Hwan¹; Choi, Nam-Kyu¹; Ko, Kyoung-Hoon¹; Kim, Kwan-Woo²

¹Asan Medical Center, Seoul, Hepato-Biliary Surgery & Liver Transplantation, Seoul, Korea, Republic of; ²

Background & Purpose. Parenchymal transection of steatotic liver might result in more bleeding intraoperatively, and higher risk of liver dysfunction and surgical complications postoperatively. Hence, person with steatotic liver is usually not acceptable as a living liver donor. At our institute, however, steatotic donors has been permissible only if left sided hepatectomy is indicated for dual-graft living donor liver transplantation(LDLT) under urgent situation. We are aim to evaluate the postoperative courses of the steatotic donors after left sided hepatectomy for LDLT.

Methods. We compared left sided hepatectomy patients according to steatosis (¡Ã50% vs <10%) and presence of middle hepatic vein or not between January 2002 and June 2005.

Results. There are left lobectomy(LL) group (18 patients), left lateral sectionectomy(LS) group (10 patients) having more than 50% steatosis in remaining right lobe, and control LL group (20 patients) having less than 10% steatosis. In steatotic groups, body mass index, ALT and cholesterol level were higher and liver/spleen ratio was less than 0.9. Resection rate between steatotic LL and control LL was 30.5¡¾4.2%, 29.7¡¾4.2% respectively, and was not different. One patient in steatotic LL was needed transfusion during operation and the changes of hemoglobin level between pre- and post-hepatectomy was significantly higher in steatotic LL(3.6gm/dl) than steatotic LS(1.6gm/dl) and control LL2.1gm/dl). Postoperatively, AST and ALT were higher in steatotic groups, but total bilirubin level was not different. In steatotic LL, the frequency of middle hepatic vein thrombosis and the degree of anterior segment congestion were more common and severe than control LL. Regeneration of steatotic liver was not impaired in steatotic groups and liver/spleen ratio was improved to more than 1.0 within 1 week.

Conclusions. When we have to use steatotic liver graft for LDLT, left lateral section graft is a better option than left lobe graft including middle hepatic vein.

PP 12.09

CYTOKINES PLAY AN ESSENTIAL ROLE IN THE LIVER REGENERATION AFTER PORTAL VEIN EMBOLISATION

Pai, Madhava; Abulkhir, Adel; Damrah, Osama; Healey, Andrew; Habib, Nagy; Jiao, Long

Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, London, United Kingdom

Background. Cytokines such as Interleukin-6 (IL-6), interleukin -1 (IL-1) and tumour necrosis factor-Ü (TNF- Ü) have been shown to play an important role in initiation and maintenance of liver regeneration in rodents.

Aim. To examine the role of inflammatory process in liver regeneration in a human model of liver regeneration following portal vein embolisation (PVE).

Methods. Fifteen patients with malignant hepatobiliary diseases including colorectal liver metastasis CLM (n = 13), hepatocellular carcinoma HCC (n = 1) and carcinoid metastasis (n = 1) underwent right PVE to induce liver hypertrophy on the contralateral side. Serum concentrations of IL-6, IL-1, and TNF- Ü together with volumetric study before and after PVE were analysed.

Results. Serum IL-6 concentrations increased one day after PVE (mean±SE, 69.09±29.08 vs. 335± 75 pg/ml, p = 0.0010) and TNF- Ü change 19± 11.18 vs. 75.31±30 pg/ml, p = 0.04). The concentrations of IL-1 remained unchanged 0.31± 0 vs. 0.33± 0 pg/ml, p = 1.000). The other inflammatory makers included CRP and ESR showing (mean±SE, 19±6 vs. 67.29±17 mg/l, p = 0.007; 43±7 vs 46.4±7.2 mm/hr unit, p = 0.45 respectively). The mean volume of the contralateral non-embolised lobe grew significantly from 624.64± 135 cm3 to 804± 253 cm3 (p = 0.04) after PVE whereas the size of embolised lobe decreased significantly from 1216.43± 420.42 cm3 to 946±337.2 cm3 (p = 0.006). The future liver remnant was increased by 13% after PVE.

Conclusion. Liver regeneration is an orchestrated response induced by specific stimuli. Cytokines would seem to play an important role in stimulating the production of acute phase reactants from hepatocytes. IL-6 and TNF- Ü seem to play an important role in the early signalling pathway contributing to the proliferation of hepatocytes and leading to liver regeneration.

PP 12.10

LIVER REGENERATION FOLLOWING PORTAL VEIN EMBOLISATION

Pai, Madhava¹; Abulkhir, Adel²; Damrah, Osama²; Healey, Andrew²; Tait, Paul³; Jackson, James³; Graham, Alison³; Habib, Nagy²; Jiao, Long²

¹Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, Du Cane Road, London, United Kingdom; ²Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, London, United Kingdom; ³Hammersmith Hospital, Imperial College, Radiology, London, United Kingdom

Background. Portal vein embolisation (PVE) is used clinically to induce compensatory hypertrophy of the non- embolised lobe for patients undergoing major liver resection.

Aim. To assess the effect of PVE on liver regeneration measured by volumetry.

Methods. Between 2000 and 2007, Fifty-seven patients with malignant hepatobiliary diseases including colorectal liver metastasis (CLM, n = 43), Cholangiocarcinoma (ChC, n = 6), hepatocellular carcinoma (HCC, n = 3), carcinoid metastasis (n = 1) and others (n = 4) underwent right PVE (n = 44) and right PVE with segment IV embolisation (n = 13) to induce liver hypertrophy on the contralateral side. PVE was done using polyvinyl alcohol (PVA) and steel coils. CT scan volumetric analysis was carried out before the surgery to asses the total liver volume and the future liver remnant (FLR). Computed tomography volumetry was carried out 6–8 weeks after portal vein embolisation to assess left lobe regeneration.

Results. All embolisation procedures were technically successful. The side effects included mild abdominal pain (n = 41), fever (n = 45), nausea and vomiting (n = 37). There were no major complications except bile leak and subcapsular hematoma in one patient. Calculated volume of the non-embolised left lobe increased significantly from 640±164 cm3 before PVE to 854±246cm3 after PVE (p < 0.0001). The volume of the embolised right lobe decreased from 1135±421 cm3 before PVE to 974±326 cm3 after PVE (p = 0.04). The FLR increased by 11% after PVE. Forty nine patients (86%) have successfully completed the surgical resection with only 3 (0.06%) patients having post resection transient liver failure.

Conclusion. PVE is a safe and effective procedure for increasing the future liver remnant before major hepatectomy and does not complicate surgical resection

PP 13.01

UNUSUAL FEATURES OF NON-FUNCTIONING PANCREATIC NEUROENDOCRINE TUMORS

Benini, Bárbara; Triviño, Marcelo; Apodaca-Torrez, Franz R.; DeOliveira, Michelle L; Triviño, Tarcisio

University Federal of Sao Paulo-UNIFESP, Surgery-Division of Gastrointestinal Surgery, Sao Paulo, Brazil

Background. Pancreatic neuroendocrine tumors are uncommon when compared to ductal adenocarcinoma of the pancreas. They account for 3–5% of all pancreatic tumors while constitute 30–50% of pancreatic neuroendocrine tumors. Few cases of non-functional pancreatic endocrine tumors associated to cystic features have been reported.

Objective. The authors present two cases of rare non-functional pancreatic endocrine cystic tumors with pathologic correlation.

Methods. Two female patients with nonfunctional cystic neuroendocrine tumors, presenting abdominal pain were evaluated.

Results. Patients underwent pylorus-preserving pancreatoduodenectomy. There was no related mortality or major morbidity. Patients are alive and without recurrence fourteen years and five months after the surgical treatment respectively. The macroscopic examination of the surgical specimen in both cases showed large cystic tumor in the head of the pancreas whereas the immunohistochemistry markers were positively stained by chromogranin A, neuro-specific-enolase and synaptophisyn.

Conclusion. Cystic neuroendocrine tumors represent a subgroup of pancreatic cystic and neuroendocrine tumors with difficult preoperative diagnosis because the majority of theses tumors are nonfunctional and radiological imaging may not differentiate these tumors from other pancreatic cystic tumors. Survival advantage may be evident in absence of liver metastases and radical tumor resection.

PP 13.02

MANAGEMENT OF PANCREATIC NEUROENDOCRINE TUMORS: A SINGLE CENTER EXPERIENCE.

Olsina, Jorge Juan¹; Sapisochin, Gonzalo¹; Dopazo, Cristina²; Ganchegui, Amaia²; Caralt, Mireia²; Escartin, Alfredo¹; Naval, Javier¹; Lazaro, Jose Luis¹; Bilbao, Itxarone¹; Balsells, Joaquin¹

¹Hospital Universitario Vall D′Hebron, HBP and Liver Transplantation Unit, Barcelona, Spain; ²Hospital Vall D′Hebron, HBP and Liver Transplantation Unit, Barcelona, Spain

Introduction. Pancreatic Neuroendocrine tumors (PNET) are rare tumors with a variety of clinical behaviors. These tumors may be functional, symptom specific and diagnosed at an earlier stage, or nonfunctional. Most of these tumors are initially benign, usually degenerate and show an indolent course of disease, but if they spread to the liver survival rates can decrease. Some of these tumors may be included in a genetic syndrome such as MEN 1. OBJETIVE: To asses our experience on PNET in the last 6 years.

Results. From 2000 to 2006, 33 patients (17 male/16 female) with a mean age of 56,1 years (r 24–82) underwent surgery for PNET in our center. Fourteen were nonfunctioning tumors (42%); 9 glucagonoma (27%); 3 insulinoma (9%); 3 ampullary carcinoid (9%); 2 gastrinoma (6%); 1 VIPoma (3%) and 1 Somatostatinoma (3%). Two patients had a Von-Hippel-Lindau disease, 2 had a MEN 1 and one of them a neurofibromatosis-1. Mean size of the tumor was 4 cm (r 0,7–20 cm). Surgical procedures performed were 12 distal pancreatectomies with splenectomy, 2 distal pancreatectomies, 11 cephalic pancreaticoduodectomies, 2 total pancreaticoduodectomies and 1 enucleation. Perioperative mortality was seen in one patient. Six patients (18,2%) have died with progression of their disease, 3 of them had liver metastases at diagnosis. Twenty-six patients (78%) are alive, 7 of them (27%) have recurrence with a mean time of 33 months, and 19 (73%) are free of disease.

Conclusions. This single-center experience demonstrates that PNET can be safely resected with a low mortality and morbidity. Patients with metastatic disease benefit of an aggressive approach with a multimodality therapy that may include RF, chemoembolization, liver resection, that may be done at the moment of diagnosis or when recurrence is observed. This aggressive approach is justified to optimize palliation and survival.

PP 13.03

3 CASES OF ADULT TYPE NESIDIOBLASTOSIS

Park, Kwan Tae; Shin, Haengchul; Kim, Songchul; Han, Duckjong

Asan Medical Center, Surgery, Seoul, Korea, Republic of

Introduction. Adult type of nesidioblastosis which cause hyperinsulinemic hypoglycemia is extremely rare. It is so difficult to differentiate nesidioblastosis from insulinoma preoperatively, which also cause hyperinsulinemic hypoglycemia. And its clinical feature, prognosis and disease inheritance trend are not clearly demonstrated. So, authors are to report our experiences of 3 cases of nesidioblastosis suffering from hyperinsulinemic hypoglycemia.

Methods. Three cases of nesidioblastosis operated in Asan Medical Center, Seoul was reviewed retrospectively.

Results. All of them were female and all of them was suffering from hyperinsulinemic hypoglycemia evaluated with prolonged fasting test, image studies of pancrease and portal vein sample test. Preoperatively one patient was diagnosed as insulinoma, other patient could not be differentiated from insulinoma and another patient was diagnosed as nesidioblastosis preoperatively. Subtotal pancreatectomy was performed and two of three patients were relieved from hypoglycemia immediately after surgery, but one patient remained on hypoglycemia. Histologic examination revealed no tumor lesion of insulinoma but islet cell hyperplasia with ductuloinsular complex consistent with nesidioblastoma. One patient died after 5 years from surgery and 2 patients remained euglycemic during follow up period (mean 18mo).

Conclusion. It is not easy to differentiate nesidioblastosis from insulinoma preoperatively. Careful preoperative evaluation would be necessary especially when no definite mass lesion detected on pancreas even by thorough radiologic imaging study. Treatment of choice is operative reduction of nesidioblastic islet cell hyperplasia. But, it is very difficult to decide the extent of pancreatic resection in order to acquire successful cessation of hypoglycemia or not to cause pancreatic endocrine insufficiency from too extensive resection.

PP 13.04

PANCREATIC TUMOURS IN THE YOUNG – MANAGEMENT DILEMMA

Amjad, Nasser¹; Kassian, Junaini¹; Singh , Harbahajan²

¹Kulliyah of Medicine, Jalan Hospital Campus, IIUM, Department of Surgery, Kuantan, Malaysia; ²Hospital Tengku Ampuan Afzan, Department of Surgery, Kuantan, Pahang, Malaysia

Pancreatic cancer rarely occurs in persons younger than 50 years and endocrine tumours are uncommon representing less than 5% of all pancreatic tumours. Majority of the endocrine tumours are usually small tumours (< 1cm). When young patients present with large tumours and inconclusive biochemical and imaging results, surgeons face a management dilemma. We present two young females, patient A who was 22 yrs and the other patient B, 35 yrs old. Both of them presented with more than three week history of progressive obstructive jaundice. These two patients did not have any symptoms or signs of functional endocrine or carcinoid syndromes. None of them had any history of acute pancreatitis or family history of pancreatic neoplasms. CT scan of patient A showed a mass in the head of the pancreas measuring more than 6 cm in diameter while patient B had mass at the same site measuring more than 9cm in diameter. At laparotomy the tumours appeared malignant and was deemed operable. Decision was made to carry out Whipple's operation in both patients. Lymph nodes were dissected out from the celiac axis in both patients. Patient A had a non-functioning endocrine tumour and patient B a non-functioning carcinoid tumour. Both made excellent progress and at three years follow-up are asymptomatic. Radical surgery is indicated even in young patients when faced with uncertain diagnosis

PP 13.05

HEPATO-PANCREATICODUODENECTOMY (HPD) COMBINED WITH TRANSARTERIAL EMBOLIZATION (TAE) FOR THE TREATMENT OF MALIGNANT GLUCAGONOMA WITH LIVER METASTASES.

Hoshino, Takanobu; Ishida, Takashi; Odaka, Akio; Hashimoto, Daijo

Saitama Medical University, Medical Center, Hepato-pancreato-biliary Surgery, Kawagoe-city, Japan

Objective. To elucidate how best to treat malignant endocrine tumors of the pancreas associated with multiple liver metastases.

Methods. Hepato-pancreaticoduodenectomy (HPD) combined with transarterial embolization (TAE) was successfully and effectively performed in a patient with malignant glucagonoma with multiple liver metastases. A 56-year-old male patient, complaining of skin erosion, erythema, and body weight loss, was admitted and diagnosed as glucagonoma based upon markedly elevated serum glucagon level (2037 pg/ml). Abdominal CT and ultrasonography demonstrated the existence of a hypervascular tumor of the pancreas head (3.8 cm in diameter) and multiple liver metastases (in S3, S5, and S8). Since medical treatment with octreotide acetate, somatostatin analogue, was not effective in controlling the tumors and glucagon level, surgical treatment (HPD) was performed to resect pancreas head tumor and metastatic tumors in the liver.

Results. Immediately following HPD, serum glucagon level dropped quickly, and skin lesions were also substantially improved. A year after the surgery, several liver metastases appeared, which were repeatedly treated by TAE, resulting in no rapid growth in number or sizes. This patient is still alive, free of symptoms, with several small liver metastases at three years six months following surgery.

Conclusion. Malignant endocrine tumors of the pancreas, such as glucagonoma, appears to be effectively treated by combination of surgical resection and TAE, even if associated with multiple liver metastases.

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VIPOMA: A RARE CASE OF PANCREATIC MASS

Cheung, Chin Cheung; Wong, Wai Man; Leung, Kam Fung

Tuen Mun Hospital, Department of Surgery, Tuen Mun, Hong Kong

Introduction. Vasoactive intestinal polypeptide secreting tumor (VIPoma) is a rare pancreatic neuroendocrine tumor. The incidence is one in 10 million. Patients usually present with chronic diarrhea and are diagnosed late because it is slow growing. About 50% of patients have metastatic spread by the time of diagnosis.

Objective. The aim is to find the result of surgical resection in one case of VIPoma of the pancreatic neck with liver metastasis.Method.: A 44-year-old lady was diagnosed by typical symptoms (profound watery diarrhea for two years with hypokalemia), high serum level of VIP, and radiological findings. Abdominal ultrasonography and computed tomography (CT scan) revealed a 3–4cm mass in the neck of pancreas with local invasion to the portal vein and multiple subcentimetre hyperenhancing nodules in liver. RESULT: Patient was treated with Sandostatin (Novartis) for symptomatic control in view of liver metastasis. Re-stage CT scan was done three months later revealed no hyperenhancing nodules found. Spleen-sparing distal pancreatectomy with wedge excision of portal vein was done. Intra-operative ultrasonography revealed a subcentimetre nodule in segment IVa, wedge excision of the liver nodule was also performed. The immunohistochemical examination was compatible with VIPoma of pancreas with regional lymph nodules and liver metastases. Patient was well with immediate resolving of symptoms and normalization of VIP level. She was regularly followed up without evidence of recurrence up to one year.

Conclusion. A case of VIPoma of the pancreas with liver metastasis was treated successfully by aggressive surgical resection.

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CLINICOPATHOLOGIC FINDINGS OF SOLID-PSEUDOPAPILLARY TUMORS

Oida, Yasuhisa; Imaizumi, Toshihide; Matsuyama, Masahiro; Yazawa, Naoki; Tobita, Kosuke; Ohtani, Yasuo; Makuuchi, Hiroyasu

Tokai University School of Medicine, Digestive Surgery, Isehara kanagawa, Japan

Background. Solid-pseudopapillary tumor of the pancreas (SPT) is a rare disease with a low-grade malignancy. It most commonly occurs in young women and has unique pathologic features. Despite growing interest in this tumor, histogenesis of these tumors is unknown and still under consideration.

Aim. To evaluate the clinicopathological features of this tumor.

Methods. The clinical features of eight surgically treated cases in our hospital between January 1994 to July 2007, were retrospectively reviewed.

Results. All patients were Asian and female. The mean age was 20 year-old (range, 14 to 34). Four patients presented with abdominal pain at presentation, 2 with palpable mass, 1 with nausea. Four tumors were located in tail, 1 in body, and 3 in head. CT and MRI revealed a well demarcated solid-cystic mass in the pancreas with slight enhancement of the cystic wall. The maximal diameter of tumors ranged from 3.8 to 12 cm (mean, 7.5cm). Surgical procedures included distal pancreatectomy with splenectomy in four patients and enucleation in four patients. All tumors contained some degree of internal hemorrhage or cystic degeneration, and were well encapsulated. Microscopically these tumors were characterized highly cellular portion composed of papillary arrangement of monotonous uniform polygonal cells around delicate and often myxoid fibrovascular stalks. All of these tumors were diffusely and strongly immunoreactive for ¿-1-antitrypsin and ¿-1-antichymotrypsin, and negative for estrogen receptor. One patient developed single liver metastasis 3 years after first operation, the tumor was enucleated. All patients were alive without evidence of recurrence with a follow-up of 9 to 74 months

.Conclusion. The behavior of SPT was less aggressive than other pancreatic tumors, even in a case with metastasis. The diagnosis can be made preoperatively with the combination of radiological and clinical features, and minimally surgery such as enucleation is applicable.

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“NONFUNCTIONAL” NEUROENDOCRINE TUMORS (NNETs) OF THE PANCREAS: DIAGNOSTIC CRITERIA AND SURGICAL TREATMENT.

Kubyshkin, Valery¹; Kochatkov, Alexander¹; Gurevich, Larisa²; Stepanova, Yulia³

¹A.V. Vishnevsky Institute of Surgery, abdominal surgery department, Moscow, Russian Federation; ²MONIKI, Moscow, Russian Federation; ³A.V. Vishnevsky Institute of Surgery, radiology department, Moscow, Russian Federation

Background. NNETs of the pancreas are rare lesions with better prognosis in comparison with pancreatic adenocarcinomas (PAC). The differences in long term survival make it necessary to preoperatively differentiate NNETs with PAC for appropriate treatment of these patients.

Methods. Data of preoperative examination, surgical procedures and long term survival of 62 patients with NNETs and 98 patients with PAC were compared to find differential diagnostic criteria. All tumors were verified morphologically and immunohistochemicaly.

Results. We did't find specific clinical symptoms of NNETs. The main clinical symptom of the disease was a palpable tumor in 20% of the patients. NNETs were located in the pancreatic head, body and tail, in 54.8% (34 pts), 25.8% (16 pts) and 19.4% (12 pts). The possibility of accurate differential diagnosis between NNETs and PAC by US and spiral CT was assessed relying on the different grade of visualization of the solid part and vascularization of the tumors. Whipple procedures were performed on 37.1% (23 pts) patients, distal pancreatectomies on 25.81% (16 pts), tumor enucleations on 30.65% (19 pts), laparotomies on 3.23% (2 pts) and laparoscopies on 3.23% (2 pts). The mean size of the removal tumors were 8.2 cm, 6.5 cm, 2.7 cm during Whipple procedu res, distal pancreatectomies and tumor enucleations, consequently. Three patients had RFA-procedures of hepatic metastasis after tumor resections. The median survival of the NNETs patients was 55.4±36.1 months in contrast of the median survival patients with PAC that was 11.8±9.2 months. The difference between the survivals is statistically significant (p = 0.01).

Conclusions. The precise preoperative differentiation of NNETs and pancreatic adenocarcinoma and staging are the keys to correct surgical treatment of the patients. Acceptable survival of the patients with the NNETs makes tissue-preserving surgical procedures on patients with small NNETs as well as surgical treatment of hepatic metastasis worthwhile.

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EXOCRINE FUNCTION IN THE TYPE 2 DIABETIC PANCREAS MAY NOT BE IMPAIRED IN ALL POPULATIONS

Bodapati, Archana¹; Turner, Richard²; Sinha, Ashim²

¹James Cook University, Cairns, Australia; ²Cairns Base Hospital, Cairns, Australia

Background. Published reports suggest an association between pancreatic exocrine insufficiency (PEI) and diabetes mellitus (DM). The evidence for this is weak, as the invasive nature of tests utilized in such studies precluded recruitment of large non-selected samples. Recently, reduced faecal elastase-1 concentration (FEC) has been used to screen for PEI. Evidence of reduced FEC in type 2 DM exists; however it has not been studied in all populations.

Aim. The study aimed to define associations between FEC and type 2 DM in a regional Australian population.

Methods. 33 type 2 diabetic patients were randomly selected from a local hospital and individually matched for age and sex to 33 controls with no clinical or documented history of DM.

Results. FEC was higher in diabetics compared to controls (p = 0.60). PEI was found in 41% of controls and 33% of diabetics (p = 0.41). Increasing age, the male sex, a high body mass index, high blood pressure, lack of exercise, smoking, and alcohol consumption appeared to be associated with reduced FEC; however this was not a significant association. Among diabetic subjects, non-significant trends for low FEC were found with clinical markers (long duration of known DM, presence of complications, insulin therapy) and biochemical markers (poor glycaemic control) of DM severity and atherogenic lipid profiles.

Conclusions. Overestimation of the difference to be detected may be responsible for the lack of power and contributed to the statistically non-significant

Results. Despite this, trends identified suggest PEI in type 2 DM may not be problematic in our population. These results do not support a recommendation for universal screening for PEI in the diabetic population studied. It is possible that the non-significant association reflects recruitment of predominantly mildly affected diabetics. Thus, future studies may benefit from staging their diabetic participants using C-peptide. Larger case-control or cohort studies are required to further explore the relationship.

PP 13.10

SOLID PSEUDOPAPILLARY TUMOR OF THE PANCREAS: AN UNUSUAL PRESENTATION

Tellioglu, Gurkan¹; Krand, Osman¹; Berber, Ibrahim¹; Kilicoglu, Gamze²; Titiz, Izzet¹

¹Haydarpasa Numune Research and Training Hospital, General Surgery, Istanbul, Turkey; ²Haydarpasa Numune Research and Training Hospital, Radiology, Istanbul, Turkey

Aim. The aim of this case report is to discuss the surgical treatment of solid pseudopapillary neoplasm of the pancreas (SPN) in case of unusual presentation.

Case Report. 19 year-old male patient referred to our clinic with mild abdominal pain. Physical examination revealed normal findings. Abdominal ultrasonography (US) revealed a solid mass located in the neck of the pancreas, and as 6.5 cm in diameter. Contrast enhanced abdominal CT revealed a solid mass lesion located in the panceatic neck. Body of the pancreas was atrophic nd there was no dilatation of the pancreatic duct. The lesion was heterogenously hypodense on noncontrast CT, while it demonstrated significant, but heterogeneous contrast enhancement with hypodense areas in the center and the periphery of the lesion. There was no evidence of adjacent solid organ invasion. Preoperative US-guided fine needle aspiration biopsy (FNAB) was not considered since perilesional dense vascularity precluded the intervention. Laparotomy was undertaken. The tumor was not invasive and soft in texture. Peripancreatic lymphadenopathies were excised and frozen section analysis reported reactive hyperplasia. The lesion was well encapsulated. Distal pancreatectomy without splenectomy was performed. The patient was discharged after an uneventfull postoperative course. Histopathologic examination revealed solid pseodopapillary tumor (SPN) of pancreas with clear surgical margins including an invasive component. Patient completed the one year follow-up without evidence of recurrence.

Discussion. The differential diagnosis of SPN with malignant transformation is not possible unless metastatic lesions and/or local invasion detected. Spleen preserving distal pancreatectomy is justified in the literature for the lesions located in the tail of pancreas. Long-term follow-up of patients treated with spleen preserving distal pancreatectomy with SPN expressing invasive component is needed.

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GALL BLADDER CANCER WITH TUBERCULOSIS

Singh, R. P¹; Singh, Shivendra¹; Agarwal, Shaleen¹; Sakhuja, Puja²; Puri, Sunil³; Agarwal, Anil¹

¹G.B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ²G.B. Pant Hospital and Maulana Azad Medical College, Pathology, New Delhi, India; ³G.B. Pant Hospital and Maulana Azad Medical College, Radiology, New Delhi, India

Background & Aim-Gall Bladder Cancer has a very high incidence in Northern India and tuberculosis is also still common. We herein report our experience of unusual coexistence of tuberculosis in patients with Gall bladder cancer and its impact on the management. Methods-We present 6 cases from 2003–2007 who presented with a diagnosis of Gall Bladder cancer and were also found to have evidence of tuberculosis on workup. Results-There were 6 females, mean age 56.6 yrs. The preoperative imaging of the patient was suggestive of mass in the GB area. 2 patients had supraclavicular lymph nodes palpable on preoperative examination. Fine Needle aspiration cytology (FNAC) of the cervical lymph nodes was positive for tuberculosis on histopathological examination. In the third patient on diagnostic laparoscopy, multiple peritoneal nodules were detected which were tubercular on HPE. 2 patients had inter-aortocaval lymph nodes frozen positive for tuberculosis. In one patient the HPE report of the radical cholecystectomy specimen was granulomatous lymphadenitis of hepatoduodenal ligament lymph nodes. 4 patients underwent Radical Cholecystectomy.

Conclusions. This paper presents cases in which Gall bladder cancer and tuberculosis co-existed. It highlights the importance of confirming the presence of distant metastasis by histopathological examination (FNAC or biopsy) before discarding the patient for curative surgery in a patient with locally resectable GBC on imaging.

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SURGICAL TREATMENT OF GALLBLADDER CARCINOMA. A COMPARISON OF TWO PERIODS

Olivares, Gabriel¹; Guerra, Juan Francisco¹; Funke, Ricardo¹; Jara, Jimena¹; Tapia, Grace¹; Torres, Javiera²; Martínez, Jorge¹; Guzmán, Sergio¹; Ibañez, Luis¹; Jarufe, Nicolás¹

¹Universidad Católica de Chile, Digestive Surgery, Santiago, Chile; ²Universidad Católica de Chile, Pathology, Santiago, Chile

Introduction. Gallbladder carcinoma is a lethal malignancy, with poor survival Results. Chile has one of the most highest rates of this cancer in the world. The aim of this study is to compare two periods regarding surgical strategy and if an aggressive approach improves survival rates.

Methods. A retrospective database of patients who underwent surgery for gallbladder carcinoma from 1978 to 2007 was reviewed. Two time period were defined. P1: patients operated from 1978 to 1997 (n = 165); and P2: patients from 1998 to 2007 (n = 35) where an aggresive surgical approach was applied

Results. A total of 200 patients were analyzed. Demographic and clinicopathological data were comparable in both groups. Preoperative diagnosis moved from 34% (P1) to 54% (P2). Curative intent surgery was performed in 46 patients of P1 (28%) and in 23 cases of P2 (65%). Radical resections (wedge, IV and V segments, extrahepatic bile duct) varied from 8% in the first period to 65% in the second. Morbidity and mortality rates improved from 28% and 6% for P1 to 14% and 0% for P2, respectively. Actuarial survival rate was 7.9% for P1 and 21% for P2.

Conclussion. In our series, increase of curative intent surgery and radical resections represents an improvement in overall and median survival rates, with decreased perioperative morbidity and mortality

PP 14.03

ROLE OF NEOADJUVANT CHEMOTHERAPY IN LOCALLY ADVANCED GALLBLADDER CANCER: AN EARLY REVIEW

Chaudhari, Ashish¹; Chhabra, Deepak¹; Navadgi, Suresh²; Shah, Rajiv C.¹; Jagannath, Palepu¹

¹Lilavati Hospital And Research Center, Surgical Oncology, MUMBAI, India; ²Asian Institute of Oncology-S. L. Raheja Hospital, Gastrointestinal Service, MUMBAI, India

Background. Gallbladder cancer (GBC) has dismal survival due to advanced stage at presentation. Neoadjuvant Chemotherapy for GBC is still under evaluation.

Introduction. Majority of patients with GBC have an advanced disease (stage III, IV) at presentation. Five year survival in stage I and II is over 80%, however, overall five year survival is only 15%. Palliative chemotherapy has produced 20–30% response. This retrospective study analyzes response of neoadjuvant chemotherapy in locally advanced GBC.

Patients and Methods. 15 patients with locally advanced and unresectable GBC (February 2001 to May 2007) who received neo-adjuvant chemotherapy were analyzed. All patients received 21 day cycle of Gemcitabine 1000mg/m2 on day 1 and day 8 and Cisplatin 100mg/m2 on days 1, 2 and 3. The response was measured on serial CT scans. Patients were categorized as PR (partial response), SD (stable disease) or PD (progressive disease) as per WHO guidelines. Patients with PR were offered surgery.

Results. 15 patients included 4males and 9 females. 13/15 patients (86.66%) showed PR, while 2 patients had SD. 11 underwent radical cholecystectomy, 1 Median Hepatectomy. 3 patients (1 PR, 2 SD) had peritoneal disease on exploration. Neoadjuvant chemotherapy increased resectability. There was no operative mortality. One patient died of recurrence 4 months after radical cholecystectomy. A median survival of 9 months and 4 months was noted in the resected and unresected group respectively.

Conclusions. Neoadjuvant chemotherapy; Gemcitabine and Cisplatin, has a promising role in downsizing locally advanced gallbladder cancer, thereby increasing resection rate and improving median survival.

PP 14.04

FACTORS INFLUENCING THE LONG TERM SURVIVAL OF T2 AND T3 ADENOCARCINOMA OF GALL BLDDER

Chen, Miin-Fu¹; Jan, Yi-Yin¹; K., Dilip Chakravarty²

¹Chang Gung Memorial Hospital, Department of General Surgery, Taipei, Taiwan; ²Chang Gung Memorial Hospital, Fellow in HPB Surgery, Dept. of General Surgery, Taipei, Taiwan

Introduction. Adenocarcinoma of gallbladder when symptomatic present as advanced carcinoma and carries poor prognosis. With the improvement in preoperative assessment, imaging, staging and surgical hepatobiliary resection and better survival is possible.

Objective. This is retrospective study carried out from 1996 to 2006 in Chang Gung Memorial Hospital, Taipei, Taiwan to study the factors influencing the long term survival in T2 and T3 adenocarcinoma of gallbladder.

Methods. In this study only T2 and T3 adenocaricnoma of gall bladder were included. T1 and T4 malignancies and other malignancies of gallbladder are excluded. Total 52 cases with T2 and T3 adenocarcinoma of gall bladder have undergone both curative and palliative surgical resection, out of which T2 adnocarcinoma are14 in no.(26.9%) and T3 adenocarcinoma are 38 in no.(73.1%). The factors which were taken into consideration are staging of tumor, lymph node metastasis, tumor marker levels, liver function tests, type of surgery offered to the patient, operative complications and post operative chemotherapy and/or radiotherapy.

Results. The overall cumulative survival rates in T2 and T3 adenocarcinoma of gallbladder in 1st, 3rd and 5th yr are 60.6%, 44.2% and 40.5% respectively. In Univariate analysis of 52 patients show that significant prognostic factors are CEA level, T staging, lymph node metastasis, pathological stage, and type of surgery (all p < 0.05). T staging hazard ratio 3.279 (1.779–10.087) with a p-value of 0.053 and type of resection (curative/palliative) has a hazard ratio of 3.984 (0.987–8.929) with a p-value of 0.001 by multivariate analysis using the Cox Proportional Hazards Model.

Conclusion. T2 and T3 Adenocarcinoma of gallbladder has better long term survival provided that the disease is diagnosed in early stage and proper staging and curative radical surgery.

PP 14.05

AGGRESSIVE TREATMENT OF GALL BLADDER CANCER

Singh, R.P; Singh, Shivendra; Mandal, Sanjoy; Agarwal, Shaleen; Mishra, P K; Sakhuja, Puja; Agarwal, Anil

G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India

Background. Carcinoma of the gall bladder is a common disease in North India and carries a poor prognosis. Here we present a Single centre experience of the surgical management of Gall bladder cancer (GBC) patients from 2000–2007.

Methods. Total of 411 patients were taken for resections, 158 with SOJ (38.44%), 253 without SOJ (61.55%). 338 patients underwent resection with a curative intent (104 with SOJ & 234 without SOJ).

Results. Of these patients, 164 had curative resections. Amongst these 164 curative resections 44 were in patients with SOJ & 120 in pts without SOJ. The overall resectability was 39.90% (27.85% for SOJ group & 47.43% for non SOJ group). In pts undergoing curative resections, Seg IVB + V were resected in 146 pts, Seg IVb + V+VI were resected in 3 pts & Ext. RH was done in 15 pts (9.03%). Adjacent organ was involved in 53 pts. In these pts with adjacent organ involvement, duodenal sleeve was resected in 17 pts, distal Gastrectomy + D1 resection was done in 24 pts, colon was resected in 23 pts, pancreaticoduodenectomy was required in 2 pts, vascular reconstruction/ligation was done in 10 pts. The morbidity and mortality rates were 42% & 12.17% respectively for pts with jaundice. The same figures were 11% & 4.3% for pts without SOJ.

Conclusion. Aggressive approach results in better resectability and improved survival in Gall bladder Cancer.

PP 14.06

COMPARISON OF TREATMENT Results IN PRIMARY VS POSTCHOLECYSTECTOMY PRESENTATION IN GALL BLADDER CANCER: EXPERIENCE AT A TERTIARY CANCER CENTER IN INDIA

Gupta, Vivek¹; Deo, SV Suryanarayana²; Kumar, Sunil²; Kar, Madhabananda²; Shukla, Nootan K²

¹Institute Rotary Cancer Hospital, Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India; ²Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Surgical Oncology, New Delhi, India

Background. Carcinoma gall bladder is an aggressive malignancy with dismal treatment Results. The aim of this study was to review the treatment results of carcinoma gall bladder cases (primary vs postcholecystectomy presentation) operated in a tertiary care centre in India and reasons for unresectability in these patients.

Methods. A retrospective analysis of 56 patients with carcinoma gall bladder operated between 1996 and 2006 was done. Only 5–6% of total outpatients with gall bladder cancer were found suitable for surgical exploration. If resectable, radical cholecystectomy with wedge resection of the liver with minimum of 2 cm margin and porto-coeliac lymphadenectomy was done. Patients with transmural infiltration of tumor or pathological node involvement also received adjuvant chemoradiotherapy.

Results. Curative resection was done in 47% of the patients. Thirty patients had undergone simple cholecystectomy previously. Rate of curative resection was higher in postcholecystectomy group (57% vs 30%), possibly because of incidental detection. Among postcholecystectomy patients resectability rate was better in post laparoscopic group as compared to open (54% vs 42%). Major nonmetastatic reasons for inoperability were extensive nodal involvement/residual disease and dense periportal fibrosis. Pathologically transmural/nodal involvement were present in 80% of curatively resected group. Three year disease free and overall survival for curatively resected patients was 54% and 64% respectively whereas 3 year overall survival for the total patient population was 34%.

Conclusion. Gall bladder cases with primary presentation have lower resectability rate as compared to postcholecystectomy cases. With judicious patient selection and multimodality treatment approach reasonable survival results can be achieved. Patient should be referred to a specialist center if preoperative/intraoperative suspicion of gall bladder malignancy is present.

PP 14.07

AGGRESSIVE MANAGEMENT OF PATIENTS WITH GALL BLADDER CANCER- IS IT WORTHWHILE?

Varma, Vibha¹; Gupta, Subash²; Soin, Arvinder³; Nundy, Samiran⁴

¹Nizam's Institute of Medical Sciences, Department of Surgical Gastroenterology, Panjagutta, Hyderabad, India; ²Indraprastha Apollo Hospitals, Liver Transplant and Gastrosurgery, New Delhi, India; ³Sir Ganga Ram Hospital, Multi Organ Transplantation Unit, New Delhi, India; ⁴Sir Ganga Ram Hospital, Department of Surgical Gastroenterology, New Delhi, India

Background. Gall bladder cancer (GBC) the commonest cause of malignant obstructive jaundice in Northern India is considered to be an aggressive and incurable disease. Recent data supports aggressive surgical resection even in advanced stages of disease with improved survival statistics.

Objective. We reviewed our data on 120 operated patients of GBC to assess whether radical surgical resection translated to better survival in GBC.

Material and Methods. Of the 129 cases of GBC admitted between July 1996 and July 2003, 120 were offered surgical treatment. There were 45 males and 75 females with a mean age of 54 (range 23 to75) years. Details of demographic data, clinical features, preoperative staging using TNM staging system, surgical treatment, follow up and their survival was analyzed.

Results. Pain in the right hypochondrium was the commonest symptom (78%), followed by abdominal lump (57%) and jaundice (52%). Gallstones were found in 62% and 17% presented with gastric outlet obstruction. Seventy-eight of 84 patients with jaundice and, or abdominal lump had advanced stage GBC. Four patients had stage I disease, 16 stage II, 28 stage III and 72 had stage IV disease. Radical surgical procedures were performed in 64 (53%) patients. Operative mortality was 7.5%. Seventy two (60%) patients were followed up. The median overall survival after curative procedure was 21 months (range 4–63 months) compared with 9 months ( range 1- 32months) for other procedures (p = 0.000).

Conclusion. Majority (83%) of patients with GBC have advanced stage disease at presentation. About half of patients with GBC are amenable to radical surgery. An aggressive surgical approach in GBC is associated with a longer survival.

PP 14.08

Estrogen Receptor ¥á, ¥â and Progesteron receptor as a possible prognostic factor in radically resected primary gallbladder carcinoma

Park, Joon Seong¹; Kim, Jae Keun¹; Jung, Wo Hee²; Hwang, Ho Kyoung¹; Cho, Sin Il¹; Yoon, Dong Sup¹; Chi, Hoon Sang¹; Kim, Byong Ro¹

¹Yonsei University Colledge of Medicine, Surgery, Seoul, Korea, Republic of; ²Yonsei University Colledge of Medicine, Pathology, Seoul, Korea, Republic of

Background.: Gallbladder carcinoma is a relatively rare malignancy with an extremely poor prognosis. The pathologic staging of gallbladder carcinoma is a key determinant of the patient¡^—s prognosis and the treatment options. However, we have often encountered patients in whom the course of their disease differed substantially from what would be predicted based on their clinical staging, which highlights the needs to consider additional predictive factors. Gallbladder carcinoma occurs more frequently in women than men, yet expression of the estrogen receptor(ER) family and progesterone(PR) have not been studied. We applied an immunohistochemical technique to examine the expression of ER¥á, ER¥â and PR in radically resected gallbladder carcinoma tissues and then compared their expression status with several clinicopathological factors.

Methods. We immunohistochemically investigated 30 specimens of gallbladder adenocarcinoma tissues using ER¥á, ER¥â and PR antibodies. The expression of ER¥á, ER¥â and PR were compared using the Chi-square test. Survival was analyzed using the Kaplan-Meier method.

Results. The results indicated that adenocarcinoma of gallbladder are both negative for ER¥á and PR, irrespective of histologic grade, TNM stage and sex. However, twenty-two of 30 cases (73.3%) were confirmed positive for ER¥â, which was significantly correlated with poor differentiated tumor grade. Overall survival rates of ER¥â-positive and negative patients were 77.3% and 37.5%, respectively (p = 0.034). In multivariate analysis, only ER¥â was statistically significant (p = 0.033).

Conclusions. Evaluation of ER¥â expression in gallbladder carcinoma may be an important factor in identifying a poor prognostic group of gallbladder carcinoma.

PP 14.09

MUCINOUS ADENOCARCINOMA OF GALL BLADDER AND MUCOCELE OF GALL BLADDER: A CLINICAL DILEMMA

Navadgi, Suresh; Shah, Rajiv; P, Jagannath

S.L. Raheja Hospital-Asian Institute of Oncology, Dept. of Surgical Oncology, Mumbai, India

Background. Impacted stone at cystic duct can lead to a mucocele of Gall bladder (GB), which may result in massive distension of Gall Bladder. Such enlarged Gall Bladder with symptoms of fever and pain may pose a diagnostic dilemma between a benign mucocele of Gall Bladder and a cystic GB malignancy. CASE SUMMARY: We report such a clinical scenario in a 65 year old female who presented with complaints of abdominal pain in right hypochondrium. She was recently diagnosed and treated for typhoid. On clinical examination she had a huge distended GB, which was enlarged up to the right iliac fossa. CA 19-9 was within normal limits. Ultrasonography was suggestive of an enlarged GB wall with thickening? Inflammatory? Neoplastic. CT scan showed a distended GB due to impacted stone at neck with wall thickening and retroperitoneal lymphadenopathy. On exploration a distended GB mass causing displacement of Stomach, duodenum and transverse colon was seen with infiltration of adjacent liver parenchyma. There were enlarged periportal and retroportal lymph nodes. A radical cholecystectomy involving wedge resection of adjacent liver parenchyma with lymphadenectomy was done. Final histopathology showed a 16x 16 cms. GB mass which was poorly differentiated mucin secreting adenocarcinoma involving full thickness of gall bladder wall with positive retroportal nodes. Liver and cystic duct margins were free.

Conclusion. Majority of GB malignancies are usually adenocarcinomas, mucin producing tumors are relatively rare. These tumors can mimic the benign mucocele of Gall Bladder which can follow an impacted stone at cystic duct

PP 14.10

DOES LAPROSCOPIC CHOLECYSTECTOMY FOR UNSUSPECTED GALL BLADDER CANCER ADVERSELY IMPACT THE OUTCOME?

Navadgi, Suresh¹; Chhabra, Deepak²; Shah, Rajiv³; Ambulkar, I⁴; Advani, S H⁴; P, Jagannath³

¹SLRH, Surgical Oncology, Mumbai, India; ²Lilavati Hospital and Research Centre, Surgical Oncology, Mumbai, India; ³S.L. Raheja Hospital-Asian Institute of Oncology, Surgical Oncology, Mumbai, India; ⁴S.L. Raheja Hospital-Asian Institute of Oncology, Medical Oncology, Mumbai, India

Background. Incidental Gall bladder cancer (GBC) has been reported in approximately 1.5–3% of cholecystectomies, majority of which undergo inadequate preoperative workup for diagnosis and staging prior to cholecystectomy. Objective of this study was to analyze the various patterns of presentation and recurrence of disease in patients who underwent Cholecystectomy for unsuspected GBC.

Methods. Retrospective review of 93 patients over a three-year period (2004 -2007) who were diagnosed as GBC, of which 23 had undergone Cholecystectomy for suspected benign disease elsewhere was carried out. Based on histopathology reports and imaging, patients were classified as organ confined, locally advanced and metastatic disease.

Results. 23 out of 93 patients had undergone Cholecystectomy for ‘benign’ gall bladder disorders of which 21(91%) were laparoscopic and 2 (9%) were open. There were 8 (35%) males and 15 (65%) females. Median age was 55 years. On presentation, CT scan was done in all patients to assess residual disease and for restaging. 8 (35%) patients were organ confined (OC) had no residual disease, 9 (39%) patients had locally advanced (LA) disease and 6 (26%) patients presented with distant metastasis (DM). Median time of presentation was 3 months from diagnosis. Due to delayed referral, patients were not suitable for revision surgery. All patients received gemcitabine and cisplatin based chemotherapy. Status at last follow up was as follows: 4(17%) are alive and disease free (3 OC, 1 LA), 5(22%) are alive with disease (4 LA and 1 DM), 11(49%) have expired (2 OC, 4 LA and 5 DM) and 3 patients are lost to follow up. Median time to death was 8.5 months.

Conclusions. Inadequate preoperative workup and histopathology reports due to lack of awareness make it difficult for the treating physician to accurately stage the disease and plan treatment. Early referral of patients to tertiary centres for evaluation may offer some advantages of revision surgery

PP 15.01

MAJOR HEPATECTOMIES IN ERDERLY PATIENTS

Contis, John¹; Karapanos, Konstantinos²; Vassilikostas, George²; Smyrniotis, Vassilios²; Voros, Dionysios²; Fragoulidis, George²

¹Univ. of Athens School of Medicine, 2nd Dept of Surgery, Athens, Greece; ²Univ of Athens School of Medicine, 2nd Dept of Surgery, Athens, Greece

Introduction. Curative liver resection has been accepted as the only chance of long-term survival for patients with primary and metastatic liver cancer. Faced with an increasing number of elderly patients presented with hepatic malignancies, we studied old age defined as 70 years or older as a prognostic factor for the early outcome of major hepatectomies.

Methods. We performed a retrospective review o f a consecutive series of patients who underwent a major hepatectomy to study old age (>70 years) as a risk factor regarding outcome. All patients undergoing major liver resection (defined as three segments or more) from January 2001 to December 2005 were included. Patients were studied in two groups: 70 years of age and older (54 patients, 70–90. mean 75 years) and less than 70 years old (138 patients). Early outcomes were analyzed. From the cohort of the last 200 patients who underwent a major hepatectomy in our center, 56 patients older than seventy years (70–90, mean 75years) and their perioperative morbidity and mortality as well as hospital stay were compared to the outcome of 144 patients younger than 70 years.

Results. Elderly patients had a 5,5% mortality (3 deaths due to MI, hemorrhage and liver failure respectively) and a 15% rate of major complications ( biliary leak 7 patients, re-operation for bleeding one patient) while their mean hospital stay was 10,9 days (3–50 days). There was no statistical difference in the incidence of perioperative complication and death rate compared to younger patients who suffered a 4.3% mortality and 16.6% morbidity rate. Their mean hospital stay was 11.3%, also not statistical different.

Conclusions. Major liver resections can be safely performed in the elderly with early results similar to those in the younger than 70 age group. Age by itself cannot be considered as contraindication for surgery in the elderly patients who could benefit from a liver resection.

PP 15.02

ANALYSIS OF HEPATIC RESECTIONS IN A NEWLY SET UP UK SPECIALIST HPB CENTRE

Mukherjee, Samrat; Bhattacharya, Satyajit; Abraham, Ajit T; Hutchins, Robert R; Kocher, Hemant M

Barts and the London HPB Centre, London, United Kingdom

Background. Advances in surgical techniques and improved perioperative patient management make it possible to perform extensive resections with acceptable morbidity and mortality rates.

Aims. We analysed the morbidity and mortality outcomes for all the liver resections undertaken for various pathological lesions in a new specialist hepatobiliary centre.

Patients and Methods. All patients undergoing a hepatic resection between January 2004 to June 2007 were extracted from our HPB database. Outcomes were analysed for morbidity, mortality and length of hospital stay.

Results. A total of 125 patients (Median age 60, range 22–80 years; Male = 64) had a hepatic resection between Jan 2004 to Jun 2007. Pathology included colorectal liver metastasis (n = 73), hepatocellular carcinoma (n = 11), cholangiocarcinoma (n = 8), carcinoid metastases (n = 4), neuroendocrine metastasis (n = 5), non-colorectal non-neuroendocrine (n = 14) and benign (n = 10). The resections performed were major resections (n = 42), extended resections (n = 14), segmental resections (n = 23), wedge resections (n = 32), left lateral segmentectomy (n = 12) and laparoscopic resections (n = 2). The mortality was 2.4% (n = 3) and the morbidity was 33.6% (n = 42). The median length of hospital stay was 10 days (range 4 -392). For patients undergoing hepatic resection for colorectal metastases (n = 73), mortality was nil and morbidity was 30.1% (n = 22).

Conclusions. Hepatic resections can be carried out for a variety of pathological liver lesions with acceptable mortality and morbidity in specialist centres.

PP 15.03

INDOCYANINE GREEN CLEARANCE FOLLOWING MINOR LIVER RESECTION

Low, Jee K¹; Mackillop, Andrew²; Clark, Debbie¹; Vadeyar, Hemant¹; Sherlock, David¹

¹North Manchester General Hospital, Surgery, Manchester, United Kingdom; ²North Manchester General Hospital, Anaesthesia, Manchester, United Kingdom

Introduction. Elimination of indocyanine green (ICG) from blood can be used to determine peri-operative hepatic function.

Aim. This technique was used to monitor the hepatic function of patients undergoing segmentectomy and re-do hepatic resection.Method.: Twelve consecutive patients scheduled for hepatic resection (segmentectomy and re-do resection) were studied. We used transcutaneous pulse densitometry for the assessment of liver function by measuring ICG plasma clearance (Limon ®). After an intravenous injection of 0.25mg/kg of ICG, we observed plasma disappearance rate (PDR) and retention rate extrapolated to 15 minutes (R15).

Results. Thirteen patients were studied, eight male and four female. The mean PDR before operation of all thirteen patients was 24.8%/min (17.7–33.3), on the first post-operative day 31.2%/min (17.5–42.0), one week later 27.5%/min (18.9–34.0) and beyond six weeks 24.5%/min (17.9–39.1) respectively. Of the seven patients who underwent segmentectomy, the mean PDR was 26.6%/min, 31.5%/min, 28.0%/min and 25.0%/min respectively. Three patients who had re-do hepatectomy had a mean PDR of 20.7%/min, 25.4%/min, 24.8%/min and 19.9%/min respectively. Of the remaining patients, one had inoperable metastatic recurrence and the other two had large gastrointestinal stromal tumours. Their mean PDR was 24.7%/min, 36.5%/min, 29.1%/min and 28.1%/min respectively.

Conclusion. The PDR was significantly higher on the first post-operative day when comparing it with the preoperative value. This suggests that the hepatic clearance of ICG is increased during the early post-operative period.

PP 15.04

LIVER RESECTIONS IN A SEMIRURAL SET UP – A PERSONAL EXPERIENCEOF 32 CASES

Desai, Sharad

Mahatma Gandhi Cancer Hospital, Miraj, India

Background. Liver resections are supramajor undertakings and requires good infrastructure. However they can also be done safely with moderate surgical equipment and routine postoperative support in the semirural set up.

Objectives. To know the results of Liver resections in semirural hospitals.

Material/Methods. – A retrospective analysis of our series of 32 major Liver resections done in various hospital and nursing homes in a small town in India was done. Most hospitals had facilities for good anesthesia and electocautery. Some of the hospitals did not have a Intensive care unit.

Results. Though none of the hospitals had sophisticated equipment, the surgeries could be done unhindered and without difficulty. Our cases involved – 10 HCC, 6 Ca Gall Bladders, 4 Metastatic resections, 4 Hemangiomas, 1 Hepatic adenoma, 1 Hepatoblastoma, 2 Hydatid cysts, 4 Refractory Abcesses. Major Blood loss(>2000 ml) occurred in 2 cases. No Intraoperative injury occurred.17 patients did not receive any transfusions. One patient died due to sepsis and another died due to liver failure from a small remnant liver. A morbidity occurred due to biliary fistula which took more than a month to heal.

Discussion. Hepatic resections can be done with safety with moderate equipment. The use of vessel sealers and CUSA does not improve the Results. Proper anatomical dissection and good anesthesia are important to obtain good Results.

PP 15.05

ENDOSCOPIC SCLEROTHERAPY VERSUS LIGATION IN THE PRIMARY PROPHYLAXIS OF ESOPHAGEAL VARICEAL BLEEDING IN CIRRHOTIC PATIENTS

Szczepanik, Andrzej B¹; Misiak, Andrzej²; Szczepanik, Anna M²; Meissner, Alfred J²

¹Institute of Hematology and Transfusion Medicine, Department of Surgery, Warsaw, Poland; ²

The AIM of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the prevention of the first bleeding from high-risk varices in patients with liver cirrhosis.

Methods. Fifty two patients with esophageal varices, endoscopically judged to be a high risk of hemorrhage (grade III or IV, red color signs), with no previous history of bleeding, were included in the study. All patients were randomly assigned to endoscopic sclerotherapy group (EST) (27 patients) or endoscopic variceal ligation group (EVL) (25 patients). Mean age of patients was 56.5 in the EST and 54.0 in the EVL group. Etiology of liver cirrhosis was: postnecrotic 18 vs 15, alcoholic 7 vs 4, other 1 vs 6 in the EST vs EVL group respectively. According to Child-Pugh classification (A/B/C) there were 12/12/3 patients in the EST and 8/14/3 in the EVL group. Endoscopic procedures were performed using endoscopes Olympus (Japan). Injection sclerotherapy with 5% ethanolamine oleate, 10–20 ml per session, was performed every week. Variceal ligation with placing 2 to 5 elastic bands (Endoloop, Olympus) was done every two weeks. Both procedures were repeated until complete variceal eradication was achieved. Endoscopic examination was then performed every 3 months in the both groups. Recurrent varices were obliterated or ligated.

Results. Eradication of esophageal varices was achieved in 26/27 (96.3%) patients in the EST group and in all in the EVL group. The mean number of procedures required to obtain eradication was higher in the EST than in the EVL group (4.9 vs 2.7). Recurrence of varices at follow-up at a median of 21 months was higher in the EVL (4/25; 16.0%) then in the EVL group (2/27; 7.4%). The compli cations were observed in 4/27 patients (14.8%) in the EST and in 2/25 (8.0%) in the EVL group. One death was observed in the EVL group and none in the EST group.

Conclusion. EST and EVL are similarly effective in the eradication of esophageal varices and in the prevention of the first bleeding.

PP 15.06

THE DEVELOPMENT OF A SWINE MODEL OF SECONDARY LIVER TUMORS FROM A GENETICALLY INDUCED SWINE FIBROBLASTS CELL LINE.

Sanabria, Juan¹; Abbas, Rime¹; Robinson, Ann¹; Adam, Stacy²; Okada, S¹; Kim, Juliam¹; Christopher, Counter²

¹University Hospitals-Case Medical Center, Surgery, Cleveland, United States; ²Duke University, Pharmacology, Durham, United States

Background. Swine models of secondary liver tumors may demonstrate to be an ideal model to study the efficacy of surgical and ablative treatment options available for liver tumors. PURPOSE. To develop a secondary liver tumor in a large animal model

.Methods. Fibroblasts from swine were isolated from ear lobule; cells then were transfected with amphotrophic retroviruses encoded with human genetic (hTERT, p5300, cyclinD-1, CDK4R24C, Myc T58A, RASG12V) material. Transformed cell lines were inoculated into swine under tacrolimus based immunosuppression (n = 4). Isolates from first pass were cultured and then inoculated as a second pass into 1) nude immunodeficient mice (n = 5), 2) immune intact wild mice (n = 2) and, 3) porcine animals without immunosuppression (n = 2).Results. Tumor growth was evident in 75% of immunosuppressed swines. One animal die with diarrhea and failure to thrive before the completion of experiment (3weeks). Growth of tumors was slow in two animals while in one animal tumor was larger with a peak growth of 42mm at three weeks. All growths showed to be malignant on histology. Cell morphology changed from initial cell line as compared with cell isolates after first pass. Tumor growth was evident in 100% of the nude immunodeficient mice with a peak size of 22mm (17 + 5mm, Mean + SD) at the time of sacrifice (3weeks). Tumor growth was evident in all wild mice with a peak size of 8.9mm at the end of the third week. Tumor growth in swine was characterized for slow growth with a peak size of 8mm at three weeks.

Conclusions. Characterization of new mutations in cell lines after first pass is the matter of current studies. Further changes may produce a more rapid growth of genetically induced tumorogenic cells in the immune-intact swine

PP 15.07

MANAGEMENT OF CHOLEDOCHAL CYST WITH PORTAL HYPERTENSION

Bora, Giri Raj¹; Singh, Shivendra¹; Gondal, Ranjana²; Agarwal, Anil¹

¹G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ²G. B. Pant Hospital and Maulana Azad Medical College, Pathology, New Delhi, India

Background & Aim: Portal hypertension is a rare complication of long standing Choledochal cyst. We analysed our cases of Choledochal Cyst complicated by presence of Portal hypertension.

Material and Methods. Over the study period of 6.5 years (January 2001 to June 2007) at a tertiary care centre in India, eleven cases of Choledochal cyst with associated portal hypertension were encountered out of 204 patients (5.39%). Clinical presentation, management, Liver histology and hospital course of these patients were analyzed in detail.

Results. There were 11 patients (2M,9F) with a mean age of 33.3 years(12 to 72 years). Eight patients had type IVA & 3, type I CDC. Pain abdomen was most common presenting feature in 8 ( 72.7%), followed by jaundice 6( 54.54%), cholangitis 1 (9.09%) and abdominal mass 1 ( 9.09%). Lower end cholangiocarcinoma (metastatic) with SBC was found in 1 patient and palliative bilio-enteric bypass was performed. Complete excision of extra hepatic portion of Choledochal cyst with Roux-en-Y Hepaticojejunostomy was feasible in 8 patients (80%) where surgery was performed with intent of excision of CDC. Cyst excision was not possible in 2 patients, one patient in the early part of the study underwent loop cystojejunostomy with jejunojejunostomy on encountering collaterals. Another patient had history of recurrent acute pancreatitis and necrosectomy. There was no post operative mortality. Ascites requiring diuretic therapy developed in 4 (40%) patient.

Conclusion. Portal hypertension complicated choledochal cysts in 5.39% (11 of 204) of our patients of CDC. Direct Excision of CDC can be performed in patients with a patent portal vein. We advocate policy of primary excision of Choledochal cyst and prior shunt surgery should probably be reserved only for those patients with a blocked portal vein/extensive pericholedochal collaterals.

PP 15.08

PROXIMAL LIENO- RENAL SHUNT IS THE TREATMENT OF CHOICE FOR EXTRAHEPATIC OBSTRUCTION

Sahoo, Duryodhan; Mohapatra, M.K; Mallick, P.K.

SCB Medical College, Cuttack, India

Introduction. The role of surgery in portal hypertension has diminished over the years. At present, the first line of treatment for bleeding oesophageal varices is endoscopic sclerotherapy, variceal ligation and pharmacotherapy. Surgery is indicated in endoscopic failures, in patient with gastric varices and portal gastropathy. In our Institution, the practice is to offer proximal lieno-renal shunt to patients with extrahepatic obstruction with good liver function.

Material and Methods. We had 35 case of EHO during last 8 years, 30 cases underwent shunt procedure (L.R. Shunt). 3 cases underwent devascularization procedure (modified Hasaab's procedure). All patients were within the age range of 10 to 28 years. Maximum number of cases were referred to us from the department of Gastroenterology, SCB Medical College, Cuttack.

Results. 1. Bleeding controlled with improvement in general health and nutrition – 32 cases. 2. Shunt block and rebleeding – 1 case 3. Rebleeding after devascularization procedure – 1case 4. Abdominal pain with subacute intestinal obstruction – 1case 5. Mortality – nil.

Conclusion. 1. In our opinion – L.R. Shunt is the treatment of choice in portal hypertension (EHO) with upper Gastrointestinal bleeding with splenic vein diameter of 6mm or more. 2. It is an onetime procedure. 3. It is cost effective (Rs. 7000–8000) in this Govt. hospital setup 4. Reasonably good shunt patency in patients having splenic vein of 6mm & above in diameter. 5. Therefore we recommend, for illiterate & poor patients living at remote places, and with scarce medical facilities, L-R shunt as the primary mode of therapy.

PP 15.09

HEPATECTOMY FOR BILOBAR LIVER METASTASIS

Vimalraj, V; Jeswanth, S.; Rajarathinam, G.; Ravichandran, P.; Rajendran, S.; Balachandar, T.G.; Kannan, D.; Surendran, R.

Government Stanley Medical College and Hospital, Department of Surgical Gastroenterology, Chennai, India

Background and Aims: We reviewed our experience with resection for bilobar liver secondaries(that included colorectal and certain other malignancies) to clarify the safety and effectiveness of this treatment and also to assess the long-term results of liver resections for bilobar liver metastasis.

Methods. Between January 1998 and January 2007, 25 patients with bilobar liver metastasis were identified from a cohort of 312 hepatic resection patients and data retrospectively analyzed.

Results. The mean age was 47 years [18 – 72 yrs]. The indications for resection were colorectal-14/25 (56%), Neuroendocrine- 4/25(16%), metastatic GIST – 4/25(16%), renal cell carcinoma – 2, wilms tumour – 1. Surgery alone was done in 14/25 patients. Combined surgery and radiofrequency ablation was done in 6/25 patients. Resection, portal vein ligation was done in 5 patients.4/5 patients underwent second stage resection. The mean blood loss of 320cc (range 50–1100 cc). Mean length of stay was 12 days (range 8–46 d). Complications were encountered in 3 patients, Bile leak – 1, Intra abdominal abscess – 1(both were managed by percutaneous drainage) and liver failure in 1 needed prolonged medical management. Follow-up ranged from 6 months to 7 years. 18/ 25 patients are alive and are on follow up.

Conclusion. Surgery alone or in combination with RFA offers both a chance of long term survival and even cure. Our data suggests that resections alone or in combination with newer strategies can be performed safely in these patients with no mortality and minimal morbidity.

PP 15.10

FIRST REPORTED NEW VALVE IN INFERIOR VENA CAVA AT DIAPHRAGMATIC LEVEL

Guo, Chenghao¹; Zhang, Hui²; Agarwal, Anil³; Wang, Zhonggao⁴

¹Institute of Pathology and Pathophysiology, School of Medicine, Shandong University, Department of Pathology, Jinan, China; ²Second Hospital of Shandong University, Jinan, China; ³G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ⁴Beijing Xuanwu Hospital, Beijing, China

Background & Aim: Membranous obstruction of the inferior vena cava is a common etiology of Budd-Chiari Syndrome in developing countries. The site is usually located at the level of the diaphragm below the right atrium.

Material and Methods. We present a case of a 38 year old Chinese man who had a new valve located in left anterior wall of IVC at diaphragmatic level on post mortem examination.

Results. The New valve was a crescent- shaped fold of the lining membrane of inferior vena cava, 16mm×5 mm size and transversely located 28 mm to entry into the right atrium. Both side of new valve had endothelium lining. The new valve location was different and lower than Eustachian valve. The location corresponds with the site of membranous obstruction of the IVC in cases of Budd Chiari Syndrome.

Conclusion. Our case describes an unreported new valve located in the hepatic portion of inferior vena cava at the diaphragmatic level. The new valve location may have an important role to explain the pathogenesis of membrane obstruction of the inferior vena cava in Budd-Chiari Syndrome.

PP 16.01

EFFECT OF EARLY ANTIBIOTIC PROPHYLAXIS WITH ERTAPENEM AND MEROPENEM IN EXPERIMENTAL ACUTE PANCREATITIS IN RATS

Catena, Fausto¹; Ansaloni, Luca²; Severi, Silvia²; Gazzotti, Filippo²; Coccolini, Federico²; D'Alessandro, Luigi²; Principe, Alfonso²; Pinna, Antonio²

¹Transplant, General and Emergency Surgery DPTSt Orsola- Malpighi University Hospital Bologna ITALY, Bologna, Italy; ²

Background. The clinical course in acute necrotizing pancreatitis is mainly determined by bacterial infection of pancreatic and peripancreatic necrosis. The effect of two antibiotic regimens for early prophylaxis was investigated in the taurocholate model of necrotizing pancreatitis in the rat.

Methods. Sixty male Sprague- Dawley rats were divided into three pancreatitis groups (15 animals each) and a sham-operated group (15 animals). Pancreatitis was induced by intraductal infusion of 3% taurocholate under sterile conditions. Animals received two different antibiotic regimes (15 mg/kg ertapenem or 20 mg/kg meropenem) one shot before the induction of pancreatitis or no antibiotics (control). Animals were examined after 24 h for pancreatic and extrapancreatic infection.

Results Early antibiotic prophylaxis with both regimens could significantly reduce pancreatic infection from 12/15 (control group) to 4/15–3/15 (antibiotic group). (p < 0.05).

Conclusions. In our animal model of necrotizing pancreatitis, early antibiotic prophylaxis with ertapenem and meropenem reduce bacterial infection of the pancreas. The effectivity of early antibiotic prophylaxis in the clinical setting should be subject to further investigation with improved study design.

PP 16.02

DELAYED SINGLE STAGE NECROSECTOMY FOR INFECTED PANCREATIC NECROSIS

Doctor, Nilesh H; Barreto, Savio G; Hussain, Maharra

Jaslok Hospital and Research Centre, Department of Gastrointestinal Surgery, Mumbai, India

Background Data on the indications, timing and technique of debridement for infected pancreatic necrosis is varied. Although early versus late and single stage versus multiple procedures have been extensively studied in Western literature, such studies on the management of infected pancreatic necrosis in India are few. Objective To analyze the feasibility and outcome of delayed single-stage necrosectomy after an early conservative, but aggressive resuscitation of patients with infected pancreatic necrosis. Methods During the time period between 1st January, 1998 and 31st May, 2006, 32 patients with severe acute pancreatitis who developed infected pancreatic necrosis and were managed by pancreatic necrosectomy, were analysed. Results Of the thirty-two pancreatic necrosectomies performed during the period between 1st January, 1998 and 31st May, 2006, 28 patients required only a single procedure. Thus a single-stage necrosectomy could be performed in 28 patients (87.5%). Patients underwent surgery a median of 29 days after diagnosis of acute pancreatitis while one patient had to be explored on the 13th day. Sepsis and multiple organ failure accounted for the 9.6% mortality rate. Enteric fistulae occurred in 18.7% of patients. The median hospital stay was 23 days, and the interval until return to regular activities was 150 days. Conclusion Delayed single-stage pancreatic necrosectomy for infected pancreatic necrosis has been documented to be an effective treatment strategy with reduced morbidity and mortality. Early antibiotic therapy with carbapenems and good supportive care may help in delaying surgery.

PP 16.03

ACUTE PANCREATITIS WITH SPONTANEOUS MASSIVE BLEEDING INTO PERITONEAL CAVITY: A CASE REPORT

Washiro, Mitsustune¹; Kusashio, Kimihiko²

¹Suzaka Hospital, Surjery, Suzaka, Japan; ²Chibarousai Hospital, Surjery, Ichihara, Japan

Massive bleeding may complicate the course of acute pancreatitis. The incidence of bleeding occurs usually after operation including necrosectomy, and the main pathogenetic mechanism of bleeding is mediated by pseudocysts or abcess. On the other hand, spontaneous bleeding due to acute pancreatitis is a rare, but frequently fatal complication of acute pancreatitis. Especially, Intraperitoneal hemorrhage is a distinctly less common manifestation. Severe inflammation and/or regional necrosis may cause major vessels or peripancreatic vessels erosion, whose eventual rupture may result in massive bleeding into peritoneal cavity. Symptoms appeared just before lethal bleeding, too late to even hazard a diagnosis. A rapid and accurate diagnosis is critically important. We report a case of massive intraperitoneal bleeding owing to disruption of peripancreatic vessels in a patient recovering from acute pancreatitis. Diagnosis of bleeding was made by computed tomography and ultrasound-guided blood aspiration. The source of the bleeding was identified intraoperatively, and a distal pancreatectomy and a splenectomy were performed. Our case confirms the necessity to add massive intraperitoneal venous bleeding to the list of differential diagnosis for sudden deterioration in patients with acute pancreatitis.

PP 16.04

VASOSPASM IN EARLY SEVERE ACUTE PANCREATITIS: A REVERSIBLE PHENOMENON!

Deshpande, AA¹; Raut, AA²; Rege, SA²; Dalvi, AN²; Hardikar, JV²

¹Seth G. S. Medical College & K.E.M. Hospital, Department of Surgery, Parel, Mumbai, India; ²Seth G. S. Medical College & K.E.M. Hospital, Department of Surgery, Mumbai, India

Background. Pancreatic ischemia due to vasospasm has been documented in experimental and clinical severe acute pancreatitis. The degree of reversibility of this vasospasm if any and its clinical implications have not been tested. In a prospective observational study we tested the hypothesis that many of the clinical and CT features of early acute pancreatitis are due to vasospasm and they may be at least partially reversible if a standardized treatment protocol is instituted within a critical time. STUDY DESIGN: Between January 2007 to June 2007, all the CT scans for acute pancreatitis performed within 48 hours of admission were reviewed. Scans showing large fluid collections, pseudocysts, emphysematous pancreatitis, and also acute on chronic pancreatitis were excluded. The scans showing severe necrotizing pancreatitis were included for the study. These were reviewed for: enhancement pattern and percentage enhancement of the gland, the Hounsfield units of the poorly perfused areas, peripancreatic inflammation, peripancreatic necrosis. The clinical charts were evaluated for: 1) duration of symptoms 2) probable etiology, 3) organ failure if any 4) total duration of stay 5) outcome and 6) mortality. The follow-up scans whenever performed were compared with the first scan.

Results. Totally 58 scans were studied, 30 were excluded. Of the 28 scans included, pancreatic enhancement was poor in 8 and absent in 16. More than 80% of the gland was involved in 20 scans. Significant peripancreatic inflammation was seen in 6 scans and peripancreatic necrosis was seen in 13. Superior mesenteric venous thrombosis was noted in 1 scan. Twenty patients had presented within 48 hours of the onset of symptoms. Standardized treatment was given to all patients including oxygenation, proper fluid management, colloid infusion daily, antibiotic, early enteral nutrition and supportive treatment as necessary. Etiology was gallstones in 4 and alcohol in 24. Organ failure was seen in 2 patients, (1 –respiratory, 1- renal). Average hospital stay was 12 days (range 6 to 31 days). Twenty six patients were discharged. Surgical intervention was done in 1. There was one readmission with infected necrosis and this patient succumbed to sepsis. Total mortality was 12% (3/28). Follow-up scans were done in 7/28 patients. 80% of these showed partial or complete reversibility of the enhancement pattern and peripancreatic changes.

Conclusions. Severity of clinical and radiological features in early acute pancreatitis is in part due to associated vasospasm. Treatment instituted in proper time is helpful in reversing the vasospasm and limiting the ischemic insult to the pancreas thereby decreasing the severity and limiting the course of the illness.

PP 16.05

LOCAL COMPLICATIONS OF ACUTE PANCREATITIS. LAPAROSCOPIC APPROACH.

Secchi, Mario

Hospital Italiano de Rosario, Surgey , Virasoro 1249, Rosario, Argentina

Authors: Mario A. Secchi MD, Lisandro Quadrelli MD and Leonardo Rossi MD Surgical Division “B” Hospital Italiano de Rosario Argentina

Objective. To consider a new agreed definition for AP as well as a laparoscopic and conventional approach of its local complications(LC) of acute pancreatitis(AP).

Design: Retrospective (1987–1997) and prospective (1998–2007) study, were performed at 4 surgicals centers: Hospitales Italiano, HECA, Provincial from Rosario and Model Clinic from Rufino. (Argentina) POPULATION: 1132 patients having AP between April, 1987, and Jannuary, 2007.Method.: Lesions and local complications were defined according to the Pancreas Club, República Argentina, 1998. All patients had AP of any etiology confirmed by morphological

Methods. A CT Scan performed after the 4th. day of the onset of AP showed an AP local involvement. The clinical therapy was to treat local lesion, and a combination of clinical, percutaneous, laparoscopic(VLP) and/or conventional surgery was performed to treat LC. 195 patients developed 263 local lesions and complications. Local lesions: 35 had acute fluid collections > 5 cm. in diameter ( 8 underwent percutaneous punction and drainage), and 47 had pancreatic necrosis (with no complications at all). 173 local complications: 30 abscesses, 49 acute pseudocyst, 5 infected acute pseudocyst and 89 infected necrosis. Abscesses of any size and pseudocysts > 5 cm of diameter were treated. Second surgical procedures for treating infected necrosis were not considered.

Results OF TREATMENT: Laparoscopic approach were used in 23 cases for treated local complications of AP (13%), This technique is feasible, safety and apropiate for recurrent abscesses (n = 6), cystograstrostomy or assisted cystoyeyunostomy ( n = 10) and focal infected necrosis less than 30% of pancreas volume (n = 7). L.C. mortality with multidisciplinary treatment: was 1.4% (16/ 1132).

Conclusion. Multidisciplinary treatment, including laparoscopic, is mandatory to obtain better results in LC of AP.

PP 16.06

A CHOICE FOR EMPIRICAL STEROID TREATMENT IN PATIENTS WITH SUSPECTED LYMPHOPLASMACYTIC SCLEROSING PANCREATITIS (LPSP): A DIAGNOSTIC TOOL.

Borobia, Francisco¹; Jorba, Rosa²; Busquets, Juli³; Valls, Carlos⁴; Serrano, Teresa⁵; Pelaez, Nuria³; Rafecas, Antonio³; Ramos, Emilio³; Torras, Jaume³; Llado, Laura³; Fabregat, Joan³

¹Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain; ²Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat. Barcelona, Spain; ³Hospital Universitari de Bellvitge, Hepatobiliopancreatic surgery, L'Hospitalet de Llobregat. Barcelona, Spain; ⁴Hospital Universitari de Bellvitge, Radiology, L'Hospitalet de Llobregat. Barcelona, Spain; ⁵Hospital Universitari de Bellvitge, Histology, L'Hospitalet de Llobregat. Barcelona, Spain

Introduction. LPSP is an autoimmune disorder that present as obstructive jaundince and can mimics a pancreatic adenocarcinoma (PA). Only histologic study after resection or steroids response gives the clue for diagnosis. OBJECTIVE To present our results and management algoritm for LPSP.

Methods. From 1999, eleven patients (8M/3F) have been diagnosed of LPSP. All patients had jaundice, progresive or self-limited. Four were referral to our Hospital with biliary stents. One were considered as extended PA and treated with biliary stent. In 4 patients LPSP was suspected, one of them was transfered after bilioenteric by-pass for suspected advanced PA with esclerosing cholangitis.

Results. Mean age were 56,8 years (24–75). CT scan appearance are diffusely enlarged pancreas or pseudotumour. MRCP shows irregular narrowing of the pancreatic duct. EUS/CT-biopsies were performed to rule out malignacy. IgG4 were elevated only in 2 patients. Six patients were resected because inaccurate suspicion of malignancy. Patient with suspected advanced PA with stent was reevaluated and LPSP were diagnosed. Patients diagnosed of LPSP were treated with steroids. In 3 patients jaundice disappeared with medical therapy, two due to LPSP and one due to sclerosing cholangitis. Another patient did not respond and was resected. Patients treated with steroid 2 years have better quality of life.

Conclusions. LPSP can be diagnosed by clinical suspicion and with TC and MRCP images. EUS and/or TC-biopsy must be done before a steroid assay. In case of no response or doubt of PA surgery must performed. A succesful steroid treatment can be considered as diagnostic.

PP 16.07

PANCREATICOPLEURAL FISTULA – TWO PHOTOGENIC CASES

Desai, Chirag¹; Desai, Maharshi²; Shah, Viral³; Upadhyay, Swati¹

¹The Apollo Hospitals Internationals Ltd., Department of GI/HPB surgery, Ahmedabad, India; ²The Apollo Hospitals Internationals Ltd., Department of Critical Care, Ahmedabad, India; ³The Apollo Hospitals Internationals Ltd., Department of Pulmonology, Ahmedabad, India

Chronic massive pancreatic pleural effusion is an uncommon and often unrecognized clinical syndrome, which results from an internal pancreatic fistula and usually presents as an effusion of unknown cause. The effusion frequently occurs without clinical evidence of pancreatitis, but occasionally it may be associated with a pseudocyst of the pancreas. In this report, two cases of chronic massive pancreatic pleural effusions are presented. Both the cases presented with dyspnoea from large pleural effusion, were treated initially for tuberculosis and both had a history of alcohol abuse. They had high level of amylase in the pleural fluid. MRCP, CT and ERCP showed mid pancreatic duct stricture with tract going to the mediastinal pseudocyst which in turn communicated well to the pleural space (One right side and other left side). Both the patients were given conservative treatment in form of chest drainage & nutritional support. One was also given octreotide. In both the cases endoscopic stenting was tried but due to the tight stricture it was technically not possible. Both the patients responded to the conservative treatment. A high index of suspicion is necessary to be aware of the presence of pancreaticopleural fistula. The conservative treatment with or without endoscopic stenting is usually successful and takes 2–3 weeks. Surgery is needed only in resistant and recurrent cases. Chronic massive pancreatic pleural effusion may be recurrent. Morbidity and mortality are reduced when a definite diagnosis is established and appropriate therapy rendered.

PP 16.08

A CASE OF XANTHOGRANULOMATOUS PANCREATITIS

Kamei, Keiko; Takeyama, Yoshifumi; Haji, Seiji; Yasuda, Takeo; Shinzaki, Wataru; Satoi, Shunpei; Fujiwara, Shozo; Ishikawa, Hajime; Yasuda, Chikao; Nakai, Takuya; Oyanagi, Harumasa

Kinki University School of Medicine, Department of Surgery, Osaka-Sayama, Japan

Background Xanthogranulomatous inflammation is well known in the gall bladder and kidney, but xanthogranulomatous pancreatitis is very rare and clinicopathological features are not enough described.

Case Report. A 55-year-old man with a history of hyperlipidemia was referred to us with a complaining of back pain. Abdominal CT showed the 3-cm-diameter low density tumor of the pancreas head. EUS revealed the high echoic mass with surrounded by low echoic lesion. We could not deny the malignant pancreatic tumor, so subtotal stomach-preserving pancreaticoduodenectomy was performed. Intraoperative findings showed the mass lesion which contained coagula. Pathological findings showed xanthogranulomatous inflammation with numerous foamy histiocytes of the pancreas head without malignant findings. His post operative course was well, and he has remained well at 12 months after the operation. Herein we report a rare case of xanthogranulomatous pancreatitis which was difficult to differentiate from pancreas cancer, with a review of the literatures.

PP 16.09

BYPASS SURGERY FOR BILIARY OBSTRUCTION IN CHRONIC PANCREATITIS

Omoshoro-Jones, Jones AO; Jeppe, Cara; Smith, Martin D

Chris Hani Baragwanath Hospital, Hepatopancreatobiliary Unit, Division of Surgery, Johannesburg, South Africa

Introduction. Bile duct stricture occurs in 10–30% of chronic pancreatitis. Hepaticojejunostomy (HPJ) or choledochojejunostomy (CD-J) and pancreaticoduodenectomy form the standard of care. Opening the intrapancreatic bile duct with incorporation into the pancreaticojejunostomy has been described. We present our experience with the use of HPJ or CD-J in the treatment of distal common bile duct stenosis (DCBDS) in patients undergoing duodenal preserving pancreatic resection for chronic pancreatitis.Method.: From a prospectively studied cohort of patients undergoing local resection of head of pancreas and pancreaticojejunostomy (LR LPJ), those that underwent concurrent HPJ or CD-J (performed to a section of the same Roux loop used for the LPJ) were analysed.

Results. Twenty seven patients had HPJ (5) or CD-J (22) with LRLPJ over a 14-yr period. All patients had significant pain at a median duration of 4 (0.5 – 15) years. Of 22 patients with DCBDS, jaundice was present in all while 7 (31.82%) pres ented with cholangitis managed with pre-operative endoscopic drainage used in all jaundiced patients. The median operative time, blood loss and transfusion rates were 4.5 (3 – 8.33) hours, 0.75 (0.3 – 2.0) L and 1 (1 – 2) units respectively. Three patients (11.11%) developed pancreatobiliary related complications: 1 self-limiting bile leak, 1 pancreatic fistula and 1 LPJ-anastomotic leak that required re-operation. There were no death and the median hospital stay was 16 (6 – 38) days. The median 7-year pain relief rate is 95.59%. No patient has recurrent jaundice.

Conclusion. DCBDS is common in chronic pancreatitis. HPJ or CD-J at the time of the primary LR LPJ is simple and safe with minimal morbidity and good long term Results. This procedure is recommended as the alternative to draining the bile duct by incorporating it into the pancreaticojejunostomy.

PP 16.10

AUTOIMMUNE PANCREATITIS AND OBSTRUCTIVE JAUNDICE– A CHALLENGING DIAGNOSIS

Malladi, S.V. Subramanyam¹; Malladi, S.V. Subramanyam¹; Chang, Yeon-Jeen¹; Mittal, Vijay¹; Maas, Luis²; Jacobs, Michael¹

¹Providence Hospital and Medical Centers, Surgery, Southfield, United States; ²Providence Hospital and Medical Centers, Gastroenterology, Southfield, United States

Background. Autoimmune pancreatitis is a chronic inflammatory condition of the pancreas constituting one quarter of Whipple resections performed for benign conditions in North America. Autoimmune pancreatitis is a steroid responsive disease. Awareness of its existence helps to avoid unnecessary resections.

Objective. We report a case of autoimmune pancreatitis associated with a pancreatic head mass that was successfully managed without a pancreaticoduodenectomy.

Methods and Results. A 50 year-old Ukrainian women with a history of Sjögrens syndrome presented with epigastric pain, jaundice and weight loss for 6 weeks. She received Imuran and prednisone for 7 years. Tumor markers were negative. Ultrasound (US) revealed an enlarged pancreas and dilated intra and extra hepatic biliary ducts. Computer tomography scan showed similar findings with a possible distal duct stone. Endoscopic Retrograde Cholangiopancreatography showed dilated biliary ducts with tapering of the distal third of the common bile duct (CBD), which was suspicious for extrinsic compression from an enlarged pancreatic head. A biliary stent was placed. Endoscopic US demonstrated a pancreatic head lesion with coarse borders. Surgical intervention was advised. Intraoperatively, the pancreas was diffusely indurated without acute inflammation. A 1.5-cm nodule was found at the junction of intra and extra pancreatic bile ducts. Intraoperative US confirmed previous findings, however, multiple transduodenal core biopsies were negative for malignancy. CBD resection and hepaticoenterostomy were performed due to the occlusive distal CBD lesion. The patient had an uncomplicated postoperative course. Histopathology of the pancreas showed autoimmune pancreatitis. CBD showed intense chronic inflammation with fibrosis.

Conclusion. Despite the significant understanding of autoimmune pancreatitis, preoperative diagnosis remains a challenge. Surgery may be necessary to establish the diagnosis and correct peripancreatic pathology such as benign biliary strictures.

PP 17.01

PANCREATICODU0DENECTOMY FOR BENIGN DISEASE FAILURES OF A DIAGNOSTIC WORK-UP ARE THERE ANY LEARNING POINT?

Manzia, Tommaso Maria; Cherian, Thomas; Toti, Luca; Attia, Magdy; Coldham, Chris; Buckels, John; Mayer, David; Bramhall, Simon; Wigmore, Stephen; Mirza, Darius

Queen Elizabeth Hospital/University of Birmingham, Liver Unit, Birmingham, United Kingdom

Background. It is well recognised that a small percentage of patients who undergo a pancreaticoduodenectomy (PD) for suspected malignancy will turn out to have benign pathology. We sought to audit our series, and access the incidence and outcome of benign conditions in patients who underwent a PD. We specifically attempted to analyse 2 subgroups: one, those in whom PD was performed for benign disease i.e. no malignancy suspected preoperatively, and two, those who underwent PD for strong suspicion of malignancy but had negative histology.

Patients and Methods. Between January 1997 and April 2006, 499 pts (457 for suspected cancer, 42 for suspected benign disease) underwent PD at the Queen Elizabeth Hospital. Prospectively collected data was reviewed and analysed.

Results. Overall 78 (15.6%) patients were negative for malignant disease on the basis of the final histological report. Our median follow up was 35 months (1–113 months). The pathology was chronic pancreatitis in 35 (7%), benign cystoadenomas in 19 (3.8%), inflammatory biliary strictures in 10 (2%) and other benign conditions in 14 patients (2.8%) respectively. Five year overall survival rate in these patients was 83.3%, with no survival difference between patients with chronic pancreatitis and those with other benign diseases. Of the 41 patients with a preoperative diagnosis of benign pathology, we found 12 cases (27%) of malignancy.

Conclusion. This study confirms previous reports that benign diseases represent approximately 10% of the PD performed for suspected malignancy. More importantly, it shows that in a third of the patients in whom PD is carried out for suspected benign disease such as chronic pancreatitis, there is an underlying malignancy.

PP 17.02

DOUBLE CANCER; ARISING IN GASTRIC HETEROTOPIC PANCREAS AND PANCREAS TAIL

Sanada, Takahiro¹; Iwasaki, Yoshiaki²; Goro, Honda³; Koji, Tsuruta³

¹Ohkubo Hospital, Surgery, Tokyo, Japan; ²Komagome Hospital, gastric surgery, Tokyo, Japan; ³Komagome Hospital, Hepato-Biliary-Pancreatic surgery, Tokyo, Japan

Introduction. A heterotopic pancreas in the gastric wall is a relatively common congenital condition, but its malignant transformation is extremely rare. Here we report a very rare case of 61-year-old Japanese woman with double cancer arising in gastric heterotopic pancreas and pancreas tail.

Patient. 61-year-old Japanese woman admitted to our hospital, complaining of epigastric discomfort. RADIOLOGICAL STUDIESComputed tomography and magnetic resonance imaging showed a cystic lesion of gastric wall and irregular change of main pancreatic duct with pseudocyst at the proximal site of the main pancreatic duct. Upper gastrointestinal endoscopy revealed a submucosal tumor in the antrum along the greater curvature, and a biopsy specimen confirmed this submucosal cystic tumor included heterotopic pancreatic tissue.

Blood Examination. CA19-9 was elevated to 167.3U/ml.

Operation. We found liver metastasis and a lot of disseminations on the abdominal wall, mesocolon, and mesojejunum. So she underwent distal gastrectomy only.

Discussion. Adenocarcinoma arising within ectopic pancreas is a rare occurrence with fewer than 40 well-documented cases reported in the world literature to our knowledge, but it should be noted that the malignant transformation of ectopic pancreas could occur.

PP 17.04

LAPAROSCOPY IN PATIENTS WITH LOCALLY ADVANCED PANCREATIC TUMOURS.

Morak, Marjolein J.M¹; Smeenk, Hans¹; Mast, Jay¹; Hermans, John J.²; Kazemier, Geert¹; van Eijck, Casper H.J.¹

¹Erasmus Medical Center, Surgery, Rotterdam, Netherlands; ²Erasmus Medical Center, Radiology, Rotterdam, Netherlands

Background. In pancreatic cancer, differentiating between resectable, locally advanced and metastasized tumours is of pivotal importance for optimal treatment. In patients with locally advanced pancreatic cancer locoregional chemoradiation is the treatment of choice.

Aim. To investigate the role of diagnostic laparoscopy in patients with locally advanced pancreatic cancer.Method.: In a retrospective study 82 patients with locally advanced pancreatic cancer were classified based on CT scan according to Phoa criteria. All patients underwent laparoscopy and in case of metastases, these were all proven histologically. In the non-metastasized patients histology was obtained with percutaneous biopsy, endoscopic ultrasound or based on Ca 19.9 levels of > 250kU/l.

Results. Metastases were found during laparoscopy in 34 (41%) of patients. The mean survival in these patients was 6.8 months. Overall survival in the locally advanced patients was 14.7 months. Twenty eight of these patients received chemoradiation, with a mean survival of 20.2 months. Twenty two patients either refused or were not eligible for chemoradiation and their survival was 8.9 months.

Conclusion. In 41% of patients with locally advanced pancreatic cancer metastases were detected during laparoscopy, which were not visualised by CT- scanning. In these accurate staged patients, chemoradiation might improve survival.

PP 17.05

CT APPEARANCES OF SOLID PSEUDO-PAPILLARY NEOPLASMS OF THE PANCREAS

Eapen, Anu¹; Suzy Cherian, Rekha¹; Lorence Vyas, Frederick²; Kurian, Susy³; Sitaram, Venkatramani²

¹Christian Medical College, Department of Radiology, Vellore, India; ²Christ ian Medical College, Department of Hepato-biliary surgery, Vellore, India; ³Christian Medical College‘, Department of Pathology, Vellore, India

Background. Solid pseudo-papillary neoplasm of the pancreas is a rare, low grade malignant tumor seen in young women. Recognition of this entity on imaging is important, as it is potentially curable after resection.

Aim. To describe CT features of solid pseudo-papillary neoplasm of the pancreas.

Methods. We retrospectively analyzed CT features of solid pseudo-papillary neoplasm of the pancreas in 10 patients who underwent surgical resection. Pancreatic tumors were analyzed with respect to location, size, attenuation {solid or cystic}, encapsulation, hemorrhage and calcification, features of malignancy (infiltration, adenopathy and liver metastasis), associated findings (duct dilatation, atrophy of gland and venous thrombosis).

Results. All 10 patients were women between the ages of 10 -36 years, (mean: 24 years). Tumor involved the body or tail of pancreas in 8. Four of these were large masses, involving both body and tail. The maximum transverse diameter of the tumor on CT varied from 3.2 to 13 cm. The lesions were solid masses (5), solid with areas of cystic change/necrosis (4) and cystic with thick enhancing wall (1). Punctate calcification within the mass was present in 3 patients. All lesions were well encapsulated with no peri-tumoral infiltration. In one patient with a previous history of pancreatitis, tumor was partly adherent to stomach. Significant adenopathy or liver metastases were not seen. Pancreatic duct dilatation upstream was present in 2 patients with lesions in the head, and atrophy of the gland was observed in 2 patients. Splenic vein thrombosis was a feature in 3 patients.

Conclusion. The CT diagnosis of solid pseudopapillary neoplasm of the pancreas should be considered when a well encapsulated, solid or partially cystic lesion is seen in young women. Punctate calcification may be present. Cystic degeneration is a common feature. Presence of peri-tumoral infiltration, adenopathy and metastasis are atypical.

PP 17.06

PANCREATICOGASTROSTOMY FOR PANCREATIC RECONSTRUCTION AFTER PANCREATICODUODENECTOMY

Pai, Madhava¹; Damrah, Oasama²; Abulkhir, Adel²; Lauretta, Andrea²; Raychaudhari, Prasenjit²; Healey, Andrew²; Habib, Nagy²; Jiao, Long²

¹Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, Du Cane Road, London, United Kingdom; ²Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, London, United Kingdom

Background. Postoperative morbidity after pancreaticoduodenectomy has been associated mainly with the development of pancreatic fistula. The aim of the present study was to investigate the postoperative morbidity in a series of pancreaticoduodenectomies with pancreaticogastrostomies.

Methods. Retrospective review of a prospectively collected database at a tertiary care university hospital. A total of 60 consecutive patients underwent pancreaticogastrostomy (PG) following pancreaticoduodenectomy (PD) between 2003 and 2006. Preoperative risk factors, intraoperative and postoperative variables, and postoperative complications along with mortality were analysed.

Results. The 4 most common indications for surgery were pancreatic adenocarcinoma (48.3%), ampullary carcinoma (8.3%), duodenal carcinoma (6.7%), and chronic pancreatitis (5%). The median operating time was 7 hours. Median blood loss was 465 ml. The median intraoperative blood transfusion was 0 U. The median postoperative length of stay was 17.5 days. Postoperative mortality was 5% (n = 3). The most common complications were wound infection (20%) followed by abdominal collection/ abscess (16.7%). Two patients had delayed arterial haemorrhage 1 of which was the cause of 1 of 3 mortalities in this series. There was no incidence of pancreatic fistula.

Conclusion. Pancreaticogastrostomy is a safe operation associated with low mortality and morbidity rates. It should be considered as a suitable alternative for management of the pancreatic remnant after pancreaticoduodenectomy.

PP 17.07

EXTENDED DUODENOPANCREATECTOMY FOR NONPERIAMPULARY TUMORS

Albagli, Rafael¹; Albagli, Rafael²; Mali Jr, Jorge³; Stoduto, Gustavo⁴

¹National Cancer Institute-Brazil, Abdominal Surgery, Rio de Janeiro, Brazil; ²; ³Cancer Hospital, Londrina, Brazil; ⁴National Cancer Institute- Brazil, Rio de Janeiro, Brazil

Introduction. To evaluate the surgical morbimortality and the evolution of the patients submitted to extended duodenopancreatectomy (DP) for nonperiampulary tumors.

Methods. It were analised retrospectivaly 15 patients submitted to DP for nonperiampulary tumors, in the abdominal-pelvic surgery service of National Cancer Institute- Brazil, from 1990 to 2005.

Results. The histologic kinds of primary tumors included the adenocarcinoma of colon (n = 9), gastric adenocarcinoma (n = 3), gastrointestinal stromal tumors (n = 2) and renal carcinoma (n = 1). The average internation time was 13,5 days (6 to 36), the average operation time was 360 minutes, the hemotransfusion average was 307 ml, the ressected limph nodes average was 19, where 3 patients had positive limph nodes, the average size of the tumor was 7,8cm (2,5 to 24), the surgical morbidity was 60%, the operative mortality was 6,6% (1/15) and the global survival average was 38 months.

Conclusion. The duodenopancreatectomy for nonperiampulary tumors is an exception procedure and it must be considered only for selected patients.

PP 17.08

EFFECT OF BLOOD TRANSFUSION ON OUTCOME AFTER PANCREATICODUODENECTOMY: A CASE-MATCH STUDY

Pai, Madhava¹; Abulkhir, Adel²; Damrah, Osama²; Limongelli, Paolo²; Habib, Nagy²; Williamson, Robin²; Jiao, Long²

¹Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, Du Cane Road, London, United Kingdom; ²Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, London, United Kingdom

Background. Although blood transfusions have allowed surgeons increased latitude in resecting pancreatic cancers, they can cause significant morbidity. Potential side effects may include transmission of infection and immunosuppression. The aims of this study were to examine the effect of blood transfusion on morbidity and mortality in association with pancreaticoduodenectomy (PD).

Methods. 102 patients underwent PD in our institution between 2002 and 2006. Patients were matched for age, sex, and histology and divided into two groups of 32 patients each, one group had received blood transfusion (BT) and the other had no blood transfusion (NBT). Their clinical data, transfusion records, postoperative outcome including morbidity and mortality were analysed.

Results. 20 patients had pancreatic ductal adenocarcinoma and 12 had ampullary adenocarcinoma in each group. The median age was 67.5 (40–82years) and 68 (36–81years) in BT and NBT groups (p = 0.7). Intraoperative blood loss (p < 0.001) and operative time (p < 0.0001) were significantly higher in the BT group. However there was no difference in intensive care unit (ICU)(p = 0.08) or hospital stay (p = 0.4). The two groups had no statistically significant difference in relaparotomy, overall morbidity or postoperative mortality.

Conclusion. Intraoperative blood loss and operative time are the two important factors influencing BT. Although BT is not shown to affect the short-term results after PD in this study, its effect on the overall survival and disease recurrence needs to be further evaluated.

PP 17.09

RARE PRIMARY PANCREATIC MALIGNANCIES- PRESENTATION AND OUTCOME.

Cherian, Thomas¹; Manzia, T²; Coldham, C²; Toti, L²; Bramhall, SR²; Mayer, D²; Buckels, JAC²; Wigmore, SJ²; Mirza, DF²

¹University Hospital, Birmingham; ²

Background. Non-ductal adenocarcinomas and non neuroendocrine tumours are unusual in the Pancreas and exhibit diverse biological behaviour. We reviewed our experience of these rare pancreatic malignancies (RPM) accumulated over 10 years.

Method. We conducted a retrospective review of all cases of RPM from Jan 1997 to 2007, from our prospectively collected database of 1551 pancreatic tumours. We discuss the clinical course, diagnosis, and treatment of these less common neoplasms of the pancreas. Pancreatic lymphomas and neuroendocrine tumours being separate, homogenous entities, merit dedicated analysis and were excluded from this study.

Results. There were 89 cases of RPM (incidence 5.6% of pancreatic tumours); 49 females; median age 61years (range 17–86); median follow-up 18 months. Histologically, 39 (45%) were cystadenocarcinomas, 15 IPMN (18%), 8 pseudopapillary tumours, 7 adenosquamous carcinomas, 4 paragangliomas, 4 acinar cell carcinomas, 3 osteclastomas and 7 other miscellaneous neoplasms. Fifty-nine patients (70%) had resectional surgery- 12 total pancreaticoduodenectomy, 33 part ial pancreaticoduodenectomy (Whipples), 14 distal pancreatectomy. Among the 15 IPMNs, 4 had carcinoma in situ and 9 invasive cancer. There was no statically significant survival difference between the various subgroups within this diverse cohort, however their overall 5-year survival was 30% compared to 5% from ductal adenocarcinomas in our institution. P < 0.05. Three-year survival rates for cystadenocarcinomas were particularly poor (33%), in contrast to the cystadenomas (52%), which often appear similar on imaging. Conclusion Rare pancreatic malignancy although fewer than ductal adenocarcinomas, form a significant part of our pancreatic cancer workload (5.6%). As awareness of the entity increases, adenocarcinomas arising from IPMN seems to form a sizeable percentage. The prognosis of these RPM appear to be better than ductal adenocarcinomas making histological confirmation essential, especially if tumours appear inoperable.

PP 17.10

PANCREATICO-DUODENECTOMY WITH ARTERIAL RESECTION FOR PANCREATIC ADENOCARCINOMA

Jaeck, Daniel; Bachellier, Philippe; Rosso, Edoardo; Tracey, Jacky; Oussoultzoglou, Elie; Pessaux, Patrick

Hopital de Hautepierre, Centre de Chirurgie Viscérale et Transplantation, Strasbourg, France

Hypothesis: Arterial resection associated with pancreaticooduodenectomy for adenocarcinoma of the pancreas is feasible and does not impair final outcome. Patients: From January 1990 to December 2005 nine patients underwent a R0 pancreaticoduodenectomy associated with an arterial resection for adenocarcinoma of the pancreas. Their records were reviewed for perioperative outcome and long term survival. Main Outcome Measures: The postoperative mortality was nil while the postoperative morbidity was 66%. Complications were of grade III in 33% of the patients. Eight patients underwent a simultaneous portal vein resection. No postoperative arterial or venous thrombosis occurred. Final pathology showed regional lymph nodes metastases in eight patients. The median survival was 10 months. The actual 1- and 2-years survival rates for all 9 patients were 33% and 13%, respectively. One patients is alive 76 months after surgery without recurrence.

Conclusions. Pancreaticoduodenectomy with AR and/ or combined venous resection for locally advanced adenocarcinoma of the pancreas can be performed safely in selected patients, whenever the arterial resection represents the only obstacle to a curative resection. Long term survival is similar to that of less extensive surgery for locally advanced adenocarcinoma of the pancreas. Whenever R0 resection cannot be achieved pancreaticoduodenectomy with arterial resection is not indicated.

PP 18.01

LEVELS OF TUMOUR MARKERS MEASURING BIOLOGICAL ACTIVITY DURING AND AFTER LIVER METASTASE RESECTION

Lipska, Ludmila¹; Visokai, Vladimir²; Vrzalova, Jindra³; Topolcan, Ondrej⁴; Levy, Miroslav⁵; Holubec, Lubos⁶

¹Thomayer Tcheaching Hospital, Department of Surgery, Praque 4, Czech Republic; ²Thomayer Teaching Hospital, Department of Surgery, Praque 4, Czech Republic; ³University Hospital Pilsen, Department of Nuclear Medicine, Pilsen, Czech Republic; ⁴Immunoanalytic laboratory, Department of Nuclear Medicine, Plzen, Czech Republic; ⁵Thomayer Teaching Hospital, Department of Surgery, Prague, Czech Republic; ⁶Immunoanalytical laboratory, Department of Nuclear Medicine, Plzen, Czech Republic

Background. Postoperative monitoring of tumour markers biological activity is important for the consideration of the effect of surgical treatment and the success of hepatic tissue regeneration.

Aims. To monitor the changes in blood levels of selected growth factors, interleukins and tumour markers during and immediately after resection of liver metastase.

Methods. Blood samples were obtained regulary from 8 patients during surgical procedure, 24 hours after the operation and day, two days and one week after the operation. Serum levels of interleukin (IL) 6, IL 8 and hepatocyte growth factor (HGF) were assessed by multiplex immunoassay and carcinoembryonal antigen (CEA), thymidinkinase (TK), insulin like growth factor I (IGFI), carbohydrate antigen (CA) 242 and tissue specific polypeptide antigen (TPS) using routin immunoassays.

Results. The results are presented as individual case reports and imply that: HGF levels increase during 24 hours and the first day after the operation and then drop gradually, IL 6 levels increase in the first 24 hours and then drop slowly, TPS levels increase rapidly from the beginning of an operation and drop rapidly during the first 24 hours after an operation, IL8 levels are elevated after an operation but not with the characteristic peak visible for e.g. HGF. TK is elevated one week after the operation but not earlier, probably as a marker of rash DNA synthesis during tissue reparation. CA 242, CEA and IGFI do not show any striking changes.

Conclusions. Our study shows the necessity of proper timing for postoperative monitoring of tumour markers biological activity. However, for the standardization of monitoring it is necessary to perform a study on a larger group of patients. This study was supported by the research project VZ MSM 0021620819.

PP 18.02

RADIOFREQENCY ASSITED LIVER RESECTION FOR COLORECTAL CANCER METASTASES PREVENTS SURGICAL MARGIN RECURRENCE

Bulajic, Predrag; Milicevic, Miroslav; Basaric, Dragan; Galun, Danijel

First surgical clinic, Clinical center of Serbia, Belgrade, Serbia and Montenegro

Introduction. Liver resection for colorectal liver metastases is the only potentially curable treatment available today. Numerous independent predictors of survival after curative surgery have been reported. The one factor most consistently related to prognosis after liver resection is surgical margine status and it is the only predictor that can be influenced by surgeons. There is no definitive evidence regarding the width of the surgical margin during hepatectomy, needed to avoid reccurence.

Objective. To evaluate the influence of radiofrequent assited liver resection technique on surgical margine recurrence.

Methods. From December 2001 to December 2006 101 patient were operated for liver only colorectal cancer metastases and 123 liver resections were performed using radiofrequency assisted technique. The technique consist of diseccation of healthy liver parenchyma using radiofrequency energy and consequent transection by scalpel through diseccated area. Multiple desiccation and cutting sequences are performed to gradually achieve transection plane through the liver parenchyma. Follow up included regular CT and tumor markers investigations and histological examination of the superficial scars on the liver when re-resection was performed.

Results. In the majority of patients a non anatomical liver resection was performed. The width of surgical margin was 0 mm in 47 patients. At a median follow-up of 23 months, 76 patients had developed a recurrence within the liver. 17 patient underwent liver re-resections. Histology of the removed surfical scar on the liver during reresection did not reveal local (surgical margine) recurrence in any of the patients (10 patints with 0 mm and 7 patients with 1 mm or more wide margin). There were no CT detectable surgical margin-related recurrences in the patients who were not reoperated.

Conclusion. Ablations of the healthy liver parenchyma in close proximity of the liver metastases can prevent surgical margin recurrence.

PP 18.03

RESECTION OF HEPATIC AND PULMONARY COLORECTAL METASTASES: WHICH IS FIRST?

Damrah, Osama¹; Raychaudhuri, Prasenjit¹; Pai, Madhava¹; Shah, Amit¹; Anderson, Jon²; Jiao, Long¹; Canelo, Ruben¹; Habib, Nagy¹

¹Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, London, United Kingdom; ²Hammersmith Hospital, Imperial College, Cardiothoracic Surgery, London, United Kingdom

Introduction. Among patients undergoing curative resection for colorectal carcinoma, lung and liver metastases develops in 40% of cases. Treatment in the form of surgical resection or radiofrequency ablation (RFA) is thought to benefit a selected group of patients. The outcome of patients who had surgical intervention first for the lung was compared to those who had surgical intervention for the liver in the first instance.

Methods. Database on 218 consecutive patients who underwent hepatic resection for colorectal liver metastases between January 2002 and December 2006 at our centre were reviewed. Of these, 51 patients had synchronous hepatic and pulmonary metastases. Patient demographics, operative interventions, and overall survival were analyzed.

Results. 11 patients with a mean age of 58 years had resection/RFA of both pulmonary and hepatic metastases. The median number of lung lesions was 2 (range 1–5) whereas that of liver lesions was 3(range1–4). Lung lesions were unilateral in 73% while liver lesions were unilobar in 45% of patients. 5 patients had lung resection before liver resection, while 6 patients had lung resection after liver resection. Overall there were 14 resections and 4 RFA for liver lesions and 8 resections and 4 RFA for lung lesions. Median survival of patients who underwent liver intervention first was 46 months while patients undergoing lung intervention first had median survival of 25 months. Overall median survival was 38 months.

Conclusion. Surgical resection and/or RFA of both hepatic and pulmonary colorectal metastases provides survival advantage in selected patients.

PP 18.04

LIVER SURGERY FOR ELDERLY: IS IT FEASIBLE?

Stoot, Jan; Van Dam, Ronald; van der Poll, Marcel; Olde Damink, Steven; Bemelmans, Marc; Dejong, Kees

University Hospital maastricht, Department of Surgery, Maastricht, Netherlands

Background. Hepatic resections for primary and metastatic tumours are performed with increasing frequency and the limits extending. However, the safety and feasibility of liver surgery in elderly patients is still under debate. AIM The aim of this study was to evaluate the feasibility and outcome of liver resections in the elderly (70 years and older).

Methods. Between January 1, 1997 and January 1, 2007 a consecutive series of 194 patients underwent 214 liver resections. The group of patients under 70 years served as control group (paediatric patients were excluded). Primary outcome was mortality. Secondary outcomes were complications, hospital length of stay and readmissions.

Results Forty six elderly patients with a median age of 75 years (range 70–88) underwent partial liver resection. Both groups matched for gender and major/minor resections. Mortality rate was higher in the elderly group compared to the control group [2/46 (4 per cent) versus 1/166 (0.6 per cent)] but within the range reported in literature. Also, complications rates were higher in the elderly [19/46 (41 per cent) versus 50/166 (30 per cent)]. The median length of hospital stay was 9 days (range 4–82) in the elderly versus 8 days (range 3–81) in the control group. There were 4 re-admissions (9 per cent) in the elderly group compared to 27 (16 per cent) in the control group. None of these differences between the groups were statistically significant.

Conclusion. Hepatic resection can be performed in elderly patients of 70 years and older with an acceptable morbidity and mortality.

PP 18.05

IS THE ‘50–50 CRITERIA’ USEFUL FOR THE PREDICTION OF HEPATIC FAILURE AND MORTALITY FOLLOWING RESECTION OF COLORECTAL LIVER METASTASES

Morris-Stiff, Gareth; Gomez, Dhanwant; Bonney, Glenn K; Toogood, Giles J; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospitals NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. The ‘50–50 criteria’ on day 5 has recently been advocated as means of predicting the development of liver failure and death following hepatectomy. A wide spectrum of pathologies were included in the analysis but with only 21% of resections being performed for colorectal liver metastases (CRLM), the commonest indication for hepatic resection in Western populations.

Aims. To validate the role of ‘50–50 criteria’ in a contemporaneous cohort of patients undergoing liver resection for CRLM, including subgroup analysis of patients with hepatic parenchymal damage.

Patients and Methods. All patients undergoing resection of colorectal liver metastases from 2000–2005 were identified from a prospectively maintained database. Data collected included: peri-operative factors (extent and complexity of resection, blood/plasma transfusion); histopathological factors (degree of steatosis/fibrosis); post-operative (morbidity rate, ICU stay, mortality).

Results. During the period of the study 386 patients (246 Male and 140 females) with a mean age of 65.9 years, 268 of which were aged > 60 years, underwent resection. Only 28/386 (7.3%) of patients fulfilled the criteria. The ‘50–50 criteria’ was not related to any of the peri- or post-operative factors and did not predict liver failure or death in patients undergoing resection of CRLM. Furthermore, subgroup analysis did not identify a predictive role for the criteria even when there was histological evidence of steatosis or fibrosis in the background parenchyma.

Conclusions. The results show that the ‘50–50 criteria’ are not there able to accurately predict outcome in patients undergoing resection of CRLM. Despite significant improvements in perioperative care, hepatic failure and mortality remain potential risks in particular when extended resections are performed and thus the search for an accurate predictive biomarker must continue.

PP 18.06

THROMBOTIC COMPLICATIONS FOLLOWING LIVER RESECTION FOR COLORECTAL METASTASES ARE PREVENTABLE

White, Alan; Morris-Stiff, Gareth; Gomez, Dhanwant; Toogood, Giles; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. Surgery for colorectal liver metastases may be expected to be associated with a significant rate of thrombotic complications due to the performance of long-duration procedures often with dissection close to the vena cava in patients aged 60 years or over. As a result all patients received low molecular weigh heparin, thromboembolic deterrent stockings and intermittent calf compression perioperatively.

Aims. The aim of this study was to determine the prevalence of clinically significant thrombotic complications including deep venous thrombosis (DVT) and pulmonary embolus (PE) in a contemporary series of patients undergoing resection of colorectal liver metastases.

Methods. All patients undergoing resection of colorectal liver metastases from 2000–2005 were identified from a prospectively maintained database with particular reference to thrombotic complications. In addition, the radiology department database was reviewed to confirm that clinically suspicious thromboses had been confirmed radiologically by ultrasound in the case of DVT or CT for PEs.

Results. During the period of the study 386 patients (246 Male and 140 females) with a mean age of 65.9 years, 268 of which were aged > 60 years, underwent resection. More than 4 segments were excised in 245 of the patients. One or more complications were seen in 39.4% of patients. Thrombotic complications were seen in 8 (2%) patients: DVT alone (n = 3) and PE (n = 5). Six of 8 thrombotic complications occurred in patients undergoing resection of 4 or more segments, 4 of which were trisectionectomies. Patients were anti-coagulated and there were no mortalities.

Conclusions. The symptomatic thrombotic complication rate was lower in this cohort than may be expected in patients undergoing non-hepatic abdominal surgery. It is uncertain as to whether this is related to s in this cohort was low. It is uncertain whether this is due entirely to effective prophylaxis or a combination of treatment and a natural anti-coagulant state following hepatic resection.

PP 18.07

LONG TERM DISEASE-FREE SURVIVAL AND PROGNOSTIC FACTORS FOLLOWING HEPATIC RESECTION FOR COLORECTAL LIVER METASTASES

Gomez, Dhanwant; Morris-Stiff, Gareth; Toogood, Giles J; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. To date, there is limited data available on prognostic factors that influence long term disease-free survival following hepatic resection for colorectal liver metastasis (CRLM). The aim of the current study was to analyse prognostic factors of patients developing recurrent disease within 5-years following hepatic resection compared to patients that have been disease-free for 5-years or more.

Methods. Patients undergoing resection for CRLM from January 1993 to March 2007 were identified from the hepatobiliary database. Data analyzed included demographics, laboratory results, operative findings and histopathological data.

Results. 705 primary hepatic resections were performed of which 434 patients developed recurrent disease during the follow-up period and 67 patients were disease-free more than 5-years. 204 patients were excluded (25 post-op deaths and 179 patients who are currently under follow-up and disease-free for < 5 years). There was a significant association between inflammatory response to tumour (IRT – raised neutrophil to lymphocyte ratio and/or C-reactive protein), blood transfusion, >2 tumours and resection margin involvement with developing recurrence during the 5-year follow-up period. On multi-variate analysis, three independent predictors for recurrent disease within the 5-year follow-up were identified: pre-operative raised IRT; blood transfusion requirement; and status of resection margin. Overall survival was significantly lower in patients with raised IRT, blood transfusion and involved resection margin.

Conclusion. Pre-operative low IRT, absence of requirement for blood transfusion and a clear resection margin are associated with long term disease free survival.

PP 18.08

PERI-OPERATIVE OUTCOME FOLLOWING CURATIVE RESECTION FOR COLORECTAL LIVER METASTASES IN PATIENTS WITH SINUSOIDAL OBSTRUCTION SYNDROME

Gomez, Dhanwant¹; Morris-Stiff, Gareth¹; Wyatt, Judy²; Ward, Janice³; Robinson, Paul³; Guthrie, Ashley³; Sheridan, Maria³; Toogood, Giles J¹; Lodge, J. Peter A.¹; Prasad, Rajendra¹

¹Leeds Teaching Hospitals NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom; ²Leeds Teaching Hospitals NHS Trust, Department of Histopathology, Leeds, United Kingdom; ³Leeds Teaching Hospitals NHS Trust, Department of Radiology, Leeds, United Kingdom

Aims. To determine the peri-operative outcome following hepatic resection for colorectal liver metastasis (CRLM) in patients with sinusoidal obstruction syndrome (SOS).

Methods. Patients undergoing curative resection for CRLM with SOS on histology from January 2005 to March 2007 were identified from the Pathology database. Data analysed included demographics, extent of hepatic resection and histopathology data.

Results. 20 patients were identified with a median age of 62 (38 – 79) years and equal gender distribution. All patients underwent neo-adjuvant oxaloplatin-based chemotherapy. 7 patients had at least one co-morbid condition. 13 patients underwent major hepatic resections (hemi-hepatectomy or trisectionectomy). Only one patient required blood transfusion post-surgery (2 units). Overall morbidity was 30% and no mortality was recorded in these patients. The median hospital stay was 8 (7 – 22) days. In this group of patients, age, gender, severity of steatosis and the presence of fibrosis were not associated with higher morbidity. Although not statistically significant, there was a trend for higher morbidity in patients with SOS that had major hepatic resections (46%; p = 0.051).

Conclusion. Patients with SOS in this study had a morbidity rate of 30%. Extent of hepatic resection could potentially affect the post-operative outcome in these patients. Further analysis in a larger sample of patients is required to determine the effect of SOS on morbidity and mortality following hepatic resection.

PP 18.09

STEATOSIS AND STEATOHEPATITIS IN PATIENTS UNDERGOING LIVER RESECTIONS-DOES IT MATTER AND IS CHEMOTHERAPY TO BLAME?

Al Momani, Hazeem¹; Gilmour, JP¹; Johnson, SC²; Boyles, TH³; Williams, GT²; Kumar, N¹

¹University Hospital of Wales, Cardiff Liver Unit, Cardiff, United Kingdom; ²University Hospital of Wales, Department of Pathology, Cardiff, United Kingdom; ³University Hospital of Wales, Department of Medicine, Cardiff, United Kingdom

OBJECTIVES:The aim of our study was to find (a) the post-surgical outcome of patients with histologically verified steatohepatitis and (b) any association between preoperative chemotherapy and steatohepatitis.

Methods. Histological specimens from patients who had elective liver resection under the care of a single surgeon over three years were reviewed by a pathologist, who was blinded to the clinical details. Steatohepatitis(SH) was defined as a Brunt score of ¡Ý4. Steatosis was quantified using a computer assisted method which was developed and validated locally. The results were correlated with the clinical data.

Results. There were 72 patients. SH was present in 19 patients. There was no significant difference in age, sex, weight, presence of diabetes, proportion of major resections, and alcohol consumption in patients with and without SH. Only body weight and histological steatosis were significantly associated with SH (p = 0.001). There was no difference in the mortality, ITU stay or hospital stay between the two groups. Chemotherapy (FOLFOX) was given to 32 patients and none to 40 patients. There was no significant difference in the degree of steatosis or SH between the two groups. Liver resection was performed at a mean of 151 days (48–783) from completion of chemotherapy. There was no difference in the frequency or the degree of steatohepatitis between patients undergoing liver resection less than, or more than, 100 days from chemotherapy.

Conclusion. We conclude that there is no apparent increase in morbidity or mortality in patients undergoing liver resections in the presence of steatohepatitis. Oxaliplatin based chemotherapy is not associated with steatohepatitis.

PP 18.10

OUTCOMES OF HEPATIC RESECTION FOR COLORECTAL METASTASIS

Cho, Eung-ho¹; Kang, Kyang-Taeae¹; Mun, Sun-Mi¹; Choi, Dong-Wook²; Mun, Nan-Mo¹; Hwang, Dae-Yong¹; Kim, Sang Bum¹

¹KIRAMS, Surgery, seoul, Korea, Republic of; ²Samsung medical center, Surgery, Seoul, Korea, Republic of

Purpose. Colorectal cancer remains one of the most common cancers, but liver metastases will develop in more than one-third of patients. Among various treatment modalities, hepatic resection is generally accepted as the only potential for cure in patients with colorectal metastases confined to the liver. The aim of this study was to evaluate the short- and long-term results of patients who underwent hepatectomies for colorectal liver metastases.

Patients and methods. From September 1993 to November 2006, patients underwent the consecutive liver resection for colorectal metastases. Clinicopathologic, operative, and perioperative data were reviewed to evaluate perioperative outcomes. Median follow up period was 23.5 months (0.7–165 month).

Results. The population of this study consisted of 100 patients undergoing consecutive hepatic resection. Median age was 61 year-old (27–84) and there were 66 male and 34 female patients. Preoperative PET was performed in 54 cases and positive rate was 96.3%. Simultaneous hepatic resection was performed in 70 cases including 15 two-stage operations. The number of synchronous and metachronous metastasis were 76 and 24 cases respectively. Major resection was performed in 47 cases. Intraoperative transfusion was done in 24 cases and median hospital stay was 14 day (2–100). The mean size and number of tumor were 3.13¡¾1.99 centimeter and 1.64¡¾1.08. In 4 cases resection margin were involved microscopically. In-hospital mortality rate was 1% (1cases) and the cause of death was myocardial infarction. Overall morbidity rate was 32.4% but major complication rates were 6.1%. During the follow up recurrence occurred in 62 cases and most common site of recurrence were liver and lung. 5 year survival rate and disease free survival rate was 33.1% and 25.7% respectively.

Conclusion. Hepatic resection was safe and effective treatment option for patients with colorectal liver metastases.

PP 19.01

INITIAL POOR FUNCTION DOES NOT AFFECT PATIENT AND GRAFT SURVIVAL FOLLOWING LIVER TRANSPLANTATION

Bonney, Glenn K¹; Kalyanaraman, Aarti¹; Attia, Magdy²; Pollard, Stephen G²; Toogood, Giles J¹; Lodge, J Peter A¹; Prasad, K Rajendra¹

¹St James' University Hospital, Department of Hepatobiliary and Tranpslantation Su, Leeds, United Kingdom; ²St James' University Hospital, Department of Hepatobiliary and Tranpslantation Su, Leeds

Background. Initial Poor Function (IPF) has been thought to predispose to primary non-function following liver transplantation. IPF has been described using a number of biochemical and haematological criteria. The aim of this study was to analyse the effect of 3 of these definitions on patient and graft survival following liver transplantation

Methods. A prospectively collected database of 661 liver transplants performed between 1998 and 2005 was used for the analysis. Biochemical and graft and patient survival data was used for the analysis. The effect of IPF, using three different published criteria was analysed. Criteria 1: Alanine Transaminase >1500 within the first 3 days of transplantation. Criteria 2: Alanine Transaminase >2500 in day 1 of transplantation. Criteria 3: Alanine Transaminase >2500 within 3 days of transplantation.

Results The IPF rate using criteria 1,2 and 3 was 14.2%, 2.6% and 3.7% respectively. IPF using and of the three definitions resulted in similar patient and graft survival when compared to non-IPF recipients. Futhermore, the occurrence of IPF, using any of the three definitions was not associated with Primary Non-Function.

Conclusion. In this study, IPF as defined by transaminitis with three different definitions here did not result in poorer patient and graft survival. Furthermore, with these definitions, it was not associated with the occurrence of Primary Non-Function. There remains a need for more robust, biochemical, clinical and pathological definitions of IPF particularly in association with the later occurrence of Primary Non-Function

PP 19.02

MANAGEMENT OF HEPATIC ARTERY PSEUDOANEURYSM AFTER LIVER TRANSPLANTATION: ONE CENTER'S EXPERIENCE

McHugh, Patrick P; Johnston, Thomas D; Jeon, Hoonbae; Gedaly, Roberto; Ranjan, Dinesh

Transplant Center, University of Kentucky, Surgery, Lexington, Kentucky, United States

Background. Hepatic artery (HA) pseudoaneurysm is a rare complication that can occur after orthotopic liver transplantation (OLT), particularly those with postoperative bile leak or intraabdominal infection. While HA pseudoaneurysms typically present with hemorrhage, they can also present nonspecifically, making prompt diagnosis challenging. Various treatment options exist to manage this complication.

Objec tive. To present our experience diagnosing and managing HA pseudoaneurysm after OLT.

Methods. Between July 1995 and July 2007 we performed 386 OLT procedures in 378 patients. Of these, three patients (0.79%) developed HA pseudoaneurysm.

Results. In all three patients the HA pseudoaneurysm was symptomatic: two presented with bleeding (hemobilia and gastrointestinal), while the third complained of vague abdominal pain. Both patients with bleeding had antecedent bile leak and local infection, but the third had no apparent cause. Diagnosis was made in all patients by screening Doppler ultrasound followed by CT scan with angiography. Two patients underwent successful pseudoaneurysm resection with cadaveric vessel bypass. In the other patient, surgical repair was unsuccessful due to hepatic hilar inflammation and friable tissues. However, the HA was successfully embolized angiographically. Followup studies in this patient have shown extensive arterial collateralization in the liver hilum. All three patients have subsequently done well, and none has evidence of biliary or hepatic ischemia.

Conclusions. Although rare, HA pseudoaneurysms are serious vascular complications that can follow OLT. A high index of suspicion, especially in patients with gastrointestinal hemorrhage or a history of hepatic hilar infection, is necessary for early diagnosis and successful therapy. Angiographic embolization may be an alternative if surgery is unsuccessful, as the development of arterial collaterals may be sufficient to prevent ischemic complications.

PP 19.03

FEASIBILITY OF VENA CAVA PRESERVATION DURING LIVER TRANSPLANTATION FOR POLYCYSTIC LIVER DISEASE

Sommacale, Danièle¹; Andraus, Wellington¹; Dondéro, Fédérica¹; Sauvanet, Alain¹; Durand, François²; Francoz, Claire²; Goasguen, Nicolas¹; Farges, Olivier¹; Belghiti, Jacques¹

¹Hospital Beaujon, HPB Surgery, Clichy, France; ²Hospital Beaujon, Hepatology, Clichy, France

Background. Liver transplantation (LT) for polycystic liver disease (PLD) is indicated in case of hepatomegaly. Total hepatectomy with caval-preservation during LT for PLD is technically difficult because the liver often surrounds the inferior vena cava (IVC). The increasing use of partial grafts inspired our group to preserve the IVC.

Methods. From 1992 to 2007, 26 patients underwent LT for PLD. There were 4 men and 22 women (mean age 55 yrs). Nineteen patients underwent LT associated with renal transplant. Previous treatments for PLD were performed in 8 (4 cyst fenestrations, 4 hepatic resection). To facilitate the IVC approach during LT procedure included cyst fenestrations, portocaval anastomosis in all cases and in two cases a partial hepatectomy were performed. Full grafts were used in 23 and partial grafts in 3 (2 split grafts and 1 living donor).

Results. IVC preservation was possible in 24 (92%) patients. Failure to preserve the IVC occurred in 2, one case of difficult dissection due to a previous liver resection and one case of intraoperative death from massive bleeding due to IVC injury. Total hepatectomy time ranged from 130 to 540 min with a mean blood loss of 3506 mL and blood transfusion rate of 9.2U. Total IVC clamping during hepatectomy was required in 7 (26%), including 5 cases of poor hemodynamic tolerance. Venovenous bypass was used in 4 (IVC preservation was always possible). Total hepatectomy duration and bloss were significantly higher in patients who had undergone previous liver resection respectively: 327±76.2 vs 243±55.2 min (p = 0.036) and 8000±2743 vs 1050±1891 cc (p = 0.013). Postoperative mortality was of 11.5% (3 patients), from septic complications (pulmonary, colonic perforation and multiorgan failure).

Conclusion. IVC preservation was feasible in 93% of LT for PLD and could be facilitated by venovenous bypass, extensive cyst fenestrations and partial liver resection. IVC preservation should be expected to be more difficult in case of previous hepatectomy.

PP 19.04

PERI-OPERATIVE OUTCOME FOLLOWING PAEDIATRIC LIVER TRANSPLANTATION FROM A MODERN SERIES

Gomez, Dhanwant¹; Morris-Stiff, Gareth¹; McClain, Paddy²; Stringer, Mark D.²; Prasad, Rajendra¹

¹Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom; ²Leeds Teaching Hospital NHS Trust, Paediatric Transplantation Unit, Leeds, United Kingdom

Background. As a result of a number of developments including: surgical techniques; immunosuppression therapy; patient selection criteria; and organ preservation, peri-operative outcomes following orthotopic paediatric liver transplantation (OPLTx) have improved significantly over recent years. The aim of this study was to report peri-operative outcomes following primary OPLTx and analyse donor, recipient and operative factors that affect post-operative outcomes in a relative new paediatric centre.

Methods. Patients undergoing primary OPLTx from January 2000 to July 2007 were identified from the transplantation database. Data analyzed included: demographic factors; donor and recipient characteristics; and operative data.

Results. 102 OPLTx were performed, of which 91 patients were primary OPLTx with a median age of 4.8 (0.05 – 17.2) years. Biliary atresia (n = 27, 30%) was the most common indication. Patients underwent 34 whole size grafts, 14 reduced size and 43 split-liver transplants. Overall mortality was 3% (n = 3). Morbidity was reported in 50 patients (55%). Four patients (4%) developed hepatic artery (HA) thrombosis and six patients (7%) had HA stenosis. Both biliary complications and primary non-function was reported in 5 patients (5%). Infection-related complications were noted in 16 patients (18%). Recipient variables including demographics and Paediatric End-Stage Liver Disease (PELD) did not influence morbidity. With respect to operative factors, blood transfusion was significantly associated with morbidity following OPLTx. Donor gender also significantly influenced post-operative morbidity. Multi-variate analysis did not reveal an independent predictor of morbidity.

Conclusion. Despite technically challenging, excellent peri-operative outcomes could be achieved in a new program. Minimizing blood loss may influence overall morbidity.

PP 19.05

IMPACT OF GRAFT TYPE ON OUTCOME FOLLOWING LIVER TRANSPLANTATION IN PAEDIATRIC PATIENTS

Gomez, Dhanwant¹; Morris-Stiff, Gareth¹; McClain, Paddy²; Stringer, Mark D.²; Prasad, Rajendra¹

¹Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom; ²Leeds Teaching Hospital NHS Trust, Paediatric Transplantation Unit, Leeds, United Kingdom

Background. The aim of the study was to analyse prognostic factors that influence graft and overall survival following orthotopic paediatric liver transplantation (OPLTx) based on graft type.

Methods. Patients undergoing OPLTx from January 2000 to July 2007 were identified from the Transplantation database. Data analyzed included demographics, donor, recipient and operative data. Patients were divided into three groups; whole, reduced-size and split-liver transplantation.

Results. 102 OPLTx were performed in 92 patients during the study period. Patients underwent 36 (35%) whole size, 18 (18%) reduced size and 48 (47%) split-liver transplantation. Patients <12 months were more likely to have a split-liver transplant compared to patients >12 months (p < 0.001). The split-liver transplant group were more likely to have a longer cold ischaemia time (p = 0.004) and shorter warm ischaemia time (p = 0.033) compared to the other groups. Graft survival at 1, 3 and 5-year was 88%, 88% and 84% in the whole-liver group, 83%, 83% and 83% in the reduced-size group and 85%, 78% and 73% in the split-liver transplantation group (p = 0.624). The 1, 3 and 5-year overall survival in the whole, reduced-size and split-liver groups were 88%, 88% and 84%, 89%, 89% and 74% and 92%, 81% and 71%, respectively (p = 0.663). Warm ischaemia time was the only variable that significantly affected graft and overall survival on univariate analysis.

Conclusion. The graft and overall survival is not affected by type of graft used. Warm ischaemia time does affect graft and overall survival.

PP 19.06

LIVER TRANSPLANTATION FOR POLYCYSTIC LIVER DISEASE

Bhatt, Anand N; Oniscu, Gabriel C; Gunson, Bridget; Coldham, Christopher; Mayer, David; Mirza, Darius F; Buckels, John AC; Bramhall, Simon R

Queen Elizabeth Hospital, The Liver and Hepatobiliary Surgery Unit, Birmingham, United Kingdom

Background. Orthotopic liver transplantation (OLT) offers a curative option for diffuse polycystic liver disease (PLD) unlike aspiration, fenestration or resection.

Aim. To examine the role of OLT in patients with PLD.

Methods. Demographic, transplant and surgical data were retrieved from the unit's prospective database as well as patients’ medical records.

Results. 22 patients (1 male/ 21 f emale) who had a liver transplant for PLD were identified among the 3000 transplants carried out between 1982 and 2007. Median age was 50 years (range 34–59). The indications for OLT were massive hepatomegaly resulting in pain and severe physical handicap (n = 21), malnutrition (n = 6) and chronically infected cysts following marsupialisation (n = 1). 6 patients (27%) had other interventions prior to OLT (3 aspirations, 2 de-roofing, 1 marsupialisation). The primary cyst pattern was multiple bi-lobar disease. Eight patients had kidney transplants (5 simultaneous, 2 sequential and 1 prior to OLT). The median weight of the explanted livers was 3555 grams (largest being 16kg). The hepatectomy time was 137 minutes (range 51–225 min) and this was comparable with OLT for other indications. The mean hospital stay was 14 days. The transplant complications are shown in the table below. 5-year patient and graft survival rates were 83% and 95% respectively (follow-up 3 months-17 years). Three patients died during the follow-up period (1 pancreatic cancer, 1 lung cancer and 1 heart attack, at 3, 6 & 11 years post OLT, respectively).

Conclusion. In patients with diffuse PLD with significant impairment of quality of life, OLT is the optimal treatment option with low complication rates and excellent survival.

Complications
Biliary leak	3
Biliary stricture	3
Hepatic artery thrombosis	1
Renal Failure	7 (5 requiring haemodialysis)
Pneumonia	4
Tracheotomy	2
Pleural effusions	4
Cardiac complications	3
Post transplant diabetes	4

PP 19.07

POSITIVE EMISSION TOMOGRAPHY WITH FLUORINE-18-FLUORODEOXYGLUCOSE IS USEFUL FOR PREDICTING THE PROGNOSIS OF LT PATIENTS WITH HEPATOCELLULAR CARCINOMA

Ryu, Je-Ho; Lee, sung-kyu; Kim, kwan-Woo; Ko, keung-Hoon; Choi, Nam-Kyu

Asan Medical Center/University of Ulsan College of Medicine, department of surgery, seoul, Korea, Republic of

(Backgrounds and aims) Positive Emission Tomography with Fluorine-18-fluorodeoxyglucose(FDG-PET) has established itself as a useful diagnostic imaging for metastatic liver tumors. However, in case of hepatocellular carcinoma(HCC), several investigators have reported controversial results and have an inadequate sensitivity of PET(50–55%). Nevertheless, a high positive rate of FDG accumulation has been reported in patients with high-grade HCC. We retrospectively reviewed 110 HCC cases that received liver transplantation(LT) at our center between Jan 2003 and December 2005 and underwent whole-body PET imaging. (methods) FDG uptake was accessed in the liver, and its prognostic factors was investigated. Of 110 patients enrolled, 34 patients had positive PET scans for liver tumor. (Results) When we analyzed the association between tumor factors and PET+(greater PET lesion uptake)in the liver, vascular invasion, number of tumors(>3nodules), and tumor size(>5cm) were found to be significantly associated with PET+(P < 0.001, P = 0.004, and P < 0.001, retrospectively). However, the preoperative AFP level and histological grade was not significantly associated with PET+(P = 0.418 and P = 0.064). The 2-year recurrence-free survival rate of PET- patients was significantly higher than that of PET + patients(89.2% vs. 61.7%)(P = 0.0005). Of 18 PET+ patients who did not meet the Milan criteria, 12 patients(66.7%) had recurrence, but 14 PET- patients who did not meet the Milan criteria, 5 patients(35%) had recurrence. (Conclusions) PET imging is useful for predicting the post-LT risk of tumor recurrence, because vascular invasion and histological grade cannot be determined preoperatively. The tumor recurrence could be highly anticipated for PET + HCC patients who do not meet Milan criteria. PET+ HCC patients could be considered seriously for LT.

PP 19.08

TECHNICAL INNOVATIONS IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION

Sood, Disha¹; Kakodkar, Rahul¹; Kumaran, Vinay¹; Mohan, Neelam²; Nundy, Samiran¹; Soin, A.S¹

¹Sir Ganga Ram Hospital, Surgical Gastroenterology & Liver transplantation, New Delhi, India; ²Sir Ganga Ram Hospital, Paediatrics, New Delhi, India

Background. Advancements in surgical technique, immunosuppression, and pre and postoperative management of patients have dramatically improved survival after pediatric living donor liver transplantation (LDLT).

Aim. To study the surgical innovations used in pediatric LDLT and their outcome.

Methods. Of the 164 patients who received LDLTs at our centre since 2004, 16 were children. Their intraoperative surgical problems, techniques used and outcome were reviewed. Graft procurement was done with ultrasonic aspirator without vascular clamping. Post transplant immunosuppression was Tacrolimus or Neoral ® based in 13 and 3 cases respectively.

Results. There were 10 males and 6 females, 1 to 15 years of age. The grafts included 4 left lateral segments, 10 left lobes, 1 right lobe and 1 reduced left lateral segment. Intraoperative surgical innovations/deviation from standard procedure were required in 6 patients. 2 needed cavoportal transposition due to complete portomesenteric thrombosis (1) and portal vein stenosis in (1). One left lateral segment that proved too large and had patchy reperfusion due to poor portal vein flow was removed, reflushed with HTK solution, reduced on the bench. One left lobe with 2 hepatic arteries needed microvascular reconstruction of both due to inadequate collaterals between the two. One graft had a short, separate segment 2 hepatic vein draining into cava that was extended using a cryopreserved vein graft, and then joined by a venoplasty to the middle and left hepatic veins to make a single outflow channel. The patient with right lobe graft had primary hyperoxaluria and also required a simultaneous kidney graft from another living donor. The patient and graft survival at a mean follow up of 23 months (2–44) was 100%. All donors are currently well.

Conclusion. To obtain good results in pediatric LDLT, surgical innovations are often required to deal with the challenges posed by portal vein thrombosis, donor vascular anomalies and large for size grafts.

PP 19.09

LIVER TRANSPLANTIONS AT A CENTER IN SOUTH INDIA

Sharma, Supriya¹; Sharma, Supriya²; Jayaram, Murali²; S, Sudhindran²; Dhar, Puneet²; OV, Sudheer²; VG, Prasad²

¹Amrita Institute of Medical Sciences and Reserce Center, Dept. of Gastro-Intestinal Surgery, Amrita Lane, Elamakkara PO, KOCHI, India; ²Amrita Institute of Medical Sciences and Research Center, Dept. of Gastro-Intestinal Surgery, KOCHI, India

Introduction. Liver transplantation (LT) has become established as the standard of care for a large number of end stage liver diseases.

Objective. To analyze the initial experience with LT at a South Indian centre.

Materials and Methods. Retrospective analysis of the medical records of nine LT performed at our centre (one cadaveric and eight living donor) from June 2004 – Aug 2007 was done to evaluate our experience.

Results. The first cadaveric transplantation was performed in 2004 June for hepatitis B related cirrhosis. He died 3 years later due to recurrent Fibrosing Cholestatic Hepatitis B. All 8 Living Donor LT (LDLT) have been performed over 10 months from 2006. Two were paediatric transplantations receiving left lobes from the mother and 7 were adults receiving right lobes with the middle hepatic vein from first degree related donors. Three transplantations were done on an emergency basis for Acute Liver Failure. There were 3 perioperative deaths (33%). The median times for the donor and recipient surgeries were 510 minutes (Range: 420–600minutes) and 780minutes (Range: 720 – 960 minutes) respectively. The median ICU stay and hospital stays for recipients were 10 days (Range: 8 – 14 days) and 24 days (Range: 8 – 31 days) respectively. Our chief complication in the recipient has been biliary leak in 2 patients, both subsequent to hepatic artery thrombosis. The median hospital stay for the donor was 11 days (Range: 7 – 15 days). Apart from mild chest infection in 2 donors, all had uninterrupted recovery. The average charge for the transplant was Rs 10,00000 (3,00,000 to 12,00,000). The entire team for transplant has been in-house, with only two surgeons being trained abroad.

Conclusions. It is possible to perform liver transplantation in experienced hepatobiliary centres without a very precipitous learning curve and with a practical price tag. The referral to our transplantation center occurs at an advanced stage of liver failure, probably accounting for the modest success rate.

PP 19.10

PORTAL VEIN RECONSTRUCTION USING RECIPIENT OWN RIGHT HEPATIC VEIN AS A INTERPOSITION GRAFT IN LIVING DONOR LIVER TRANSPLANTATION

Niitsu, Hiroaki¹; Tashiro, Hirotaka²; Itamoto, Toshiyuki²; Amano, Hironobu²; Ohdan, Hideki²; Asahara, Toshimasa²

¹Hiroshima Unversity, Surgery, Hiroshima, Japan; ²Hiroshima University, Surgery, Hiroshima, Japan

Background. Portal vein reconstruction is a key factor of successful living donor liver transplantation when portal vein stenosis or thrombosis has been observed. In such a case, portal vein is reconstructed using interposition vein graft consisting of recipient internal jugular vein or external iliac vein graft, but recipient requires additional surgery. We have recently reported that the middle hepatic vein tributaries draining segments V (V5) and VIII (V8) of a right lobe graft are reconstructed with the recipient□fs own middle hepatic vein or right hepatic vein which was harvested ex vivo from recipient liver. Here, we report that portal vein was reconstructed using interposition vein graft consisting of recipient right hepatic vein which was harvested ex vivo from recipient liver.Method.: 33 year old female suffered from biliary atresia. Preoperative CT revealed complete obstruction of portal vein trunk and huge splenorenal shunt. She underwent living donor right liver transplantation. After total hepatectomy, right hepatic vein graft with 5 cm length was harvested from recipient liver at back-table. The right hepatic vein graft was anastomosed to the recipient□fs superior mesenteric-splenic vein confluence, and then the graft portal vein was anastomosed to the right hepatic vein graft. RESULT: The postoperative course was uneventful. Postoperative ultrasonogrphy and CT showed good inflow of portal vein.

Conclusion. The use of the recipient□fs own right hepatic vein is a suitable option for reconstructing portal vein in right-liver living donor transplantation. This method does not require an additional surgery for the patient.

PP 20. 01

THE ROLE OF DYNAMIC POSITRON EMISSION TOMOGRAPHY TO DIFFERENTIATE INTRAHEPATIC CHOLANGIOCARICNOMA AND PULMONARY INFLAMMATORY DISORDER

Liao, Chieh-Hung; Yeh, Ta-Sen; Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung University, Department of General Surgery, Taipei, Taiwan

Backgrounds. Intrahepatic cholangiocarcinoma (ICC) is associated with a dismal prognosis because of early intrahepatic and distant metastasis. It is mandatory to exclude the presence of occult distant metastasis before subject to surgical resection. We herein tested the efficacy of positron dynamic positron emission tomography (PET) to differentiate ICC and pulmonary inflammatory disorder.

Materials and Methods. Murine cholangiocarcinoma and pulmonary inflammatory model was established using Sprague-Dawly rats fed thioacetamide for 30 weeks. The experimental animals underwent FDG-PET-CT examination at week 30. Standardized uptake value (SUV) and retention indices (RI) of experimental animals were calculated. Expression of glucose transporter 1 and hexokinase II in liver and lung tissues were determined using immunohistochemistry.

Results. Of 26 rats fed thioacetamide for 30 weeks, 22 developed ICC while the remaining four did not. Of 22 ICC rats, 9 (41%) developed non-bacterial bronchopneumonia. In contrast, none of shamed controls (n = 4) and those fed thioacetamide but without ICC (n = 4) had bronchopneumonia. All nine ICC rats associated with bronchopneumonia displayed strong PET signals at their liver and lung fields, 13 ICC rats without bronchopneumonia displayed strong PET signals at liver field alone, while the remaining four rats fed thioacetamide but without ICC did not displayed PET signal at their liver and lung fields. Furthermore, the mean RI of lung lesions and liver lesions were 0.058¡Ó0.013 and ¡V0.082¡Ó0.019, respectively (p = 0.0008). Expression of glucose transporter 1 in liver and lung lesions of ICC rats were weakly and moderately positive respectively, while the expression of hexokinase II in liver and lung lesions of ICC rats were moderately and strongly positive, respectively.

Conclusions. PET might disclose ICC and pulmonary inflammatory disease with an acceptable sensitivity. Dynamic PET further helped to differentiate these two diseases.

PP 20.02

THALIDOMIDE ATTENUATES TUMOR GROWTH AND PRESERVES FAST-TWITCH SKELETAL MUSCLE FIBERS OF CHOLANGIOCARCINOMA RAT

Ouyang, Chun-Hsiang; Yeh, Ta-Sen; Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung University, Department of General Surgery, Taipei, Taiwan

Background. We present a rat model of cholangiocarcinoma cachexia and demonstrate that thalidomide attenuates tumor growth and improves cachexia.

Methods. A cholangiocarcinoma cachectic model was established using Sprague-Dawley rats fed thioacetamide for 40 weeks. Cholangiocarcinoma cachectic rats were treated using either thalidomide for eight weeks. Tumor growth and weight were recorded for all animals. The expression of CD31, VEGF, eIF4E, and apoptosis of cholangiocarcinoma were also determined. Further, Fas- mediated apoptosis genes of cholangiocarcinoma were determined. The distribution of fast-twitch soleus skeletal-muscle fibers and the expression of TNFa and TGFb1 were analyzed.

Results. The mean weight of saline- and thalidomide-treated rats was 24% and 19%, respectively, less than that of sham group. The mean tumor volume of thalidomide-treated rats was 1.9¡Ó0.4 cm2 compared to 4.6¡Ó1.3 cm2 for saline-treated rats. The expression of CD31, eIF4E and VEGF was lower for thalidomide-treated rats than for saline-treated rats. The expression of Fas, caspase-3 and Bax mRNA of thalidomide-treated rats was greater than for saline-treated rats. The mean number of fast-twitch skeletal-muscle fibers of sham group, saline- and thalidomide-treated rats was respectively 43¡Ó6, 14¡Ó3, and 41¡Ó8. The expression of TNFa and TGFb1 from soleus muscles for thalidomide-treated rats was lower than that for saline-treated rats.

Conclusion. Using our rat cholangiocarcinoma cachectic rat model, we demonstrated that thalidomide inhibited tumor growth and was associated with a reduced eIF4E and VEGF expression, and that thalidomide preserved fast-twitch skeletal-muscle fibers, which was associated with reduced TNFa and TGFb1 expression.

PP 20.03

PATTERNS OF RECURRENCE OF INTRAHEPATIC AND HILAR CHOLANGIOCARCINOMA

Morris-Stiff, Gareth; Gomez, Dhanwant; Murphy, Laura; Toogood, Giles J; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. Surgical resection is the treatment of choice for intrahepatic (IHC) and hilar cholangiocarcinomas (HC). Recurrence rates following resection are high but the interval and distribution of recurrences in Western populations have not yet been defined.

Aims. To determine the patterns of recurrence following curative resection of IHC and HC.

Methods. Patients undergoing resection of either IHC or HC were identified from the database. Only patients in whom an R0 resection was obtained, and who survived the perioperative period were included. Patterns of recurrence were based upon findings of protocol-based cross-sectional imaging using CT, with radiology results being reviewed to determine distribution of recurrences. The database was interrogated to determine the management and outcome of recurrent disease.

Results. During the study period, 52 patients (27 IHC and 25 HC) achieved an R0 resection of which 46 were enrolled in the screening program (26 IHC and 20 HC). In the IHC group, recurrence occurred in 21 of 26 (88.5%) at a median time of 10.5 months. Recurrence was most common in the remnant liver (n = 14), followed by peritoneum (n = 10), lung (n = 6), lymph nodes (n = 2), bone (n = 1). 20 of the recurrences occurred within 24 months of resection. None of the patients were suitable for resection. 20 of 21 patients with recurrence have died with a median interval between diagnosis and death was 3.5 months. In the HC group, recurrence occurred later at a median of 15 months and was seen in 11 of 20 (55%) of resections. The peritoneum (n = 6) was the commonest site for recurrence, followed by liver (n = 5), lung (n = 2) and lymph nodes (n = 1). 78% (8 of 11) recurrences occurred within 24 months. 9 of 11 patients with recurrence have died with a median interval of 3.5 months following diagnosis.

Conclusions. Recurrence is common following resection of HC and IHC with similar patterns of dissemination. Although the interval between resection and recurrence is longer for HC, the time from resection to death is idental.

PP 20.04

PATTERNS OF FIRST FAILURE AFTER MANAGEMENT OF HILAR CHOLANGIOCARCINOMA

Lee, Keon-Young; Bang, Tae-Jun; Ahn, Seung-Ik; Hong, Kee-Chun

Inha University College of Medicine, Surgery, Incheon, Korea, Republic of

Background. The pattern of recurrence after management of hilar cholangiocarcinoma is still unclear.

Aims. To evaluate the patterns of disease progression after either resection or palliative management of hilar cholangiocarcinoma and to clarify the polarity of the resection margin.

Methods. The medical records of 78 hilar cholangiocarcinoma patients who admitted at the Inha University Hospital from June, 1996 to May, 2006 were retrospectively reviewed. Pattern of recurrence was compared between the margin positive, margin negative and the palliative management groups. Factors influencing recurrence and survival were analyzed using Cox proportional hazard model.

Results. 56 patients (71.8%) were identified to have recurred after initial treatment and the median progression free survival (PFS) was 10.1 months. The 3-yr estimates of overall relapse, the median PFS were 90.7%, 17 months in resection group (n = 32) and 100%, 7 months in palliative group (n = 46), respectively (p = 0.045). There was no significant difference of the 3-yr estimates of overall disease progression, the median PFS according to the margin positivity or resection.

Methods. In the analysis of disease progression pattern, there was no significant difference between the groups. The survival analysis showed that resection with curative intent increased survival compared to the palliative management group (p = 0.001). Adjuvant chemotherapy or radiotherapy did not affect the recurrence or the survival. Poor differentiation was the only significant prognostic factor for survival.

Conclusion. Considering the absence of difference in the pattern of disease progression, aggressive surgical resection should be attempted to prevent recurrence and to increase survival even in cases with suspicious positive resection margin.

PP 20.05

PROGNOSTIC ANALYSIS OF SURGICAL TREATMENT OF PERIPHERAL CHOLANGIOCARCIOMA:THREE DECADES OF EXPERIENCE AT CHANG GUNG MEMORIAL HOSPITAL

Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung University, Department of General Surgery, Taipei, Taiwan

Aim . to analyze the prognostic factors influencing the overall survival of peripheral cholangiocarcinoma (PCC) patients undergoing surgical treatment during 30 years at a single institution.

Methods. This study retrospectively reviewed prospectively collection data about 433 patients with histologically proven PCC who underwent surgical treatment between 1977 and 2006.

Results. Four hundred and thirty-three PCC patients (188 men and 245 women) underwent surgical treatments from 1977 to 2006. Among them, 228 PCC patients underwent hepatectomy and 137 had curative resection. The follow-up duration ranged from 0.10 to 169.0 mo(mean/median = 15.2/7.2mo). Overall cumulative survival rates at 1,3 and 5 years were 38.1%,14.2%,7.8%, respectively. Univariate log-rank analysis identified the following as adverse influences on overall survival: presence of symptoms, presence of physical findings, absence of mucobilia, elevated CEA and CA19-9 levels, non-papillary tumor type, receiving non-hepatectomy, advanced tumor staging, lack of post-operative chemotherapy and radiotherapy. Meanwhile, multivariate Cox¡∣s proportional hazard analysis demonstrated that presence of symptoms, non-papillary tumor type, advanced tumor staging, non-hepatectomy and lack of post-operative chemotherapy were the five independent prognostic factors that adversely affected overall survival.

Conclusion. Favorable overall survival of PCC patients undergoing surgical treatment depends on early tumor stage, absence of symptoms, papillary tumor type, hepatic resection and post-operative chemotherapy.

PP 20.06

TREATMENT WITH GEMCITABINE FOR ADVANCED OR RECURRENT EXTRAHEPATIC BILE DUCT CANCER

Onuki, Manabu¹; Nakayama, Mao²; Takahashi, Tetsu²; Fukuda, Koji²; Akashi, Tatsuru²; Ando, Hideaki²; Tanaka, Yuichi²; Hanaoka, Takao²

¹Nakadori General Hospital, Akita city, Japan; ²Nakadori General Hospital, Division of Surgery, Akita city, Japan

Background. Extrahepatic bile duct cancer has a bad prognosis and there was no standard chemotherapy for advanced and recurrence cases. Recently, Gemcitabine(GEM) was applied for biliary tract cancer, so this study shows the effectiveness of GEM for extrahepatic bile duct cancer.

Patients and Methods. Between 2003 to 2006, 18 patients were treated with GEM. These patients were 10 advanced cases(more than Stage III by UICC criteria) and 8 recurrence cases. Effectiveness of GEM treatment was comparison with non-randomized 22 cases, treated with biliary drainage without any chemotherapy. Endpoint of this study was survival ratio which were compared using Kaplan-Meier survival curves. GEM(1,000mg/m2) was administrated through a vein, within thirty minutes and once a week for three weeks in a row, followed by a week without treatment. RESULT: There was no adverse event over Grade IV with GEM treatment. GEM treatment was one to 32 times, average 13 times/case, administrated by case, and during 224 days by average. Main reason of change of the dosing regime was cholangitis. Response rate was 25%; NE 2 cases, CR 1, PR 1, SD 9, PD 5. Survival rates in without GEM at 6 and 12 months were 82% and 45%, survival rates in GEM therapy at 6, 12 were 94%, 94%.

Conclusion. GEM therapy was useful for advanced and recurrent extrahepatic bile duct cancer without any severe adverse events.

PP 20.07

ANALYSIS OF CLINICAL OUTCOME AND PROGNOSTIC FACTORS IN PATIENTS WITH HILAR CHOLANGIOCARCINOMA

Kim, Dong-Goo; Lee, Kyung-Keun; Kim, Sae June

KangNam St. Mary's HospitaL, Surgery, Seoul, Korea, Republic of

Introduction. The aim of the present study was to find the proper treatment for improving the survival of patients with hilar cholangiocarcinoma by analyzing many factors affecting the patients' survival.

Methods. Between January 1991 and April 2006, 152 patients with hilar cholangiocarcinoma and who underwent surgery were reviewed. One hundred fifteen patients underwent attemped curative resections and 37 patients had findings that precluded any further intervention. Of the 115 patients who underwent concomitant hepatectomy. The clinicopathogical data of these patients was analyzed.

Results. The 3 year overall survival and disease-free survival rates were 41.2% and 52.5%, respectively. The overall recurrence rate was 40.9%(47/115) and of patients with recurrence, those who had been treated aggresslvely survived longer than those who had been treated conservatively(P=.039). Of the patients' factors that affected survival, only preoperative weight loss was meaningful(P=.024). Of the histologic factors, tumor cell differentiation(P=.048) and the presence of lymph node metastasis(P=.028) were associated with survival. Of the perioperative factors, only achivement of complete tumor resection affected survival. On comparing between resection of the extrahepatic bile duct only and concomitant partial hepatectomy, the latter achived more definitely negative histologic margins(63.6% vs 39.5%, respectively, P=.037) at the expense of a more prolonged operation time and hospital stay and greater complications.

Conclusions. Preoperative weight loss, poor differentiation, lymph node metastasis and a positive hitoligic margin could be included in the poor prognostic factors affecting survival. Concomitant liver serection could be rationalized in that it could attain a more negative histologic margin for treating resectable hilar cholangiocarcinoma, but it could increase mortality and morbidity rates.

PP 20.08

MODIFIED LIVER HANGING MANEUVER TO FACILITATE LEFT HEPATECTOMY AND CAUDATE LOBECTOMY FOR HILAR BILE DUCT CANCER

Hwang, Shin; Lee, Sung-Gyu; Lee, Young-Joo; Ha, Tae-Yong; Ko, Kyoung-Hoon; Kim, Kwan-Woo; Choi, Nam-Kyu

Asan Medical Center, University of Ulsan, Department of Surgery, Seoul, Korea, Republic of

Background. The liver hanging maneuver (LHM) is a useful technique enabling a safe anterior approach, but it has several technical limitations for resection of the hepatic paracaval portion.

Patients and Method. We present a modified LHM that facilitates concurrent resection of the paracaval portion, a technique applicable to left liver resection for hilar bile duct (HBD) cancers. During 6 months from December 2006 to May 2007, 6 of 20 HBD cancer patients underwent curative left liver resection using the modified LHM. This method included initial partial transection of the caudal paracaval portion. Thus, subsequent blind tunneling over the retrohepatic inferior vena cava can become as short as 2–3 cm in length, resulting in effective prevention of short hepatic vein injury. The parenchyma transection plane was tailored to remove most of the paracaval portion.

Results. This modified LHM technique was safely and effectively applied to all 6 patients, resulting in a shorter time for caudate lobe isolation. No significant bleeding occurred during retrohepatic tunneling. The final parenchymal transection plane after left liver resection using modified LHM was the same as that following conventional surgical technique for HBD cancers.

Conclusion. This modified LHM was an effective, technically simpler procedure for left liver resection in HBD patients.

PP 20.09

GTREATMENT STRATEGY FOR HILAR CHOLANGIOCARCINOMA(H: A SPECIAL REFERENCE TO OUR NEW TREATMENT FOR NON-CURATIVE AND UNRESECTABLE CASES

Morine, Yuji; Mistuo, Shimada; Imura, Satoru; Ikegami, Toru; Kanemura, Hirohumi; Mori, Hiroki; Arakawa, Yusuke; Kanamoto, Mami; Hanaoka, Jun; Tokunaga, Takuya; Sugimoto, Kouji

The University of Tokushima, Japan., Department of Surgery, Tokushima, Japan

Introduction. Hilar cholangiocarcima have poor prognosis even though with radical resection. Furthermore, the effective adjuvant therapy has not been established yet. This study was conducted to identify the validity of surgical treatment, and to clarify the effectiveness of GFP chemotherapy (Gemcitabine combined with CDDP and 5FU) for hilar cholangiocarcinoma.

Patients and Methods. A retrospective analysis was conducted for 59 patients with hilar cholangiocarcinoma. Of these 40 patients underwent surgical treatment (67.8%). We investigated the prognostic clinicopathorogical variables after surgery using univariate analysis. GFP chemotherapy applied to advanced hilar chorangiocarcinoma (non-curative: n = 3, unresectable: n = 3). 4-week cycle GFP chemotherapy regimen as follows: Gemcitabine at 1000mg/m2 on days 1,8,15, and 22. 5-FU at 250mg/m2 and CDDP at 3mg/m2 on days 1 to 5, 8 to 12, 15 to 19 and 22 to 26.

Results. In operable cases, 36 of 40 patients (90%) received radical hepatectomy combined with caudate lobectomy and lymphadenectomy. Actual 3- and 5-year survival rate in operable cases were 52.3 and 30.5%, respectively. In unresectable cases (n = 19), no survival cases over 2-years have been observed. Univariate analysis revealed that surgical curability and lymph nodes metastasis were the independent prognostic factors. In non-curative cases with GFP chemotherapy (n = 3), all patients survived over 1-year without tumor progression. Furthermore, in unresectable cases with GFP chemotherapy (n = 3), median survival time was 12 months and prognosis was improved compared with other treatment cases (n = 16) Conclusions: Surgical resection is an effective treatment for hilar cholangiocarcinoma, even if non-curative treatment. Furthermore, GFP chemotherapy is promising to improve the prognosis of non-curative and unresectable cases.

PP 20.10

HILAR CHOLANGIOCARCINOMA AND LYMPH NODE REACTION TO PORTAL VEIN EMBOLISATION: A CASE REPORT

Fuks, David; Chatelain, Denis; Brehant, Olivier; Dumont, Frederic; Sabbagh, Charles; Yzet, Thierry; Delcenserie, Richard; Regimbeau, Jean-Marc

CHU Nord Amiens, Federation Digestive Diseases, Amiens, France

Background. Only surgery with R0 resection can improve survival in hilar cholangiocarcinoma. Presence of lymph nodes discovered on CT-scan is unrare. We report the case of a 59-year-old woman with para-aortic lymph nodes on pre-operative staging of a hilar cholangiocarcinoma. After portal vein embolisation, several new lymphs nodes appeared. DISCUSSION Right lobectomy with extended lymph node resection was performed and histological analysis did not find malignant infiltration of the 10 lymph nodes resected. Only mineral oil lipidosis were found in these lymph nodes. This case emphasizes that radical surgery should be discussed for patients with resectable cholangiocarcinoma even in case of lymph node on CT-scan.

Conclusion. CT is not accurate for the prediction of nodal involvement. Lymph node reaction to radiopaque oils should be known after portal vein embolisation.

PP 21.01

PROSPECTIVE STUDY OF BIOCHEMICAL PARAMETRES IN ESTIMATION OF ETIOLOGY AND TREATMENT OF OBSTRUCTIVE JAUNDICE

Zajic, Sasa; Jovanovic, Milan; Zdravkovic, Rade; Milojevic, Vladeta

Health Centre Krusevac, Surgery department, Krusevac, Serbia and Montenegro

In the period from 01.05.2006. till 01.03.2007., this prospective study encompassed the patients with obstructive jaundice. During this period the total number of 87 patients were analysed, out of which 39 women (42,83%), and 48 (55,17%) men, average age 64,72 years (the youngest 27, the oldest 83 years old). The analysed parametres on the basis of which the type of obstruction was estimated, besides standard biochemical parametres, were also alkaline phosphatase and bilirubin. Among the patients included in this study there were 60 (68,97%) benign obstructions and 27 (31,03%) malign obstructions. In cases of malign obstructions the level of the abovementioned parametre of total bilirubin was between 127,8 and 789,5 mmol/L (average 274,76 mmol/L). Level of alkaline phosphatase in malign obstructions was from 236 till 3066 U/L (average 815,04 U/L). In cases of benign obstructions level of total bilirubin was between 22,1 and 347,1 mmol/L (average 117,9 mmol/L), and the level of alkaline phosphatase from 79 till 1666 U/L (average 361,35 U/L). On the basis of the compared parametres the etiology of the type of obstruction was estimated, and the optimal type of treatment of the patients was determined. Compared laboratory values of alkaline phosphatase and total bilirubin are in relation with clinical picture of both benign and malign obstruction. On the basis of compared parametres it is possible to estimate pre-surgically with high certainty level whether it is a case of benign or malign obstruction.

PP 21.02

EFFECT OF PREOPERATIVE ENDOSCOPIC BILIARY DRAINAGE AND STENTING ON POSTOPERATIVE INFECTION AND THE OUTCOME OF SURGERY FOR BENIGN OBSTRUCTIVE JAUNDICE.

Elsebae, Magdy1; Ezzat, Hussin¹; Helmy, Ahmed Hazem¹; Fakhry, Sameh²

¹Theodore Bilharz Medical Research Institute, General Surgery, Cairo, Egypt; ²Theodore Bilharz Medical Research Institute, Tropical Medicine, Cairo, Egypt

Introduction. Obstructive jaundice (OJ) patients come to the care of the endoscopist, before going to surgery. (ERCP) and stent insertion preoperatively became the routine in our institute. no study was found that specifically identify the organisms present in bile in patients with benign obstructive Jaundice before endoscopic biliary stent insertion and after it at the beginning of surgical procedure. The aim of this study: was to evaluate the effect of preoperative endoscopic biliary drainage on the outcome of surgery for patients presenting with benign obstructive jaundice.

Materials and Methods. The study involved 79 of patients with surgically corrected benign obstructive jaundice at TBRI. Preoperative (ERCP) was done for all of the patients and stent insertion was made in 60 of them. Bile specimens were obtained by flushing technique and intra-operatively by puncture before incising the common bile duct. Bile samples were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant postoperative septic complications such as wound infection and cholangitis were also assessed.

Results. Bile culture of intra-operatively obtained specimens was positive in 39/60 (65.0%) of the patients in Group II (ERCP+ biliary stent), a significantly higher incidence than that observed in group I (ERCP only), in which 7/19 (36.8%) of the patients presented positive cultures (p = 0.001). There was no significant difference in general postoperative morbidity between groups. When infective complications (cholangitis, pneumonia, wound infection) were analyzed separately, a higher incidence, although without significance, was found in Group II than in Group I.

Conclusion. Preoperative biliary drainage using the endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion in patients subjected to surgery for benign obstructive jaundice could provokes biliary bacterial colonization with a possible appearance of infective complications during the postoperative pe

PP 21.03

RUPTURE OF THE RIGHT HEPATIC DUCT INTO AN ECHINOCOCCAL CYST DUE TO CHOLEDOCHOLITHIASIS

Sapalidis, Kostantinos¹; Michalopoulos, Antonios²; Michalopoulos, Nikolaos¹; Papavramidis, Theodossis S²; Souleimanis, Christos¹; Fyllosoglou, Aspasia³; Papavramidis, Spiros T.¹

¹A.H.E.P.A University Hospital of Thessaloniki, Aristotle's University of Thessaloniki, 3rd Surgical Department, Thessaloniki, Greece; ²A.H.E.P.A University Hospital of Thessaloniki, Aristotle's University of Thessaloniki, 1st Propedeutic Surgical Department, Thessaloniki, Greece; ³A.H.E.P.A University Hospital of Thessaloniki, Aristotle's University of Thessaloniki, Department of Anesthesiology, Thessaloniki, Greece

Background. Echinococcal cyst is typically an asymptomatic mass. In rare cases, the cyst may rupture into the biliary tree and show symptoms. The present case is extremely rare because choledocholithiasis increased biliary tree pressure and rupture of the right hepatic duct into the echinococcal cyst occurred.

Case Report. A 60 years-old female patient presented to the emergency department with right upper quadrant pain and jaundice. She had a known cholelithiasis and an echinococcal cyst in the liver. The biochemical and hematological screening revealed leucocytosis with elevated PMNs, transaminasemia and hyperbilirubinemia. Ultrasonography revealed multiple echinococcal cysts of the liver, distended bile ducts and cholelithiasis. CT described the presence of a large multisegmented echinococcal cyst occupying the segments V, VI and VIII. The patient was treated conservatively for the acute cholelithiasis, was scheduled for cholecystectomy and discharged. Ten days after the discharge, she revisited us with jaundice. Two day after the reentry, an acute fall of the hyperbilirubinemia occurred. MRCP proved communication between the echinococcal cyst and the right hepatic duct, while the common hepatic duct and the common bile duct were full with material. Emergency operative management included cholecystectomy with exploration of the common bile duct, excision of the echinococcal cyst and removal of pigmented gallstones from the cyst. The intra-operative cholangiography revealed communication of the echinococcal cyst with the right hepatic duct. The right hepatic duct was ligated; a T-tube was put in the common bile duct and drainages placed.

Conclusion.Typically the echinococcal cyst ruptures into the biliary tree and biliary colic, jaundice or anaphylaxis occurs. In the present case the reverse course seemed to occurred since the increased intrabiliary pressure lead to a rupture of the right hepatic duct into the cyst.

PP 21.04

ENDOSCOPIC REMOVAL OF COMMON BILE DUCT STONES USING DOUBLE□∣BALLOON ENTEROSCOPE AFTER TOTAL GASTRECTOMY WITH ROUX□∣EN□∣Y RECONSTRUCTION

Takahata, Shunichi; Sadakari, Yoshihiko; Ienaga, Jun; Tanabe, Reiko; Tanaka, Masao

Graduate School of Medical Sciences, Kyushu University, Department of Surgery and Oncology, Fukuoka, Japan

Background. Bile duct stones sometimes occurs, after total gastrectomy; however, Roux-en-Y reconstruction used to have excluded the biliary diseases from endoscopic procedures. Recent developed double-balloon enteroscope (DBE) facilitates endoscopic exploration of the afferent Roux-en-Y jejunal limb and enable to treat bile duct stones. PATIENTS: We experienced 3 patients with common bile duct stones who had previously undergone total gastrectomy for gastric cancer followed by Roux-en-Y reconstruction.□@They are 2 male and 1 female, with a mean age of 75.0(62–85). Fujinon EC450BI5 (Fujinon Corporation, Saitama -Shi, Saitama, Japan) were employed for DBE. Needle type sphincterotome was used for endoscopic sphincterotomy.

Results. All the patients were successfully cured by endoscopic sphincterotomy and extraction of stones. Endoscopic cholangiogram revealed 1 or 2 stone for each patients. Mean size of stones was 10.4mm (7–15) in maximum diameter. 2.7(2–4) endoscopic interventions were required for complete stone removal. No major complication was observed. Placement of biliary tube stent prior to sphincterotomy was useful.

Conclusion. DBE-sphincterotomy and stone extraction is safe and useful technique for management of common bile duct stone in patients after Roux-en-Y reconstruction.

PP 21.05

LONG CYSTIC DUCT STUMP WITH CALCULI CAUSING RECURRENT CHOLANGITIS

Khare, Ritu¹; Raja, Kaiser²; Shetty, Sukrith³; Kumar, Ashok⁴

¹New Medical Centre Hospital, Laparoscopic Surgery, Abu Dhabi, United Arab Emirates; ²New Medical Centre Hospital, Gastroenterology, Abu Dhabi, United Arab Emirates; ³New Medical Centre Hospital, Surgery, Abu Dhabi, United Arab Emirates; ⁴New Medical Centre Hospital, Radiology, Abu Dhabi, United Arab Emirates

Background. Post cholecystectomy biliary pain can occure in 6–10% of cases. It has a variable etiology (CBD stones, biliary stricture, cystic duct stump syndrome, SOD, dyspepsia). However recurrent cholangitis is uncommon in the absence of stones or stricture in the common bile duct. We present a case of multiple calculi in unusually long cystic duct stump presenting as reccurent upper abbominal pain and fever.

Case Report. A 46-year-old lady presented 12 years after cholecystectomy with recurrent episodes of right uppper quadrant pain and fever. Initial investigations done during an episode of pain revealed leukocytosis and raised C-reactive protein. Liver enzymes were minimally elevated (twice normal) without any hyperbilirubinemia. Abdominal ultrasound did not reveal any obvious calculi or dilation of the common bile duct. However, a CT abdomen was suggestive of multiple calculi in the common bile duct. At ERCP, no calculi were detected in the CBD. A long remnant, unusually low inserted cystic duct (just above the papilla) with multiple filling defects was visualized. Repeated attempts at endsocopic extraction of cystic duct calculi did not relieve her pain despite extraction of several calculi on more than one occasion. The patient eventually underwent excision of the cystic duct stump with choledocho-duodenostomy. Two residual calculi were found impacted in the proximal end of the stump. The patient bacame symptom free after the surgery.

Conclusion. Long remnant cystic duct stump with retained/recurrent calculi can be a cause of recurent pain/cholangitis after cholecystectomy in the absence of pathology in the common bile duct. Endoscopic extraction of impacted cystic duct calculi may not always be successful.

PP 21.06

LAPAROSCOPY ASSISTED ERCP IN FAILED PRE OPERATIVE ERCP

Kota, Venugopal; Varma Gunturi, Surya Ramchandra; Peshwe, Harish; Kona, Lakshmi Kumari; Cherukuri, Anil Kumar; Ravindranath, K.

Global Hospitals, Hyderabad, India

Introduction. Laparoscopic Cholecystectomy (LC) is the gold standard for the management of symptomatic gallstones in the present era. A minority have accompanying choledocholithiasis. Therapeutic Endoscopic Retrograde Cholangio Pancreatography (ERCP) is successful over 90% of patients in experienced hands in extracting common bile duct (CBD) stones failing which surgical intervention either laparoscopically, if amenable or open is required. We hereby describe laparoscopy assisted ERCP in the operation theatre to manage choledocholithiasis where pre operative ERCP in extracting the CBD stones was unsuccessful.

Methods. Four patients underwent LC and Laparoscopy Assisted ERCP in our hospital over last 2 years. The reasons of failure of preoperative ERCP were: Location of papilla in or adjacent to a large duodenal diverticulum (n = 3) and Malrotation(n = 1). The age group ranged from 29–75 years, 2 Males and 2 Females. A 5 F ureteric catheter was passed through cystic duct and CBD into duodenum. Using this as an aid, the CBD was accessed endoscopically.

Results. All 4 patients had a successful CBD stones clearance.

Conclusion. Laparoscopic Cholecystectomy with Laparoscopy Assisted ERCP can be a option for failed preoperative ERCP, enabling to do both of them in a single stage and when successful, avoids CBD exploration and its accompanying risks.

PP 21.07

LAPAROSCOPIC CBD STONE MANAGEMENT

Sinha, Rajeev

MLB Medical College, General surgery, Jhansi, India

Background. The CBD stone management is again undergoing a change. The accepted routine of ERCP followed by Laparoscopic cholecystectomy(Lap Chole) is being challenged by laparoscopic transcystic or transductal CBD exploration at the same sitting along with Lap Chole.

Aim. The advantages of this same sitting surgery although obvious to some extent, need to be more clearly defined.

Methods. We have operated on 32 patients of CBD stone by laparoscopic transductal choledocholithotomy using a 4 mm urethroscope and later a 17FG nephroscope for stone visualization and complete visualization of the proximal extrahepatic biliary channels and distally upto the duodenum. Dilatation of ampulla was carried out using a urethral dilator in patients with tight ampullary opening. T tube intubation was optional. CBD closure was by intracorporeal suturing.

Results. Five ports were used 10mm(2) and 5 mm (3). The operating time varied from 45 minutes to 105 minutes. T tube was used in only 7 patients with doubtful clearance or closure. Closure was with intra corporeal continous 3–0 monocryl suturing. Morrison's pouch drain was used in all patients. Discharge time was 4 days. PeriT tube bile leakage persisted for 4 days in one patient, port site infection was seen in 2 patients. Retained stones were recorded in 2 patients. Conversion to open surgery was carried out in 5 patients.

Conclusion. Lap CBD exploration gives results equal to open exploration and because it can be done in the same sitting as Lap Chole the morbidity is less than that of ERCP followed by Lap Chole. But it requires training and expertise in intracorporeal suturing.

PP 21.08

PROPOSED PATHWAY FOR MANAGEMENT OF CHOLEDOCHOLITHIASIS TO REDUCE THE INCIDENCE OF NEGATIVE ERCP

Al-Jiffry, Bilal Omar¹; El-Fateh, Abdeen²; Saleem, Absher²

¹Al-Hada Armed Forces Hospital, General Surgery, Taif, Saudi Arabia; ²

OBJECTIVE. We propose a less-invasive pathway in managing choledocholithiasis.

Background. There is no consensus up to date on the diagnosis and treatment of choledocholithiasis. Though ERCP is the most effective, it has complications up to 10%, mortality less than 1%, and can be negative in 75% when selection is based on an abnormal liver function test (LFT). MRCP can detect CBD stones. However, the capital expense and running cost limit's widespread availability. Also, normal duct size can be a source of false-positive stone detection.Method.: All patients from November 06 to August 07 with proven gallstones and abnormal LFT and/or abnormal ultrasound became eligible. We consider the US to be abnormal if CBD was dilated (=/> 7mm) or stones were detected. If both tests were abnormal the patient had an ERCP followed by surgery with intra-operative cholangiogram (IOC). However, if the US was normal, MRCP was done and an ERCP was reserved for abnormal tests only followed by surgery and IOC.

Results. Total NO was 49. 22 (45%) abnormal LFT, 2 (4%) abnormal US and 25 (51%) both abnormal (LFT and US). The 22 had MRCP, 14 tests normal (64%), 6 stones (27%) and failed to have the test in 2 (9%). ERCP done for 6 (positive MRCP) and stones found in 4 (67%) and negative in 2 (33%). 27 had abnormal US, 6 stones (22%), 11 CBD dilatation (41%) and 10 (37%) both (dilatation and stone). All 16 with stones on US were proven to have CBD stones by ERCP. 7 out of the 10 with dilatation had stones (70%), 2 from 3 w/o stones (dilatation group) had a normal LFT. So, 1 out of 25 with abnormal LFT and US did not have CBD stones. Total 33 ERCP done with 28 patients with stones and 5 negative ERCP (15%). The incidence of stones was 96% when both tests were abnormal and 17% if any of the tests was normal.

Conclusion. Patients with an abnormal LFT and US have a high incidence of CBD stones and ERCP is indicated and the coast of MRCP is not warranted. However, if any of the tests are normal MRCP is indicated to decrease the NO of negative ERCP

PP 21.09

REFRACTORY CHOLEDOCHOLITHIASIS AND CHOLANGITIS AFTER CHOLEDOCHOJEJUNOSTOMY BY TWISTED ROUX-EN-Y JEJUNUM LIMB

Ienaga, Jun; Takahata, Shunichi; Sadakari, Yoshihiko; Tanabe, Reiko; Toma, Hiroki; Yamaguchi, Koji; Tanaka, Masao

Graduate School of Medical Sciences, Kyushu University, Department of Surgery and Oncology, Fukuoka, Japan

Background. Anastomotic stenosis is well known as major complication of choledochojejunostomy and cause of cholangitis. However, there are a few reports of cholangitis due to stenotic Roux-en-Y jejunal limb. We report a case of refractory choledocholithi asis and cholangitis associated with twisted jejunum limb after choledochojejunostomy and propose a hypothesis of its etiology.

Case Report. The patient was a 77-year-old Japanese woman who had undergone a side-to-side choledochojejunostomy for choledocholithiasis 25 years previously. After the surgery, choledocholithiasis and cholangitis were repeated and endoscopic lithotomy had been required each time. Cholangiogram suggested disruption of jejunal limb and we decided to have a surgical treatment. Laparotomy revealed that the jejunal limb was twisted and stenotic. The site of side-to-side choledochojejunostomy including the twisted limb was resected and a new end-to-end anastomosis was made. After the operation, the patient did not have any complaint. Neither malignancy nor specific inflammation was found in the resected specimen by pathologic exploration.

Discussion. The repeated choledocholithiasis was caused by torsion of the Roux-en-Y limb. The obstructed jejunum became a blind pouch producing intestinal juice. Bile stasis and bacterial infection in the jejunum should form the recurrent stones.

Conclusion. Twisted Roux-en-Y jejunal limb after choledochojejunostomy could cause refractory choledocholithiasis and cholangitis. Surgical operation is recommended for the condition.

PP 21.10

SURGICAL OUTCOME IN BENIGN BILIARY DISORDERS

Singh, Rajinder¹; Adhikari, Devbrata²; Patil, Bhushan²; Bhange, Snehal²; Shetty, Tilakdas²; Joshi, Rajeev²

¹T.N Medical College & B.Y.L Nair Ch Hospital, Mumbai, Dept of Surgery, A.L Nair Road, Mumbai, India; ²T.N Medical College & B.Y.L Nair Ch Hospital, Mumbai, Dept of Surgery, Mumbai, India

Background. Bile duct pathologies present a formidable challenge with varying management protocols and long term Results. Despite the emergence of therapeutic endoscopy surgery continues to play a major role.

Objective. To evaluate the outcome following surgeries done for benign biliary disorders.Method.: Analysis of 160 cases (81 bile duct injuries, 55 choledocholithiasis, 16 choledochal cysts, 5 Mirizzi's syndrome and 3 post H-Jstomy strictures), surgically treated from February 1999 to July 2007. RESULT: H-Jstomy was done in 69 cases of biliary injury, choledochoduodenostomy (CD) in 7, T-tube placement and bilio-biliary anastomosis in 4 and 1 case respectively. For choledocholithiasis, CD was performed in 48 cases, H-Jstomy in 3 and T-tube placements in 4 cases.16 choledochal cysts were completely excised. Choledochoplasty in 3 cases, partial cholecystectomy and T-tube placement in 1 case each, was done for Mirizzi's syndrome. Revision H-J was done in 3 post H-Jstomy strictures. Complications (16.88%), included wound infection (6.25%), bile leak (5%), adhesive obstruction, anastomotic stenosis and intra-abdominal sepsis.1 patient of H-Jstomy expired due to biliary peritonitis. 3 patients developed anastomotic stenosis by 32 months, 2 were treated with balloon dilatation and 1 with revision surgery.

Discussion. Though not routinely performed, we found PTBD useful in patients with biliary injuries detected postoperatively. It helped in controlling sepsis, intraoperative identification of anatomy and decompression of anastomosis. Predictors of adverse outcome are well known. 3 patients who restenosed had proximal stricture, prior attempt at repair and end to end biliary anastomosis.

Conclusion. Despite the emergence of therapeutic endoscopy and interventional radiology, surgical intervention is mandatory in select benign biliary disorders, and if appropriately timed and well performed has shown best long term results in biliary injuries.

PP 21.11

MANAGEMENT OF IATROGENIC BILE DUCT INJURY:A STUDY OF 30 CASES

Trivedi, Dilip¹; Trivedi, Mayuri²; Shetty, Arun³

¹Sir H.N Hospital, Mumbai, India; ²Mumbai, India; ³Hiranandani Hospital, Mumbai, India

Background. The aim of the study was to assess the use of hepaticoduodenostomy in Bismuth I type of common bile duct (cbd) injury and study the results of other Bismuth type cbd injury retrospectively. This study of cbd injury was carried out in Sir H N Hospital, Mumbai, India in a single surgical unit.

Method. 30 cases of cbd injury are retrospectively analyzed. Majority of the patients were managed primarily. However three patients were reconstructed secondarily after the failure of the primary surgery at other centers. The procedures carried out were roux en y hepaticojejunostomy in majority of the patients. However in Bismuth type I injury where available duct length was more than 2 cms. Hepaticoduodenostomy was performed after mobilizing duodenum to achieve tension free anastomosis.

Results These patients were operated and they were followed up for a period of three years regularly. The longest follow up is for 14 years.

Conclusion. Hepatico duodenostomy is the operation of choice in Bismuth type I injury. The advantage is that the anastomosis is available for manipulation endoscopically in case of complications like stenosis or recurrent cbd stones at a later date. Hepatico jejunostomy is the operation of choice for other Bismuth type of cbd injuries. Best results are obtained in the tertiary care centers where experienced surgeon as well as good backup is available for the investigations and the postoperative management. If expertise is not available at the time of first surgery, it is advisable to drain the bile duct and send the patient to tertiary care centre for further management. The long term results of the surgery are definitely better when the patients were treated at the tertiary care centre.

PP 22.03

THE ROLE OF SURGERY IN THE LIVER METASTASES OF OVARIAN CARCINOMA

Saribeyoglu, Kaya¹; Pekmezci, Salih¹; Arvas, Macit²; Demirkiran, Fuat²; Aytac, Erman¹

¹Istanbul University, Cerrahpasa Medical Faculty, Department of General Surgery, Istanbul, Turkey; ²Istanbul University, Cerrahpasa Medical Faculty, Department of Gynecologic Oncology, Istanbul, Turkey

Introduction. Surgery plays an important role in ovarian carcinoma metastases as most of the patients benefit from tumor debulking which is chemosensitive. However the management strategy of liver metastases of this tumor was seldom reported. Removal of all macroscopic tumor is crucial in this type of tumor and it is only achievable by liver resections. This study includes a series of patients who had ovarian carcinoma metastases to the liver and underwent liver resection.

Methods. The patients who underwent surgical resection of ovarian carcinoma metastases were included. Demographic features, technical details, surgical outcome and prognosis were evaluated.

Results. Eight patients underwent surgical management of liver metastases related to ovarian carcinoma between March 2003 – May 2007. Operations included right hepatectomies, left lateral segmentectomy and tumor resections. Extended lymphadenectomy was performed in a patient where pathological paraaortic lymph nodes were present. In another patient additional visceral resection was necessary. There was neither surgery related morbidity nor mortality. The operations was resulted with complete removal of all macroscopic tumors.

Conclusion. Liver resection is feasible and useful in ovarian carcinoma metastases. Larger series including long term follow-up are needed for an ultimate Conclusion.

PP 22.04

RADIOFREQUENCY THERMAL ABLATION AS A PALIATION METHOD IN PATIENTS WITH CARCINOID SYNDROME DUE TO LIVER METASTASES

Zadrozny, Dariusz¹; Sledzinski, Zbigniew¹; Studniarek, Michal²; Adamonis, Walenty¹; Gorycki, Tomasz²

¹Medical University of Gdansk, Poland, Dept of General, Endocrine and Transplant Surgery, Gdansk, Poland; ²Medical University of Gdansk, Poland, Dept of Radiology, Gdansk, Poland

Background. Liver metastases from carcinoid tumors are often a cause for carcinoid syndrome. The syndrome results from vasoactive substances (serotonin, bradykinin, histamine, prostaglandins, polypeptide hormones) secreted by the tumor and is characterized by cutaneous flushing, abdominal cramps, and diarrhea. The symptoms may be reduced by octreotide or somatostatin administration, but this treatment is very expensive. Tumor excision or destruction may result in complete relief of symptoms. MATERIAL: Between 2001 and 2006 five patients (3M, 2F) aged 46–68 years (mean 56,3) were treated in our institution for to carcinoid syndrome. In 3 cases liver metastases from carcinoid tumor of appendix and in 2 – from jejunum were the cause of symptoms. All patients were scanned for the possibility of radionuclide treatment and treated with standard chemotherapy with rapid progression. Octreotide was administered in all patients for 3–5 months and rejected. Patients were referred for percutaneous radiofrequency thermal ablation of liver metastases after disqualification from liver resection. At the admission time mean 7 (4–10) tumors 1–8 cm (av. 3,7) in diameter were found in the liver.

Results. No complication of RFTA occured in this group of patients. Mean observation time is 2,4 years (1–4), all patients are alive. Formatio n of new tumors was found in 4 of 5 patients (80%), in one patient the disease is stable after one RFTA session. Overall number of ablation sessions was 15 (1–9, mean 3 per patient). After each ablation relief of symptoms was observed, the effect was stable for 4–5 months. Relapse of syndroms was the indication for subsequent ablation of local recurrence or new foci. The patient's quality of life is good.

Conclusion. Radiofrequency thermal ablation can used as a paliative treatment in patients with carcinoid syndrome resistant to other therapy

PP 22.05

ANATOMIC VARIATIONS OF EXTRA-HEPATIC BILIARY TRACT AND HEPAITC VASCULATURE;A REVEIW OF LITERATURE

Dhumane, Parag¹; Shah, Niraj²; Mansukhani, verushka³; Bharucha, Manoj⁴

¹LILAVATI HOSPITAL, General surgery, Mumbai, India; ²Lilavati Hospital, Genaral Surgery, Mumbai, India; ³LILAVATI HOSPITAL, General Surgery., Mumbai, India; ⁴LILAVATI HOSPITAL, G I Surgery, Mumbai, India

Anatomic variations of extra-hepatic biliary tree and hepatic vasculature are so common that it is difficult to find an individual patient with completely orthodox hepatobiliary system. Healey and Schroy, Bowden championed research in this field in 1950s. Literature has reported anatomical variations to the tune of 38% for biliary system (n = 300), 20% for portal venous branching (n = 507) and 45% for hepatic artery branching (n = 200). Be it for a general surgeon, hepatobiliary surgeon, endoscopist, or radiologist, it becomes imperative to have the thorough knowledge of these anomalies, especially in this era of liver transplantation and laparoscopic surgery. Apart from the biliary tract, Gall bladder anomalies can be divided as variations of formation, number and position. Seven gross variations in biliary tree branching have been described. Its knowledge is essential for the safe conduct of hepatobiliary procedures. While doing hepatic resection and surgeries at porta, it becomes absolutely essential to have sound knowledge of about ten variations in hepatic artery branching and six variations in portal vein branching. More importantly, vascular and biliary anatomic variations do not correlate with each other. With advances in the imaging technologies, especially MRCP, preoperative identification of anomalies looks possible, so that surgical strategies can be designed accordingly. Thus, in this important aspect of hepatobiliary surgery, more in depth research is needed in the fields of diagnostics, clinical implication and surgical innovations.

PP 22.06

ANATOMICAL VARIATION OF SEGMENT IV HEPATIC ARTERY

YU, HEE-CHUL; Jin, Guang Yu; Cho, Baik-Hwan

Chonbuk National University Medical School, Surgery, Jeonju, Korea, Republic of

Background. Anatomical complications of split and living donor liver transplantation (LDLT) have promoted comprehensive understanding of liver anatomy and embryology in greater depth and encouraged to view the matter from many different perspectives than ever before.

Objective. To investigate the points of origin of segment IV artery (A4) of the liver.

Methods. Meticulous dissection of livers (n = 62) to study the types and the prevalence of the anatomical variation found in the principal A4.

Results. A4 was found to be extra- or intra-hepatic branches of the right, left or proper hepatic arteries. We classified and characterized four different types of A4 according to their origin in the livers (n = 46) without aberrant left hepatic artery (abLHA). The RHA type, originated from the right or right anterior hepatic artery, was identified in 24 cases (52.2%) in our series. Based on our dissection study, we developed what we called a ¡°sliding model¡± of stemming of A4 roots that originated from either the RHA or the LHA. The A4 roots (n = 19) had a strong tendency of stemming from the RHA (n = 12) rather than from the abLHA (n = 5) even in the livers with abLHA(n = 16).

Conclusions. According to our dissection study RHA type is the most prevalent type of variation which is found in the principle A4. In the era of LDLT using extended right lobe, comprehensive knowledge paying particular attention to the point of origin of A4 is prerequisite in planning surgery.

PP 22.07

Erythropoietin strongly protects the liver from ischemia reperfusion injury in a pig model

Shimoda, Mitsugi; Sawada, Tokihiko; Iwasaki, Yoshimi; Kijima, Hiroaki; Okada, ,s,□,“,∧,‰,…; Kubota, Keiichi

Dokkyo University School of Medicine, Second Department of Sugery, Mibu, Japan

Background. Erythropoietin (EPO) has various extrahematopoietic effects. We investigated the protective effect of EPO against liver ischemia reperfusion (IR) injury in a pig model

.Methods. Partial hepatic ischemia for 60 min was created in pigs. Pigs were allocated to 2 groups (n = 5 each): Vehicle; IR injury, EPO group; IR injury with three injections of EPO at 5000 IU/kg. In the EPO group, EPO was injected 10 min before and 30 min and 60 min after the ischemia.

Results. At 3 h after IR injury, liver function test and histological evaluation were significantly better in EPO-treated groups than those in the Vehicle group. Apoptotic indices in the Vehicle and EPO groups 3 h after IR injury were 2.40±0.93, 1.36±0.12 (P = 0.036), respectively. The apoptotic idex of EPO group was significantly lower than that of the Vehicle group.

Conclusions. EPO treatment significantly ameliorated liver IR injury by inhibiting apoptosis.

PP 22.08

ASSESSMENT OF HIP/PAP1 EFFECT ON COLORECTAL CELL PROLIFERATION: Results OF IN VITRO AND IN VIVO STUDY ON RAT.

VIBERT, Eric¹; CAM, Laurence²; MONIAUX, Nicolas¹; SAMUEL, Didier³; AMOUYAL, Pierre¹; AMOUYAL, Gilles¹; BRECHOT, Christian¹; FAIVRE, Jamila¹

¹Paul Brousse hospital (AP/HP), INSERM U785-Centre Hepato Biliaire, VILLEJUIF, France; ²Paul Brousse Hospital, INSERM U785-Centre Hepato Biliaire, VILLEJUIF, France; ³

Introduction. Human Hepatocarcinoma-Intestine-Pancreas/Pancreatic Associated Protein 1 (HIP/PAP1 or HIP), is an hepatic growth factor presenting mitogenic and anti-apoptotic activities in primary hepatocytes in vitro and in vivo. It is also a promising candidate for stimulating liver regeneration post-hepatectomy

Objective. To evaluate whether or not the recombinant HIP protein exhibits an oncogenic effect on colorectal cells (CC) in vitro and in a model of liver metastasis (LM) in BDIX rats.

Methods. The DHDK12 CC line was cultured in 96-well microplates in a DMEM medium containing 1% or 5% fetal calf serum (FCS). The CC were incubated every day with a fresh medium containing 0, 0.5, 1 or 2 µg/mL of the HIP recombinant protein or the buffer (control cells). Cell counting and viability were performed at 5 time points post-incubation (H24, H48, H72 and H96) using the WST-1 assay. The colorectal LM model was made by injecting 20×106 DHDK12 CC through the portal vein of BDIX rats (n = 12). At day 8, the recombinant HIP protein (200 µg) diluted in 1 mL of saline buffer (n = 6) was injected via the portal vein during a second laparotomy, and compared with the control groupe (n = 6) injected with 1 mL of buffer. At day 14, all animals were sacrificied for examination.

Results. The cell viability was similar in HIP-treated and in control CC at the different time points whatever the concentration of FCS. There is no difference of cell viability depending of the HIP concentration. The mean number of LM was of 22±14 and 19±15 in HIP-treated and in control group, respectively (p = 0.76). The mean volume of LM was of 6.5±8 mm3 and 4.7±4.3 mm3 in HIP-treated and in control group, respectively (p = 0.65). Histological features were similar in the 2 groups.

Conclusion. HIP has no deleterous effect on CC proliferation in vitro and does not stimulate tumor growth of LM in vivo. The effects of HIP in the colorectal LM rat model followed hepatectomy are ongoing to make sure that the recombinant HIP protein has interest in liver surgery

PP 22.09

IDENTIFYING POTENTIAL MOLECULAR MARKERS FOR HCV-POSITIVE, HBV-POSITIVE AND NON VIRAL HEPATOCELLULAR CARCINOMA

Privato, Marta; Kubrusly, Marcia S; Stefano, Jose T; Oliveira, Andre C; Bacchella, Telesforo; Machado, Marcel C.C

Sao Paulo University, Department of Gastroenterology, Sao Paulo, Brazil

Introduction. Hepatocellular carcinoma (HCC) is a multi-step process associated with changes in gene expression. Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the most important factors associated with HCC. Some individuals who develop HCC are neither infected with HBV nor HCV. Molecular analysis by gene expression in this rare type of HCC, may allow the determination of molecular signature that would help to distinguish genetic events and pathways involved in carcinogenesis of these three HCC types.

Aim. To gain insights into regarding the similarities and differences in mRNA abundances betwee n non viral (NV-HCC) and viral HCC (HBV-HCC or HCV-HCC) using microarray.

Methods. Tumor samples obtained from 9 patients (3 HBV-HCC, 3 HCV-HCC and 3 NV-HCC) were evaluated for differentially expressed mRNAs by using CodeLink™ Human Whole Genome Bioarrays with ∼57,000 transcripts.

Results. Using filtering criteria of 2.0-fold-change in expression and t-test (p <0.05), different transcriptional levels of genes were found for the comparisons: 1671 for HBV vs NV-HCC, 2257 for HBV/HCV vs NV-HCC, 1141 for HBV vs HCV and 1584 for HCV vs NV-HCC. Using Gene Ontology software no common pathways with differentially expressed genes were found comparing all groups. Specific pathways were identified in HBV-HCC vs NV-HCC (2,4-Dichlorobenzoate degradation, Ascorbate and aldarate metabolism, Coumarine and phenylpropanoid biosynthesis, Fatty acid biosynthesis, Glycosaminoglycan degradation, Heparan sulfate biosynthesis), HBV/HCV-HCC vs NV-HCC (Amyotrophic lateral sclerosis-ALS), HBV-HCC vs HCV-HCC (Alkaloid biosynthesis I, Novobiocin biosynthesis, O-Glycan biosynthesis) and HCV vs NV-HCC (Glyoxylate and dicarboxylate metabolism, Nicotinate and nicotinamide metabolism).

Conclusion. This study reveals a difference in molecular signature between NV-HCC and viral HCC. Further studies by tissue microarray will be addressed to confirm our findings. Supported by FAPESP 06/56127-5.

PP 23.01

TREATMENT OF HEPATOCELLULAR CARCINOMA IN NON-CIRRHOTIC LIVER

Ardiles, Victoria; Bregante, Mariano; Salceda, Juan; Fernandez, Diego; Juan, Pekolj; de Santibañes, Eduardo

Hospital Italiano de Buenos Aires, HPB Surgery and Liver Transplant Unit, Buenos Aires, Argentina

Background. Presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. There are few studies of hepatocellular carcinoma in non-cirrhotic livers.

Objective. To analyse a cohort of patients operated on for hepatocellular carcinoma in non-cirrhotic liver identifying prognostic factors of recurrence and long- term survival.

Material and Methods. Fifty-one patients were operated on between 1990 and 2006. A retrospective database until 2001 and a prospective database as from the same year were created. Data was gathered from the pre, intra and postoperative period. Univariate and multivariate analyses were carried out to identify the factors associated with recurrence and long- term survival.

Results. Thirty-three male patients (mean age: 49.8 years). A major hepatectomy was carried out in 72%. Intraoperative mortality and morbidity were 0% and 43%, respectively. One-, 2-, 3-year survival rates were 90%, 75% and 67%, respectively. One-, 2-, 3-year disease-free survival rates were 65%, 41% and 37%, respectively. Vascular invasion and positive nodes were statistically significant for survival in univariate analysis. Neither of them were statistically significant for survival in multivariate analysis.

Conclusion. Major hepatic resection is a safe procedure for the treatment of hepatocellular carcinoma in non-cirrhotic liver. Vascular invasion and positive nodes were identified as independent prognostic factors of survival.

PP 23.02

OUTCOMES OF HEPATECTOMY FOR HEPATOCELLULAR CARCNOMA MEETING MILAN CRITERIA WITH PRESERVED LIVER FUNCTION

PARK, SH; LEE, DS; YUN, SS; KIM, HJ

Yeungnam University Hospital, Surgery, Daegu, Korea, Republic of

Background. Hepatic resection and liver transplantation are surgical therapeutic option for small-sized HCC. But, patients with single tumors and preserved liver function present a therapeutic dilemma.

Purpose. in this study, we examined the outcomes of surgical resection for HCC patients meeting Milan criteria with preserved liver function and rationale of hepatic resection as the initial treatment for HCC meeting Milan Criteria.

Material. Between 1990 and 2005, 248 patients with HCC underwent Keratectomy. In 158 primary HCC patients meeting Milan criteria (Group M) and in 90 patients beyond Milan criteria (Group N). Median age were 54.5 years in group M and 52.4 years in group N.

Results. Most of patients have A of Child -Pugh scores, bur 4 patient in group M and 1 patient in group N have B of CPS. The tumor size, mean survival months, level of AFP, E-S grade and vascular invasion rate were significantly different between two groups. 67 patients in group M and 22 patients in group N have intrahepatic recurrence after primary hepatectomy. The 1, 3, and 5 years disease-free survival rate were 86.7%, 59.6% and 40.2% in group M and 67.1%, 52.3%, and 50.5% in group N, respectively. The cumulative 1, 3, and 5 year survival rates were 86.0%, 68.2%, and 54.7% in group M after primary hepatectomy and 62.2%, 45.5%, and 29.4% in group N, respectively.

Conclusion. Because of high survival rate and long-term survival after adequate treatment of recurrence, primary hepatectomy is resonable option as first-line treatment for HCC meeting Milan criteria with preserved liver function

PP 23.03

A Case of Huge Hepatocellular Carcinoma With Aplastic Anemia in Young Aged Man

Won, Yong Sung¹; Cho, Jin Bum²; KIM, Jung Ah³

¹St. Vincent hospital, Surgery, 93-6 Ji-dong Paldal-gu, Suwon, Korea, Republic of; ²St. Vincent hospital, Surgery, Suwon, Korea, Republic of; ³St. Vincent hospital, Hematology, Suwon, Korea, Republic of

Aplastic anemia is a disease that characterized by the pancytopenia and bone marrow suppression. Generally, the diagnosis is performed by bone marrow biopsy and hematopoietic stem cell transplantation is regarded as curative treatment. We experiended one case of aplastic anemia with hepatocellular carcinomoa and complete response for the aplastic anemia had been documented without hematopoietic stem cell transplantation after Rt hepatic lobectomy for hepatocellular carcinoma. 28 years old male visted our hospital. He complained Rt upper quadrant pain and epigatric pain. he was diagnosed with hepatocellular carcinoma of the hepatic 8th segment ( 17×12×10 cm) 3 months ago, and then he received three cycles of TACE. The operation for Hepatocellular carcinoma was scheduled. At the admission, we checked complete blood cell counts which showed pancytopenia ( Hemoglobin level was 8.7g/dl, platelet count was 10,000/mm6, White blood cell count was 1,870/mm6). We perfromed bone marrow biopsy and bone marrow suppression was confirmed ( ceullarity 10–20%), So we could diagnosed aplastic anemia and considered Hematopoietic stem cell transplantation or immunosuppresive treatment, but the progression of the hepaticoellular carcinoma was expected. Furthermore, the patient was Hepatitis B carrier, so when immunosuppression, aggravation of the infection could be foresighted. We transfused Packed red cell and platelete concentration and injected granulocyte stimulating factor preoperatively. Then Rt. hepatic lobectomy was performed.(2005.8.2) After the surgery, complete blood cell counts were recoveryed spontaneously without specific treatment. ( On postoperative 10th day, hemoglobin count was 11.1g/dl, white blood cell count was 6110/mm3, platelet count was 100,800/mm6), Now, two yeara later, there is no evidence of relapse of the hepatocelular carcinoma and aplastic anemia.

PP 23.04

EVALUATION OF THE USE OF HABIB-4X SEALER DURING LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENTS

Ibrahiem, Tarek; Soliman, Hossam Eldeen; Soliman, Bassem; Marwan, Ibrahiem

national liver institute, Menoufia University, Department of Hepatobiliary and liver transplantat, Egypt

Background. Hepatocellular carcinoma is a common tumor in patients with liver cirrhosis. Bleeding tendency, portal hypertension and the general status of the patient are important factor in planning therapeutic option. Habib-4x sealer has emerged a simple and safe tool during liver resection in those patients.

Aims. Evaluation of the use of this tool during liver resection in cirrhotic patients especially as regards safety, and outcomes.

Patients and Methods. We had performed 30 consecutive liver resections in cirrhotic patients in the department of Surgery, National Liver institute, Menoufia University since the first of August 2006 to the end of July 2007 using this device. Patients were Child class A with equal sex distribution and with single hepatic focal lesions (mean diameter 8.5±3 cm). All the patients had HCC with no other forms of therapy before or during the procedure. Five cases had formal resections, 12 had bisegmentectomy and 13 had non-anatomical resections. We collected the preoperative tumor characteristics, patient's operative data, postoperative details including hospital stay, the in-hospital complications and early follow for two postoperative months.

Results. There were no operative or in-hospital mortality. The operative time was 120± 30 minutes; blood loss was less than 100 cc in most of the cases. Hospital stay was 5±2 days. Complications included ascites production and leak in 4 cases, wound infections in 3 cases and pleural effusion in 3 cases.

Conclusions. Although the Habib-4x Sealer is a safe, fast technique that reduces operative time hospital stay and costs but this technique must be performed by well trained hepatobiliary surgeons especially in formal resections and in lesions near the major vessels especially the hepatic veins.

PP 23.05

HIGH PREOPERATIVE C-REACTIVE PROTEIN LEVEL AFFECTS UNFAVORABLY THE PROGNOSIS OF PATIENTS WITH HEPATICELLULAR CARCINOMA AFTER CURATIVE RESECTION

Hwang, Yoon Jin¹; Kim, Jong Yeol¹; Chang, Su Kurn¹; Lee, Sun Gi²; Kee, Se Kook³; Chun, Jae Min⁴; Kim, Sang Geol¹; Kim, Yang Il⁵

¹Kyungpook National University Hospital, Surgery, Daegu, Korea, Republic of; ²Andong Sungso Hospital, Surgery, Andong, Korea, Republic of; ³Kumi Cha Hospital, Surgery, Kumi, Korea, Republic of; ⁴Samsung Medical Center, Surgery, Seoul, Korea, Republic of; ⁵Japan

Background. The prognosis of the patients with hepatocellular carcinoma (HCC) is unfavorable even after curative resection. Host responses to tumor such as local and systemic inflammatory responses and immune reactions as well as tumor factors and liver function status may affect the overall survival. C-reactive protein (CRP) has been reported to affect the prognosis of various gastrointestinal and hematological malignancies.

Methods. We reviewed 82 patients who underwent curative resection for HCC retrospectively. Correlation between preoperative CRP level and clinical factors was analyzed. The clinical factors, overall survival, and disease free survival of high CRP group (>10 mg/L, n = 18) and normal CRP group (<10 mg/L, n = 64) were compared. Univariate and multivariate analysis was performed to identify the prognostic factors.

Results. 72 patients were male and 10 patients were female. The mean age was 53.9 years old. All patients except only one patient of Child B stage were in Child A stage. The median size of tumors and level of serum AFP were 60.3mm and 599.92ng/ml respectively. The mean serum albumin was 4.1¡¾0.45 mg/dl. Vascular invasion of tumor was present in 36.6%. The median preoperative CRP was 8.8 mg/L. The CRP level was inversely correlated with serum albumin level (r = -0.382; p < 0.001), Patients of high CRP group (n = 18) had lager mean size of tumors, lower mean level of albumin, higher incidence of stage 3, and higher incidence of vascular invasion compared to the patients of normal CRP group. In high CRP group, 1 and 3 year overall survival rate was 61.1% and 25.5%, whereas 1, 3, and 5 year overall survival rate was 87.5%, 72.9%, and 60.1% in normal CRP group (p < 0.001). Multivariate analysis revealed that preoperative CRP level and vascular invasion are independent prognostic factors of survival and recurrence after curative resection.

Conclusion. This study showed preoperative CRP level in addition to the presence of vascular invasion is an independent and significant prognostic factor.

PP 23.06

PERCUTANEOUS ABLATION FOR SMALL HEPATOCELLULAR CARCINOMA EQUAL TO OR LESS THAN 2 CM IN DIAMETER

Kuang, Ming¹; Xu, Zuo F²; Lu, Ming D¹; Liang, Li J¹; Peng, Bao G¹; Xie, Xiao Y²

¹The First Affiliated Hospital of Sun Yat-Sen University, Department of Hepatobiliary Surgery, Guangzhou, China; ²The First Affiliated Hospital of Sun Yat-Sen University, Department of Medical Ultrasonics, Guangzhou, China

Objective. To investigate the thereapeutic effects of percutaneous ablation for hepatocellular carcinoma (HCC)? 2 cm in diameter.

Methods. Thirty-three cases of pathologically conformed HCC sized up to 2 cm were treated with percutaneous microwave ablation (MWA) or percutaneous ethanol injection (PEI) using a multi-pronged needle. All patients signed written informed consent before the treatment. Follow-up ranged from 3 to 37 months (mean, 18 months±9). Patients were observed for progression of the treated tumors and for appearance of new lesions in the liver. Primary aims were disease-free survival rates and overall survival rates. Risk factors to the local effectiveness, and survival were assessed with Chi-square test, univariate and multivariate analysis.

Results. The complete ablation rate was 93.9%, the local recurrence and distant recurrence rates were 9.1% and 33.3%, respectively. One, 2-, and 3-year disease-free survival rates were 62.6%?62.6%?62.6%, respectively. Overall survival rates were 84.0%?74.5%?63.9%, respectively. Of all 16 variables assessed by univariate analysis, only pre-ablation?-fetoprotein (AFP) level was significantly related to recurrence-free survival, while AFP level and distant recurrece were significantly related to overall survival. In multivariate analysis, AFP level and distant recurrece were independent risk factors to overall survival.

Conclusions. Percutaneous ablation is capable of eradicating HCC? 2 cm in size. Pre-ablation AFP level and post-treatment distant recurrence are significantly related to prognosis.

PP 23.07

LOCO-REGIONAL MANAGEMENT OF LIVER TUMORS

KANTHARIA, CHETAN¹; PRABHU, RAMKRISHNA²; BAPAT, RAVINDRA²; SUPE, AVINASH²

¹Kem Hosital & Seth Gs Medical College, Surgical Gastroenterology, Mumbai, India; ²Kem Hospital & Seth Gs Medical College, Clinical Pharmacology, Mumbai, India

Introduction and Aim. Liver cancer causes death in 75 percent of patients within a year of diagnosis. Other than conventional surgical treatment, loco-regional treatment modalities like radiofrequency ablation, Trans arterial Chemo-embolization and chemotherapy, are used. This study determines the role of loco-regional modalities in management of Liver Malignancy. Method: 38 patients of Liver Tumors (31M: 7 F, age range: 45–78 years) presented from 2003–2006. Of these, 27 were of Primary Liver Malignancy (8 cirrhotic), 3 recurrence and 8 were metastatic- (colorectal). Although preoperative investigations revealed feasibility of resection in 13 cases, on exploration only 12 patients were found to resectable. Resection done were segmental resection (segment III)-3 patient, Right Hepatic resection 6 patients, Left hepatic resection 2 patients and Extended Right in 1 patients. In 4 patients no therapy was given in view of extensive disease, all of whom died within 6 months. Of the remaining 22 patients, 8 patients were subjected to RFA, 3 patients to TACE, 9 patients to a combination of RFA and TACE and 2 patients to chemo-infusion, and. The average follow up was for 18 months. Their survival and The Quality of Life (Modified SF-36 score) was assessed.

Results.

GROUP	MEAN SURVIVAL IN MONTHS	AVERAGE QOL
Resected group	18 (1–32)	7.42
Group left alone	2.5 (1–4)	2.75
RFA	12	6
TACE	12 (11–13)	4
TACE +RFA	20.5 (16–25)	6.5
Chemotherapy	6	4

Conclusion. Loco-regional treatment has a definite role in the management of Liver tumor, with the patient leading a good quality of life.

PP 23.08

STEROETACTIC RADIOSURGICAL ABLATION USING CYBERKNIFE IS A SAFE METHOD FOR PROVIDING EFFECTIVE TREATMENT FOR UNRESECTABLE HEPATIC MALIGNANCIES

Stephenson, G. Robert; Grabbe, Kelly; Sorgen, Stephen D.; Buchanan, Sam W.; La Nasa, Peter

Harris Methodist Fort Worth Hospital, Fort Worth, United States

Introduction. The Cyberknife radiosurgical ablation system with precision can deliver high dose radiation to essentially any site in the body. There are many patients with malignant liver tumors who are not candidates for the standard local therapies (e.g. surgical resection, radiofrequency ablation, or transplantation).

Objective. The aim of this retrospective chart review is to determine whether radiosurgery may be able to safely provide effective local control for malignant liver tumors.

Methods. Between July 2006 and June 2007, 15 patients with primary or secondary hepatic malignancies underwent radiosurgery using the Cyberknife system. Seven patients had primary liver tumors (5 hepatocellular carcinoma; 1 intrahepatic cholangiocarcinoma) and nine had liver metastases from a variety of primary sites. All patients were not candidates for standard local therapy. The average tumor size was 5.9 cm (range 2.6–14 cm). Patients received an average dose of 3.8 Gy in 3 or 4 fractions.

Results. None of the patients was admitted to hospital for either short or long term toxicity related to treatment. There was no treatment related mortality. Half of the patients noted mild, self-limiting treatment related symptoms. The overall response rate was 87%. The one year actuarial survival rate was 73%. One patient with a 14 cm hepatocellular carcinoma was subsequently able to undergo resection nine months after radiosurgery. The patient's tumor had decreased to a diameter of 7 cm and the resected tumor was 70% necrotic on final pathology.

Conclusion. In summary, this early experience indicates that radiosurgical ablation using Cyberknife is a remarkably safe treatment that can produce a high rate of biological response in patients with hepatic malignancies who are not candidates for standard local therapies and may also have a role in downstaging patients with large unresectable tumors in order to make them resectable.

PP 23.09

LAPAROSCOPIC RADIO FREQUENCY ABLATION OF LIVER TUMORS

CHINNUSAMY, PALANIVELU; PALANISAMY, SENTHILNATHAN; RAMAKRISHNAN, PARTHASARATHI; PALANIVELU, PRAVEEN RAJ; RANGASAMY, SENTHILKUMAR

GEM HOSPITAL, GI SURGERY, COIMBATORE, India

Introduction. Resection is the best modality of treatment for liver tumors as they have prolonged survival following resections. But still only 25% of these tumors are amenable for resection due to various factors. Radio-frequency thermal ablation is one of the most promising minimally invasive techniques for the treatment of unresectable hepatic tumors.

Objective. To evaluate the use of laparoscopic radiofrequency ablation for liver tumors and the potential advantages over other modalities.

Methods. Between April 2004 and July 2007, we have performed 37 laparoscopic radiofrequency ablations mainly for hepatoma and liver secondaries. We performed a diagnostic laparoscopy and laparoscopic ultrasonogram for localization of the lesion and detecting additional lesions. Under ultrasonic guidance radio frequency ablation is done using RITA system. The process of ablation is monitored by real time ultrasound. Follow up CT's are taken after 2 months to assess the completeness of ablation

.Results. The average size of the lesions was 3.7 cm (2to 5.5 cm). Out of 37 lesions in 31patients, 29 have resolved completely and in the remaining 8 patients we performed reablation. The lesions that were inadequately ablated were more than 4.5 cm. The lesions were distributed throughout the liver. We have not applied Pringle maneuver in any of our patients. There were no detectable changes in hemoglobin levels, platelets counts and liver biochemistry in any of our patients. The mean hospital stay was 3 days. Over a period of 3 year follow-up, we had 4 recurrences.

Conclusion. Laparoscopic RFA for management of liver tumors results in decreased morbidity and quicker recovery especially in the background of cirrhosis.

PP 24.01

LAPAROSCOPIC MANAGEMENT OF BENIGN CYSTIC LESIONS OF THE LIVER

Varma Gunturi, Surya Ramachandra; Kota, Venugopal; Kona, Lakshmi Kumari; Ravindranath, K.

Global Hospitals, Hyderabad, India

Introduction. The widespread success of Laparoscopic Cholecystectomy worldwide, enabled by advances in technology has prompted surgeons to explore the role of laparoscopy in other surgical conditions including liver diseases. Laparoscopic management of cystic lesions of the liver has been described to be a safe approach. We describe our experience in laparoscopic management of benign cystic lesions of the liver in a tertiary care center.

Materials and Methods. 56 Patients over last 7 years underwent Laparoscopic Liver Surgery for symptomatic benign cystic lesions. Indications were: Simple Cysts (n = 33), Polycystic Liver Disease (n = 1) and Hydatid Cysts (n = 22). Data was collected prospectively and retrospectively. Deroofing±Omental packing was the preferred treatment in simple and polycystic liver disease. In Hydatid cysts, puncture and aspiration, scolicidal injection and reaspiration followed by deroofing + omental packing was performed.

Results. In 55 patients, the procedures were completed laparoscopically. Conversion to Laparotomy was needed in 1. Complications were seen in 3 patients: Anaphylaxis (n = 1), bilioma (n = 2) which were managed successfully non surgically. There was no mortality. Follow up period ranged from 3–60 months.

Conclusions. Laparoscopic management of benign liver cysts in selected patients is safe in experienced hands.

PP 24.02

GIANT HEPATIC CYSTS-THE FEASIBILITY OF LAPAROSCOPIC SURGERY

Seah, Melanie; Kow, Alfred; Chan, Chung Yip; Ho, Choon Kiat; Liau, Kui Hin

Tan Tock Seng Hospital, General Surgery, Singapore, Singapore

Background. Selected patients with symptomatic giant hepatic cysts stand to benefit the many advantages that come with laparoscopic surgery.

Aim. The objective of this study is to review our experience and the surgical outcome of laparoscopic management of giant hepatic cysts (>8cm) in a tertiary institution.

Methods. From January 2002 to December 2006, seven patients underwent surgery by the hepatobiliary team for symptomatic giant hepatic cysts (>8cm). The demographic and operative data were collected and analyzed.

Results. There were 4 males and 3 females with the median age of 64 (50 to 78) years. The median size of the cyst by radiological measure is 18 (9 to 30) cm. Partial cystectomy leaving behind the cyst wall adjacent to liver parenchyma was performed for all patients. Six underwent laparoscopic surgery with one conversion to open surgery due to dense adhesions and a posteriorly sited cyst in segment VI. One patient underwent open surgery due to the pre-operative suspicion of hydatid cyst. The median length of surgery was 200 (105 to 230) minutes for patients managed laparoscopically compared to 225 minutes for those managed with open surgery. Post-operatively, one patient who was managed laparoscopically had deep vein thrombosis while one patient who underwent open surgery had pleural effusion. There was no mortality. The median length of stay was 3 (1 to 12) days for those who were managed laparoscopically compared to 9 days for those with open surgery.

Conclusions. Laparoscopic partial cystectomy for giant hepatic cysts is safe and effective. It can be performed within reasonable time limits with minimal morbidity. Patients recover faster and enjoy a shorter hospital stay.

PP 24.03

LAPAROSCOPIC DRAINAGE AND PARTIAL CYSTECTOMY FOR LIVER HYDATID DISEASE.

Tepetes, Konstantinos; Spyridakis, Michael; Baloyannis, John; Christodoulidis, Gregory; Hatzitheofilou, Constantine

University Hospital of Larissa, Surgery, Larissa, Greece, Greece

Laparoscopic and percutaneous minimal invasive techniques have been recently used for the management of hepatic hydatid disease with results similar to those following open conventional methods, regarding safety and efficacy. We present our laparoscopic technique for draining and excising liver hydatid disease. The safety of our method is based on the appropriate mobilization and isolation of the involved liver segment and the use of a 18 mm trocar for the aspiration of the cyst contents [fluid, daughter cysts, inner layer]

PP 24.04

RADIOFREQUENCY ASSISTED LAPAROSCOPIC LIVER RESECTION IN A WOMAN WITH BENIGN LIVER TUMOUR; A NOVELL, SAFE AND RELIABLE TECHNIQUE

Mir, Jose¹; Redondo Cano, Carlos R²; Bruna Esteban, Marcos¹; Artigues, Enrique¹; Fabra, Ricardo¹

¹Hospital general Universitario de Valencia, Hepatic surgery, Valencia, Spain; ²Hospital general Universitario de Valencia, Genera l and digestive surgery department, Valencia, Spain

Background. The hepatic surgery has developed fast in the last years. Nowadays, the progress in the surgical technique and the evolution parenchymal transection systems; has improved the results in patients submitted to hepatic resections. The radiofrequency assisted hepatic resection has proved to be a very safe transection method, decreasing the surgical times, and the complications rate. Laparoscopic access for the hepatic resection is growing in acceptance; many authors support its good Results.

CLINICAL CASE: A 33 years-old woman, who refers an history of recurrent abdominal pain, mainly in epigastrium and both hypochondriums, there were no fever, icterus, or nausea, the blood tests results were normal. A magnetic resonance was accomplished, discovering a big liver lesion located in the left lobule, which displaces the gastric cavity, this lesion does not infiltrate adjacent structures. The radiologic aspect suggests a liver angyoma.

Methods. The patient underwent a resection of the left lateral segment, accessing the abdomen trough 4 Throcars; the parenchymal transection was performed using the Habibtm 4x laparoscopic device with RITA 1500X RF Generator and software (RITA Medical Systems, Inc. 46421 Fremont, CA 94538 USA), There was no needing for blood transfusions after the surgery; the patient was discharged on the fifth postoperative day without complications.

Discussion. The implement of laparoscopic in hepatic surgery has demonstrate to be beneficial, permitting less discharge times of patients, the us of radiofrequency for the laparoscopic transection of hepatic parenchyma helps to improve results, allowing a faster, safer and reliable surgery, as well as decrease the needing of blood transfusions.

PP 24.05

THE EFFICACY AND SAFETY OF RADIOFREQUENCY ABLATION THERAPY UNDER SMALL THORCOTOMY FOR HEPATOCELLULAR CARCINOMAS

UCHIDA, SHINJI; HORIUCHI, HIROYUKI; HISAKA, TORU; KAWASHIMA, YUSUKE; FUJISHITA, MANAMI; KINOSHITA, HISAFUMI; SHIROUZU, KAZUO

Kurume University Hospital, Surgery, KURUME, Japan

Background; We have performed radiofrequency ablation therapy(RFA) for hepatocellular carcinomas(HCC). At that time, we often meet some difficult cases to introduce under ultrasound guidance cause of lung and lib. We could performe RFA in safety through the diaphragm under ultrasound guidance after small thoracotomy. So we examined the efficacy and safety of RFA under the thoracotomy for HCC patients. Patient and Method; We perform RFA at the 13 HCC patients under thoracotomy. If we cannot detect the tumor, we marked the point of thoracotomy before surgery. After thoracotomy, an electrode cannula was introduced into the tumor through diaphragm under ultrasound guidance, which was then ablated at 40w to 90w under ultrasound imaging monitoring, using a RFA device at the frequency of 460kHz. The efficacy of this RFA therapy was evaluated by intraoperative enhanced ultrasound, perioperative and follow-up CT scans. Results; The RFA effectively ablated in all tumor(100%). Complications included intercostals neuralgia; however, there was no serious mobidity such as pleural effusion and bleeding. Conclusions; The present study has demonstrated that the RFA under small thoracotomy is able to provide a safe and effective means in controlling HCC.

PP 24.06

SAFETY AND RESULTS OF LIVER RESECTION AT A NEW SPECIALIST UNIT IN INDIA

Philip, Sujith¹; Doctor, Nilesh²; Nagral, Sanjay²

¹Jaslok Hospital and Research Centre, GI Surgey, Mumbai, India; ²Jaslok Hospital and Research Centre, GI Surgery, Mumbai, India

Introduction. Liver surgery is a blossoming field in India. But data on results are scarce. We present an experience of 111 hepatic resections over an 8year period at a specialist unit.

Objectives. Safety and outcome of liver resections at a new HPB unit in India.

Methods. A retrospective analysis was done of 111 liver resections between 1999 to 2007 focusing on patient details and outcome. Resections were done with intermittent porta clamping except in living donor. The liver was divided with an ultrasonic dissector. Intraoperative ultrasound was used.

Results. Patients included 68 males, 43 females with a mean age of 47 yrs (range 6 months to 74 years). Indications included Hepatocellular carcinoma in 27, Carcinoma GallBladder 12, Hepatoblastoma 11, Cholangiocarcinoma 17, Haemangioma 11, Metastases 9, Donor Living Liver Transplant 7 & others 17. Procedures included Right Hepatectomy 33, Right Extended Hepatectomy 10, Right Lateral Segmentectomy 2, Left Hepatectomy 14, Left Lateral Segmentectomy 12, Segmental Resections 24, Non anatomical resections 16. There were 6 postoperative deaths giving a mortality rate of 5.4%. All deaths were in patients with malignancy. Post operative morbidity included Post Hepatectomy Liver Failure in 11, bile leak or bilioma in 18 (stenting in 8), re-bleeding in 2 and prolonged cholestasis in 1. The overall major morbidity rate is 28.82% and was influenced by ASA Score and extent of resection. Both were less in latter half of the series. The mean follow up is 52 months (range 2–84). 17 patients are lost to followup. All patients with benign indications are well at last follow up. The mean survival for patients with HCC is 11 months, cholangiocarcinoma 33 months &metastases 25months.

Conclusions. Although ours is a new unit in a developing country the morbidity and mortality of liver resections compare favourably with literature from developed countries.

PP 24.07

R.F. ASSISTED HEPATECTOMY Results OF 50 LIVER RESECTION R Pellicci, A. Percivale, A. Gandini, S Baldo S. Corona Hospital, Italy

Pellicci, Riccardo

Santa Corona Hospital, Pietra Ligure, Italy

Introduction. Surgical resection remains the best treatment for liver tumors. A new technique first described by Habib using radiofrequency has increasingly been utilised in the past years: this new procedure, employs the heat produced by a radiofrequency needle electrode to obtain a previous coagulation of the tissue before cutting it and to perform a liver resection.

Methods. From June 2002 to September 2005 fifty patients underwent liver resection with the Habib technique (21 HCC and 29 ColonRectal metastasis) with the evaluations of recurrences on the surgical margins, blood loss and blood transfusion requirement, ICU admission and technical related complications. Patients were enrolled in to 3 groups looking for margin of resection: Group A enrolled 9 patients: no margin; Group B: 19 patients:<1 cm and Group C: 22 patients > 1 cm. Six patients receive blood transfusion with a mean of 2,7±1,5 units of red blood cells. Two patients required fresh frozen plasma. The mean overall operative time was 210±80 minutes: the mean resection time was 65±43 minutes.

Results. Cumulative survival rates were calculated with the Kaplan Meier method Factors found to be significant predictors of survival and disease free survival on univariate analysis were subjected to multivariate analysis using the Cox's proporzional hazard mode. At a median follow up of 50 months 31 patients were alive and 19 died. No recurrence on the line of resection was diagnosed. Thirty patients experienced recurrence in the remnant liver: extrahepatic recurrence occurred in 7 patients.

Conclusion. Although this study was not designed to compare Habib technique with other resection technique, we can say that this new technical monopolar and bipolar devices used to perform hepatic resection seems to be effective in order to decrease the transfusion requirement intraoperative blood loss and ICU admission. Moreover the margin of necrosis induced by the coagulative necrosis is adequate for a complete sterilization of the resection site.

PP 24.08

REPORT OF AN IN VIVO ON PIG LIVER STUDY OF LAPAROSCOPIC BLOOD-SAVING LIVER RESECTION USING A NEW RF-ASSISTED DEVICE

Navarro, Ana Cristina¹; Burdio, Fernando²; Berjano, Enrique³; Güemes, Antonio⁴; Sousa, Ramon⁵; Rufas, Maria⁴; Subira, Jorge⁶; Burdio, Jose Miguel⁷; Castiella, Tomas⁸; Tejero, Eloy⁴; De Gregorio, Miguel Angel⁹; Grande, Luis²; Lozano, Ricardo⁴; Gonzalez, Ana¹⁰

¹HCU Lozano Blesa and FH Calahorra, Department of Surgery, Zaragoza and Calahorra, La Rioja, Spain; ²Hospital del Mar, Department of Surgery, Barcelona, Spain; ³University of Valencia, Dept of Electric Engineering and Communications, Valencia, Spain; ⁴HCU Lozano Blesa, Department of Surgery, Zaragoza, Spain; ⁵HCU Lozano Blesa, Department of Surgery, Zaragoza; ⁶HCU Lozano Blesa, Department of Urology, Zaragoza, Spain; ⁷University of Zaragoza, Dept of Electric Engineering and Communications, Zaragoza, Spain; ⁸HCU Lozano Blesa, department of payhology, Zaragoza; ⁹HCU Lozano Blesa, Depertment of interventional Radiology, Zaragoza, Spain; ¹⁰Veterinary Faculty, University of Zaragoza, Department of Animal Pathology and Surgery, Zaragoza, Spain.

Introduction. The aim of any device designed for liver resection is to allow blood-saving and quick resections, this may be optimized using minimally-invasive approach. In this article we d escribe a radiofrequency-assisted device, combining a cooled blunt tip electrode with a sharp blade on one side, on an in vivo preliminary study using hand-assisted laparoscopy to perform partial hepatectomies.

Methods. A total of 8 partial hepatectomies were performed on pigs through hand-assisted laparoscopy, using the radiofrecuency-assisted device as only method for transection and hemostasia. Main outcome measures were: transection time, blood loss, transection area, transection speed, blood loss per transection area and tissue coagulation depth. Risk of biliar leak was also assessed using methylene blue test.

Results. Transection time of 13±7 min for a mean transected area of 34±11 cm2. Mean total blood loss was 26±34 cc. Mean transection speed was 3±1 cm2/min, and blood loss per transection area was 1±1 ml/cm2. Abdominal examination showed no complications in nearby organs. One biliar leak was indentified in one case using methylene blue test. Transection surface was 34±11 cm2. Mean tissue coagulation depth was 9±2 mm. The inviability of the coagulated surface was assessed by NADH staining.

Conclusion. The RF-assisted device has demonstrated in a laparoscopic approach that it can perform liver resections quicker and with less blood loss than other commercial devices, using a single device in a minimally invasive approach without vascular control, while results have no significant differences with the same device used in open approach.

PP 24.09

ISOLATED TOTAL CAUDAL LOBECTOMY

Kotenko, Oleg

Institute surgery and transplantology, Department of the liver transplantation and surger, Kiev, Ukraine

Introduction. The caudate lobe of the liver lies deep between the hepatic hilus and the inferior vena cava. Isolated total caudal lobectomy usefull for treatment different tumor of the liver.

Aim. Aim was to present surgical techniques of isolated total caudate lobectomy.

Materials and Methods. Three techniques have been reported for isolated total caudate lobectomy: the anterior approach by Yamamoto, the posterior approach with or without total hepatic vascular exclusion by Yanaga and Takayama, and the left lateral approach by Colonna. A lot of surgeons used left lateral approach. We would like to demonstrate technique anterior transhepatic approach and the posterior approach for caudate lobectomy. The anterior transhepatic approach provides a safe procedure for an isolated caudate lobectomy. The opening of the hepatic parenchyma overlying the caudate lobe exposed the major hepatic veins and the hilar plate to direct view, facilitating control of venous bleeding and interruption of the ascending paracaval portal branches along the hilar plate. Its especially important for surgery Klatskin tumor Bismuth II. We are demonstrating technique of isolated total caudate lobectomy in case with Klatskin tumor by anterior transhepatic approach. In another case huge benign tumor of the caudate lobe we used right posterolateral approach. The division of the ascending paracaval portal branches, originating from the craniodorsal aspects of the hilar plate, and the control of the bleeding from the hepatic venous branches are formidable work, especially when the tumor is large. We don't use counterstaining technique to separate margin caudate lobe because upper anterior wall were hepatic veins. Liberation of the liver, securing the major hepatic veins, and complicated liver transaction requires a considerable amount of time, a shortcoming of this procedure

.Conclusion. Thus isolated total caudal lobectomy is parenchyma saving procedure for treatment local tumor of the liver different etiology.

PP 24.10

COMPARISON BETWEEN THE MINIMUM MARGIN DEFINED ON PREOPERATIVE IMAGING AND THE FINAL SURGICAL MARGIN AFTER HEPATECTOMY FOR CANCER. HOW TO MANAGE IT?

Elias, Dominique¹; Bonnet, Stéphane¹; Honoré, Charles¹; Kohneh-Shahri, Niaz¹; Tomasic, Gorana²; Lassau, Nathalie³; Dromain, Clarisse³; Goéré, Diane¹

¹Institut Gustave Roussy, Surgical Oncology, Villejuif, France; ²Institut Gustave Roussy, Pathology, Villejuif, France; ³Institut Gustave Roussy, Radiology, Villejuif, France

Background. The liver surgeon's decision to operate is based on imaging. However, no clear practical guidelines are available enabling surgeons to safely predict tumor-free margins after a partial hepatectomy. The aim of our study was to compare the preoperative margin measured on imaging to the final histological margin measured on the specimen, and to propose to the liver surgeon some simple practical guidelines to manage this surgical margin.

Patients and methods. Forty patients with liver metastases, who underwent an anatomical right or left hepatectomy, passing along the median hepatic vein, were selected for this study. The radiological margin was measured on 2 liver imaging and defined as the smallest distance between the LM and the median hepatic vein. Liver transection was always performed by parenchyma crushing. Results The median tumor-free excision margin was 5 mm at pathological analysis, significantly different (p < 0.0001) from the tumor-free margin measured on preoperative imaging (15 mm). The mean difference between these two measurements was 10±4 mm (median 9). This difference was partly due to the technique of transection, and partly due to technical deviations in relation to the ideal resection line. Conclusion the liver surgeon must consider that roughly a 5 to 8 mm tumor-free margin will disappear during hepatectomy when comparing measurements based on preoperative imaging versus tumor-free specimen margins. If the histologically assessed minimum 2-mm tumor-free margin is added, the surgeon must plan to have a 7 to 10 mm tumor-free margin on preoperative imaging.

PP 24.11

ELECTIVE LIVER RESECTION-A MULTIVARIATE ANALYSIS OF PARAMETERS DETERMINING THE POSTOPERATIVE OUTCOME

Schön, Michael R¹; Wiegel, Natalie M.¹; Kaps, Maria²; Hauss, Johann P.²; Scholz, Markus³; Zaatar, Mohamed¹

¹Klinikum Karlsruhe, Surgery, Karlsruhe, Germany; ²Universtiy of Leipzig, Surgery, Leipzig, Germany; ³Universtiy of Leipzig, Medical Informatics and Statistics, Leipzig, Germany

Introduction. Postoperative morbidity and mortality after liver resection has been reduced significantly over the past years. To further improve upon the postoperative outcome we analyzed a series of patients undergoing elective liver surgery.

Methods. Out of 200 patients, 152 underwent liver resection for malignancy and 48 for benign lesions. Procedures performed were extended right-hepatectomy (n = 35), right- (n = 58), extended left- (n = 2), left (n = 24), left lateral- (n = 18), and segmental-hepatectomy (n = 63). More than 150 pre- and intraoperative parameters of every patient were registered and statistically correlated with the postoperative outcome. For univariate analysis, the t-Test, Mann-Whitney-U-Test, Chi-Quadrate-Test and Fisher-Exact-Test were applied and for multivariate analysis, a binary logistic regression model.

Results. In 130 patients no complications occurred and in 37 patients complications were considered as minor (pleural effusions, superficial wound infections). 27 patients suffered from severe complications such as pulmonary embolism, sepsis, liver dysfunction. The 30 day hospital mortality was 3% (n = 6). Preoperative parameters such as age, diabetes, ASA classification and fibrosis and intraoperative factors such as duration, transfusion and simultaneous procedures were correlated with postoperative morbidity and mortality. Multivariate analysis revealed that diabetic patients and liver resection with simultaneous procedures were both correlated with high morbidity and mortality. The correlation for diabetes and simultaneous procedures with a poor clinical outcome was even stronger than i.e. for cirrhosis and age.

Conclusion. Considering that this group of 200 patients undergoing elective liver surgery already was selected for well established exclusion criteria and considering that simultaneous procedures often are not a matter of choice we suggest that focusing more on diabetes and its treatment in the selection process will result in a further improvement of the clinical outcome.

PP 25.01

EMERGENCY LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: THE DELAY BEYOND 72 HOURS DOSE NOT INCREASE OPERATIVE DIFFICULTY OR RISK.

Darwish, Ammar¹; Al-Hourani, SA²; Ammori, Basil²

¹Manchester Royal Infirmary, General Surgery, Oxford Street, Manchester, United Kingdom; ²Manchester Royal Infirmary, General Surgery, Manchester, United Kingdom

Background. There is reluctance to perform emergency laparoscopic cholecystectomy (LC) in patients with acute cholecystitis (AC) if surgery is delayed beyond 72 hours in fear of increased operative difficulty, morbidity and conversion to open surgery.

Aims. To evaluate the safety and feasibility of delayed urgent LC, Methods. We adopted a policy of offering an emergency LC to patients with AC regardless of the delay incur red while awaiting access to the CEPOD theatre. The outcomes of surgery in patients operated on within 72 hours of admission (Group I) were compared with those who underwent delayed emergency LC (Group II).

Results. Between 2001 and 2006, 75 patients underwent emergency LC for AC (Group I, n = 22; Group II, n = 53). There was no difference between the groups with regard to age, sex distribution, ASA score and frequency of previous abdominal surgery. The interval between admission and surgery was significantly shorter in Group I (median, 2 vs. 7 days, p < 0.001). There were no conversions to open surgery. No differences were observed between the groups in the frequency of gangrene of gallbladder (9% vs. 6%, p = 0.627), operating time (median, 80 vs. 80 minutes, p = 0.456), postoperative morbidity (4.5% vs. 7.5%, p = 0.664) and mortality (4.5% vs. 1.9%, p = 0.503), or postoperative hospital stay (median, 2 vs. 2 days, p = 0.403). There were no bile duct injuries.

Conclusions. The delay in performing emergency LC for AC beyond 72 hours does not increase operative difficulty or risk of operative morbidity. Patients with AC should not be denied an emergency LC if access to theatre was delayed.

PP 25.02

EFFICACY OF PERCUTANEOUS CHOLECYSTOSTOMY FOR PATIENTS WITH ACUTE CHOLECYSTITIS and ASA CLASSIFICATION MORE THAN 3

Yun, Sung Su¹; Lee, Dong Shick¹; Kim, Hong Jin²

¹Yeungnam University Hospital, Department of Surgery, Taegu, Kuwait; ²Yeungnam University Hospital, Department of Surgery, Taegu, Korea, Republic of

Background/AIMS:Percutaneous Cholecystostomy(PC) has been proposed as an effective bridge procedure before elective cholecystectomy for acute cholecystitis. But many centers have different indications of PC including old age, comorbidity, sepsis and liver function abnormality etc. Among them, we designed this study to evaluate the efficacy of PC in patients with acute cholecystitis and ASA classification more than 3.Method.: For recent 3 years, we did PC in 29 patients with acute cholecystitis and ASA classification more than 3. We did PC as a bridge procedure before elective cholecystectomy(bridge group) in 20 patients and as a palliation of symptom in 9 patients(palliation group). We evaluated patients characteristics, complication rate after PC, ASA classification change before and after PC, resumption of oral intake after PC and success rate of laparoscopic cholecystectomy(LC) etc.

Results. Mean age of bridge group and palliation group were 72.7 ¡¾ 9.7(Mean ¡¾ S.D.) and 75.3 ¡¾ 8.5 years old, respectively. Mean ASA classification before and after PC were 3.7 ¡¾ 0.5, 2.3 ¡¾ 0.8 and 4.0 ¡¾ 0.8, 3.4 ¡¾ 0.7, respectively in both group. There was only one complication after PC(peritonitis after PC, 3.4%), who is one of two mortality cases in palliation group(22.2%). Resumption of oral intake was possible 3.2 ¡¾ 2.1 days after PC in bridge group and 3.0 ¡¾ 2.4 days in palliation group except two mortalities due to underlying diseases. We tried 12 LC and one failed due to bile duct injury (success rate was 91.6%). Mean operation time for LC was 106.8 ¡¾ 32.5 which is a little bit longer than our elective LC. The postoperative course of all patients received LC and open cholecystectomy were uneventful.

Conclusion. PC is a good procedure for bridge procedure before elective LC and palliation of symptom in patients with acute cholecystitis and ASA classification more than 3.

PP 25.03

THREE-PORT-CHOLECYSTECTOMY AS A ROUTINE PROCEDURE IN ACUTE CHOLECYSTITIS

Riesener, Klaus-Peter; Wichary-Janoschka, Claudia; Roth, Marcus

Marien-Hospital Marl, Department of General and Visceral Surgery, Marl, Germany

Background. During recent decades laparoscopic cholecystectomy has been established as the procedure of choice for the treatment of acute cholecystitis. The four-trocar technique can been regarded as the standard procedure. The aim of the study was to show the feasibility and safety of a three-trocar-technique as the routine procedure in acute cholecystitis.

Methods. Between January 1st, 2002 and December 31st, 2005, 380 consecutive patients underwent cholecystectomy for gallstone disease. Of these 106 patients presented with acute cholecystitis. 96 patients were selected for laparoscopic cholecystectomy, in 10 cases primary open cholecystectomy was performed. Any laparoscopy was started using the three-trocar technique.

Results. The three-trocar-technique was feasible in 77 patients with acute cholecystitis. A fourth trocar was added in 5 additional patients. The insertion of the fourth trocar was mainly performed due to poor visualization of the structures of Calot‘s triangle. In 14 further patients laparoscopy was converted to open cholecystectomy. There were no postoperative deaths and no major operative complications.

Conclusion. The three-port technique for laparoscopic cholecystectomy is safe and feasible in the majority of patients with acute cholecystitis. Extension towards a four-trocar technique is useful in selected cases. Early conversion towards open cholecystectomy in patients with poor identification of the Calot‘s triangle keeps the rate of complications reasonable and avoids lesions of adjacent structures. The main advantages of the three-port technique are that it is less expensive, it can be performed by a single surgeon under the assistence of a nurse, and it leaves fewer scars.

PP 25.04

LAPAROSCOPIC SUBTOTAL CHOLECYSTECTOMY-OUR TECHNIQUE AND A NEW CLASSIFICATION PROPOSAL

Chinnusamy, Palanivelu; P.S, Rajan; Palanisamy, Senthilnathan; M.V, Madan Kumar; K, Sendhilkumar

Gem Hospital, Gi Surgery, Coimbatore, India

Background. Laparoscopic cholecystectomies for acute cholecystitis are being performed commonly. We are presenting our surgical experience over the past 16 years (July 1991 to Jan 2007) in the management of the acute cholecystitis.

Materials and Methods. Total numbers of cases were 458 with 297 male and 161 female patients. Age group ranges from 34 years to 80 years. Duration of symptoms ranged from 1 to 5 days. 357 patients presented with pain abdomen. 234 patients had co morbid illness diabetes mellitus being the commonest one. 138 patients had right hypochondrial mass on clinical examination. Laparoscopic subtotal cholecystectomy (LSC) was performed in all patients (LSC I and LSC II) LSC I is the technique of leaving behind the posterior muscular wall of the GB which is adherent to the liver bed. LSC II includes the division of the GB at the infundibulam and suturing, after stripping of the mucosa.

Results. Out of 458 patients, 21 patients were converted to open cholecystectomy to complete the procedure. The mean operating time was 55 minutes for laparoscopic subtotal cholecystectomy and 132 minutes for open cholecystectomy. Mean blood loss was 67 ml. Hospital stay was 2.8 days.

Conclusion. Laparoscopy has a great role to play in the surgical management of the acute cholecystitis with excellent outcome and minimal morbidity. LSC offers all the benefits of minimally invasive surgery to the patients with very low conversion rate.

PP 25.04

LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS PERFORMED AFTER WORKING HOURS IS ASSOICATED WITH A POORER OUTCOME?

Chong, Charing C.N; Teoh, Anthony Y.B.; Wong, John; Lee, K.F.; Lai, Paul B.S.

Prince of Wales Hospital/ The Chinese University of Hong Kong, Surgery, Shatin, New Territories, Hong Kong

Background. Performing laparoscopic cholecystectomy LC for acute cholecystitis at night is challenging and is supposed to be associated with suboptimal performance and a higher conversion rate. Data on this aspect are lacking. OBJECTIVE To determine whether LC performed after working hours (nine am to five pm) was associated with increased rate of conversion in patients with acute cholecystitis.

Patients and Methods. Medical records of patients admitted for acute cholecystitis with emergency LC performed between July 1997 and June 2004 were reviewed. Clinical outcomes of patients who received the operation during and after working hours were compared.

Results A total of 158 patients were included. Eighty nine (56.3%) patients were operated before five pm and sixty-nine (43.7%) patients were operated after five pm. There were no significant differences in demographics between the two groups. Patients operated during normal working hours had to wait significantly longer for the operation (3.7 days vs 3.1 days, P = 0.026) [Table 1] while those operated during after hours were associated with a significantly higher conversion rate (29.2% vs 22.9%, P = 0.042). There were no significant differences in operative time, hospital stay, complication rate, percentage of operation performed by trainees and mortality rate. [Table 2].

Discussion and Conclusion. Laparoscopic cholecystectomy performed after working hours was associated with a higher conversion rate. These operations should be performed during normal working hours provided the patient remains stable and theatre lists are available.

	During working hours	After working hours	P
N (%)	89 (56.3)	69 (43.7)
Age *	58.0 (15.2)	57.7 (15.1)	0.898
Duration of onset of symptoms (days) *	3.7 (2.1)	3.1 (1.9)	0.026

	During working hours	After working hours	P
N (%)	89 (56.3)	69 (43.7)
Operative time (minutes) *	101.6 (51.9)	111.9 (54.9)	0.121
Hospital stay (days) *	7.7 (3.5)	7.4 (2.5)	0.986
Complication rate (%)	16.9	15.9	0.879
Operation performed by trainees (%)	30.0	21.7	0.226
Mortality (%)	0	0
Conversion rate (%)	29.2	44.9	0.042

* Data presented as mean (S.D.)

PP 25.06

PERCUTANEOUS CHOLECYSTOSTOMY FOR ACUTE CHOLECYSTITIS IN HIGH RISK PATIENTS: A RISING STANDARD?

Melloul, Emmanuel¹; Denys, Alban²; Demartines, Nicolas¹; Calmes, Jean Marie¹

¹CHU Vaudois, Visceral Surgery, Lausanne, Switzerland; ²CHU Vaudois, Radiology, Lausanne, Switzerland

Background. As percutaneous cholecystostomy (PC) is an alternative treatment to surgery in some cases of acute calculous/acalculous cholecystitis (ACC/AAC), we aimed to evaluate in a standardized high risk population PC procedure and its impact on both 30 days morbidity and mortality.Method.: Patients presenting ACC and AAC treated by PC or surgery were reviewed. Previous comorbid conditions at admissions were evaluated by the Simplified Acute Physiology Score II (SAPS). Complications after surgery and PC were classified using the Clavien and al. and SIR classifications, respectively. Cholecystitis was diagnosed by clinical signs, blood sampling and ultrasound (US) or CT scan. PC was performed by approach throughout the liver parenchyma under CT or US guidance after 2 to 4 days of broadspectrum IV antibiotics trial. Surgery was performed by laparoscopic or conventional cholecystectomy. All hydrocholecystitis or choledocolithiasis were excluded.

Results. Seventy nine percent (68/86) of patients underwent surgery and 21% (18/86) PC. The median SAPS score was 38 (15–71) for PC group and 18.5 (0–37) for SG group (p < 0.05) with a Predicted Death Rate (PDR) of 21% and 3%, respectively (p < 0.05). The overall 30 days mortality observed after PC and SG was 22% and 0%, respectively. The mortality rate was neither related to cholecystitis nor to PC procedure. The respective 42% (3/7) and 9% (1/11) mortality rate observed after PC in the AAC and ACC subgroups was only related to the severity of patients critical state (SAPS score of 56.5 and 33.5, respectively (p < 0.05)). PC resolved 94% of the acute episode. One patient required emergency cholecystectomy. Major complications rate after PC and surgery was of 0% and 3%, respectively (p > 0.05).

Conclusions. PC allows resolution of AC with a low procedure related morbidity and mortality and should be proposed to high risks patients. Early morbidity and mortality is related to patient's comorbidities rather than AC or PC.

PP 25.07

Case Study of Xanthogranulomatous Cholecystitis Mimicking Gallbladder Cancer with Metastasis□@of the Liver

Okano, Yusuke; Kotera, Yosihito; Katagiri, Satoshi; Ariizumi, Shun-ichi; Takahashi, Yutaka; Yamamoto, Masakazu

tokyo women's medical university, institute of gastroenterology, Tokyo, Japan

Xanthogranulomatous cholecystitis can often be difficult to preoperatively differentiate from the gallbladder cancer, as the peripheral organ tends to show a symptom of inflammatory infiltration. In recent years, however, the diagnostic imaging system has enabled preoperative identification of xanthogranulomatous cholecystitis in many cases. This paper reports a case of xanthogranulomatous cholecystitis with tumor of the liver, which was unidentifiable with gallbladder cancer with metastasis of the liver. The patient, 62 year-old male, had abdominal pain on the right side as well as emesis with fever after meal in April 2007, and visited local hospital. The Ultrasonography, CT, and MRI exposed a sign of gallbladder cancer, and the patient was referred to our institute for further check and treatment. The patient showed no symptom when hospitalized except for high figures in AST, ALT and bile tube-related enzyme. Markers for jaundice or tumor and inflammatory reaction were all normal while ICG was 7.2%. CT shows high thickening of the gallbladder wall and poorly-demarcated mass. We also found a viable lesion 15mm in diameter, which is suspected of hepatic metastasis. ERCP also shows two stones in the common bile duct, but there was no clear indication of stenosis. The cytology on the bile detected only up to class III a, but we decided to carry out the operation for gallbladder cancer with hepatic metastasis on June 5. The operation found scattered nodules in the liver, which we suspected to be a sign of hepatic metastasis. The gallbladder suffered adhesion to the peripheral tissues and could not be decorticated. We performed anterior segmentectomy, resection of Segment 4 of the liver, together with duodenum, and extra bile duct resection and choledochojejunostomy. The pathological test concluded the case was xanthogranulomatous cholecystitis with no malignancy. The tumor on the right hepatic lobe, which was also removed in the operation, had a similar sign of granulomatous lesion.

PP 25.08

TOTAL EXCISION OF THE EXTRAHEPATIC BILIARY TREE FOR CHRONIC BILIARY PAIN: IMPLICATIONS FOR OUR UNDERSTANDING OF SUCH PAIN.

Stubbs, Richard

Wakefield Hospital, The Wakefield Clinic, Wellington, New Zealand

Background. Chronic acalculous biliary pain is generally thought of as being either gallbladder in origin (acalculous gallbladder pain) or related to sphincter of Oddi dysfunction (SOD). The former is generally resolved by cholecystectomy and the latter may be resolved by sphincter division. However, many patients suffering from the condition have ongoing pain and disability following both cholecystectomy and sphincterotomy.

Aim. Does our current thinking on this condition fail to recognise other mechanisms for chronic biliary pain? Methods. We present the case histories of two patients who were seriously disabled by narcotic dependent chronic acalculous biliary-type pain, who had previously been treated with cholecystectomy and sphincter division (even repeated) with temporary or no relief. Both patients had experienced continual problems for a number of years and both had abnormalities of biliary dynamics as demonstrated by quantitative HIDA scanning. As a last resort, and after much discussion, both underwent excision of the extrahepatic, suprapancreatic bile duct with reconstruction by Roux Y hepatico-jejunostomy.

Results. Both patients were immediately relieved of their chronic narcotic dependent pain and have returned to normal life. Freedom from pain has now persisted for over 18 months in both cases. No histological abnormality was noted in the resected bile duct.

Conclusion. There is good reason to believe we do not yet have a clear enough understanding of the mechanism of chronic acalculous biliary pain, to be confident of the range of treatment options that can or should be offered for this condition. Failure to recognise this may leave a proportion of patients with disabling chronic pain and symptoms in the long term.

PP 25.09

EFFECTIVENESS OF A SUBCUTANEOUS LOOP IN BILIO-ENTERIC ANASTOMOSIS

Carrillo-Maciel, Vicente; Carrillo-Maciel, Jose Evaristo; Acosta-Saludado, Alma Leticia; Silva-Vasquez, Rene; Ramos-Linaje, Samuel

IMSS UMAE 134, Surgery, Torreon, Mexico

Background. At the end of the XIX century the first cholecystectomy was performed, also setting the beginning of biliary duct injuries. Approximately 95% of the injuries are benign. Treatment for these types of injuries is bilio-enteric anastomosis. The most common problem that we face is postoperative strictures, with a frequency of 13 -30% of the cases. Postoperative strictures cause an increase in morbidity and mortality subduing the patient to more invasive and complex procedures. Roux en Y reconstruction is the recommended procedure. A modification of this technique includes the employment of the proximal end-loop in a subcutaneous fashion, which permits access to the anastmosis with endoscopic equipment. This permits dilatation of strictures as many times as it is required.

Objective. Demonstrate the effectiveness of a subcutaneous loop in bilio-enteric anastomosis.

Materials and Methods. 50 patients with benign biliary duct injuries in the last ten years were revised. The patients were divided into two groups. Group I: Traditional reconstruction and Group II: Subcutaneous loop.

Results. 41 patients in group I and 9 patients in group II. Group I: One patient deceased. Group II had two patients with strictures treated with hydrostatic dilatation and three post-incisional hernias.

Discussion. The subcutaneous loop was helpful in two of nine patients in which postoperative strictures were present. These patients were reinstated to productive life faster once the problem was resolved.

Conclusions. We recommend the subcutaneous loop in young patients and Bismuth injuries 2, 3, and 4.

PP 25.10

'EMPYEMA NECESSITATIS': A RARE COMPLICATION OF GALLBLADDER DISEASE

Madhok, Brijesh¹; Gunasekaran, Thenral²; Cooper, Michelle²; Capozzi, Patrizia²; Blower, Anthony²

¹Royal Albert Edward Infirmary, General Surgery, WWL NHS Trust, Wigan, United Kingdom; ²Royal Albert Edward Infirmary, Wigan, United Kingdom

Background. The term ‘empyema necessitatis’ essentially means a ‘burrowing abscess’ of the abdominal wall as a result of chronic gallbladder inflammation i.e. cholecystocutaneous abscess. The early use of modern diagnostic tools, antibiotics and early surgical intervention has greatly reduced i ts incidence with less than 20 case reports in the last 50 years. We report a case of an abdominal wall abscess, which was diagnosed as a cholecystocutaneous abscess intra-operatively not being diagnosed upon initial investigations.

Aims. This case highlights the need to have a high degree of suspicion of this rare entity in all cases of abdominal wall suppuration or cellulitis.

Methods. A 76-year-old female presented with a mass in right hypochondrium. On examination the patient looked well and was not jaundiced. A 10×10 cm mass was found in the right hypochondrium. An ultrasound scan of the abdomen revealed a large hypoechoic mass in the right upper quadrant. A CT scan confirmed a 12×8 cm loculated cystic collection in the abdominal wall deep to the external oblique muscle. The gallbladder was contracted with its fundus in close proximity to the collection. However, no definite communication between the gallbladder and the collection was identified.

Results. On incision and drainage the abscess was found to be communicating with the gall-bladder resulting into open cholecystectomy and on-table cholangiogram. External biliary abscess or fistula may result from intrahepatic abscess, calculous cholecystitis or other inflammatory process involving the biliary tree. Now it is most common following hepatobiliary surgery or trauma.

Discussion. This case highlights that in all cases of abdominal wall suppuration or cellulitis, a high degree of suspicion should be maintained in regards to this rare entity and a CT scan should be considered in all cases. Two different approaches of management have been described. In the near future a laparoscopic one-stage approach may become the treatment of choice

PP 25.11

XANTHOGRANULOMATOUS INFLAMMATORY STRICTURES OF EXTRAHEPATIC BILIARY TREE: PRESENTATION AND SURGICAL MANAGEMENT

Ravula, Phani Krishna¹; Kumar, ashok²; Singh, Rajneesh kumar²; Saxena, Rajan²; Kapoor, Vinay K²

¹Sanjay gandhi post graduate institute of medical sciences, Surgical gastroenterology, Lucknow, India; ²

Introduction. Xanthogranulomatous cholecystitis (XGC) is variant of chronic cholecystitis characterized by intense inflammation and occasionally, invasion of adjacent organs. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis may present with jaundice and mimic malignancy.

Aim. We describe clinico-pathological features and management of four patients with xanthogranulomatous inflammatory biliary strictures.

Methods. Review of a prospectively maintained database for XGC.

Results. Out of 6150 cholecystectomies performed, we had 10% incidence of XGC (n = 620). 4 patients had xanthogranulomatous choledochitis causing biliary stricture. All four presented with jaundice and 3 out of 4(75%) had history of cholangitis. All patients had associated gallstones with thick-walled gallbladder. Two patients had hilar stricture (Bismuth type-III and IV), one patient each had mid-CBD stricture and lower-CBD stricture with a dilated pancreatic duct. All four patients had a preoperative diagnosis of malignancy. Operative findings revealed extensive subhepatic adhesions, pericholedochitis and thick-walled gallbladder in all four patients. Three patients underwent resection of the stricture- CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture and Right hepatectomy with hilar excision for hilar stricture with atrophy-hypertrophy. In one patient hilar stricture was unresectable due to encasement of the common-hepatic artery. Therefore hepaticojejunostomy was performed after obtaining intraoperative hilar tissue biopsy. All 4 patients are asymptomatic at 1 to 3 year follow-up. CONLUSIONS: Xanthogranulomatous pericholedochitis can involve any part of the biliary tree. It may be suspected in the presence of a thick walled gallbladder and gallstones especially in areas where XGC is common. However imaging and cytology are unreliable in ruling out malignancy. Therefore resection of the stricture should be performed whenever possible.

PP 26.01

QUANTIFICATION OF LIVER CELL VIABILITY AFTER ISCHEMIA AND REPERFUSION INJURY IN RAT LIVER

Yun, Sung Su; Lee, Dong Shick; Kim, Hong Jin; Park, Sang Hwan

Yeungnam University Hospital, Department of Surgery, Taegu, Korea, Republic of

Background/AIMS: Liver cell damage after ischemia and reperfusion injury has been a major cause of death after liver surgery. But there has been no exact and practical guideline for liver cell damage after ischemia and reperfusion injury. The aim of this study was to quantify liver cell viability after ischemia and reperfusion injury.

Methods. Seventy percent partial liver occlusion model with Spraque Dawley Rats was used. ATP content of liver tissue, palmitic acid metabolic rate and histologic change(H/E, TUNEL stain) were measured to assess liver cell viability during 120 minutes ischemia by 30 minutes interval. At 24 hours reperfusion after 30, 60 and 120 minutes ischemia, the same parameters and AST/ALT level in the blood were measured.

Results. ATP content was decreased below 20% compared to normal liver after ischemia, but there were no significant change in histology and palmitic acid metabolic rate during 120 minutes ischemia. At 24 hours reperfusion after 30, 60 and 120 minutes ischemia, ATP content were decreased around 50% in all groups and palmitic acid metabolic rate were decreased 90.9¡¾2.4, 80.0¡¾5.3 and 79.1¡¾7.7%, repectively, compared to control liver. But histologic change was not as much as in change in ATP content and palmitic acid metabolic rate.

Conclusion. With these results, liver had relatively well tolerance during ischemia but after reperfusion, liver had damage depending on duration of ischemia. This study might be very helpful as a guide line of liver damage after ischemia and reperfuion in clinical practice and basic reserach.

PP 26.02

SIGNIFICANCE OF BIOELECTRICAL IMPEDANCE AND LIVER CELLl VIABILITY DURING ISCHEMIA-REPERFUSION INJURY IN THE RAT LIVER

Yun, Sung Su¹; Lee, Dong Shick²; Kim, Hong Jin²; Choi, Mi Lan³; Ahn, Hyun Soo³; Shin, Hyoun Jin³

¹Yeungnam University Hospital, Department of Surgery, 317-1 Daemyung Dong, Nam Gu, Taegu, Korea, Republic of; ²Yeungnam University Hospital, Department of Surgery, Taegu, Korea, Republic of; ³Yeungnam University, Institute of Biomedical Engineering, Taegu, Korea, Republic of

Background/AIMS: During liver resection and liver transplantation, liver is damaged by ischemia-reperfusion injury. Until now, there is no approved method to measure or predict the extent of liver injury during the operation.: This is the preliminary study to make the real time monitoring system by quantification of bioelectrical impedance and ischemia-reperfusion injury in liver.Method.: Male Spraque-Dawley rats, weighting 250–300g were used. We applied different periods of 70% partial hepatic ischemia(30, 60, 90 and 120minutes) and 24 hours reperfusion. Liver tissue bioelectrical impedance were measured at various frequency(120 Hz-100 KHz) every five minutes interval with LCR meter (GS-4311B, ANDO, Japan). Cell viability was assessed by metabolic capacity of palmitic acid metabolic rate, ATP content and histological examination(H&E and TUNEL staining) at every 30 minutes interval during ischemia.

Results. Bioelectrical impedance was changed significantly (p < 0.05) during ischemia in lower frequency compared to higher frequency. Liver tissue bioelectrical impedance(120 Hz) increased after ischemia but had tendency to maintain plateau after 1 hour. ATP content was decreased below 20% compared to normal liver after ischemia, but there were no significant change in histology and palmitic acid metabolic rate during 120 minutes ischemia. At 24 hours reperfusion after 30, 60 and 120 minutes ischemia, ATP content were decreased around 50% in all groups and palmitic acid metabolic rate were decreased 90.9¡¾2.4, 80.0¡¾5.3 and 79.1¡¾7.7%, repectively, compared to control liver. But histologic change was not as much as in change in ATP content and palmitic acid metabolic rate.

Conclusion. We found the possible role of bioimpedance to measure and predict the extent of ischemia-reperfusion injury in liver. But we need further study to clarify the relationship between bioimpedance and ischemia-reperfusion injury.

PP 26.03

PREVALANCE OF OCCULT HBV INFECTION IN THE LIVER OF HBsAg NEGATIVE GALL BLADDER CANCER PATIENTS

Bose, Sujoy¹; Kazim, S. N.²; Agarwal, Anil¹; Sakhuja, Puja¹; Ramakrishna, Gayatri³; Sarin, S. K.¹

¹G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ²Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi, India; ³Lab for Cancer Biology, Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India

Background. HBV infection is common in India. Magnitude of Occult HBV infection, defined as presence of HBV genome in hepatitis B surface antigen (HBsAg)-negative individuals (HBV DNA and/or anti HBc positive) is not known.

Aim. A retrospective study was undertaken to estimate the prevalence of occult HBV infection in patients of Gall bladder cancer (GBC) managed surgically.

Methods. 50 operated GBC patients (2001- 2005) were studied. Total hepatic tissue DNA was isolated from stored liver biopsies. Basal core promoter/precore/core and X-region of HBV genome were PCR amplified in two separate reactions. Subsequently direct DNA sequencing was done where PCR amplification was there. HBV genotyping was done with the help of multiplex PCR. HBsAg, anti HCV and anti HIV status was also obtained.

Results. All patients (n = 50) were serologically negative for HBsAg and anti HCV. Presence of occult HBV infection was found in 5/50 (10%). None of these 5 patients had a history of blood transfusion. Genotypically 3/5 (60%) was Genotype D and 2/5 (40%) was A + D mixed genotype. Presence of mutations at 1762/1764 was observed in 2/5 occult cases. In one patient mutations at 1762/1764 and major deletions in the basal core promoter, precore and the core region of HBV genome was also observed. Liver biopsy showed the features of histological inflammation and moderate fibrosis.

Conclusion. The prevalence of HBV infection was 10% (5/50) in this cohort, with a negative test for HBsAg (0/50). There is a significant incidence of occult HBV infection HBV prevalence area, India. The study emphasizes that conventional HBsAg screening alone is not adequate for pre-vaccination screening for hepatitis B infection or in high-risk population, patients undergoing surgery and medical personnel.

PP 26.04

IMPACT OF PRINGLE MANEUVER IN HEPATOCELLULAR FUNCTION IN THE MURINE MODEL WITH NORMAL LIVER

Tralhao, Jose¹; Abrantes, Ana²; Laranjo, Mafalda²; Portela, Ivan¹; Goncalves, Cristina³; Figueirinha, Rita⁴; Cardoso, Dulce⁵; Sarmento-Ribeiro, Ana B³; Ponciano, Emanuel⁴; Botelho, Maria F⁴; Castro Sousa, Francisco⁶

¹Coimbra University Hospitals, Surgery/Biophysics Biomathematics Faculty Medicine, Coimbra, Portugal; ²CIMAGO, IBILI-Faculti of Medicine, Biophysics/Biomathematics Institute, Coimbra, Portugal; ³CIMAGO, Faculty of Medicine, Biochemistry Institute, Coimbra, Portugal; ⁴CIMAGO, IBILI-Faculty of Medicine, Biophysics Biomathematics Institute, Coimbra, Portugal; ⁵Coimbra University Hospitals, Nuclear Medicine, Coimbra, Portugal; ⁶Coimbra University Hospitals/Faculty of Medicine, Surgery, Coimbra, Portugal

Pringle maneuver (PM) is used to prevent bleeding during transection of the hepatic parenchyma. However, PM itself causes ischemia and reperfusion injury. This experimental study aimed to estimate the impact of PM in hepatocyte (H) function, viability and the longest safe duration of PM. Three groups of male Wistar rats were subjected to a total liver ischemia period for 60 min: group A (n = 15)-a continuous inflow occlusion; group B (n = 16)-intermittent clamping (IC) for 30 min with 5 min of reperfusion; group C (n = 16)-IC for 15 min with 5 min of reperfusion. The group D (n = 16)-no PM. A partial hepatectomy was doing at the end of ischemia period. The degree of tissue injury was evaluated using: 1) blood markers: AST, ALT, AF, GGT, TB, LDHÍ and hepatic extraction fraction (HEF) by radioisotopic methods 3 days before laparotomy and after reperfusion; 2) HE staining; 3) apoptosis, necrosis and oxidative stress were investigated after collagenase H isolation by flow-cytometry using the followed probes: propidium-iodide, annexin-V, DCFH2-DA and JC-1. Statistical analysis-variance analysis and, if applicable, post-hoc comparisons by Turkey-test were performed (p < 0.05). The results are: 1) ALT (p < 0.001), AST (p < 0.001), GGT (p < 0.006), TB (p < 0.013) and LDH (p < 0.011) show values in groups A and B; 2) no time dependence is observed for HEF however, the time increases significantly with time dependence (p < 0.006), being the signification the differences groups A and B (p < 0.03); 3) decrease of viability associated with an increase of H death preferentially by necrosis in groups A and B; these results agree with increase of ROS production and change on mitochondrial membrane potential in the same groups; 4) statistically increased of mortality between group A and C (p = 0.03) and D (p < 0.001).

Conclusions. intermittent PM 15 min cycles is highly protective of hepatocellular function. This data, if confirmed in humans, may represent a change in the knowledge of current practice of hepatic surgery.

PP 26.05

HEPATOBILIARY SCINTIGRAPHY FOR EVALUATION OF LIVER FUNCTION IN A RAT MODEL OF HEPATIC ISCHEMIA REPERFUSION INJURY WITH PARTIAL LIVER RESECTION

de Graaf, Wilmar¹; Spruijt, Onno¹; Maas, Adrie¹; de Bruin, Cora²; Bennink, Roelof J.²; Gulik, Thomas M.¹

¹Academic Medical Center, Department of Surgery/Surgical Laboratory, Amsterdam, Netherlands; ²Academic Medical Center, Department of Nuclear Medicine, Amsterdam, Netherlands

Background. A rodent model of 70% partial hepatic ischemia and reperfusion (I/R) injury is commonly used to study the mechanisms underlying I/R injury. A clinically more relevant model is the combination of I/R injury with a partial liver resection. I/R injury and outcome of interventions are usually assessed by biochemical (ALT, AST) and histological parenchymal damage parameters. Functional recovery, however, is determined by both liver regeneration and hepatocellular damage. Indocyanine green (ICG) clearance is a valuable quantitative liver function test, however it requires repeated blood samples and is therefore difficult to apply in rodents.^99mTc-mebrofenin hepatobiliary scintigraphy (HBS) has been introduced for non-invasive assessment of liver function.

Aim. To evaluate functional recovery after hepatic I/R injury combined with partial resection using ^99mTc-mebrofenin HBS and ICG clearance.

Methods. A rat model of 70% partial liver I/R was combined with resection of the non-ischemic lobes (30%). Different ischemia times were used including 0, 15, 30, 45 and 60min (n = 7 per group). A group undergoing no operation served as control. At 24 hour reperfusion, ALT, AST prothrombin time (PT, synthetic liver function), ICG clearance test and 99mTc-mebrofenin HBS were performed.

Results. Correlation between ^99mTc-mebrofenin HBS and ICG clearance test (Pearson r = 0.93) as well as PT(r = 0.83) was strong and significant. Partial liver resection (30%) alone resulted in a significant increase of ALT and AST levels, while no significant decrease in liver function (HBS, ICG and PT) was observed. ALT and AST increased with longer ischemia times. HBS was significantly impaired only after 30 (79.6%), 45 (40.6%) and 60min (27.8% of baseline) of ischemia.

Conclusion. Conventional biochemical damage parameters do not provide sufficient information on functional recovery after hepatic I/R injury combined with partial resection. ^99mTc-mebrofenin HBS is a valuable alternative for the assessment of postoperative liver function.

PP 26.06

NON OPERATIVE MANAGEMENT OF BLUNT HEPATIC TRAUMA REQUIRES INVASIVE PROCEDURES

Mulieri, Giacco; Fuks, David; Yzet, Thierry; Loyer, Arnaud; Robert, Brice; Dumont, Frederic; Brasseur, Aline; Frigerri, Arnaud; Dupont, Hervé; Verhaeghe, Pierre; Regimbeau, Jean-Marc

CHU Nord Amiens, Federation Digestive Diseases, Amiens, France

Background. Non operative management (NOM) of blunt hepatic injuries has become a standard of care with more than 80% of success. The aim of our study was to analyse prospectively management of blunt hepatic trauma in our center.

Methods. 43 consecutive patients were managed in Amiens Universitary Hospital during 30 months (February 2005 – July 2007). In hemodynamically stable patients with blunt hepatic injury, NOM was treatment of choice with under close surveillance in intensive care unit. Surgery was performed in case of hemodynamically instable patients or failure of NOM. We analysed morbidity, mortality, additional interventional procedures of this strategy.

Results There were 28 men and 15 women with a mean age of 34 (16–84). Mean Injury Severity Score was 32 (4–75). Hepatic injury was associated with others multiples injuries in 72% of cases. 58% of patients had high-grade hepatic injuries (AAST > II). There were 14 patients with AAST III, 7 with AAST IV and 4 with AAST V. 6 patients underwent initial surgery in emergency for hemodynamic instability with blood transfusion more than 4 units. NOM was realised in 37 (74%) of all patients and was successful in 30 (81%) patients. Surgery (packing with damage control n = 2, hemostasis n = 4, drainage n = 5) was necessary in 7 (18%) patients with failure of NOM (AAST III n = 4, AAST IV n = 3). Overall mortality rate was 4% (hemorrhagic shock n = 2). Complications occurred in 37% (haemorrhage n = 14, hemobilia n = 4, biliary fistula-bilo ma n = 5, abscess n = 1). Among patients managed by NOM, mortality was 0%, selective embolisation was performed in 8 (16%) patients and successful in 5 patients (62%). Endoscopic retrograde cholangiopancreaticography was realised in 13% (intrahepatic biliary stenting and nasobiliary drainage). Median length of stay was 27 days.

Conclusion. NOM of hepatic injuries can be safely accomplished with low mortality. However, to obtain high rate of success, this strategy requires additional invasive procedures with a multidisciplinary management.

PP 26.07

ANALISIS OF LIVER HEPATIC TRAUMA IN A REFFERAL HOSPITAL CENTER

Paterna, Sandra; Serrablo, Alejandro; Cebollero, Pilar; Ruiz-Montoya, Jaime; Cerdan, Rafael; Esarte, Jesus

Miguel Servet University Hospital, HPB Surgical Unit, Zaragoza, Spain

Introduction. Hepatic trauma occurs in approximately 5% of all admision in emergency rooms and it is the main cause of death by abdominal severe trauma (10–15% of mortality rate). In the last decades, there has been a increasing interest in the conservative management even in the severe liver injury if the patient is clinically stable.

Aim. To evaluate all liver trauma charge in the emergency room in a refferal hospital Materials and Methods. Retrospetic analisis of all liver trauma treated in our hospital from January 2000 to June 2006. We analized the following variables: age, cause, clinical characteristic, severity status (AAST), intra and extraabdominal injuries, management and outcome.

Results. 57 patients (46 male and 11 female) were treated by liver trauma. The mean age was 32.08 years old. The road traffic accidents, falled from the top and knife injuries were the most important causes of trauma, 64.9, 21 and 14%, respectively. The main clinical symptons and signs were abdominal pain, abdominal wall defense, breath insufficiency and cutaneus-mucosa paleness. The CT and ultrasonography were the more frecuent diagnostic test (40.3 and 35%) The liver trauma score accoding to AAST were: 42% of II grade, 33 of III, 14 of I and 11% of IV and V grade. 54% of patients were treated by conservative management. In 12% of patients treated by operative management, the extrahepatic injury was the principal cause. (Table 1) The mean of length of ICU and hospital stay were 8.1 and 17 days, respectively. The mortality rate was 17.5%.

Conclusions. Nowadays, the conservative management is goal standar in liver trauma with regards to clinical status. In spite of refferal hospital the mortality rate in severe liver trauma was high although 60% of death was caused by extrahepatic injuries.

Grade	CONSERVATIVE MANAGEMENT	SURGICAL MANAGEMENT
I	6	2
II	13	11
III	8	11
IV	3	1
V	1	1

PP 26.08

ERCP IN THE MANAGEMENT OF BILE LEAKS FOLLOWING HEPATIC TRAUMA

Kochhar, Rakesh¹; srinivasan, Thiagarajan²; nagi, birender¹; dutta, Usha¹; sinha, saroj k¹; Gupta, Rajesh²; yadav, Thakur D²; kalra, naveen³; singh, kartar¹; Wig, Jai D²

¹PGIMER, Chandigarh, India, Gastroenterology, chandigarh, India; ²PGIMER, Chandigarh, India, General Surgery, chandigarh, India; ³PGIMER, Chandigarh, India, radiodiagnosis, chandigarh, India

Background.: Biliary leaks following liver laceration are difficult to manage AIMS: Retrospective analysis of therapeutic ERCP done in patients with bile leak following trauma to liver.

Material and Methods. Data on all patients of hepatic trauma referred to us for ERCP over the last 10 years were analysed for indications, results and outcome of the procedure.

Results. A total of 16 patients (age 13–48 yr, 14 males, 2 females) with hepatic trauma and biliary leak were seen by us. Two patients had stab injury, one had gunshot injury and 13 had blunt injury to abdomen following road side accident. Indications for ERCP were persistent bile leak and biloma after surgery (n = 11) or after conservative treatment (n = 5). On ERCP localized leak was seen from right hepatic duct in 11 patients, left hepatic duct in 1, at porta hepatis in 1 and from multiple sites in right ductal system in 3 patients. Three patients had broncho-biliary fistula. 4 patients had liver abscess. A nasobiliary drain (NED) was placed in the desired ductal system in 14 patients, and a biliary stent was placed in two patients. 7 patients underwent sphincterotomy as well. Pig tail catheter drainage was carried out in 6 patients. All patients benefited from the therapeutic procedure with resolution of biliary leak over 4 to 12 weeks. Only in one patient ERCP was repeated to replace a non functioning (NBD). Two patients having hepatic artery aneurysm received embolization.

Conclusions. ERCP and placement of NBD/biliary stent and sphincterotomy are uniformly successful in managing biliary leaks following traumatic injury to the liver.

PP 26.09

IDIOPATIC LIVER ABSCESSES-Results OF PROSPECTIVE EVALUATION AND TREATMENT

Otto, Wlodzimierz; Cieœlak, Bartosz; Najnigier, Bogdan; Mackiewicz, Anna; Krawczyk, Marek

Medical University of Warsaw, General, Transplantation & Liver Surgery, Warsaw, Poland

Background. Idiopathic liver abscess is the pathology of the liver arising without any apparent cause. The aim of study conducted from 1998 to 2007 was to evaluate the results of treatment according to the prospective protocol.

Material and Methods. There were 128 patients (m.77, f.51, m.a.50) presented with abdominal pain and hectic fever in 100% of cases but with right hydrothorax and jaundice in 35% and 19% of cases, respectively. Ultrasound and CT scans were the main diagnostic tools and enabled to establish the single abscess in 97 patients (76%) and the multiloculated or multiple abscesses in 31 patients (24%). The primary treatment included of antibiotic therapy alone for the abscesses < 6cm in size in 36 patients, percutaneous aspiration for the single abscess > 6cm in size in 48 patients and the open drainage and/or liver resection for multiloculated or multiple abscesses in 44 patients. In the case of failure patients were treated with additional drainage procedures and/or liver resection.

Results:Out of 36 patients treated with antibiotics alone 20 (55%) required percutaneous drainage;12 (60%) of them required additionally open surgical drainage and 3 (15%) liver resection. Out of 48 patients treated with percutaneous aspiration 32 (66.6%) required open drainage or liver resection;4 (8%) of them developed complications and 1 (2%) die due to sepsis. Out of 44 patients treated primarily with open drainage 8 (18%) developed complications that required percutaneous drainage in 3 (7%) and open drainage or liver resection in 5 (11%);3 (6.8%) of them die due to sepsis. Culture of the pus obtained from 112 patients (except 16 patients treated successfully with antibiotics) was positive for Staphylococcus (28%), Enterococcus (19%), Escherichia coli (16%), Klebsiella (14%), Serratia (6%), Acinetobacter (5%), other (12%).

Conclusions. Antibiotic therapy, percutaneous aspiration and the open surgical drainage are the complementary methods of treatment. The results are dependent upon the peculiarity of the abscess itself.

PP 26.10

IMPAIRED LIVER REGENERATION IN DIABETIC RATS FOLLOWING PORTAL VEIN LIGATION

Yeh, Ta-Sen; Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung University, Department of General Surgery, Taipei, Taiwan

Background. Percutaneous transhepatic portal vein embolization has been widely applied prior to major hepatic resection. The aim of this study was to audit impaired liver regeneration in diabetic subject following portal vein embolization.

Material andMethods. Male Sprague-Dawley rats weighing 250¡Ó50 gm were used. Diabetic rats were created by streptozotocin injection. Portal vein ligation (PVL) (branches of median lobe and left lobe) was performed. The animals were thereafter sacrificed at day 1, 3, 5 and 7. The regeneration index was quantified using the formula: weight of non-ligated lobes/ weight of whole liver. The experimental animals underwent sulfur colloid and DISIDA test using NanoSPECT/CT to represent their liver volume and bile-secretion function, respectively. DNA synthesis was evaluated using BrdU assay. mRNA of cell cycle genes and apoptosis-related genes were determined using quantitative PCR.

Results. Regeneration index of normal rats was greater than diabetic rats (80.5¡Ó3.9% versus 69.8¡Ó5.2%, p< .01). which was in match with that detected by sulfur colloid scan. Bile secretion function detected by DISIDA scan predominantly took place at the non-ligated lobes. Paradoxically, DNA synthesis in diabetic rats was greater than normal rats following PVL. mRNA expression of cyclin D1, cyclin A2, PCNA, cyclin B1 and BclXL of normal rats were increased compared to those of diabetic rats; while the mRNA expression of Bax, DAXX and JNK of normal rats were decreased compared to those of diabetic rats.

Conclusion. Liver regeneration was attenuated in diabetic rats following PVL, with 10% discrepancy compared to normal rats. Blockade of cell cycle at synthesis phase and increased proapoptotic genes expression in diabetic rats might explain their disturbed liver regeneration.

PP 26.11

PELIOID HEPATOCELLULAR CARCINOMA MIMICKING LIVER HEMANGIOMA

Shah, Sudeep¹; Desai, Devendra²; Deshpande, Ramesh³

¹PD Hinduja Hospital and MRC, GI Surgery, Mumbai, India; ²PD Hinduja Hospital and MRC, Gastroenterology, Mumbai, India; ³PD Hinduja Hospital and MRC, Pathology, Mumbai, India

Background. Asymptomatic liver hemangiomas may be conserved. MR is a good modality to diagnose these lesions. However, the MR appearance may be misleading in certain cases, which the clinician needs to be aware of.

CASE REPORT: A 55 year old lady with no co-morbid illnesses presented with an asymptomatic liver lesion, detected on ultrasonography. This was evaluated by CT scan and MR angiography and was diagnosed to be a liver hemangioma. Her tumour markers were negative and she was HbsAg and anti-HCV negative. The lesion increased in size over a year following which she was re-evaluated. A repeat MR angiography was performed and the same diagnosis was provided. In view of the progressive increase in size, she was referred for surgery. CT chest and bone scan ewere negative. An initial diagnostic laparoscopy revealed a large solid, non compressible lesion in the right lobe of the liver, the remaining liver was non cirrhotic. She proceeded to have a right extended hepatectomy. The histology from the resection specimen confirmed a pelioid variant of hepatocellular cancer. The large vascular lakes within the tumour were responsible for the appearance on the MR study. The patient is recurrence free on follow up one year after surgery.

Conclusion. Rarely, vascular tumours mimic hemangioma of the liver. Rapid increase in size should be an indication for surgical resection

PP 10.10

RESULTS OF 5 YEARS EXPERIENCE OF LIVER SECONDARIES TREATED BY RADIOFREQUENCY ABLATION

singh, vikrant¹; jaiswal, rashmi²; mishra, prateek²; singh, mandeep²; sharma, sandesh²; naik, saleem²; purohit, dipak²; varshney, subodh²; mauddar, kk²

¹bmhrc bhopal, gi surgery, bhopal, m.p., bhopal, India; ²bmhrc, gi surgery, bhopal, India

Introduction. Radiofrequency ablation (RFA) is a new percutaneous tissue ablative therapy. Role of RFA in treating liver secondaries is not widely studied. We present our 5 years experience of RFA of liver secondaries.

Material and Method. Using Berchtold (Tuttlingan, Germany) RF generator (50–60 watt output), 1500–2000 watts energy/cc tumour was delivered according to the volume of liver secondaries. Inclusion crite rias were: lesion <5cm in size, Non-invasion of portal vein, no proximity to large vessel or duct technically feasible. Exclusion criterias were: extra-hepatic disease not being treated by chemotherapy, diminished hepatic function (eg. Child Pugh Class C), refractory coagulopathy, massive ascites. Between February 2001 and October 2006, 81 patients (52 males and 29 females), aged 39 to 72 years (mean 56 years) had RFA of 252 liver secondaries from gall bladder = 22, colorectal = 36, breast = 14, carcinoid or neuroendocrine = 5, stomach = 4 cancers. Lesions were sized <3 cm in 69, 3–4 cm in 118 and >4 cm in 65. RF needle was placed, US guided in 76, CT guided in 1 and at an open surgery in 4 patients. Follow up was done by contrast enhanced CT scan between 1–4 weeks after the procedure.

Results. There was no procedure related mortality. All patients were discharged within 24 hours except two. There was no major morbidity. There were 10/81 (8%) minor morbidity (self limiting ascites = 3, severe abdominal pain = 3, self limiting pleural effusion = 4). EFFICACY: Complete necrosis was seen in all (100%,) of lesion up to 3 cm size and (40.6%,) of lesion 3–4 cm in size. None of the lesion >4 cm had complete necrosis. Recurrence at completely treated site at mean follow up of 12 months was (8.54%). On more than 12 months follow up, (63%) patients developed new hepatic or systemic recurrence. SURVIVAL: One year survival was 59% and 2 year survival was 24% of whole group.

Conclusion. RFA is safe and effective local tissue ablative method for liver secondaries. More randomized trials are required to ascertain efficacy

PP 27.01

PRIMARY HEPATIC GLOMUS TUMOR OF UNCERTAIN MALIGNANT POTENTIAL-A CASE REPORT

Lee, JungNam; Kim, KeonKuk; Song, SeulGee; Choi, SangTae; Choi, MyungMin; Park, YeonHo

Gil Medical Center, Gachon University of Medicine and Science, Department of Surgery, INCHEON, Korea, Republic of

Glomus tumors are small, benign tumor that mostly occur in the peripheral soft tissues. However, they have also been reported in the deep soft tissue, bone, lungs, and gastrointestinal tract. It has recently been proposed that deep-seated glomus tumors, especially if larger than 2.0 cm, need a close follow-up due to uncertain malignant potential. To date, only two cases of primary hepatic glomangioma have previously been reported. We present a case of a glomus tumor primarily arising in the liver of a 70-year-old woman who presented with dyspepsia of several months' duration. Ultrasonography and CT scan reveals 4.5cm sized mass that centrally located between segment VII and VIII of liver. US-guided biopsy showed a primary glomus tumor of liver. Immunostains showed the tumor cells to be diffusely positive for and smooth muscle actin and to be focally positive for CD34. Owing to possibility of malignant potential of glomus tumor, we conducted right hemihepatectomy. Further histological evaluation of the tumor did not reveal malignancy. The patient had an unremarkable postoperative course. In conclusion, we have reported an unusual case of primary glomus tumor of the liver with uncertain malignant potential.

PP 27.02

A CASE OF CURATIVE RESECTION FOR ANGIOSARCOMA OF LIVER

Cho, Chol Kyoon¹; Koh, Yang Seok¹; Kim, Hyun Jong¹; Kim, Jung Chul¹; Hur, Young Hoi¹; Park, Chang Hwan²; Lee, Wan Sik²; Choi, Sung Kyu²; Rew, Jong Sun²; Jeong, Yong Yeon³; Shin, Sang Soo³; Lee, Jae Hyuk⁴

¹Chonnam National University Medical School, Surgery, Gwangju, Korea, Republic of; ²Chonnam National University Medical School, Internal Medicine, Gwangju, Korea, Republic of; ³Chonnam National University Medical School, Radiology, Gwangju, Korea, Republic of; ⁴Chonnam National University Medical School, Pathology, Gwangju, Korea, Republic of

Background. The primary angiosarcoma of liver(PAL) is a rare malignant tumor with a incidence of 2% of all primary hepatic tumor. The PAL is aggressive tumor and the prognosis is very poor with a median survival of only 6 months. In one large review only 3% of patients survived more than 2 years. Surgical resection is usually unsuccessful because most patients present with advanced tumors with huge size or multiple lesion in both lobes. Hepatic resection is feasible in only an extremely small number of patients.

Aim/Methods. We present a patient who underwent hepatic resection for incidentally detected hepatic tumor which was confirmed PAL pathologically. A 62 year-old-male was admitted for incidentally detected liver mass. CT scan and MRI of abdomen showed 2.7×2.2 cm sized peripheral enhancing, low attenuated lesion with enhancement of mosaic pattern in hepatic dome area. The laboratory findings including tumor markers were non-specific. In operation, there was 2×2 cm sized soft mass in superficial portion of the segment 7 and resection of segment 7 was performed.

Results. In gross finding of specimen, 2×1.5 cm sized white to red colored mass lesion with hemorrhagic foci was observed in cut surface. In microscopic exmination, the specimen showed numerous, irregular, anastomosing vascular space lined by variably pleomorphic, hyperchromatic endothelial cells showing multilayering and papillary formation. The results of immunohistochemical staning were as follow; CK(-), Vimentin(+), CD34(+), Factor VIII(+), HSA(-), AFP(-), c-kit(+). Histopathological diagnosis was consistent with angiosarcoma of liver. The postoperative course was unremarkable and no adjuvant therapy was administered. The patient is well alived without evidence of recurrence in a 3 year follow up evaluation.

Conclusions. We report a case of incidentally detected primary angiosarcoma of liver with unusually small size which was treated with curative hepatic resection.

PP 27.03

LEIOMYOSARCOMA OF THE FALCIFORM LIGAMENT

Shah, Sudeep¹; Shah, Shrenik¹; Desai, Devendra²; Bhaduri, Anita³

¹PD Hinduja Hospital, GI Surgery, Mumbai, India; ²PD Hinduja Hospital, Gastroenterology, Mumbai, India; ³PD Hinduja Hospital, Pathology, Mumbai, India

Background. Tumours of the falciform ligament are unusual. We present one such case excised surgically.

Methods. A 40 year old male was found to have a mass in his falciform ligament on sonography investigating abdominal pain. CT scan showed a 4 cm vascular lesion at the root of the falciform ligament, overlying the umbilical portion of the portal vein. He was subjected to a left hepatectomy as the segment III and IV venous branches were adjacent to the tumour. Histology revealed a poorly differentiated lieomyosarcoma. Immunohistochemistry for c-kit receptors was negative and the adjacent liver parenchyma was uninvolved. The patient is well on follow up of 3 months.

Discussion. Tumours of the falciform ligament are rare in literature. Unusual forms such as myomelanocytic tumours occur at this site. Only solitary case reports exist for lieomyosarcomas at this location. Surgical resection is the therapeutic modality of choice.

PP 27.04

ANTENATALLY DIAGNOSED HEPATOBLASTOMA: SUCCESSFUL TREATMENT BY CHEMOTHERAPY AND SURGERY

Shah, Sudeep¹; Almel, Sachin²; Motiwale, Sandeep³

¹PD Hinduja Hospital, GI Surgery, Mumbai, India; ²PD Hinduja Hospital and MRC, Oncology, Mumbai, India; ³PD Hinduja Hospital and MRC, Pediatric Surgery, Mumbai, India

Background. Hepatoblastomas are rare tumours occurring in young children. Isolated cases of antenatal diagnosis of liver tumours have been reported the outcome in these cases has been poor. We report a case of antenatally diagnosed hepatoblastoma which has successfully been treated with combination chemotherapy and surgery.

Case Report. A 34 week foetus was found to have a 5 cm liver lesion on ultrasonography. The previous USG had been at 12 weeks and was normal. The mother delivered soon after. A biopsy showed hepatoblastoma and chemotherapy was commenced in the first month. The lesion remained the same size and was subsequently excised by performing a left extended hepatectomy. The child is now 18 months old, fit and well, with normal AFP levels.

Conclusion. With appropriate pro-active management, antenatally diagnosed hepatoblatoma can be successfully treated.

PP 27.05

HEPATOBLASTOMA: Successes and Pitfalls of therapy.

Dastidar, Arindam; Sen, Sudipta; Chacko, Jacob; Karl, Sampath; Kumar, Jyotish

Christian Medical College and Hospital, Department of Paediatric Surgery, Vellore, India

Background. Hepatoblastoma is a common primary hepatic malignancy in pediatric age group. The aim of this study is to analyze the outcome of treatment in patients with Hepatoblastoma.

Material and Method. 26 Children with primary hepatic malignancy were seen in the period 2000–2007; of these 21 were hepatoblastoma (14 males 7 females, age range 8–84 months). Initial diagnosis was achieved by Ultrasonography, CT scan, Chest X-ray, Serum AFP and True-cut biopsy. Serum AFP was raised in all and beta-hCG in one child. Another child had concomita nt thoracic Neuroblastoma. PRETEXT Staging was as follows; I: 4, II: 5, III: 10, IV: 2, two patients had pulmonary metastasis at presentation.

Results. Among these 21 children, 5 either refused or discontinued chemotherapy, 2 died during chemotherapy, while 14 underwent hepatic resections. There were no operative or perioperative deaths. Four ultimately died of disease recurrence while one is alive with recurrent disease for the past four years.10 children are alive with out disease.

Conclusion. Disease free survival in our series of Operated children was 64%, while overall disease free survival was 43%.

PP 27.06

RIGHT TRISECTIONECTOMY WITH CAUDATE LOBECTOMY, PORTAL VEIN RESECTION AND ANASTOMOSIS FOR INTRAHEPATIC MALIGNANT PARAGANGLIOMA; A CASE REPORT

Lee, Heuy Seong; Paik, Kwang Yeol; Ryu, Dong Do; Lee, Hyung Geun; Heo, Jin Seok; Choi, Seong Ho; Choi, Dong Wook

Samsung Medical Center, Surgery, Seoul, Korea, Republic of

Paragangliomas are unusual neoplasms embryologically derived from neural crest cells. The most common location of these neoplasms is the adrenal medulla, where they are known as pheochromocytomas. Approximately 10% of these neoplasms occur in extraadrenal sites, most commonly in the retroperitoneum. Isolated cases have been reported in a variety of unusual locations, including the carotid body, orbit, mediastinum, larynx, mesentery, lung, stomach, and urinary system. The unusual presentation of a paraganglioma in the intrahepatic duct, has not, to our knowledge, been previously reported. A 56 year-old man was referred to Samsung Medical Center for evaluation of huge liver mass. She had been admitted in an outside hospital for jaundice and during work-up for the origin of the jaundice, an abdominal CT was done and the liver mass detected in right lobe. Total bilirubin was 7.7mg/dl and CA19-9 was 56.3U/dl. Abdominal CT showed 9cm sized irregular mass in the liver right lobe. Surgical exploration was done and right trisectionectomy with caudate lobectomy, portal vein resection and anastomosis was carried out. Macroscopically, the cut surface of the tumor showed a white solid mass. Histopathological findings showed nests of polygonal cells and immunohistochemistry showed S-100 and Ki67 strong positive tumor cells. The final pathological report was malignant paraganglioma of the intrahepatic duct. We describe the clinical and pathologic findings and therapeutic approach in this unusual case.

PP 27.07

DIAGNOSIS AND TREATMENT OF FOCAL NODULAR HYPERPLASIA AND HEPATOCELLULAR ADENOMA; A REAPPRAISAL

Esschert van den, Jacomina W¹; Erdogan, Deha¹; Phoa, Saffire SKS²; Delden van, Otto M²; Bennink, Roelof J³; Busch, Olivier RC⁴; Kate ten, Fiebo JW⁵; Gouma, Dirk J⁴; Gulik van, Thomas M¹

¹Academic Medical Center Amsterdam, Surgical Laboratory, Amsterdam, Netherlands; ²Academic Medical Center Amsterdam, Radiology, Amsterdam, Netherlands; ³Academic Medical Center Amsterdam, Nuclear Medicine, Amsterdam, Netherlands; ⁴Academic Medical Center Amsterdam, Surgery, Amsterdam, Netherlands; ⁵Academic Medical Center Amsterdam, Pathology, Amsterdam, Netherlands

Background. Hepatocellular adenoma (HCA) and focal nodular hyperplasia (FNH) are benign liver lesions which may give rise to diagnostic problems due to common features on imaging studies.

Objective. To evaluate the features of FNH and HCA on US and CT imaging studies and to assess the additional value of liver scintigraphy. An algorithm for diagnosis and treatment is proposed.

Methods. Retrospective analysis of 81 patients with radiological suspicion on and/or histologically proven HCA or FNH.

Results. FNH was diagnosed in 45 patients and HCA in 36 patients, of whom 27 presented with spontaneous bleeding. On US, FNH was hypoechoic in 49%, isoechoic in 29% or hyperechoic in 17% of patients, compared to respectively 43%, 29% and 29% in case of HCA. On non-enhanced CT, FNH was hypodense in 67%, isodense in 21% and hyperdense in 13% of patients, compared to hypodense in 75% and isodense in 25% in case of HCA. A central scar was seen in 13% of patients with FNH on US, compared to 37% on CT imaging. The HIDA-scan showed normal uptake with normal excretion into the common bile duct in 71% and normal uptake with decreased excretion in 29% of the patients with FNH. In case of HCA it showed normal uptake and biliary excretion in 67% and no uptake in 33% of patients. Resection was undertaken in 18 patients with abdominal bleeding, 8 specimens showed remnants of HCA. In 22 patients without bleeding, 18 resection specimen were histologically diagnosed as FNH and 4 as HCA.

Conclusion. Differentiation of HCA and FNH is difficult based on imaging studies. A central scar is characteristic for FNH. Scintigraphy has limited value and should only be used when radiological imaging is inconclusive. Surgical treatment is indicated for FNH in case of symptoms or when differentiation from HCA is uncertain for lesions > 5 cm. In case of HCA, oral contraceptive use should be discontinued and surgical resection is indicated when size exceeds 5 cm.

PP 27.08

HEPATIC RESECTION FOR LIVER CYSTIC LESIONS

CHOUILLARD, ELIE¹; ata, toufic²; de jonghue, bernard³; outin, hervé³; cherqui, daniel⁴

¹CENTRE HOSPITALIER INTERCOMMUNAL, GENERAL AND LIVER SURGERY, POISSY, France; ²Centre Hospitalier, general and liver surgery, poissy, France; ³Centre Hospitalier, intensive care, poissy, France; ⁴hopital henri mondor, general and liver surgery, creteil, France

Background. Up to 5% of the population has one or more liver cysts 90% of which are simple biliary cysts, usually asymptomatic with no specific treatment required (i.e., laparoscopic deroofing). Other cystic lesions require appropriate treatments including, drainage, cystic resection or even liver resection. DESIGN: We assessed our experience in the management of liver cystic lesions requiring liver resection emphasizing results as well as management guidelines. SETTING: A retrospective review of hepatic resections for liver cystic lesions performed between 1992 and 2006 in one university hospital and one general hospital affiliated to a university program. PATIENTS: 33 patients who underwent 39 liver resections were included.

Results. 24 women and 9 men had 39 liver resections (14 left lobectomies, 12 right hemihepatectomies, 7 left hemi-hepatectomies and 6 segmentectomies). Final diagnoses included hydatid cyst (30%), cystadenoma (18%), simple cysts (18%), Caroli's disease (12%), cystadenocarcinoma (9%) and miscellaneous (12%). No mortality and a 15% overall postoperative morbidity rate were encountered.

Conclusions. Hepatic resection for a presumed non-biliary cystic lesion is a safe procedure which provides satisfactory long-term symptom control in benign disease and may provide cure in case of malignancy. Almost 50% of such lesions were simple cysts or hydatid cysts. It is legitimate to perform en-bloc liver resection for every liver cystic lesion which it is neither typically parasitic nor bearing features of a simple cyst.

PP 27.09

CYSTOJEJUNOSTOMY IN THE SURGICAL MANAGEMENT OF THE LIVER HYDATID CYST

Simon, Ioan¹; Cebotari, Oleg²; Cazacu, Mircea²

¹Surgical Clinic, General Surgery, Cluj-Napoca, Romania; ²University of Medicine and Pharmacy, General Surgery, Cluj-Napoca, Romania

Even if radical methods are considered to be ideal operations for liver hydatid cysts, they are feasible in only 10% of the cases. The major problem of the conservative procedures is the surgical management of the residual cavity. Observing the frequent complications after external drainage or obliteration of the cyst cavity, we decided to evaluate the results of internal drainage by cystojejunostomy. Between January 2004 and December 2006, 8 patients with liver cystic hydatidosis were included in ths study. The 8 patients had 9 hydatid cyst: 5 protruding on the upper surface, 3 on the inferior surface and 1 on both surfaces of the liver. In 5 patients the cysts were complicated. The surgical procedure performed in all cases was the Roux en Y cystojejunostomy. The common bile duct was approached twice. The postoperative course was uneventfull in 7 cases and complicated once. We registered no mortality. We can conclude that cystojejunostomy constitute a valuable treatment method for both simple and complicated cysts. Obviously this procedure is more advantageous in cysts with large biliary fistulae avoiding complications that usually occure in other surgical techniques.

PP 28.01

ISCHEMIC ACUTE PANCREATITIS: CLINICAL FEATURES, DIAGNOSIS, THERAPY AND OUTCOME.

Hackert, Thilo¹; Hartwig, Werner²; Schneider, Lutz²; Strobel, Oliver²; Buechler, Markus²; Werner, Jens²

¹Department of Surgery, University of Heidelberg, Heidelberg, Germany; ²Department of Surgery, Heidelberg, Germany

Background. Acute pancreatitis (AP) can be caused by various triggers. Besides alcohol excess and gallstones, pancreatic ischemia can cause AP. Although this entity is poorly defined clinically or radiologically, it should be considered when no other obvious reasons can be defined. Aim of this study is to define ischemic AP with regard to its pathophysiological, radiological and clinical conditions.

Methods. Eleven patients suffered from acute pancreatitis caused by mesenteric hypoperfusion of different origin. Course, severity and outcome of the disease as well as diagnostic and therapeutic measures are presented. In addition, a special focus is put on the differentiation between acute pancreatitis and elevated pancreatic enzyme levels, which can often be observed in ICU patients without further clinical complications.

Results. Acute ischemia-induced pancreatitis was either caused by hemorrhage and hypotension (7 patients) or mesenteric macrovessel occlusion (4 patients). Therapy of the patients was conservative in 4 patients and operative with surgical hemostasis, necrosectomy and drainage in the other 7 patients. Seven of the patients died within 38 days after the onset of AP, 4 patients recovered completely.

Conclusion. Ischemia is an important etiology of acute pancreatitis. Different causes of ischemia lead to a hypoperfusion of the pancreas with consecutive induction of an inflammatory response. Severity of the disease can range from moderate edematous affections up to severe courses with fatal outcome. However, the indication for surgical intervention in ischemia induced AP is more aggressive, diagnostic and conservative therapeutic procedures are similar compared to those performed in AP of other etiologies.

PP 28.02

CLINICAL CHARACTERISTICS AND MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS: EXPERIENCE FROM A SINGLE CENTER

Dulundu, Ender; Erkan, Ozkan; Kayahan, Munire; Ozel, Yahya; Akyuz, Cebrail; Topaloglu, Umit

Haydarpasa Numune Education and Research Hospital, 5th Department of Surgery, Istanbul, Turkey

Introduction and Aim. In our city acute pancreatitis (AP) is an important cause of morbidity. The current study reviews our department's experience which is situated in one of the largest teaching and reference Hospital in the Asian side of Istanbul.

Patients and Methods. Consecutive patients admitted with AP between December 2003 and June 2007 were identified and retrospectively analyzed. Patients in whom pancreatitis was related to malignant disease were excluded from the survey.

Results. We identified 80 patients, of whom 55 (69%) were woman. The mean age was 50 years. In 60 (75%) of cases AP was associated with biliary illness followed by alcohol abuse in 6 (7.5%) of patients. Abdominal pain was the most common symptom at onset 97.5%. High serum amylase level (87.5%), followed by leukocytosis (75%) was the most abnormal laboratory test. Hospital stay varied between 4 to 43 days, mean hospital stay was 8 days. Ranson's criteria was used as a prognostic evaluation and ultrasonography and computed tomography was used for the morphologic evaluation of the pancreas. There was only one hospital mortality.

Conclusion. Majority of the patient of acute pancreatitis requiring hospitalization at our hospital was biliary pancreatitis. The correct and rapid clinical diagnosis of acute pancreatitis with an appropriate treatment it does not increase the morbidity and mortality.

PP 28.03

EFFECTS OF HYPERBARIC OXYGENATION AS A COMPONENT OF INTENSIVE CARE (IC) IN PATIENTS WITH ACUTE PANCREATITIS (AP) ON OXIDATIVE STRESS (OS).

Pavars, Maris¹; Lisagors, Ilans²; Sondore, Antonina³; Schesters, Andrejs⁴; Jaunalksne, Inta⁵; Silova, Alise⁴; Eklona, Anete⁶; Pronkova, Anastasia⁷; Gormalova, Jelena⁷; Porina, Ieva⁶

¹Paul Stradins University Hospital, Surgery, Riga, Latvia; ²Riga Stradins University, Anaesthesiology and Intensive Care, Riga, Latvia; ³Rigas Stradins university, Anaesthesiology and Intensive Care, Riga, Latvia; ⁴Rigas Stradins University, Laboratory of biochemistry, Riga, Latvia; ⁵Rigas Stradins Univertsity, Center of immunology, Riga, Latvia; ⁶Paul Stradins University Hospital, Anaesthesiology and Intensive Care, Riga, Latvia; ⁷Rigas Stradins University, Riga, Latvia

Background. Presence of local ischemia and global hypoxia in the pathogenesis of AP suggests potentially positive effects of HBO as addition to the standardized therapy. At the same time little is known about the pro-oxidative effects of hyperbaric oxygenation AIM of the study was to determine the impact of HBO as an additive treatment of AP and its effects on OS.

Methods. A prospective case-controlled study was performed on 16 patients (pts.) with AP. 8 pts. were in HBO group (gr.), 8-in the control gr. (C gr.). HBO course (c) of 6 sessions (s), once a day (d), under 1,7 ATA in a monoplace chamber was initiated within 24 h after admission. Pts. were assessed using APACHE II, SOFA, Ransons scores and biochemical analyses. Global and splanchnic hypoxia were evaluated during 6 days after admission, by arterial blood gases (ABG), lactate, gastric tonometry (GT); intensity of OS; by the plasma level malondialdehyde (MDA), lucinogen induced hemiluminescence (HCL); activity of anti-oxidative system-by plasma total antioxidant capacity (TAC), level of selenium (Se), superoxiddismutase (SOD), vitamin E.

Results The demographics and severity of SAP were similar in both gr. SOFA score improved faster in HBO gr. Blood glucose decreased for 1, 5 – 2, 4 mmo/l after each HBOT s. (mean 1,85 mmol/l). There was low level of O2 in 40% of pts. of HBO gr., 50% in C gr., mucosal acidosis was noted in 40% of pts. of both gr. on admission. In HBO gr. MDA decreased for 41.69%, for 66.46% in C gr., luminol-enhanced chemiluminescence (h) for 25,12% and 21,14%. Vit. E increased for 32,64% in HBO gr. and did not change in C gr. An early low plasma Se was established in 8 p. (100%) (67 ngr/ml). It wasn't affected by HBOT c. SOD increased in 5 pts. for 14.8% in HBO gr. TAC was within the norm in both gr.

Conclusion. Applied regimens of HBO to the standard IC of AP alleviated lipid peroxidation and improve course of the disease, possibly by improving oxygenation and tissue metabolism

PP 28.04

PANCREATITIS IN PREGNANCY: LITERATURE REVIEW AND PROPOSED CLINICAL GUIDELINES

Dhingra, Vandana¹; Chin, Kirk²

¹Birmingham Womens Hospital, Obstetrics & Gynaecology, Mitchley park road, Edgbaston, Birmingham, United Kingdom; ²Staffordshire general hospital, Obstetrics & Gynaecology, Stafford, United Kingdom

Pregnant women frequently present with abdominal pains of varying severity during pregnancy. The aetiology may be pregnancy-specific; however, non-obstetric causes can and do occur. The dynamic changes of pregnancy can hinder a prompt diagnosis, especially when abdominal complaints persist ABSTRACT Acute pancreatitis complicating pregnancy can be a life-threatening emergency. Reported mortality is 20%higher in pregnant than non-pregnant women of the same age. It is also associated with a high perinatal mortality 38% The incidence of pancreatitis ranges from 1 in 1066 live births to 1 in 3333 pregnancies. Pancreatitis can occur during any stage of pregnancy with the highest incidence in the third trimester and in multiparous women. The common misdiagnosis of pancreatitis in the first trimester is hyperemesis gravidarum. The most common predisposing cause is cholelithiasis and hypertriglyceridaemia. This results from the increased estrogen effect and the familial tendency for some women toward high triglyceride levels. Pregnancy per se does not adversely affect the prognosis of pancreatitis thus termination of pregnancy is unnecessary unless severe fetal compromise ensues during the course of the illness Various treatment options are available to manage pancreatitis in pregnancy;conservative medical management, ERCP, endoscopic sphincterotomy or surgical management; surgical management of symptomatic cholelithiasis in pregnancy is safe, decreases hospitalisation and reduces the rate of induction of labour and preterm deliveries. The relapse rate for gallstone-related pancreatitis is higher up to 70% with conservative treatment only This case presents the surgical management (with video clip) of a 36 year old woman in her second trimester of pregnancy, who was admitted several times with pancreatitis secondary to cholelithiasis. We will also discuss the literature review of acute pancreatitis complicating pregnancy and suggest guidelines for the management of pancreatitis specifically debating the use of ERCP in pregnancy

PP 28.05

TREATMENT OF SEPTIC SUPPURATIVE COMPLICATIONS OF NECROTIZING PANCREATITIS

Petrushenko, Viktoria

Vinnitsa national medical university, Department of surgery, Vinnitsa, Ukraine

Introduction. Diagnostics and treatment of necrotizing pancretatitis still constitutes the issue of the day in abdominal surgery. Correct timing of appropriate surgical access to the area of destructive changes is still at discussion.

Methods. Our study is dedicated to the analysis of 88 cases of surgical treatment of patients with various forms of acute pancreatitis at the stage of septic suppurative complications. Treatments were performed in the period 2002 to 2007. Severity of each case was determined according to SAPS scale. There were 39 females and 49 males in the total number of cases.

Results. 3 5 patients had phlegmon of retroperitoneal space (unlimited septic suppurative process, duration since the beginning of the disease:15,4±2.1 days), in 53 patients para-pancreatic abscess was diagnosed. There were 32 cases of late abscess and 21 cases of early abscess. Various types of surgeries have been performed, depending on the type of suppurative complication. Drainage under control by ultrasonic method has been performed in 15 patients with abscess of omental bursa. Two drainages for flow lavage were implemented in 7 cases. Abscess volume varied from 50 to 300 ml. Patients underwent fractional lavage of cavity by antiseptics. Dynamic fistulograms and bacteriological test of punctuate were used to monitor whether adequate response is obtained by application of drainages and by therapeutic procedure in general. Duration of drainages varied from one (1) to four (4) weeks, depending on dimensions of nidus of suppuration and development of destructive process. 17 patients underwent middle laparotomy with drainage of necrotic suppurative nidi and abdominal cavity with subsequent elective relaparotomy. 21 patients underwent laparotomy with selective drainage of abscess by application of stoma of retroperitoneal space and subsequent mini-invasive sanation.

Conclusions. The present results emphasize that mini-invasive methods are required by practical reasons and extensive laparotomy is an induced measure.

PP 28.06

PANCREATICOPLEURAL FISTULA AS A COMPLICATION OF THE CHRONIC PANCREATITIS. HOW I DO IT.

Sabol, Martin¹; Straka, Martin²; Sabol, Martin²; Straka, Vladimír²

¹St. Elisabeth Oncological Institute, Department of Oncological Surgery, Heydukova 10, Bratislava, Slovakia; ²St. Elisabeth Oncological Institute, Department of Oncological Surgery, Bratislava, Slovakia

Background. Pancreaticopleural fistulas are rare, typical internal pancreatic fistulas arising most of all during an acute exacerbation of underlying chronic alcohol- associated pancreatitis. In posterior disruption of pancreatic ducts leaking pancreatic juice may track through the esophageal and aortic hiatus to the mediastinum

.Methods. Clinical data of 6 patients with chronic alcohol-associated pancreatitis were analyzed in whom pancreaticopleural fistula arised always with left-sided pleural cavity.

Results. In all patients we confirmed pancreaticopleural fistula with disruption of panreatic duct by means of ERCP and/or CT and perioperative fistulography. Visualisation of anatomy and location of pancreatic duct obstruction is important. In one patient with proximal pancreatic duct obstruction successful duodenopancreatic drainage was performed by endoscopic stent placement. Five patients were operated on after initial conservative treatment failure. In 2 patients we created latero-lateral fistulopancreaticojejunostomy Roux-en-Y. In one patient we made segmental(central) resection of the proximal part of pancreas body and termino-terminal pancreaticojejunostomy Roux-en-Y. Two patients with communicating pancreatic pseudocyst were solved by pseudocysto-gastrostomy. Postoperative course in all patients was complications free. Postoperative mortality was 0.0%. During the follow-up after 5, 6, 7 and 9 years there was no exacerbation of pancreatitis.

Conclusion. Initial way of treatment is short-term conservative practice. In the case of its failure invasive approach on the basis of imaged pancreatic duct anatomy should proceed. Fistula is caused by an obstructed pancreatic duct followed by its disruption. The aim is to provide the outflow of the pancreatic duct or its part that possessed impaired drainage. In the case of suitable pathomorphologic finding we prefer an early surgical intervention without worthless delay.

PP 28.07

SPLANCHNIC ARTERY PSEUDOANEURYSMS IN CHRONIC PANCREATITIS: IS THERE A ROLE FOR SURGICAL MANAGEMENT?

Kumar, Santosh; Rajkumar, K.; Agarwal, Shaleen; Singh, Shivendra; Tyagi, Sanjay; Agarwal, Anil

G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India

Background/Aims: Splanchnic artery pseudo aneurysms are an unusual but often serious complication of chronic pancreatitis. The treatment modalities for this entity include transcatheter arterial embolization and surgery. In this study we reviewed our experience of management of splanchnic artery pseudo aneurysms associated with chronic pancreatitis.

Methods. Prospectively collected data of 14 patients of chronic pancreatitis with splanchnic artery pseudo aneurysms, managed at our centre between January 1996 and December 2005 was analyzed retrospectively.

Results. The incidence of splanchnic artery pseudo aneurysm in patients with chronic pancreatitis was 9%( 14/157 patients). Splenic artery was involved most often (n = 10, 71%) followed by gastro duodenal artery in two patients (14%). Emergency angioembolization of pseudo aneurysm was performed in 5 patients (36%). Two patients who underwent angioembolization had rebleeding after the procedure and required emergency surgery for control of bleeding. Pseudo aneurysms were managed surgically in 11 patients (79%). There was no rebleeding in any of the patients managed surgically.

Conclusion. Surgery is safe and highly effective in life threatening circumstances such as hemodyanamically unstable patients, after failed angioembolization and patients of chronic pancreatitis with incidentally detected pseudoaneurysm requiring surgery for the management of underlying pancreatic pathology.

PP 28.08

SIGNIFICANCE OF SPLENIC VEIN THROMBOSIS IN CHRONIC PANCREATITIS

Agarwal, Shaleen; Rajkumar, K.; Singh, Shivendra; Agarwal, Anil

G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India

Background & Aim: Splenic vein thrombosis leading to sinistral portal hypertension and variceal bleeding is a complication of chronic pancreatitis. The management of these patients without variceal bleed remains controversial.

Methods. A total of 157 patients of chronic pancreatitis were managed consecutively in our center during the period of Jan 1996-Dec 2005. Thirty four patients with chronic pancreatitis were diagnosed to have splenic vein thrombosis.

Results. The incidence of splenic vein thrombosis in patients with chronic pancreatitis was 22%. 15% of patients with chronic pancreatitis and splenic vein thrombosis presented with gastro esophageal variceal bleed. Nine patients underwent splenectomy along with pancreatic procedures and 21 patients underwent pancreatic procedures only. Adding splenectomy with the pancreatic procedure did not lead to increased morbidity or mortality.

Conclusion. Splenectomy should also be added to the pancreatic procedure in patients who have evidence of portal hypertension on preoperative evaluation, especially if gastric varices are found

PP 28.09

SURGICAL MANAGEMENT OF PANCREATIC ASCITES

Varma Gunturi, Surya Ramachandra; Kota, Venugopal; Reddy, G. Sambi; Narayana Rao, D.V.L.; Prabhakar, B.; Hasan, Ibrahim; Malleshwara Rao, G.L.N.

Osmania Government General Hospital, Hyderabad, India

Introduction. Pancreatic ascites is exudative ascites caused by non malignant pancreatic disease, characterized by very high fluid amylase levels over 1000 U/L and protein concentrations > 3 gm/dl. Surgical management is needed when conservative methods including endoscopic approaches fail. This study describes our results in the management of pancreatic ascites.

Methods. This is a combined retrospective and prospective study of 14 patients diagnosed and treated as pancreatic ascites with chronic pancreatitis in a tertiary referral government health centre over a period of 4 years. Patients were initially conservatively managed with ascitic fluid drainage, octreotide and nutrition in the form of either TPN (Total Parenteral Nutrition) or nasojejunal feeding with blenderized diet for 3 weeks. Failures were taken up for surgical intervention. The type of surgery depended on the site of leak and associated pancreatic pathology as demonstrated by ERCP (Endoscopic Retrograde Cholangiopancreatography) and Contrast Enhanced Computerized Tomography (CECT) scan of abdomen.

Results. Nine patients needed surgical intervention: Distal Pancreatectomy (n = 7), Longitudinal Pancreaticojejunostomy (n = 1) and Pancreatic Cystojejunostomy (n = 1). All had successful resolution of pancreatic ascites postoperatively. One patient had a secondary hemorrhage, which responded to conservative management.

Conclusion. ERCP is the road map to determine the pathology of pancreatic duct and to determine upon the type of surgery needed. Nasojejunal blenderized feeds are an alternative form of nutrition, especially helpful in developing countries. Surgery provides definitive treatment in pancreatic ascites where conservative methods fail.

PP 28.10

PREVALENCE OF TROPICAL CHRONIC PANCREATITIS IN ORISSA & SURGICAL OUT COME AFTER DRAINAGE PROCEDURE.

Mihir k Mohapatra, Mihir

S C B Medical college., Surgical Gastroenterology., Cuttack, Cuttack, India

Introduction. Tropical chronic pancreatitis (TCP) is common in orissa. Two third of our patients are being managed conservatively and one third have required ope rative management, the leading indications being intractable pain & complications like pseudocyst & obstructive jaundice. Frey's procudere has offered the most satisfactory Results.

Methods. During the period from April 1997 to Aug 2007, 227 patients of chronic Pancreatitis were treated in the Dept. of Surgical Gastroenterology, SCB Medical college, Cuttack, Orissa, out of which 117(75%) were male & 57(25%) were female. Most of the patients (127,56%) were with in 21–40 years. These patients were worked up for history of pain, diabetes& malnutrition & pancreatic structural changes. Glucose tolerance test, serum amylase&lipase, calcium&phosphate, X-ray abdomen&Ultrasound was done in all cases.68 patients had surgery, the main indication being intractable pain followed by pseudocyst(11) & obstructive jaundice(9). Pancreatic calcification& calculi was found in all cases. MPD was in range of 4–18 mm in 67 patients.43(63%)patientswere offered drainage procedure(Frey's procedure in 29(43%) & Patrington & Rochelle procedure in 13(19%), Izbicki'sprocedure in 1(1.4%). Whipple procedure in2(2.8%), Cystogastrostomy & cystoduodenostomy in 11(16%), Cholecystojejunostomy in 5(7%) and other procedure in 7(10%) patients.

Results -Pain relief was excellent in 28(98.5%) patients after Frey procedure & in 11(84%) after Patrington & Rochelle procedure. There was no further worsening of endocrine & exocrine function in any of the patients undergoing the above drainage procedures. Nutritional status & quality of life have improve in all patients after drainage procedure. There was no mortality & majore complication like haemorrhage or pancreatic fistula after Frey or Patrington/Rochelle procedure.

Conclusion. Surgical out come(pain relief&improved diabetic & nutritional status)after an adequate drainage is excellent in TCP.

PP 29.01

ANTE SITUM LIVER RESECTION UNDER TOTAL VASCULAR EXCLUSION AND VENOVENOUS BYPASS WITH HYPOTERMIC PERFUSION

Chu, Chong-Woo¹; Kim, Hyung-Chul²

¹Soon Chun Hyang University Hospital, Surgery, Bucheon, Korea, Republic of; ²

We present a case of a recurrent rectal cancer liver metastasis that was managed with ante situm liver resection under total vascular exclusion (TVE) and venovenous bypass with hypothermic perfusion. A 58-year-old man had been transferred to our hospital with a rectal cancer liver metastasis in January 2006. Left lateral sectionectomy had been performed. A recurrent lesion developed in segment I, IV, and VIII one year after the first hepatectomy. It was involved in the origin site of middle hepatic vein and retro-hepatic vena cava. The tumor size was 5 cm. The authors thought that incomplete tumor free margin and massive bleeding were expected under conventional liver resection. Moreover, vena cava reconstruction was expected. Therefore, we planned ante situm liver resection under TVE and venovenous bypass with hypothermic perfusion. After adhesiolysis, hilar dissection was carried out. Inflow of medial segment was interrupted. And then liver and IVC were fully mobilized. During short hepatic vein control, we found adhesion of hepatocaval portion. So, Venovenous bypass was performed and suprahepatic IVC transection underwent. Long conduit of V5 was preserved during hepatic parenchymal dissection. Paracaval portion of caudate lobe was easily detached from IVC. Suprahepatic IVC reconstruction was performed after V5 reconstruction with saphenous vein. And then portal vein anastomosis was carried out. After reperfusion, end to side anastomosis was performed between saphenous vein and IVC. Finally, roux-en-Y HJ was carried out. The patient remains well without recurrence 7 months after operation.

PP 29.02

LIVER RESECTIONS FOR COLORECTAL METASTASIS IN MELBOURNE

Choi, Julian; Beitner, Sarah; Usatoff, Val; Haydon, Andrew; Evans, Peter

Alfred Hospital, Melbourne, Australia

Introduction. Colorectal cancer is a major health problem in Australia. 1 in 20 Australia will develop the disease in their life times and 50–60% of them will develop liver metastases. Liver resection is the treatment of choice for the colorectal liver metastases when appropriate. There is limited data published on Australian experience of liver resection for colorectal metastases.

OBJECTIVES. The aims of this study are; to identify our operative morbidity and mortality for liver resection; to determine overall and disease free survival rates after liver resection; to examine if pre-operative biopsy of liver lesions affect overall and disease free survival.

Methods. A retrospective review of 135 consecutive liver resections done over 11 years (Jan 1995 – Dec 2005) at the Alfred and Cabrini hospitals was performed. Patients’ demographics, clinical data, 30 days morbidity and mortality, overall and disease free survival data were collected. Pre-operative biopsy results were also noted with their impact on overall and disease free survival.

Results. 135 consecutive liver resections have been performed during this 11-year period with operative morbidity and mortality rates of 1.5% and 33.7% respectively. The 5 years overall and intra-hepatic disease free survival was 52% and 36% respectively. 38 patients required pre-operative biopsy of their liver lesion, which did not result in difference of their overall or intra-hepatic disease free survival.

Conclusions. This is an important study representing Australian experience of liver resection for colorectal liver metastases. Our operative morbidity, mortality and overall survival rates are comparable to other published series. Selective use of pre-operative biopsy in our series did not affect overall or disease free survival.

PP 29.03

PUSHING THE “BOUNDARIES” – IMPACT OF RESECTION MARGIN AND TUMOUR BIOLOGY ON OUTCOME FOLLOWING HEPATIC RESECTION FOR COLORECTAL METASTASES

Gomez, Dhanwant; Morris-Stiff, Gareth; Toogood, Giles J; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospitals NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. The evolution of hepatic resection for patients with colorectal liver metastasis (CRLM) has lead to expansion of conventional selection criteria, in particular tumour size and number. The aim of the study was to analyse prognostic factors and outcome of patients based on a selection criteria based on tumour number and size.

Methods. Patients undergoing resection for CRLM from January 1993 to March 2007 were identified from the hepatobiliary database. Patients were divided into 3 groups: Conventional criteria (<3 met and/or <3cm), extended criteria (4–7mets and/or >3- < 5cm) and hard-line criteria (>8 mets and/or >5cm).

Results. 705 patients that underwent primary resection were included. There were 154, 262 and 289 patients in the conventional, extended and hard-line group respectively. The 5-year disease-free (p < 0.001) and overall (p < 0.001) survival were significantly different between the groups. Inflammatory response to tumour [IRT-raised neutrophil to lymphocyte ratio (NLR) and/or C-reactive protein, p < 0.001], extent of resection (p < 0.001) and resection margin status (p < 0.001) were significantly different between the groups. Sub-group analysis revealed that IRT was the only adverse predictor for poorer disease-free and overall survival in the conventional group. In the extended group, IRT was the only predictor of poorer disease-free survival on multi-variate analysis. In addition, IRT also predicted poorer overall survival in this group. For patients in the hard-line criteria group, resection margin and blood transfusion were independent predictors of poorer disease-free survival. On multi-variate analysis, age, resection margin and IRT were independent predictors of overall survival in this cohort.

Conclusion. By extending the selection criteria, resection margin influence the long term outcome of patients within the hard-line criteria group, hence the importance of achieving good clearance in these patients. IRT significantly influences the outcome of patients with less aggressive disease.

PP 29.04

IMPACT OF SYSTEMIC NEUTROPHIL TO LYMPHOCYTE RATIO IN HISTOPATHOLOGICAL FEATURES OF COLORECTAL LIVER METASTASES

Gomez, Dhanwant¹; Prasad, P²; Wyatt, J²; Morris-Stiff, Gareth¹; Toogood, Giles J¹; Lodge, J. Peter A.¹; Prasad, Rajendra¹

¹Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom; ²Leeds Teaching Hospital NHS Trust, Department of Pathology, Leeds, United Kingdom

Aims. An elevated pre-operative neutrophil to lymphocyte ratio (NLR) has been implicated as a poor prognostic factor in patients udergoing hepatic resection for colorectal liver metastasis (CRLM). The aim of this study was to determine whether systemic NLR correlates with degree of tumour lymphocytic infiltration in CRLM.

Methods. Patients undergoing curative resection for CRLM were identified from the pathology and hepatobiliary databases. The histopathological slides were reviewed by a single pathologist. NLR was calculated by dividing the absolute value of neutr ophils to the value of lymphocytes. NLR > 5 was considered elevated.

Results. 151 patients were included, of which 27 patients had a raised NLR. Of these 27 patients, 24 patients (89%) had no lymphocytic infiltration and 3 patients (11%) had mild infiltration. No patients showed either moderate to severe lymphocytic infiltration. The degree of lymphocytic infiltration in patients with a NLR <5 was: none 77% (n = 95); mild 16% (n = 20); and moderate to severe 7% (n = 9) respectively (p = 0.253). There was no significant difference between patients with a NLR >5 compared to <5 in terms of tumour number, tumour size, biliary invasion, satellite nodules or capsular infiltration. However, patients with a high NLR exhibited a significantly higher rate of vascular invasion (p = 0.029).

Conclusion. The systemic NLR does not represent the degree of tumour lymphocytic infiltration in cases of CRLM.

PP 29.05

RESULTS OF RFTA TREATMENT IN PATIENTS WITH INOPERABLE COLORECTAL CANCER LIVER METASTASES ON STANDARD (5-FU + FOLINIC ACID) CHEMOTHERAPY REGIMEN

Zadrozny, Dariusz¹; Sledzinski, Zbigniew¹; Studniarek, Michal²; Gorycki, Tomasz²; Adamonis, Walenty¹

¹Medical University of Gdansk, Poland, Dept of General, Endocrine and Transplant Surgery, Gdansk, Poland; ²Medical University of Gdansk, Poland, Dept of Radiology, Gdansk, Poland

Background. Liver metastasis from colorectal cancer (CRC), when inoperable, are connected with poor prognosis. On standard” chemotherapy (5-Fluorouracil + Folinic Acid) the median survival time from metastasis discovery is short –6–12 months. Radiofrequency thermal ablation (RFTA) seems to be an option of treatment for these patients MATERIAL: 195 patients with inoperable liver metastases from CRC were treated using percutaneous RFTA between 2001 and 2007. Ninety five of them (48,7%, 65 M and 30 F) were on standard” chemotherapy. Mean age in this group was 65,7 (38–85) years. 186 ablation session were performed (1–7 per patient, average 1,97). At the start of treatment 237 lesions were recognised as RFTA targets (1–7 mean 2,5 per patient), but due to disease progression overall 347 tumors were destroyed (1–12, av. 3,65 per patient and 1,87 per intervention).

Methods. Ultrasound-guided percutaneous thermal ablation under total intravenous anesthesia was performed in all patients. The Cool-Tip (Radionics, Burlington, USA) equipment was used. EARLY.

Results. There were no perioperative deaths. In one patient early complication (liver abscess and colon perforation) occured (1%). In all except one patient hospital stay was shorter than 72 hours. LATE.

Results. Median survival time was 18,48 months from the first thermal ablation and 24,0 months from the discovery of liver metastases. The computed 5-year surviwal is 18%. There were no differences in survival in patients with synchronic vs metachronic lesions, neither between patients with single and multiple lesions. The CEA level, sum of lesions diameters, chemotherapy response and team experience have significant impact on patients survival.

Conclusion. Percutaneous RFTA is safe and efficient method of treatment for inoperable colorectal cancer liver metastases. 18% 5-years survival may be achieved even in patients treated with old school” chemotherapy.ts

PP 29.06

PATTERN OF INTRA-HEPATIC RECURRENCE FOLLOWING NON ANATOMIC FIRST HEPATECTOMY IN PATIENTS WITH COLORECTAL LIVER METASTASES

Yeluri, Sashidhar¹; Malik, HZ²; Gomez, Dhanwant²; Cluskey, S²; Toogood, GJ²; Lodge, J Peter A²; Prasad, K Rajendra²

¹St. James's University Hospital, Department of HPB and Transplant Surgery, Beckett Street, Leeds, United Kingdom; ²St. James's University Hospital, Department of HPB and Transplant Surgery, Leeds, United Kingdom

Background. Non anatomical liver resections (NALR) have become common place in the management of colorectal liver metastases (CRLM). The purpose of the present study was to determine the pattern of intra hepatic tumour recurrence in NALR.

Methods. A prospectively maintained database was used to identify 100 patients with CRLM who underwent primary NALR in the period between 1995 and 2006. Data analyzed included demographics, hepatic metastases site pre-NALR, and patterns of intrahepatic recurrence.

Results. The median age of patient was 68 years (S.D 9.8). There were 65 males and 40 patients presented with synchronous disease. The median metastases size was 28 mm with 15 patients having multiple (4 or more) metastases. There were 35 intrahepatic recurrences. Analysis suggested that in 28 of these 35 patients an initial anatomical resection would have prevented subsequent intra-hepatic recurrence within the same sector. The only clinico-pathological factor preoperatively that predicted for recurrence in the same hepatic sector was the presence of multiple metastases (p = 0.003).

Conclusion. Non-anatomical resection remains an acceptable option for the management of CRLM. However, the presence of multiple metastases preoperatively may predict the need for an initial anatomical resection.

PP 29.07

INTERMITTENT PRINGLE MANOEUVRE IS NOT ASSOCIATED WITH ADVERSE LONG TERM PROGNOSIS

Wong, Vincent KH; Hamady, Zaed ZR; Malik, Hassan Z; Prasad, K Rajendra; Lodge, J Peter; Toogood, Giles J

St. James University Hospital, Hepatopancreatobiliary & Transplant Surgery, Leeds, United Kingdom

Background. Intermittent clamping of the porta-hepatis (IPM) is often used for inflow control during parenchymal liver transection. However, IPM remains controversial with risk of ischaemic-reperfusion injury. A recent murine study showed that ischaemic-reperfusion injury accelerated the outgrowth of hepatic colorectal liver metastases.

Objective. The aim of this study is to analyse whether IPM is associated with any adverse long-term outcome following liver resection for colorectal liver metastases (CRLM).

Methods. All patients undergoing resection for CRLM between 1993 and 2006, in which data on IPM was recorded were included in this study. A total of 563 patients were available for analysis.

Results. 51.3% of patients undergoing resection had an IPM performed. The duration of IPM ranged from 2 to 104 minutes (median 22). There were no differences in clinico-pathological features between the two groups. Furthermore, there was no difference in post-operative morbidity between the IPM and no- IPM groups. There was no difference in intra-hepatic recurrence between the 2 groups with the median survival for those undergoing IPM was 55.6 months compared to 48.9 months for those not having an IPM, p = 0.406. Similarly, there was no difference in disease-free survival between the two groups, 0.199.

Conclusion. IPM is not associated with adverse long-term prognosis.

PP 29.08

RADIOFREQUENCY ABLATION OF COLORECTAL LIVER METATSTASES DOWNSTAGED BY CHEMOTHERAPY

Knudsen, Anders¹; Kannerup, Anne-Sofie¹; Mortensen, Frank Viborg¹; Sørensen, Steen Mellerup²; Nielsen, Dennis Tønner²

¹Aarhus University Hospital, Department of Surgery L, Aarhus, Denmark; ²Aarhus University Hospital, Department of Radiology R, Aarhus, Denmark

Aim. To evaluate the long-term survival in patients treated by radiofrequency ablation (RFA) for colorectal liver metastases after downstaging by systemic chemotherapy.

Methods. Forty-three patients with colorectal liver metastases initially unsuitable for local treatment were downstaged by chemotherapy and treated by RFA. All patients were managed in a single institution during a nine year period from 1998 to 2007. Chemotherapy mainly consisted of 5-fluorouracil and leucovorin combined to oxaliplatin or irinotecan. Multinodularity, size of tumours or limited hepatic reserve was the main cause of patients being unsuitable for local treatment. Patients with extrahepatic disease were excluded from RFA treatment. Pre – and posttreatment evaluation was performed with contrast-enhanced computed tomography.

Results. Twenty-three men and twenty women with a median age of 65 years (47–79) were treated with RFA after being downstaged by chemotherapy. Thirty-two patients had a colon cancer as a primary cancer. The five-year overall survival rate was 37% (19–58), with a median survival of 47 months.

Conclusion. Patients with unresectable liver metastases from colorectal cancer can, after being downstaged by systemic chemotherapy, be treated by radiofrequency ablation with an excepted 5-year survival rate on 37%.

PP 29.09

COMBINED LIVER RESECTION AND RADIOFREQUENCY ABLATION FOR COLORECTAL LIVER METASTASES

Kannerup, Anne-Sofie¹; Nielsen, Dennis Tønner²; Sørensen, Steen Mellerup²; Mortensen, Frank Viborg³

¹Aarhus University Hospital, Aarhus, Department of Surgery L, Aarhus, Denmark; ²Aarhus University Hospita l, Department of Radiology R, Aarhus, Denmark; ³Aarhus University Hospital, Department of Surgery L, Aarhus, Denmark

Aim. Liver resection in combination with radiofrequency ablation (RFA) is a novel approach in patients with colorectal liver metastases who are otherwise untreatable with resection. The aim of this study was to evaluate the results of the combined treatment.

Methods. Eighteen patients with colorectal liver metastases were treated with surgical resection combined with RFA. All patients were followed prospectively with CT-scanning of thorax and abdomen during a five-year period: one, four, eight and 12 months after treatment and every six months thereafter for the next four years. Main outcome were recurrence and survival.

Results. Eleven men and seven female patients with a median age of 65 years (43–77) were treated with combined surgery and RFA. Seventy-six metastases were treated, 34 of these with resection. Median survival rate in the entire group were 35 months. The estimated 1-, 2- and 3-year overall survival rates were 100%, 87% and 45%, respectively. Five-years overall survival was 33.7%. Twelve patients had recurrence. Four of these developed hepatic recurrence while eight patients developed extrahepatic disease, primarily in the lungs.

Conclusion. The combination of surgery and radiofrequency ablation augments the number of patients with colorectal liver metastases who can be treated surgically and seems to increase long-term survival when compared to chemotherapy.

PP 29.10

CONTRAST ENHANCED INTRAOPERATIVE ULTRASOUND HELPS IN THE DETECTION OF ADDITIONAL COLORECTAL LIVER METASTASES AND CHARACTERISATION OF FOCAL LESIONS

Shah, Ankur¹; Pope, IM¹; Callaway, Mark²; Finch-Jones, Meg D¹

¹Bristol Royal Infirmary, HPB surgery, Bristol, United Kingdom; ²Bristol Royal Infirmary, Radiology, Bristol, United Kingdom

Background. Intraoperative ultrasound (IOUS) is the standard intra-operative investigation for assessing liver metastases prior to a resection. However, small and iso-echoic lesions may be missed due to size or poor characterization.

Aims. To determine whether Contrast enhanced ultrasound (CE-IOUS) detects additional metastases and improves the assessment of liver lesions as compared to B-mode IOUS prior to liver resection.

Methods. This prospective cohort study had ethical approval. All patients for a liver resection for colorectal metastases were invited to participate in this study. Pre-operative staging was performed with multi-slice CTscan plus MRI and/or Laparoscopic ultrasound. A standard protocol was followed for IOUS and contrast. Following surgical exploration, IOUS was performed. All lesions were characterized and mapped. CE-IOUS was then performed with an intravenous injection of sulphur hexafluoride microbubbles (Sonovue®), and the characteristics, number, size and position of lesions were recorded. Any additional lesions/changes with reference to the non-enhanced IOUS findings were documented. Any alteration in the surgical management was recorded. Finally, the resected specimen was correlated with the findings.

Results. Our preliminary data is based on 23 consecutive patients. 3 patients were inoperable on initial laparotomy and excluded. The total number of lesions detected in 20 patients by IOUS was 30 (out of the 36) as compared to 35 (out of 36) with CE-IOUS. 1 lesion was missed by both the modalities. CE-IOUS made one cancer inoperable by detecting multiple bilobar metastases and altered the operative plan in another patient. The accuracy of CE-IOUS was 97.2% compared to 83% for IOUS. In summary, CE-IOUS picked up 17% additional lesions and changed management in 10% of patients.

Conclusion. Our preliminary results suggest that CE-IOUS helps to detect additional metastases and characterize lesions better. CE-IOUS can be useful as an added tool prior to a resection for colorectal metastases.

PP 30.01

ROLE OF SPIRAL CT SCAN AND EUS IN DIAGNOSIS OF PERI-AMPULLARY TUMOURS.

Hegab, Bassem¹; El-Kased, Ahmed²; Okasha, Hussein³; Fawzi, May⁴; El-Badry, Ahmed⁵; Korayem, Enas²

¹National Liver Institute, University of menoufiya., Menoufiya, Egypt; ²Egypt; ³Cairo University, Egypt, Egypt; ⁴Cairo University, Egypt⁵

Introduction. Pancreatic cancer is associated with an extremely poor prognosis with less than 5% of patients surviving 5 years after the diagnosis. Current preoperative staging modalities include various cross-sectional imaging techniques, including spiral CT and endoscopic ultrasound (EUS). Aim of the work: demonstrating the role of spiral CT and endoscopic ultrasonography in early diagnosis and staging of periampullary tumors.

Patients and Methods. Sixty-two patients with periampullary tumors were included in this study. All cases were subjected to abdominal ultrasound, Spiral CT, ERCP, EUS and operative interference. Surgical findings were considered the gold standard for assessing the sensitivity of spiral CT and EUS in diagnosing, staging and estimating resectability of periampullary tumors.

Results. Endoscopic Ultrasonography was very sensitive in detecting periampullary masses (93.5%) especially masses smaller than 20mm while the sensitivity of spiral CT was 71%. EUS was also very sensitive in detecting ampullary masses (100%) in contrast to spiral CT that missed the diagnosis of the 14 ampullary masses found in our work. EUS was more sensitive than Spiral CT in detecting malignant vascular invasion (95% versus 75%) while it was slightly less specific than spiral CT in that context (74 versus 80%). The predictive value of spiral CT was 60% for tumor resectability while is was 100% for tumor unresectability. The predictive value of EUS was 73.5% for tumor resectability while it was 96.4% for tumor unresectability. When combining both techniques the predictive value for tumor resectability was 65% while it was 100% for tumor unresectability. No complications were encountered in both techniques.

Conclusions. EUS is more sensitive than spiral CT in detection and staging of periampullary masses. Also, the non-invasive spiral CT and the minimally invasive EUS are very valuable tools in predicting unresectability of periampullary masses while EUS is slightly more valuable in detecting tumor resectability.

PP 30.02

EUS EVALUATION OF CYSTIC TUMOURS OF THE PANCREAS- STRENGTHS AND PITFALLS.

Winkles, C; Cherian, PT; Taniere, P; Hejmadi, RK; Mahon, Brin

University Hosptial, Birmingham, United Kingdom

Background. Awareness of the malignant potential of cystic lesions of the pancreas and increased availability of EUS has lead to increased use of this modality in their evaluation. We reviewed our practice, especially with regards to size, morphology, and analysis of aspirates from EUS to identify learning points. Method: A retrospective review of consecutive patients referred to us for evaluation of cystic tumours between May 2005 and Feb 2007 using hospital records.

Results. 87 patients were reviewed. Presenting complaints ranged from being incidental (26.4%) to pain, jaundice, weight loss, chronic pancreatitis and cyst surveillance. Mean cyst size varied with presenting features. Of the 87 samples, 27 were positive for mucin, of whom 13(48.1%) had definite or suspected malignancy on cytology. An attempt at aspirate CEA levels was made. EUS morphology of these 27 patients were complex/multi-septated (18), simple/benign (7) and not described (2). Only in 10 of the 13 malignant cases was morphology suggestive of malignancy. Of the 7 in whom morphology was considered benign, one was mucin positive. Among the 23 ‘incidental’ patients, 7 were mucin positive and 2 mucin positive and malignant. Sixteen cysts had amylase levels >1000 and were probably pseudocysts, of whom only 68.8% had history or EUS findings suggestive of pancreatitis.

Conclusions. In the evaluation of cystic pancreatic lesions, neither history nor EUS morphology is reliable for diagnosis, and aspirate analysis is crucial. Presence of mucin is an indicator for malignancy with almost 50% of them being malignant if present. A combination of history, high amylase levels and typical EUS morphology allows separation of benign pseudocysts in most cases.

PP 30.03

SURGICAL CHOICE IN PANCREATIC HEAD MASS WITH UNCERTAIN DIAGNOSIS. CASE REPORT.

La Greca, Gaetano; Sofia, Maria; Lombardo, Rosario; Barbagallo, Francesco; Chisari, Andrea; Gagliardo, Salvatrice; Russello, Domenico

University of Catania, catania, Italy

Background. Because of its silent course, late clinical manifestation and rapid growth, pancreatic adenocarcinoma is been considered as a silent killer. Differential diagnosis for pancreatic head mass includes malignant tumor, ampullary carcinomas, neuroendocrine tumors, acute and chronic pancreatitis and at least autoimmune pancreatitis (AIP). We report a case of pancreatic head mass in which differential diagnosis has led to resolve some questions about diagnostical and therapeutical choice.

CASE REPORT. C.G., male 52 years old, was admitted in our department due to abdominal pain. Laboratory bloody test showed acute pancreatitis. An abdominal ultrasonography identif ied a pancreatic head mass. The abdomen CT was then performed, confirming the mass that involved the superior mesenteric vessels. Bloody tumoral makers levels were normal. Suspecting a malignant neoplasm, a EUS with FNA was performed, but it revealed a chronic pancreatitis. The patient was discharged with a EUS follow-up at 2 months, but after 2 weeks he came back due to abdominal pain and jaundice. An explorative laparotomy was performed. The intraoperative incisional biopsy was suspected for neoplasm. Due to the unresectability of the mass a coledoco- jejunal anastomosis was performed and the patient was led to the oncologist for adjuvant chemotherapy. The definitive istological result of the incisionale biopsy, reveal a chronic pancreatitis. After 3 months of chemotherapy the pancreatic mass was disappeared, and an AIP was suspected in this patient, but until now not confirmed.

Conclusions. Not all pancreatic head mass are malignant tumor, the 9.2% of Whipple resection are performed for benign but clinically suspected for malignant mass of the pancreas. The most common benign etiology in this case is the AIP. Preoperative diagnosis of this disease is very rare but in patients responders to risk factor for AIP, serum level of IgG4 should be performed. This screening may avoid unnecessary surgery and chemotherapy in future case.

PP 30.04

ACUTE PANCREATITIS AS FIRST SIGN OF PANCREATIC CANCER

Massani, Marco

Regional Hospital, IV Dpt Surgery, Treviso, Italy

Background. Pancreatic cancer is the fourth cause of death in eastern country, with an incidence increased twofold during last 40 years. Approximately 95% arise from exocrine cells and two thirds occur in the pancreatic head. Initial symptoms are various and insidious and relatively non specific. This may delay diagnosis. Acute pancreatitis as first sign of pancreatic cancer is rare and sometime the diagnosis could be difficult.

Methods. In a cohort of 1026 patients with proven acute pancreatitis we retrospectively reviewed our experience. In a group of five patients we have considered 2 patients (0,19%) with recurrent, non chronic, pancreatitis. Both where referred to our institution with diagnosis of idiopathic pancreatitis after, at least, two acute episodes. We reviewed images with our dedicated radiologist and we discovered in both patient a small cephalic lesion, present since the beginning of the history of pancreatitis, probably explained as focal pancreatitis or small necrotic component of the inflammation. The two patients required a duodenopancreatectomy and definitive specimen showed a pancreatic adenocarcinoma.

Conclusion. Our experience confirms that acute pancreatitis as first sign of pancreatic cancer is an uncommon event but confirms also that all patients with diagnosis of idiopathic pancreatitis need an accurate evaluation and follow up. In presence of a small lesion is mandatory to obtain a diagnosis.

PP 30.05

GROOVE PANCREATITIS MIMICKING PANCREATIC MALIGNANCY: A REPORT OF FOUR CASES

Gandhi, Vidhyachandra¹; Varma, Vibha²; Bheerappa, Nagari²; Regulagadda, Adikesava Sastry²

¹Nizams Institute of Medical Sciences, Surgical Gastroenterology, Panjagutta, Hyderabad, India; ²Nizams Institute of Medical Sciences, Surgical Gastroenterology, Hyderabad, India

Background. Groove pancreatitis is a rare form of segmental chronic pancreatitis characterized by a focal lesion confined to the groove between the duodenum, pancreatic head and bile duct with Brunner gland hyperplasia, cystic areas in the duodenum, dilated pancreatic ductules with mucinous plugs within. Despite all advances in imaging technologies, differentiating it from pancreatic malignancy has remained a persistent problem.

Aim. It is a study of four cases of pancreatic head mass with diagnostic dilemma treated in our unit for their presentation, investigation and management.

MATERIAL & Methods. Four middle aged patients, 3 males (chronic alcoholic) and 1 female, presented with chronic upper abdominal pain and vomiting. One patient presented with duodenal obstruction and upper gastrointestinal endoscopy confirmed obstruction due to a submucosal mass. Two other patients had mural thickening of the medial wall of duodenum. One patient presented with recurrent episodes of jaundice.

Results. Abdominal computed tomography in all the patients showed a mass lesion in the groove between duodenum and pancreatic head with duodenal wall thickening and cystic areas within. Pancreatic malignancy could not be ruled out despite multiple biopsies and estimation of CA 19-9. Pancreaticoduodenectomy was done in three cases, while one case was deemed inoperable due to vascular encasement (anomalous common hepatic artery arising from superior mesenteric artery). Frozen biopsy from the lesion was reported as chronic pancreatitis. Histology confirmed groove pancreatitis in all four cases and was corroborated by imaging.

Conclusion. Groove pancreatitis is difficult to differentiate from malignancy and pancreaticoduodenectomy is the commonest procedure performed for such cases. Follow-up and conservative management is offered if diagnosis is made on imaging and clinical features.

PP 30.06

Screening in Familial and Hereditary Pancreatic Cancer

Erdmann, Joris¹; Poley, Jan Werner²; Van Eijck, Casper H. J.³; Kuipers, Ernst J.⁴

¹Erasmus MC, Surgery, Rotterdam; ²Erasmus MC, Gastroenterology and Hepatology, Rotterdam; ³Erasmus MC, Surgery, Rotterdam, Netherlands; ⁴Erasmus MC, Gastroenterology and Hepatology, Rotterdam, Netherlands

Pancreatic cancer (PC) has a poor prognosis. Early detection of pre-malignant lesions (IPMN, PanIN) or small asymptomatic tumors could improve outcomes. Since pancreatic cancer is relatively rare, screening of the general population is unfeasible. However, 5–15% of all PC is considered to be familial or hereditary in origin. By using endoscopic ultrasound (EUS) it is possible to examine both pancreatic parenchyma and pancreatic duct in detail. Furthermore, cytological specimens can be obtained.

Methods. Since 2005 patients with familial or hereditary PC were offered EUS screening. Procedures were carried out under conscious sedation and performed by an experienced endoscopist. When abnormalities were found, EUS was followed by CT and/or MRI.

Results. 20 patients from 14 families (M/F 10/10) were screened. Genetic background was diverse: patients with at least two first-degree relatives with PC (familial PC, n = 8), patients with familial PC and/or familial atypical multiple mole melanoma syndrome (FAMMM) with unclassified variants (UV) in the p16 gene (n = 5), Peutz-Jeghers syndrome (n = 2), genetically proven FAMMM syndrome (n = 4)and one carrier of a pathogenic BRCA2 mutation in a family with familial PC. No procedure related complications occurred. Significant pathology was found in three patients (15%): in a patient with a p16 UV multifocal side-branch intraductal papillary mucinous neoplasms (IPMN) were found, all less than 1,5 cm in size. In a patient with familial PC one side-branch IPMN of 5 mm was found. Furthermore, one small solid lesion in the pancreatic tail (22 mm) in an asymptomatic BRCA2 carrier was found. This patient underwent a resection of the pancreatic tail without complications. Histopathological examination confirmed an adenocarcinoma.

Conclusions. EUS screening has a significant yield in selected asymptomatic high-risk patients and may lead to resections. Whether this improves outcome in these patients remains to be proven.

PP 30.07

PANCREATIC CARCINOMA OCCURRING IN CHRONIC CALCIFIC PANCREATITIS OF TROPICS

Iype, Satheesh¹; SubhaLal, N²; Kuruvilla, A P²; M L, Arun Kumar²; Anandakumar, M³; Kocher, H M¹

¹Royal London Hospital, HPB Surgery, London, United Kingdom; ²Medical College Hospital, Dept. Of Surgical Gastroenterology, Trivandrum, India; ³Medical College Hospital, Retd. Dept. Of Surgical Gastroenterology, Trivandrum, India

Introduction. Chronic calcific pancreatitis of tropics(CCPT) is a juvenile form of chronic calcific non-alcoholic pancreatitis prevalent almost exclusively in the tropical countries. Kerala, the southwestern state of India has found to be one of the ‘hot spots’ with high incidence of CCPT. The characteristics of this disease have been described as “pain in childhood, diabetes in adolescence and death at the prime of life.” Carcinoma developing in chronic calcific pancreatitis of tropics has been hypothesized since last 3 decades without adequate cohort studies to define the clinical presentation of the disease or its assessment in comparison to pancreatic cancer occurring de novo.

Methods. We reviewed 2 cohorts of patients in a single tertiary referral centre: CCPT with malignancy (n = 90) and de novo pancreatic ductal adenocarcinoma (n = 195) during a 9-year period from March 1998 to October 2006.

Results. Salient clinical difference in the two groups are listed in table

	De novo Pancreatic cancer	Ca in CCPT
Age (median, range)	62 (43–81) years	42 (26–77) years
M:F	140:55 (2.54:1)	66:24 (2.75:1)
Symptoms
Jaundice	89.23%	73.33%
Pain	7.36%	95.55%
Loss of weight	35.38%	81%
Diabetes Mellitus	11.28%	78.50%
Median size(cm)	3.72	4.11
Histology for resected
WDAC	43 (56%)	14 (37%)
MDAC	21 (26%)	15 (41%)
PDAC	15 (18%)	8 (22%)
Histology for unresected
WDAC	12 (67%)	5 (20%)
MDAC	3 (16.5%)	10 (38%)
PDAC	3 (16.5%)	11 (42%)
Location of tumour
Head	88.22%	74.70%
Body	10.25%	22.80%
Tail	1.53%	2.50%
Operation types
Biliary bypass	20 (10.3%)	19 (21.2%)
Biliary bypass + GJ±Other procedures	87 (44.6%)	13 (14.4%)
Classical Whipple	21 (10.7%)	4 (4.4%)
PPPD (Pylorus Preserving Pancreatoduodenectomy)	45 (23.1%)	28 (31.2%)
Distal pancreatectomy	9 (4.6%)	4 (4.4%)
Others	13 (6.7%)	22 (24.4%)

Conclusion. Carcinoma occur at younger age in CCPT patients, as compared to de novo pancreatic cancer suggesting the pre-malignant state of the CCPT. Also Ca in CCPT tended to occur twice more commonly in the head and generally tumours were of the worse grade and less likely to be resectable.

PP 30.08

BBILIARY BYPASS FOR PALLIATION

Dariwala, Shekhar

NRS Medical College Hospital, Kolkata, India

Holbrook and colleagues (January 1990 JRSM, p 12) report the results of biliary bypass surgery in patients with pancreatic cancer. They pose the question whether a gastroenterostomy is necessary at the time of primary surgery. They note that 48 of 165 (29%) patients underwent a gastroenterostomy either to prevent gastric outlet obstruction or to treat it. They note a much higher mortality following biliary bypass with gastroenterostomy (10 of 37, 27%) compared with biliary bypass alone (18 of 128, 14%).

PP 30.09

ADENOSQUAMOUS CARCINOMA ORIGINATING FROM PAPILLA OF VATER

Ozkan, Erkan¹; Dulundu, Ender¹; Ozel, Yahya¹; Kayahan, Munire¹; Gunes, Pembegul Binbir²; Topaloglu, Umit¹

¹Haydarpasa Numune Education and Research Hospital, 5th Department of Surgery, Istanbul, Turkey; ²Haydarpasa Numune Education and Research Hospital, Department of Pathology, Istanbul, Turkey

Introduction. Adenosquamous carcinoma of the pancreas is a rare agressive subtype of exocrine pancreatic neoplasms. Clinical features and course of the tumor is similar to those of pancreatic adenocarcinomas. A patient is presented here that was operated for periampullary tumor and that the pathological examination of the specimen resulted in adenosquamous carcinoma. We aimed to discuss the histopathological and clinical characteristics of the neoplasm in the light of literature. Material and Method: A 58-year-old woman was admitted to hospital with the complaints of abdominal pain and jaundice lasting for one month. On computerized tomography of the abdomen common bile duct was dilated with an irregular contour and a blind end and the density changed in that localization. A 10-mm polipoid lesion of soft tissue density was observed proximal to the transvers part of duodenum as an area with contrast defect. Total bilirubin level was increased to 23.9mg/dl (N: 0.4–0.8mg) and CA 19-9 level to 69.8U/ml (N: <35U/ml). On laparotomy we removed the tumor via Whipple operation. Histopathological examination of the tumor showed that the localization was on the papilla of Vater and that the patology was moderately differentiated adenosquamous carcinoma. Tumor was reported to have invaded choleduct and pancreas and metastasized to common hepatic duct, small intestines and peripancreatic lymph nodes. She left hospital without any complications and started to have oncologic treatment.

Conclusion. Adenosquamous carcinoma is the type with the worst prognosis among ductal carcinomas of the pancreas. It originates in the duct following mutation of K-ras oncogene. Adenosquamous carcinoma of the pancreas is presented in literature as sporadic and small series. Survival is less than one year in spite of surgical treatment in most patients. Adenosquamous carcinoma should be kept in mind in the differential diagnosis of a mass localized at the head of the pancreas.

PP 30.10

CONTINUOUS VERSUS INTERRUPTED PANCREATIC ANASTOMOTIC TECHNIQUES IN WHIPPLE'S PANCREATO DUODENECTOMY

Patil, Vrishali; Low, Jee K; Manu, Mangta; Vadeyar, Hemant; Sherlock, David

North Manchester General Hospital, Surgery, Manchester, United Kingdom

Introduction. Interrupted pancreatic anastomosis is the commonly performed anastomotic technique in Whipple's pancreatoduodenectomies. The pancreatic-jejunal anastomosis may be done using interrupted two layers or continuous two layered method. OBJECTIVE To compare the leak rate of continuous versus interrupted methods of pancreatic anastomosis in Whipple's surgery.

Methods. A review was undertaken for 50 patients who underwent pancreato-jejunal anastomosis during Whipple's pancreatico-duodenectomy between 2006 and 2007 at a tertiary HPB referral centre. Indication for the operation, age group, gender, operative set up, post operative care, clinical outcomes, histological grade were assessed for the occurrence of anastomotic leaks.

Results. 23 patients underwent interrupted pancreatic jejunal anstomosis using absorbable sutures and telescoping the pancreas.27 patients underwent continuous anastomosis using identical Methods. Pancreatic leak rate was 4.3% in the interrupted group and 3.7% in the continuous group. There is no statistically significant difference in the leak rates and the post operative morbidity in both study groups.

Conclusion. It is safe to perform continuous pancreatic-jejunal anastomosis and there are no added disadvantages over interrupted techniques.

PP 31.01

SURGERY IN MALIGNANT OBSTRUCTIVE JAUNDICE: PROGNOSTIC INDICATORS OF MORBIDITY AND MORTALITY

Bhange, Snehal¹; Patil, Bhushan²; Adhikari, Devbrata²; Singh, Rajinder²; Shetty, Tilakdas²; Joshi, Rajeev²

¹T.N. Medical College & B.Y.L. Nair Ch. Hospital, General Surgery, A.L.Nair Road, Mumbai, India; ²T.N. Medical College & B.Y.L. Nair Ch. Hospital, General Surgery, Mumbai, India

Background. Pancreatico-duodenectomy although a formidable operative procedure is been increasingly performed and palliative bypass procedures do have a role despite the emergence of endoscopic palliation.

Objective. Analyse factors contributing to morbidity and mortality following curative and palliative procedures and identify prognostic indicators.Method.: 218 patients (126 pancreatico-duodenectomy, 7 Klatskin tumour resections and 85 palliative bypass procedures) were analysed from February 1999 to July 2007.

Results. Morbidity and mortality following curative surgeries were 50.37% and 7.51% respectively and 31.76% and 4.7% respectively following bypass procedures. On univariate analysis in the curative surgery group, higher post-operative morbidity and mortality was associated with hemoglobin <9gm% ( p < 0.055), WBC counts >11,000/cumm (p < 0.078), and low albumin <2.2mg/dl (p< 0.051). Pre-operative endobiliary drainage although associated with the same was not statistically significant. On multivariate analysis, values of hemoglobin, alkaline phosphatase and bilirubin taken together improved the predictability of outcome in the patients. On univariate analysis in the palliative group, a significant association was seen between alkaline phosphatase >650 U/L and higher post-operative morbidity and mortality (p< 0.026). On multivariate analysis values of hemoglobin, albumin and bilirubin taken together, improved the predictability of outcome.

Conclusion. Mortality rate of 7.51% after curative surgery is encouraging in Indian context as most of our patients are anaemic or hypoproteinemic with fairly advanced disease. Complications decrease with gain in experience, dedicated peri-operative management and team approach. In the palliative surgery group higher mortality and morbidity was seen in patients with low hemoglobin and albumin and high bilirubin. Even in the presence of these adverse factors the surgical option needs to be exercised if endoscopy fails.

PP 31.02

PANCREATICODUODENECTOMY IN ELDERLY PATIENTS

Ito, Takaaki; Hiramatsu, Kiyoshi; Kato, Kenji

Kiryu Kosei General Hospital, Surgery, Kiryu, Japan

Background./AIMS: Due to long life expectancy, a case of resectable pancreatic cancer or bile duct cancer in the periampullary lesion are increasing among elderly patients. They may need to undergo pancreaticoduodenectomy (PD) for the curative therapy. PD is a procedure with relatively high rate of mortality and morbidity as compared with the other digestive surgery. The risk and benefit of PD in elderly patients is still unclear. Therefore, the aim of this study was to investigate the safety of the PD in elderly patients over 75 years old.

OBJECTIVES. Between 1992 and 2007, One-hundred and forty-nine PDs were performed at Department of Surgery, Kiryu Kosei General Hospital. These consecutive cases were divided into two groups by age 75. Fifty patients were 75-year-old or older (elderly-patient-group: EP). Ninety-nine patients were under 75-year-old (younger-patient-group: YP). We evaluated morbidity and mortality in these groups.

Results. Morbidity: These two groups were statistically similar with respect to sex, intraoperative blood loss, and operative time. Preoperative comorbidity rate was 32.0% (17/50) in EP and 24.2% (24/99) in YP. Complications associated with surgical techniques, such as pancreatic fistula, anastomotic leakage, delayed gastric emptying, wound infection etc., occurred in and 32 cases (64%) in EP (p = 0.323, N.S.) and 55 cases (55.6%) in YP. Mean length of hospital stay was 47.8 days in EP and 45.5 days in YP. (p = 0.420, N.S.) Mortality: Four patients died within 30 days of operation. The three of them (6.0%) were in EP and one of them (1.0%) was in YP (p = 0.075, N.S.).

Conclusions. Although high aged patients have trend o f high rate of preoperative comorbidity, PD for elderly patients is as safe as for younger patients. We conclude that careful selection of the patients can keep safety of pancreaticoduodenectomy even in the elderly patients.

PP 31.03

PANCREAS-SPARING DUODENECTOMY FOR ADVANCED DUODENAL CARCINOMA WITHOUT LYMPH-NODE METASTASIS AND PANCREATIC INVASION

Arimitsu, Hidehito¹; Cho, Akihiro²; Yamamoto, Hiroshi²; Nagata, Matsuo²; Kainuma, Osamu²; Takiguchi, Nobuhiro²; Souda, Hiroaki²; Gunji, Hisashi²; Miyazaki, Akinari²; Matsumoto, Ikuko²; Ikeda, Atsushi²; Nagao, Yoshiko²; Ryu, Munemasa²

¹Chiba Cancer Center Hospital, Division of Gastroenterological Surgery, Chiba, Japan; ²

Pancreatoduodenectomy (PD) is often required to obtain curative surgical resection for advanced duodenal carcinoma. However, leakage from pancreaticoenteric anastomoses after PD remain associated with intra-abdominal hemorrhage and subsequent high mortality rates, especially in high-risk patients. In contrast, recent advances in diagnostic imaging and the surgical anatomy of the pancreatoduodenal region have made limited resections of the periampullary area possible. Pancreas sparing-duodenectomy (PSD) has emerged during the last few years as an alternative to PD and is becoming increasingly accepted as a technique for the treatment of benign diseases and low-grade malignancies, such as familial adenomatous polyposis syndrome, villous adenoma, and duodenal trauma. We successfully performed supra-ampullary PSD for two high-risk patients of advanced duodenal carcinoma without lymph-node metastasis and pancreatic direct invasion. Although our experience is limited and appropriate indications must await future studies, we believe that supra-ampullary PSD can be feasible and safe in highly selected patient. This report describes an operative procedure of supra-ampullary pancreas-sparing duodenectomy.

PP 31.04

THE JUSTIFICATION OF PERFORMING A WHIPPLE′S PROCEDURE IN CIRRHOTIC PATIENTS

Pereira, Jorge; Duarte, Emanuel Vigia; Coelho, João; Pereira, José António; Marques, Hugo; Mira, Paulo; Martins, Américo; Barroso, Eduardo

Hospital de Curry Cabral, Centro Hepatobiliopancreático e de Transplantação, Lisboa, Portugal

Background. Pancreatoduodenectomy (PD) is a major surgical procedure only justified in fit patients that might benefict from such an unavoidable dissection with a low morbimortality. The coexistence of cirrhosis adds a new risk to the procedure, increasing the probabilities of major morbimortality.

Aims. to prove that cirrhotic patients with periampulary tumors are still candidates to major pancreatic resections.

Methods. since 2003, 97 PDs were performed for periampulary tumors. Among these, 3 patients had cirrhosis:2 male (65 and 62 years old) with alcoholic cirrhosis and 1 female (69 years old) with criptogenic cirrhosis;all CHILD A desease and one with coexistent 2 CHC nodes (< 3 cm); they all were submited to Whipple's operation (same surgical team). Alcoholization was performed simultaneously in the CHC case as a bridge to eventual further liver transplantation.

Results. histology revealed an ampuloma in one case (pT1N0Mx) and a 4 and 5 cm IPMN of the pancreatic head in the other two. All the 3 operations were performed by the same surgical technique (ligasure dissection, 2 units of red blood cells in one case).There was no mortality;Morbidity:ascitic fluid infection followed by reoperation at post-op day 7 (one case);biliary fistula was detected by the drainage treated conservatively. In all 3 patients, major ascitis was present for some weeks, complicating pos-operative period with important hidroelectrolitic imbalance. Patients were discharged at days 18, 25 and 30, uneventfully.

Conclusions. we conclude, from our experience, that Whipple's procedure may be indicated in cirrhotic patients with periampulary tumors, provided they are CHILD A and fit for a potential curative pancreatic resection.

PP 31.05

HEPATIC ARTERY RECONSTRUCTION IN PANCREATICODUODENECTOMY BY DIRECT ANASTOMOSIS UTILIZING PANCREATICODUODENAL ARTERY.

Hoshino, Takanobu; Ishida, Takashi; Hashimoto, Daijo

Saitama Medical University, Medical Center, Hepato-pancreato-biliary Surgery, Kawagoe-city, Japan

OBJECTIVE. To present technical aspects and advantages of hepatic artery (HA) reconstruction by direct anastomosis utilizing pancreaticoduodenal artery (PDA) as a useful option in pancreaticoduodenectomy.

Methods. Pancreaticoduodenectomy was performed in a patient with complete obstruction of celiac trunk. A 69-year-old female patient, complaining of jaundice, was admitted with diagnosis of cancer of either pancreas head or CBD. Angiography demonstrated complete obstruction of celiac trunk, because of arteriosclerosis, and marked dilation of the arcade between inferior and superior PDAs. Blood flow of HA turned out to be supplied only from superior mesenteric artery (SMA) via arcades of PDAs. Therefore, it was mandatory to perform HA reconstruction to safely complete pancreaticoduodenectomy. OPERATION: Intraoperative findings revealed no tumor exposure on the surface of pancreas or CBD. There was no tumor invasion to adjacent tissue and no lymph node swelling, either. Therefore, we decided to utilize the arcade of PDAs for HA reconstruction. Anterior arcade of inferior and superior PDAs was carefully dissected and freed, first, by ligating and dividing small branches communicating to pancreas head. Following complete dissection of the anterior arcade of PDAs, we performed reconstruction of HA by end-to-end anastomosis between gastroduodenal artery and dilated anterior inferior PDA (4 mm in diameters for both arteries). After adequate blood flow of HA (through this vascular anastomosis) was confirmed, the rest of pancreaticoduodenal resection followed by biliary and alimentary tract anastomoses were completed in usual fashion.

Results. Postoperative course was uneventful, and no complication, including vascular problems such as anastomotic occlusion or leakage, was observed. This patient is still alive, free of disease, at four years three months following surgery.

Conclusion. HA reconstruction utilizing PDAs appears to be one of the useful options when adequate diameters of the arteries are available.

PP 31.06

REFERRAL PATTERNS AND MANAGEMENT OF PANCREATIC CANCERS AT A SINGLE, LARGE REFERRAL CENTRE IN THE UK.

Sethi, Harsheet¹; Madanur, Mansoor¹; Deshpande, Rahul²; Heaton, Nigel³; Rela, Mohamed³

¹Kings College Hospital, Hepatobiliary surgery, London, United Kingdom; ²Royal Marsden Hospital, Hepatobiliary surgery, London, United Kingdom; ³Kings College Hospital, Hepatobiliary surgery and Transplantation, London, United Kingdom

Background. The NHS Cancer plan recommends that specialist assessment and interventions for patients with pancreatic cancer should be provided by a multidisciplinary team based at a Regional Pancreas cancer centre serving populations of 2–4 million. This was implemented in 2005 aiming to increase resection rates and reduce hospital morbidity and mortality. We present management of patients at the regional centre of the South-east England cancer network since centralisation.

Methods. A retrospective analysis of all pancreatic cancer referrals to the Multidisciplinary meeting at the regional cancer centre from 2005 till 2007 was carried out. Of the total number of referrals (557), 511 were for suspected cancer, and 426 were characterized as malignant disease. Pre-operative staging indicated metastatic disease in 93, locally advanced in 114 and operable tumour in 182 patients. The resectability rates, post-operative morbidity and mortality were analysed.

Results. 145 patients (29.6%) underwent surgery for pancreatic cancer with 114 pancreatico-duodenectomies, including 3 laparoscopic and 18 vascular resections. 71% of the resections were for tumours in the head, 22% peri-ampullary and 5.5% for cystic tumours in body and tail of pancreas. Post-op morbidity was 32.5%, with pancreatic leak rate of 8.7%. The post-operative mortality was 2.4%, with a 30-day mortality of 1.2%.

Conclusions. This initial audit of the working of a specialised cancer unit has provided encouraging data to back-up the role of centralisation in improving outcomes in pancreatic cancer. Studies focussing on long-term survival benefits and Quality of life assessment are underway.

PP 31.07

SURGICAL RESECTION FOR MANAGEMENT OF PANCREATIC CANCER IN OCTOGENARIANS.

Sethi, Harsheet¹; Marangoni, Gabriele¹; Bartlett, Adam¹; Rela, Mohamed¹; Heaton, Nigel²

¹Kings College Hospital, Hepatobiliary surgery, London, United Kingdom; ²Kings College Hospital, Hepatobiliary surgery and Transplantation, London, United Kingdom

Background. We live in a rapidly aging society with the highest demographic growth in the very elderly group, over the age of 80 years. Incidence of pancreatic cancer peaks after the 7th decade. We present management of pancreatic cancer in octoge narians at a tertiary referral centre.

Methods. A review of departmental data bases of pancreatic cancer referrals from 2005 to 2007 identified 64 patients over the age of 80 years. Pre-operative staging included assessment of performance status and discussion at the multidisciplinary meeting. At initial assessment, 9 patients had metastases, 27 with locally advanced disease and 28 had resectable tumours. 12 patients were found unfit for surgery, 4 refused surgery, and 12 underwent surgery. We evaluated peri-operative morbidity, mortality and 6 month follow-up in these patients.

Results. The surgeries include pancreatico-duodenectomy in 9 patients including 2 laparoscopic resections, 1 laparoscopic distal pancreatectomy, and 1 bypass for irresectable tumour found at laparotomy. The tumour was located in the ampulla and head of pancreas in 5 patients each. The median duration of surgery was 320 minutes (range 150 – 660). The median HDU stay was 1 day (range 1–6) and the median post-operative hospital stay was 15 days (range 2–48). The post-operative morbidity of 50% did not include any pancreatic leak. One patient died on POD2 following a myocardial infarct. Follow-up at 6 months demonstrated a disease free survival of 92%.

Conclusion. Surgery for pancreatic cancer in octogenarians can be carried out in a safe and effective manner and chronologic age alone cannot be considered a contraindication to radical surgery.

PP 31.08

PREOPERATIVE STAGING AND EVALUATION OF PANCREATIC CANCER PROGNOSTIC FACTORS

Kubyshkin, Valeriy¹; Kochatkov, Alexander¹; Kriger, Andrei¹; Karmazanovsky, Grigory²; Gurevich, Larisa³; Stepanova, Yuliya²; Zborovskaya, Irina⁴

¹A.V. Vishnevsky Institute of Surgery, abdominal surgery department, Moscow, Russian Federation; ²A.V. Vishnevsky Institute of Surgery, radiology department, Moscow, Russian Federation; ³MONIKI, Moscow, Russian Federation; ⁴N.N. Blikhina RONC, Moscow, Russian Federation

Background. We assessed the surgical value of staging and molecular factors in predicting resectability and survival rates of patients with pancreatic head cancer (PHC).

Methods. 92 patients with PHC were grouped into three classes of resectability: 1 – resectable (55.44%), 2 – questionably resectable (22.82%), and 3 – non-resectable (21.74%). We investigated DNA ploidy, mutations in the K-ras and ð53 genes, LOH of ð16INK4a/15INK4b, DPC-4, expression of E-cadherin, matrix metalloproteinases-2 (MMP-2), ð53 and Ki-67 as possible prognostic factors.

Results. Tumor DNA content was aneuploid in 73.9% pts and in 92.3% G3 tumors. Mutations in the K-ras oncogene occurred in 76% tumors. We did't find any correlations between K-ras mutation and cancer stage. Mutations in 273 codon of ð53 gene were found in 35.8% tumors. We found a significant correlation between Ki-67 index and DNA tumor content. Ki-67 index was 27.2±7 and 13±2.8 in aneuploid and diploid tumors (p = 0.017). Expression of MMP-2 was found in 63% tumors. The mean overall survival was 11.54±9.27 months. The survival for R0 and R2 patients was 14.8±10.7 and 5.5±2.8 months; and for patients of the 1st, 2nd and 3rd groups was 16.1±8.3, 8.65±4.0, 5.4±2.9 months respectively. The mean survival of patients with diploid and aneuploid tumors was 28.8±16.34 and 11.6±8.8 months (ð = 0.006). Molecular Alteration Index (MAI) did't have any correlations to the stage of PHC and tumor grade (ð = 0.75, ð = 0.36). For patients who were alive for less than a year, for less than 2 years and for more than 3 years mean values of MAI were 77.27±5.56%, 45.75±8.34% and 34.6±9.6%, (ð = 0.006). MAI was a significant prognostic factor in PHC. The lower the MAI the better was long-term outcome.

Conclusions. The worst PHC prognostic factors are partial or complete circumscription of the vessels, with or without hepatic metastasis, as well as tumor cell aneuploidy, high level of Ki-67 index, 273 codon p53 gene mutations and expression of MMP–2.

PP 31.09

EIGHTY CONSECUTIVE PANCREATICODUODENECTOMIES WITHOUT MORTALITY.

Tank, Avinash Kumar; Singh, Rajneesh Kumar; Behari, Anu; Ashok Kumar,; Saxena, Rajan; Kapoor, Vinay Kumar

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Surgical Gastroenterology, Lucknow, India

Introduction. Pancreaticoduodenectomy (PD) is an operation that has conventionally been associated with a high morbidity (30–60%) and mortality (1–28%). Recent results from high volume centers report a significant lowering of mortality and morbidity. However there are only a few published reports of PD without any mortality.Method.:Eighty consecutive patients underwent PD without any mortality (from July 2005 to May 2007) and were analyzed from a prospectively maintained database with regard to presentation and outcome.

Results. The median age was 53 (range 17–82) years. The commonest presenting symptoms were jaundice 70 (88%), weight loss 71 (88%) and cholangitis 44 (55%). The mean hemoglobin was 11.4 gm/dl, mean serum albumin was 3.5 gm/dl and 27 (33%) patients had maximum bilirubin > 15 mg/dl. Fifty-two (65%) patients underwent preoperative biliary drainage. Pylorus preserving PD was done in 39 (49%) patients and classical Whipples’ PD was done in 41 (52%) patients. The mean operation time was 7 (range 3.5 to 11) hours and the mean blood loss was 568 (range 100 to 2000) ml, 45 (56%) patients did not require peri-operative blood transfusion. The pathology of the resected specimen showed ampullary carcinoma in 52 (65%) patients, cholangio-carcinoma in 9 (11%), pancreatic head adenocarcinoma in 7 (9%), duodenal carcinoma in 5 (6%) and no malignancy in 7 (9%) patients. Major postoperative morbidity was seen in 35 (44%) patients: this included bleeding 12 (15%), pneumonia 11 (14%), pancreatico-jejunal anastomotic leak 11 (14%), hepatico-jejunostomy anastomotic leak 6 (8%), intra-abdominal abscess 7 (8%), and duodeno-jejunal or gastro-jejunal anastomotic leak 2 (4%). Re-operation was required in 6 (8%) patients. There was no mortality. The median post-operative hospital stay was 15 (range 7–41) days.

Conclusion. Though the morbidity of PD still remains high, it is possible to achieve a nil operative mortality with improved postoperative care and better understanding of the postoperative complications

PP 31.10

SURGICAL OUTCOME IN ADENOCARCINOMA OF PANCREATIC HEAD AND UNCINATE PROCESS WITH SMV-PV RESECTION.

K, Dilip Chakravarty¹; Hwang, Tsann-Long²; Liu, Keng-Hao²; Yeh, Chun-Nan²; Yeh, Ta-Sen²; Jan, Yi-Yin²; Chen, Miin-Fu²

¹Chang Gung Memorial Hospital, Fellow in HPB Surgery, Dept. of General Surgery, Taipei, Taiwan; ²Chang Gung Memorial Hospital, Department of General Surgery, Taipei, Taiwan

Introduction. Adenocarcinoma accounts for more than 80% of all pancreatic malignancies. 5 yr survival is 15 to 25% in most series. The recent approach towards early diagnosis and aggressive resectability has some impact on the surgical outcome.

Objective. This is retrospective study carried out from 1996 to 2006 in Chang Gung Memorial Hospital, Taipei, Taiwan to study the surgical outcome in patients undergoing surgery for pancreatic head and uncinate process malignancies with encasement of SMV-Portal vein.

Methods. Only stage II and III adenocarcinoma involving head and uncinate process were included. Stage I, IV and adenocarcinoma involving pancreatic neck, body and tail were excluded. Total 87 cases in stage II and III undergone curative resection. Whipple with PV-SMV resection 12 cases (13.8%), Whipple without SMV-PV resection 57 cases (65.5%) and PPPD without SMV-PV resection18 cases (20.7%). 20 cases patients received palliative treatment in the form of surgery, CT and RT. The factors taken into consideration are pre-operative staging of tumor, histological type, lymph node status, tumor size, tumor markers, type of surgery, complications, adjuvant chemoradiotherapy.

Results. The surgical outcome in terms of mortality, morbidity and survival rate is compared with PPPD and Whipple procedure with/without SMV-PV resection. The overall cumulative survival rate in 2 yrs and 4 yrs in patients of whipple and PPPD is 22.7%,11.3% and those with PV-SMV resection 18.8%,18.8% respectively. 1 yr and 2 yr survival in those with PV-SMV resection is 50.0% and 31.3% and those patients who undergo palliative resection/CT, RT is 25.0% and 6.3% respectively.

Conclusion. Pancreatic head and uncinate process adenocarcinoma with encasement of PV-SMV does not preclude operability and should not be regarded as a contraindication for radical resection. SMV-PV resection can be performed safely, without increase in the morbidity and mortality in carefully selected patients.

PP 32.01

INFECTIOUS COMPLICATIONS IN LIVING DONOR LIVER TRANSPLANT RECIPIENTS ARE A MAJOR RISK FACTOR OF EARLY MORTALITY

van den Broek, Maartje¹; Saner, Fuat²; Olde Damink, Steven W.M.¹; Rath, Paul³; Paul, Andreas² ; Nadalin, Silvio²; Broelsch, Christoph E.²; Malagó, Massimo⁴

¹University hospital Maastricht, Department of Surgery, Maastricht, Netherlands; ²University hospital Essen, Dept. of General, Visceral and Transplant Surgery, Essen, Germany; ³University hospital Essen, Institute of Medical Microbiology, Essen, Germany; ⁴University College London, Department of Surgery, London, United Kingdom

Background. Living donor liver transplantation (LDLTx) has gained increasing acceptance for patients with end-stage liver disease. Despite advances in graft preservation, operating techniques and post-transplant care, recipient morbidity and mortality remain considerably high.

Objective. We analyzed the influence of post-transplant clinically significant infections (CSI) on recipient survival after LDLTx.

Methods. All adult LDLTx recipients transplanted in our Unit between 2004 and 2007 were studied. Patients were treated in a single ICU, applying standardized care consisting of triple immunosuppression, antimicrobial prophylaxis and selective digestive decontamination. CSI were defined as pulmonary, intra-abdominal or blood stream infections proven by culture with accompanying symptoms that reacted to therapy. The influence of CSI on recipient survival was analysed using Fisher′s exact test. P < 0.05 was considered significant.

Results. Sixty patients constituting of 35 males and 25 females with a mean age of 49.3±11.6 years, underwent LDLTx during the study period. Mean MELD score was 14±7.7. Indications for LDLTx were cirrhosis associated HCCs (18), viral hepatitis (11), cholestatic liver disease (7), alcoholic liver disease (5), autoimmune hepatitis (4), acute liver failure (4) and other (11). CSI arose in 26 (43%) recipients, consisting of 8 pulmonary, 14 intra-abdominal and 14 blood stream infections. Sixteen (27%) recipients died during their hospital stay after a median of 18 (0–69) days and the main cause of recipient death was septic multi-organ failure in 10 (63%). The risk of mortality was 5.7 times increased when a clinical significant infection occurred (p = 0.0008).

Conclusion. CSI in LDLTx recipients confer a major risk of early post-transplant mortality. Prevention of such infections is crucial to achieve higher post-transplant survival rates. Therefore, active identification of graft and recipient related risk factors is of key importance to improve LDLTx outcomes.

PP 32.02

TREATMENT OF PORTAL VEIN STENOSIS AFTER LIVING DONOR LIVER TRANSPLANTATION USING INTERVENTIONAL RADIOGRAPHY

Amano, Hironobu¹; Hirotaka, Tashiro²; Itamoto, Toshiyuki³; Oshita, Akihiko²; Ohdan, Hideki²; Toyota, Naoyuki⁴; Asahara, Toshimasa⁵

¹Hiroshima University Hospital, Hiroshima, Japan; ²Hiroshima University Hospital, Surgery, Hiroshima, Japan; ³Hiroshima University Hospital, Surgery, Hiroshima; ⁴Hiroshima University Hospital, Radology, Hiroshima, Japan; ⁵Hiroshima Univercsty Hospital, Surgery, Hiroshima, Japan

Background. Portal vein stenosis is significant factors leading to graft loss after liver transplantation. However, surgical treatment for this complication is sometimes very difficult and too much invasive for patients. Recently, interventional radiography (IVR) technique was developed and applied to treat this complication. We evaluate IVR as a therapeutic strategy for postoperative portal vein stenosis based on our experience.

Methods andResults. We have performed 102 cases of living donor liver transplantation and applied IVR procedure to 3 cases to treat portal vein stenosis after transplantation. These patients showed clinical signs such as ascites, jaundice, and liver dysfunction after transplantation, and Doppler US were useful to diagnose these complications. Three-dimensional computed tomography (3D-CT) was used to confirm the indications for IVR. Both of 2 patients suffering from portal vein stenosis were treated by percutaneous transhepatic approach using metallic stent following balloon dilatation, and showed excellent long-term patency after stenting. On the other hand, one patient suffering from stenosis of anterior and posterior branches of portal vein was treated by jejunal vein approach using metallic stents, and also showed exellent long-term patency after stenting. We experienced no complications with these IVR procedures.

Conclusions. IVR can be safely and successfully applied to the treatment of portal vein stenosis before graft dysfunction becomes irreversible.

PP 32.03

INTRAOPERATIVE PORTAL VEIN STENTING: A SIMPLE METHOD FOR SEVERE PORTAL VEIN STENOSIS IN LIVING DONOR LIVER TRANSPLANATION

Ahn, ChulSoo; Lee, SungGyu; Hwang, Shin; Kim, KiHun; Moon, DeokBok; Ha, TaeYong; Song, Giwon; Jung, Donghwan; Lee, HyoJun; Park, JeongIk; Ryu, JeHo

Asan Medical Center, Surgery, Seoul, Korea, Republic of

In cirrhotic liver, portal thrombosis or stricture is not uncommon due to the portal hypertension. But maintaining the adequate portal flow is essential for initial graft function and its regeneration after living donor liver transplantation(LDLT). Usually thrombectomy or venoplasty is applied to improve portal flow. But it may be insufficient if the luminal narrowing is located more proximally. We used the intraoperative portal vein stent to solve this problem. After the explantation of diseased liver, we examined the portal stump, if the lumen was narrowed we have performed thrombectomy or venoplasty. Direct portogram was taken through inferior mesenteric vein just after the anstomosis and reperfusion of the graft and intraportal stents was inserted. We applied balloon dilatation when the lumen was not fully expanded after stenting. Some of collaterals of portal vein were also embolized during portogram, to prevent portal flow steal. From Jan.2004 to Nov.2006, 615 adult to adult living donor liver transplantations were performed in Asan Medical Center. In 114 cases(18.5%), portal vein thrombosis or stricture were detected. We did direct portograms in 20 cases(3.2%). The patients were 14 men and 6 women. The underlined disease were hepatitis B associated cirrhosis in 14, alcoholic cirrhosis in 3, others in 3, and 8 of them had hepatomas. In three cases, we did only portogram without stenting, and we inserted 20 stents(metallic stent diameter 1cm, length 4–8cm) in 17 cases. Balloon venoplasty was applied in 6 cases, which showed severe narrowing after stent insertion. Coil embolization of coronary vein was performed in one case. The median follow up period was 20 months(1–34 months), and all patients has good portal flow until now except one case who expired at postoperative10 month due to the intracranial hemorrhage. In conclusion, in the case of severe portal vein stenosis, intraoperative stent insertion can be a simple and good solution to get sufficient portal flow to the transplanted graft.

PP 32.04

ACUTE PANCREATITIS WITH PSEUDOANEURYSM RUPTURE AFTER LIVING DONOR LIVER TRANSPLANTATION

Hyo-Jun, Lee¹; Sung-Gyu, Lee²; Shin, Hwang²; Ki-Hun, Kim²; Chul-Soo, Ahn²

¹Asan Medical Center, University of Ulsan College of Medicine, Division of Hepato-Biliary Surgery and Liver trans, Seoul, Korea, Republic of; ²Asan Medical Center, Seoul, Korea, Republic of

Background. Acute Pancreatitis(AP) is a rare life-threatening complication occurring 3% to 4% after liver transplantion(LT). It has been described mainly after orthotopic liver transplantation(OLT) or pediatric OLT in some cases. It is associated with a mortality rate of more than 50%. (OBJECT) Herein we report a immediate postoperative acute pancreatitis case with pseudoaneurysm rupture after adult living donor liver transplantation(LDLT).

Method. A 37-year-old man who had undergone LDLT, right graft(750gram) for fulminent hepatitis due to hepatitis A virus infection developed fatal acute pancreatitis. Donor was his cousin, 37-year-old male. Preoperatively mental status was comatous. Child-Pough score is 12(Class C). MELD scrore is 37. UNOS status is 1.

Result. On preoperative CT scan, he underwent panreatitis with peripancreatic fluid collection and swelling. Immediate postoperatively pancreatitis was markly subsided with decreased serum amylase/lipase level. But On Postoperative 40th day, he underwent emergent reoperation(bleeding control with gauze packing & external drainage) due to pseudoaneurysm rupture of peripancreatic vessels with fatal acute pancreatitis. After bleeding control he was successfully managed with another percutanous drainage, supportive care with feeding tube through the directly jejunum. Although the patient repeatedly had gotten into septic condition(pneumonia, peritonitis, bactremia), he have the luck to discharge with recovery at postoperative 289th day.

Conclusion. In conclusion, although AP with pseudoaneurysm rupture after LDLT is very rare and sereous complication, it is possible to save a life as a adequetly supportive care.

PP 32.05

SAFETY OF LIVING DONOR LIVER TRANSPLANTATION IN ELDERLY PATIENTS

Singh, Amanjeet¹; Kakodkar, Rahul²; Kumaran, Vinay¹; Nundy, Samiran¹; Saigal, Sanjiv¹; Saraf , Neeraj¹; Soin, Arvinder¹

¹Sir Ganga Ram Hospital, Surgical Gastroenterology and Liver Transplant, New Delhi, India; ²Sir Ganga Ram Hospital, Surgical Gastroenterology and Liver Transplant, New Delhi, India

Background. With advancement in perioperative care and better surgical techniques, similar graft survival can be achieved with liver transplantation in patients older than 60 years of age. As living liver donation is relatively new, there is insufficient data to prove safety of living donor liver transplants in elderly patients. AIM To assess the safety and efficacy of living donor liver transplants in elderly patients.

Material and Methods. A retrospective analysis of prospectively collected data was performed. The preoperative workup, intraoperative course and the posttransplant outcome of elderly patients (more than 60 years age) was analysed.

Results. From Jan 2005 to July 2007, of the 150 patients who received living donor liver transplants at our centre, 13 were aged 60 years or more. There were 10 males and 3 females with a mean age of 63.5 years (60–69 years). The indications for transplant were Hepatitis C with HCC (5), cryptogenic (3), alcoholic (2), primary biliary (2) and Hepatitis B cirrhosis (1). 9 patients received right lobes, 3 left lobes and one had a dual lobe transplant (a right and a left lobe graft each from two donors). Postoperatively, 2 patients had de novo cardiac problems, recovered with conservative management. 3 patients had re-explorations, 2 were for bile leaks and one for drain site bleed. There was no perioperative mortality. The mean ICU stay was 9.3 days (5 – 40 days) with a mean hospital stay of 20.4 days (10 – 47days). Two patients lost their grafts, died at 7 and 14 months after transplant due to non-compliance. Rest are alive at a median follow up of 6.2 months (1 – 21 months).

Conclusion. In our experience, elderly patients did well after liver transplant in the short and medium term. This may be explained by the extensive preoperative evaluation done for these patients to rule out age related risk factors. With rigorous preoperative screening and meticulous perioperative care, chronological age per se is not a barrier to living donor liver transplantation.

PP 32.06

RIGHT ANTERIOR SECTORIAL DUCT JOINING THE CYSTIC DUCT.

A REPORT OF THE CASE OF DONOR SURGERY OF THE LIVING DONOR LIVER TRANSPLANTATION.

Ishiguro, Yasunao; Hyodo, Masanobu; Fujiwara, Takehito; Sakuma, Yasunaru; Hojo, Nobuyuki; Kawarasaki, Hideo; Yasuda, Yoshikazu

Jichi Medical University, Surgery, Tochigi, Japan

The donor was a 35 year old lady who had a second son suffered from biliary atresia followed by biliary cirrhosis. The donor surgery was planed to take the left lateral segment for the liver graft. Preoperative examination revealed no abnormal findings except congenital absence of the right kidney. The intraoperative cholangiography is routinely performed to demonstrate the biliary system before dissecting the hepatoduodenal ligament. During the cholangiography through the incision of the cystic duct, the catheter was easily inserted into the right anterior sectorial duct (RASD) because of it was joined to the cystic duct with the right posterior sectorial duct joined to the left hepatic duct. The incision of the cystic duct was carefully closed not to make biliary stenosis. After harvesting the left lateral segment, the final cholangiography was performed through the stump of the left hepatic duct to confirm the appearance of the confluence of the RASD and the cystic duct. Postoperative course was uneventful. Although the biliary anatomical variation is frequently encountered, this case is a rare anomalous biliary connection different from the past reports described as the cystohepatic ducts. If the RASD is injured, the repair might be difficult because of the thin duct without dilatation. MRCP is still unsatisfied to demonstrate small biliary branches especially in the case of donor surgery. We recommend the careful intraoperative cholangiography through the incision of Hartmann pouch instead of the cystic duct before dissection of the hepatoduodenal ligament for the safety of donor surgery.

PP 32.07

BILIARY COMPLICATIONS AFTER LIVE DONOR LIVER TRANSPLANTATION-A SINGLE CENTRE EXPERIENCE

Yadav, Thakur Deen¹; Chawda, Hitesh²; Kangho, Lee²; Tan, K C²

¹PGIMER, Chandigarh, India, General Surgery, Chandigarh, India; ²Asian centre for liverdiseases and transplantation, Singapore, Singapore

Aim: To analyze the biliary complications after live donor liver transplantation(LDLT) and to assess the recipient's morbidity related to the overall biliary complications, and their management.

Patients and Methods. From April 2002 to June 2007 we performed 93 right hemiliver transplants from living donors. There were 73 male recepients. Liver size and vascular anatomy were assessed by multislice computed tomography (MSCT) scan with vascular reconstruction. Biliary anatomy was investigated using an intraoperative cholangiography. Right lobe transplantation was performed excluding the middle hepatic vein in all cases. The prospectively kept Data of the patients with short and long term complications have been analysed.

Results. Biliary complications occurred in 20(21.5%) patients. In 10 cases we found a single right biliary duct (50%) and in 7 we found two right biliary ducts (35%), small subsegmental ducts in two(10%) and three right ducts in one patient(5%). We performed single biliary anastomosis in 14 cases (70%) and double anastomosis in the remaining six (30%) cases. Arterial anatomy was normal in 15(75%) patients. The following biliary complications were observed: External biliary fistula-15, intra abdominal collection/ abscess-12, late anastomotic strictures-6, peritonitis -5. Five patients with biliary complications died with the mortality rate of 25%. Two patients required laparotomy to control the sepsis and the rest were managed with non operative measures.

Conclusions. In conclusion biliary complications affected our series of ALDLT with a high percentage. Most of the biliary complications were successfully treated without surgery by interventional radiologists or by endoscopic interventions. Sometimes the patients who developed a biliary complication needed multiple treatment and consequent short hospital readmissions.

PP 32.08

THE VENOUS RECONSTRUCTION AT LIVING RELATED LIVER TRANSPLANTATION

Kotenko, Oleg; Popov, Alexey; Korshak, Alexandr; Gusev, Andrey; Grinenko, Alexandr; Fedorov, Denis

Institute surgery and transplantology, Department of the liver transplantation and surger, Kiev, Ukraine

INTRODUCTION. Transplantation of a part of a liver from the alive donor allows expanding opportunities of cadaveric transplantation and to lower mortality in a waiting list. Feature of living related liver transplantation (LRLT) is deficiency of functional weight of a graft in adult and autovenous a plastic material for performance of vascular reconstruction.

Aim. Aim was studying efficiency of venous reconstruction at LRLT.Materials and Methods. 51 patients with end stage liver diseases received LRLT from August 2003 till March 2007, there were 26 adults (51%) and 25 (49%) patients in the pediatric age group. From 22 patients with biliary atresia in 1 case took place agenesis of the portal vein, in 1 – congenital fibrosis of the portal vein.

Results. From 51 LRLT venous reconstruction was made at 40 patients. From 7 patients with a portal vein thrombosis at right lobe LRLT in 5 cases has executed thrombectomy with the subsequent imposing portoportal anastomosis. In 2 cases due to degenerate changes of a wall portal vein it was resected and reconstructed. At 1 case dual LRLT portal vein resection and the subsequent Y-shaped autovenous plasty portal vein has made due to portal vein thrombosis. At left lateral section LRLT in 2 cases with congenital portal vein fibrosis portal vein reconstruction in recipient has made with donor's left ovarian vein. In other 2 cases cavaportal transposition was made. For this purpose suprarenal part of inferior vena cava was anastomosed with left portal vein of a graft. Cavaportal transposition used in one case of right lobe LRLT at the patient with viral liver cirrhosis and total portal veins system thrombosis. In 8 cases adults LRLT right lobe harvested with middle hepatic vein.

Conclusion. Venous reconstructions of a grafts allows to expand indications to donation parts of a liver from the alive donor, to made LRLT of patients with a portal vein thrombosis which were considered unpromising earlier and to provide adequate graft function.

PP 32.09

LONG-TERM OUTCOME OF HEPATIC ARTERY ANASTOMOSIS USING CONTINUOUS SUTURE TECHNIQUE IN LIVING DONOR LIVER TRANSPLANTATION

Yi, Nam-Joon; Suh, Kyung-Suk; Lee, Hae Won; Shin, Woo Young; Kim, Juhyun; Lee, Kuhn Uk

Seoul National University College of Medicine, Surgery, Seoul, Korea, Republic of

Background. In living donor liver transplantation (LDLT), hepatic arterial anastomosis (HAA) requires interrupted suture technique (IST) under a microscope. Continuous suture technique (CST) is simple and time-saving procedure, but there has been no report HAA using CST in LDLT.

Patients and Methods. From Jan. to Dec. 2005, 7 recipients underwent HAA using CST in LDLT. Six patients were male, and mean age was 44 (35–62) years. The original liver diseases were viral hepatitis in 6 and primary sclerosing liver cirrhosis in 1. Although 3 patients had hepatocellular carcinoma, there was no history of transarterial chemoembolization. The indications of CST in HAA were large graft hepatic artery (internal diameter > 2.0mm) and good quality of recipient hepatic artery. HAA was performed under microscope using Nylon 8–0 in an end-to-end fashion. Patency of arterial flow was followed-up using a US doppler for 5 days and then using a liver dynamic CT scan 1, 4, and 12 months after surgery. The mean follow-up period was 23 (21.6–25.8) months.

Results. All grafts were right livers. The internal diameter of hepatic artery was 2.2 (2.0–2.5) mm. The used recipient artery was the right hepatic artery in 6 and the proper hepatic artery in 1. The mean time of HAA was 28 (20–42) minutes; it was significantly shorter than that of matched historical control group who underwent HAA using IST (48 minutes) (p < 0.05). There was no mortality and no complication in HAA during follow-up period. There were 2 biliary strictures at the anastomosis site resolved by non-surgical method. A 34-year-old male patient suffered multiple postoperative complications; atrial fibrillation, pneumonia, intrapeirtoneal bleeding, ascites associated with portal vein stenosis resolved with non-surgical treatment, and mitral regurgitation corrected by surgical valve replacement. Concision. In LDLT, HAA using CST was feasible and saved operation time for HAA compared with conventional HAA using IST. In addition, it may guarantee long-term safety.

PP 32.10

VARIATIONS IN BILIARY ANATOMY AND MODIFICATIONS OF RECONSTRUCTION IN 62 LIVING DONOR LIVER TRANSPLANTS

Kumaran, Vinay¹; Kakodkar, Rahul²; Saigal, Sanjiv³; Saraf, Neeraj¹; Mohan, Neelam⁴; Nundy, Samiran¹; Soin, Arvinder S¹

¹Sir Ganga Ram Hospital, Surgical Gastroenterology, Liver Transplantation, New Delhi, India; ²Sir Ganga Ram Hospital, Surgical Gastroenterology and Liver Transplant, New Delhi, India; ³Sir Ganga Ram Hospital, Gastroenterology, New Delhi, India; ⁴Sir Ganga Ram Hospital, Pediatric Gastroenterology, New Delhi, India

Background. Biliary complications are common after live donor liver transplant (LDLT) due to frequent variations in biliary anatomy neccessitating technical modifications.

Aim. Study the influence of variations in biliary anatomy on incidence, morbidity and mortality of biliary complications.

Methods. We studied 62 consecutive LDLTs from November 19th 2006 to July 31st 2007. Biliary anatomy, reconstructive technique, complications and their management were analyzed.

Results. Of the 62 patients, 48 received right, 12 left, 1 left lateral and 1 dual lobe grafts. All the left lobe grafts had a single bile duct. 10 had duct-to-duct (DD) reconstruction and 2 had hepaticojejunostomy (HJ). Of the right lobe grafts, 41 had single ducts, 6 had 2 ducts and 1 had 3. In the grafts with single ducts, 37 had DD reconstruction and 4 had HJ due to primary sclerosing cholangitis (2) or unsuitable recipient duct (2). Of the grafts with 2 ducts, 3 had a common sheath. 2 had DD reconstruction while 1 had HJ. Of the other 3, 2 had a HJ and DD reconstruction to one duct each and 1 had 2 DD anastomoses. The patient with 3 ducts had a HJ. In the dual lobe transplant, the right lobe had a DD reconstruction and the left lobe had a HJ. There were 5 bile leaks (8%) and 2 strictures (3%). 2 of the bile leaks were in left lobe recipients while 3 were in right lobes. None resulted in mortality. Both left lobe recipients with leaks were explored and found to have cut surface leaks, 1 of which was sealed with fibrin glue while the other was sutured. Of the 3 leaks in right lobe grafts, 1 was explored and a leak from the cut surface was sealed with fibrin glue. An anastomotic leak was managed with endoscopic stenting and a biloma was drained percutaneously with resolution of the leak. The two strictures were managed by percutaneous balloon dilatation and stenting.

Conclusion. Modifications in the technique of biliary reconstruction can minimize the rate of biliary complications despite frequent variations in biliary anatomy in LDLT

PP 33.01

THROMBOPHILIA IN PATIENTS WITH NON-CIRRHOTIC PORTAL VEIN THROMBOSIS AND BUDD-CHIARI SYNDROME

Shah, Sudeep¹; Abraham, Philip²; Joshi, Anand²; Desai, Devendra²; DasGupta, Amar³

¹PD Hinduja Hospital and MRC, GI Surgery, Mumbai, India; ²PD Hinduja Hospital and MRC, Gastroenterology, Mumbai, India; ³PD Hinduja Hospital and MRC, Hematology, Mumbai, India

Background. Thrombophilia is thought to be responsible for non-cirrhotic portal vein thrombosis (PVT) and the Budd-Chiari syndrome. The significance of multiple co-existant conditions has not been well studied.

AIMS: To determine thrombophilias in patients with PVT and BCS with normal synthetic liver function and compare this with matched controls and patients developing deep vein thrombosis (DVT)

Methods. Over a 3 year period, 33 patients of PVT and 4 with BCS were evaluated, after excluding patients with liver dysfunction and secondary causes of PVT (eg tumour. pancreatitis). Thrombophilia screen was performed. The incidence of thrombophilia was compared with 18 patients developing de-novo DVT following joint surgery and 50 healthy controls.

Results: Of the thrombophilias, Protein C deficiency was the most prevalent (n = 13), followed by Protein S (n = 10) and Antithrombin (n = 8). Anticardiolipin antibody syndrome, lupus anticoagulant, Factor VIII elevation and hyperhomocysteinemia were rare. Factor V Leiden mutation was seen in 3 patients. Overall, thrombophilias were seen in 22 patients with PVT and 2 with BCS- both having polycythemia rubra vera. In contrast to patients with DVT where only one of the patients had more than one thrombophilia, 10 of those in the study group had multiple thrombophilia (p = 0.08, Fisher's exact test).

Discussion: Thrombophilias were present in the majority of patients with PVT. Patients with BCS were difficult to recruit as few had normal synthetic liver function. Factor V Leiden mutations were less common as compared to the West. Multiple thrombophilic states were seen in 30% of PVT patients and this was more common than in patients with DVT.

PP 33.02

LOW INCIDENCE OF THROMBOEMBOLIC EVENTS AND SAFETY OF LOW MOLECULAR WEIGHT HEPARIN THROMBOPROPHYLAXIS IN LIVER RESECTION-10 YEAR CAMBRIDGE EXPERIENCE

Kan, Yuk-Man; Jah, Asif; Paulvannan, Subramanian; Sadat, Umar; Gibbs, Paul; Praseedom, Raaj K; Jamieson, Neville V; Huguet, Emmanuel L

Addenbrooke's Hospital, Hepatobiliary and Transplant Surgery, Cambridge, United Kingdom

Introduction. Thromboembolic events are a recognised complication in patients undergoing major surgery but the incidence post liver resection has never been reported. Prophylactic anticoagulation with low molecular heparin in this group of patient is controversial and world wide practice varies. This study is the first to document the incidence of thromboembolic events and the safety of clexane use in patients undergoing major liver resection.

Methods. Over a 10 year period between 1997 to 2007, 301 major liver resections were undertaken for malignancy of the liver or biliary tract. Mean age was 56.8 years. All received thromboprophylaxis with clexane, compression stockings and intra-operative pneumatic calf compression. Resections were undertaken by open technique except for one which was performed laparoscopically. Operative, post op clinical, biochemical and haematological outcome parameters were recorded with particular reference to coagulation related complications.

Results. Mean operative time was 167 minutes; mean blood loss was 500mls and mean blood transfusion 200mls. Only 3 patients (1%) developed a thromboembolic event with radiologically proven pulmonary emboli. There was a 25% drop in platelets levels immediately post operatively from day 0 to 3 but this returned to pre-operative levels by day 7. Only one case of heparin induced thrombocytopenia was identified and one patient returned to theatre for haemorrhage. There were no epidural related complication.

Conclusions. Thromboembolic events are a rare event in our institution following major liver resection for malignancy. This may in part be due to the antithrombotic strategies we employ but the observed post operative derangement in the clotting profile and our findings of falling platelets in these patients may also contribute. The use of prophylactic clexane appears to be safe in these patients.

PP 33.03

EVIDENCE BASED LIVER SURGERY: IS IT FEASIBLE?

van den Broek, Maartje¹; van Dam, Ronald M.¹; van Breukelen, Gerard²; Malagó, Massimo³; Dejong, Cornelis H.C.¹; Olde Damink, Steven W.M.¹

¹University hospital Maastricht, Department of Surgery, Maastricht, Netherlands; ²University hospital Maastricht, Deptartment of Methodology and S tatistics, Maastricht, Netherlands; ³University College London, Department of Surgery, London, United Kingdom

Background. Evidence based guidelines are the gold standard in patient care. However, the evidence base of surgical practice in hepatobiliary surgery is low since only a small number of randomized controlled trials (RCT) have been performed.

Objective. To determine the feasibility of conducting an RCT in hepatobiliary surgery.

Methods. A structured literature search retrieved all descriptive English articles published in the last decade using mortality or morbidity after partial hepatectomy as endpoint. The sample size (a = 0.05 and β = 0.1) for a hypothetical RCT aiming to show a reduction in mortality or morbidity by a third or one half was calculated using 25% trimmed mean incidence rates.

Results. Out of 892 studies, eighteen studies were included comprising 7,499 patients (7,704 resections). Thirty day and in-hospital mortality were 2.8% (±0.3) and 4.4% (±0.9), respectively. Total morbidity rate was 37.2% (± 8.0) and the incidence rates of the clinically most relevant complications were pneumonia (6.0%), bile leakage (5.5%), intra-abdominal abscess (5.5%), wound infection (5.3%), sepsis (4.0%) and post-resectional liver failure (3.7%). The smallest numbers of patients necessary to enrol in an RCT aiming to show a 33% reduction of in-hospital mortality and the clinically relevant complications bile leakage and post-resectional liver failure were 6892, 5448 or 8298 or to show a 50% reduction were 2766, 2188 or 3328, respectively.

Conclusion. The conductance of an RCT in liver surgery seems hardly feasible, since it would imply extreme multi-centre collaborations or exceptionally long inclusion periods given the required sample size. However, studies designed with fewer patients are underpowered and should be interpreted with care. Therefore, surrogate endpoints represented by highly specific and sensitive biomarkers should be developed and considered as primary outcome parameters for RCTs.

PP 33.04

OXIDATIVE STRESS IN PORTAL VEIN EMBOLIZATION; FACT OR FICTION?

Makay, Ozer¹; Firat, Ozgur¹; Gurcu, Baris¹; Gokce, Goksel²; Sapaz, Nazli¹; Zeytunlu, Murat¹; Yenisey, Cigdem³; Coker, Ahmet¹

¹Ege University Hospital, General Surgery, Izmir, Turkey; ²Ege University, Pharmocology, Izmir, Turkey; ³Adnan Menderes University Hospital, Chemistry, Aydin, Turkey

Background. Whether liver failure develops after hepatectomy depends on how well the remnant liver functions after resection. Preoperative treatment with portal vein embolization (PVE) has been reported to increase resectability and to reduce posthepatectomy complications. The evidence that oxidative stress has any impact on complications and hepatic regeneration is weak. This study was conducted to investigate the role of reactive oxygen radicals in the pathogenesis of PVE.

Methods. Rats were divided into three groups that underwent (1) laparotomy only (control group); (2) right portal vein ligation (RPL) group – sacrificed postoperative 72nd hour; (3) RPL – sacrificed postoperative 15th day. Serum levels of AST, ALT, GGT and cholesterol were measured for determining hepatic reserve and levels of oxidative stress markers like malondialdehyde (MDA), nitric oxide (NO), glutathione (GSH), catalase (CAT), superoxide dismutase (SOD) and gluthatione peroxidase (GPx) were determined.

Results. When compared to group 1, the mean MDA and NO levels were higher, while GSH, CAT, SOD and GPx were lower in group 2 and group 3 (p < 0.01). Differences of all assessed oxidative stress markers between group 2 and 3 reached no significance (p > 0.05). Moreover, serum AST, ALT and GGT levels were significantly higher in group 2 and 3, compared to group 1 (p < 0.05). There was also a significant difference between groups in means of cholesterol levels (p < 0.05).

Conclusion. These data collectively support that oxidative stress is a critical step in PVE related injury in the acute and the late phase, and suggest that antioxidant strategies designed to either inhibit free radical formation or to scavenge free radicals may provide protection during hepatic regeneration.

PP 33.05

ROLE OF ERCP IN COMPLICATED HYDATID DISEASE OF LIVER

Kochhar, Rakesh¹; Dutta, Usha¹; puri, pankaj¹; nadkarni, Nikhil¹; Kochhar, s²; sinha, saroj k¹; sriram, PVJ²; nagi, birender¹; wig, Jai D³; singh, kartar¹

¹PGIMER, Chandigarh, India, Gastroenterology, chandigarh, India; ²PGIMER, Chandigarh, India, radiodiagnosis, chandigarh, India; ³PGIMER, Chandigarh, India, General Surgery, chandigarh, India

Background.: ERCP has emerged as an effective form of management in biliary rupture of hepatic hydatid cysts.

Aims. Retrospective analysis of outcome of therapeutic ERCP in patients with complicated hydatid cysts of liver.

Material and Methods. Records of all patients of complicated hydatid cysts (HC) of liver seen by us between 1993 and 2007 were retrieved and analysed for clinical presentation, radiological features, endoscopic procedures done and outcome.

Results. A total of 24 patients (13 males, age 13–50 yr) had presented to us with cholangitis (n = 16), pain and jaundice (n = 3) and post-operative biliary fistula (n = 4). 17 patients had a single cyst, 4 had two and 3 had three cysts, 19 patients had cysts in the right lobe, 2 in left lobe and 3 in both the lobes. ERCP revealed intrabiliary rupture of HC in 18, a fistula in 5 (cystobiliary in 4, brocho-cysto-biliary in 1) and dilated CBD with daughter cysts/membranes in 12. 12 patients underwent sphincterotomy, 22 underwent nasobiliary drainage (NBD) (into cyst cavity in 5, in hepatic duct in 17), CBD stent placement in 3 and extraction of daughter cysts/membranes in 12. 16/16 patients with cholangitis had resolution, 4/5 with biliary leak resolved, with NBD/stent placement for 6–12 weeks. 18 patients were subsequently operated upon, while 7 patients did not need any surgery. One patient with broncho biliary fistula died post operatively.

Conclusion. ERCP will nasobiliary drainage/stenting helps resolve cholangitis in patients with ruptured HC, and is also effective in management of post-operative biliary fistula in such patients, avoiding surgery in the latter.

PP 33.06

ETIOLOGICAL PROFILE OF PEDIATRIC PORTAL HYPERTENSION IN SOUTH INDIA

Simon, Ebby; Joseph, A J; George, Biju; Zachariah, Uday; Eapen, C E; Chandy, George; Ramakrishna, B S; Kurian, George; Chacko, Ashok

Christian Medical College, Dept of GI Sciences, Vellore, India

Introduction. Causes of portal hypertension in children are different from those in adults. Extrahepatic portal vein obstruction (EHPVO) is the most common cause of upper GI bleed in children

Objective. To study the etiological profile of pediatric portal hypertension in our centre.

Methods. Retrospective analysis of patients < 16 years old, who had upper GI endoscopy and abdominal imaging for portal hypertension in our institution between May 2000 and April 2007.

Results. Of 724 pediatric patients who had upper GI endoscopy, 171(24%) had portal hypertension (male: female ratio 2.8:1 and mean age 9.2(SD 3.4) years). 63(38%) were from West Bengal and 56(34%) were from Tamil Nadu. The etiology of portal hypertension was as follows: EHPVO -113(66%), intrahepatic causes-56(33%) and Budd Chiari-2(1%). Among the intrahepatic causes, 38(66%) had cirrhosis, 6(11%) had NCPF, 1(2%) had Caroli's syndrome and 11(19%) were unclassified. Among those with cirrhosis, 21(55%) had Wilson's disease, 4(10%) had autoimmune hepatitis, 2(5%) were HBV related, 1(3%) had biliary atresia, 1(3%) had primary sclerosing cholangitis and 9(24%) were cryptogenic.

Conclusion. In our centre, the commonest causes of pediatric portal hypertension were EHPVO and cirrhosis. Wilson's disease was the most common cause of cirrhosis in this series.

PP 33.07

FIBRIN-COATED COLLAGEN FLEECE PATCHES OR LIQUID FIBRIN GLUE? CLINICAL OUTCOME AND COST EFFECTIVENESS IN LIVER RESECTION

Schön, Michael R¹; Zaatar, Mohamed¹; Kaps, Maria²; Hauss, Johann P.²; Wiegel, Natalie¹

¹Klinikum Karlsruhe, Surgery, Karlsruhe, Germany; ²University of Leipzig, Surgery, Leipzig, Germany

Background. Improved dissection techniques and sealing of the resection surface with fibrin glue are essential to reduce blood losses in liver surgery. Fibrin glues are available in the form of fibrin-coated collagen fleece patches that are fitted to suit the resected area, and also as liquid fibrin sealant for spray application.

Objective. This study compares the postoperative outcome and cost effectiveness of both fibrin products in patients undergoing liver resection.

Methods. Liver resection was carried out in 50 patients. In group 1 fibrin-coated coll agen fleece patch (Tachocomb, n = 25) was used as a sealant. In group 2 a liquid fibrin glue (Quixil, n = 25) was used by spray application. Both groups were matched for age, sex, type of pathology, American Society of Anesthesiologists (ASA) classification, operation time and resection extent. Transfused blood/plasma, ICU-/hospital stay and cost per segment/patient were analysed.

Results. Differences in number and weight of resected segments, transfusion requirements, complications, ICU and hospital stay were not significant between both groups (p < 0,05). The median costs of haemostatic agents per patient were 583 Euros in group 1 and 316 Euros in group 2 (p = 0.014). For a better comparison costs spent for haemostatic agents per resected liver segment were calculated. In group 1 the median costs were 146 Euros per resected segment and 105 Euros in group 2 (p = 0,019).

Conclusion. Fibrin-coated collagen fleece patches (Tachocomb) and liquid fibrin glue (Quixil) have comparable hemostatic properties. There are no significant differences in the postoperative outcome of the patients in both groups. However, application of liquid fibrin glue has a financial advantage over fibrin-coated collagen fleece patches.

PP 33.08

GADOXETIC ACID (PRIMOVIST) IMPROVES THE SPECIFICITY OF MRI FOR MALIGNANT LIVER LESIONS COMPARED TO GADOLINIUM/SUPRAMAGNETIC IRON OXIDE(RESOVIST)

patel, bhavik¹; Pring, Christopher²; Ko, Hyun³; Tesar, Paul³; O'rourke, Nicholas³

¹royal brisbane and womans hospital, brisbane, Australia; ²royal brisbane and womans hospital, Australia; ³Australia

Background. Distuinguishing benign and malignant liver lesions on MRI scanning remains a challenge. The introduction of contrast agent gadoxetic acid(Primovist), which functions by hepatocyte uptake, should improve the specificity of MRI scanning, which compared to gadolinium plus supramagnetic iron oxide (Resovist), which functions by Kupffer cell uptake. AIM To assess the improved diagnostic accuracy of primovist over Resovist in determining benign and malignant liver lesions.

Methods. We have performed a retrospective cohort analysis of all patients in our unit who had a liver resection, between January 2005-September 2007.We analysed the MRI images and the final histology, to assess the specificity of Primovist and Resovist in determinig benign and malignant lesions.

Results We performed approximately 90 liver resections over the study period. 15 of these had preoperative MRI imaging with Primovist and 25 had preoperative imaging with gadolinium and Resovist. 40%of the resections were benign lesions in the Primovist group and 52% were for benign lesions in the Resovist group.

Conclusions. This small retrospective study, which indicates that the new agent Primovist may have higher specificity for malignant lesion than Resovist.

PP 33.09

CONSERVATIVE TREATMENT OF BLUNT ABDOMINAL TRAUMA INVOLVING THE LIVER AND AT LEAST ANOTHER SOLID ABDOMINAL ORGAN

Papavramidis, Theodossis S¹; Kartalis, Nick²; Potsi, Stamatia²; Michalopoulos, Antonis¹; Papadopoulos, Vassilis N.¹; Paramythiotis, Daniel¹; Duros, Vassilios¹; Kouskouras, Konstantinos²; Dimitriadis, Athanasios²; Harlaftis, Nikolaos¹

¹A.H.E.P.A. University Hospital, Aristotle's University of Thessaloniki, Macedonia, Greece, 1st Propedeutic Department of Surgery, Thessaloniki, Greece; ²A.H.E.P.A. University Hospital, Aristotle's University of Thessaloniki, Department of Radiology, Thessaloniki, Greece

Background. The diagnosis of blunt abdominal trauma is suspected on the basis of the mechanism of injury and the presence of associated injuries. In trauma centers, ultrasonographic examination elucidates many aspects of the trauma; nevertheless CT scanning is necessary in grading blunt abdominal trauma. The present study aims to evaluate the conservative treatment when multiple solid organs are implied in blunt abdominal trauma.

Material. Between 1/1/2003 and 31/12/2006 43 patients (among 1866 trauma patients) with blunt abdominal trauma involving the liver and at least another solid organ were treated our clinic. There were 36 men and 7 women with average age of 42.72y (range: 18–80yrs, SD 20.32yrs). The liver injuries were combined in 15 patients (34.9%) with splenic injury, in 16 (37.2%) with kidney injury, and in 12 (27.9%) with both splenic and kidney injury. According to AAST the patients had the following types of injuries: (i) Liver: Grade I 2 patients, Grade II 15 patients, Grade III 9 patients, Grade IV 15 patients, Grade V 2 patients; (ii) Spleen: Grade I 4 patients, Grade II 11 patients, Grade III 8 patients, Grade IV 2 patients, Grade V 2 patients; (iii) Kidney: Grade I 5 patients, Grade II 9 patients, Grade III 7 patients, Grade IV 7 patients. 15 patients had hemodynamic instability and necessitated surgery, while 28 were treated conservatively.

Results. The mean hospitalization was 60.2 days for the surgically treated patients, while it was 12.3 days for the conservatively treated patients. The overall mortality rate for the surgically treated patients was 53.3%, while for the conservatively treated patients it was 10.7%.

Conclusion. Liver trauma is a difficult problem in emergency surgery. When radiological imaging associates liver trauma with other solid abdominal organ injuries conservative treatment is not common practice. The present study demonstrates that the non-operative treatment has to be considered when hemodynamic stability is present even in multi-organ injured patients.

PP 33.10

MANAGEMENT OF BUDD-CHIARI SYNDROME-SINGLE CENTRE EXPERIENCE

Khan, Abdaal; Dafallah, Mutasim; El-Sarraj, Ibrahim; Sabra, Bilal; Al-Baiz, Khuloud; Nafea, Osama; Al-Abdulkareem, Abdulmajeed

KING ABDULAZIZ MEDICAL CITY, HEPATO-BILIARY SCIENCES, RIYADH, Saudi Arabia

Background. Budd Chiari Syndrome (BCS) is a rare hepatic disorder, which results from obstruction of hepatic venous outflow tract. With the advent of transjugular intrahepatic portal systemic shunt (TIPS), surgical shunts are less commonly performed.

Methods. We retrospectively reviewed the experience of management of this syndrome by medical treatment alone, surgical shunt, TIPS (since 1998) and liver transplantation over the last 15 years at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Results. A total of 25 cases were reviewed. There were 17 males. Mean age at diagnosis was 29.6 (10.4) years. Presentation was fulminant in 3, acute in 14 and chronic in 8 patients. The etiology was confirmed for 40% of cases and included 16% with myeloproliferative disorders, and Behcet's syndrome 12%. The site of block was restricted to the hepatic veins in 60% while 32% had hepatic venous obstruction combined with inferior vena cava (IVC) involvement. Majority presented with ascites (88%) and hepatomegaly (68%). Best medical treatment was given to 11 patients of whom 4 died in hospital. A surgical shunt was performed in 9. TIPS were scheduled in 8 patients. There was complete blockage of IVC in 3 patients. TIPS were successfully placed in 4 of 5 patients. TIPS revision was required in 3 patients. The 5- year survival (Kaplan-Meier) was 45.44%. Hospital mortality was 24%. Median follow-up of survivors was 12 months (Range 1- 120 m). One patient underwent liver transplantation.

Conclusions. TIPS has supplanted surgical shunts in the management of BCS in selected patients.

PP 33.11

MANAGEMENT OF IATROGENIC BILIARY INJURIES IN A REFERRAL CENTER: ANALYSIS OF 54 PATIENTS

gurcu, baris; uguz, alper; aydin, unal; firat, ozgur; parildar, mustafa; memis, ahmet; ersoz, galip; tekesin, oktay; zeytunlu, murat; kilic, murat; coker, ahmetege university school of medicine hospital, HPB working group, izmir, Turkey

Background. To evalute the changes in the pattern of iatrogenic biliary injury and consequential effects on treatment stategy and outcome.

Methods. F[ygrave]fty four patients treated for iatrogenic biliary injury (IBI) between 2003 July –2007 May at a tertiary care center in izmir, turkey were retrospectively analysed.

Results. Underlying diseases were; missed tumör (n:2%3,7)biliary surgery (n:47%87) and hydatic disease (n:3%5,5) in recent years with a gradual increase in the availability of endoscopic and radiologial expertise the majority of patients underwent extensive preoperative diagnostic and therapeutic procodures including endoscopic retrograd panceratography (n:17%31,4) and percutaneus transhepatic cholangiography (n:29 53,7). definitive surgery was performed in all patients. roux en y hepaticojejunostomy was the reconstruction most frequently performed (n:28%51,8) there was only one (% 1,85) hospital mortality. restenosis developped in two patient (%2,9) and was reoperated. percutaneus baloon dilatation was failed in three patients as a first treatment option. none of patients died of disease related causes during the follow up period.

Conclusion. Increased experinece in laparoscopic biliary surgery might be caused to attempt more challenging cases and increased bilary tract injuries.

PP 34.01

P ERIOPERATIVE USE OF THE LIMON METHOD OF INDOCYANINE GREEN ELIMINATION MEASUREMENT TO DETECT POST-HEPATECTOMY LIVER FAILURE

de Liguori Carino, Nicola; O'Reilly, Derek A.; Wong, Chang; Ghaneh, Paula; Poston, Graeme J.; Wu, Andrew

University Hospital Aintree, Supra-Regional Hepato-Biliary Unit, Liverpool, United Kingdom

Introduction. There are few practical and reliable tests for the estimation of hepatic functional reserve in patients being assessed for hepatic resection. Recently, a non-invasive liver function monitoring system, the LiMON (Pulsion Medical Systems, Munich, Germany), has been developed that measures indocyanine green (ICG) elimination by pulse spectrophotometry. The aim of this study was to assess the utility of the LiMon system in the prediction and early detection of liver failure post-hepatectomy.

Methods. Indocyanine green elimination, using the LiMON system, serum liver function tests and Child-Pugh score were assessed in 31 patients undergoing major liver resection (>50%) pre-operatively and at days 1, 5 and 10 post-operatively. Post-operative course, complications and final outcome were recorded.

Results. There were 22 men and 9 women with a median age of 67 years (range 39–77). Linear regression using Sperman's rank correlation shows that there is a significant correlation between ICG Plasma Disappearance Rate (PDR%/min) value as measured on post-operative day 1 and Bilirubin levels at post-operative days 1, 5 and 10, p < 0.001, <0.001, <0.001 respectively. Albumin levels at post-operative days 5 and 10 are significantly correlated (p < 0.006, <0.001) to ICG Plasma Disappearance Rate (PDR%/min) as measured on post operative day 1. There is no significant relationship between pre-operative PDR value and Bilirubin levels at post-operative days 1, 5 and 10, p = 0.67,=0.79,=0.35, respectively.

Conclusions. LiMON ICG elimination by pulse spectophotometry is a quick, non-invasive and reliable liver function test in patients undergoing liver resection that aids in the early identification of post-hepatectomy liver failure.

PP 34.02

LIVER REGENERATION AFTER HEPATECTOMY IN HGFA DEFICIENT MICE

Uchiyama, Shuichiro¹; Nagaike, Koki¹; Chijiiwa, Kazuo¹; Tanaka, Hiroyuki²; Fukushima, Tsuyoshi²; Kataoka, Hiroaki²

¹Miyazaki University School of Medicine, Surgical Oncology and Regulation of Organ Function, Miyazaki, Japan; ²Miyazaki University School of Medicine, Section of oncopathology and regenerative biology, Miyazaki, Japan

Background.: Hepatocyte growth factor activator (HGFA) is a serum protease that is responsible for proteolytic activation of the precursor form of hepatocyte growth factor (HGF) in injured tissues. HGF□@functions as a mitogen, morphogen,□@motogen, and angiogenic factor for various cells through MET receptor tyrosine kinase. HGFA is strongly detected in the liver, which has been thought to be the major source of HGFA. We generated mice deficient in HGFA, and we have previously demonstrated that HGFA deficient mice were viable and fertile without obvious abnormalities, and that regeneration of injured intestinal mucosa was impaired in HGFA-deficient mice.

Aim. To investigate the precise role of HGFA in the mechanisms of HGF activation during liver regeneration, we performed a 70% hepatectomy in wild type mice and HGFA-deficient mice.□@ Expression of Hepsin and matriptase-2, hepatic transmembrane serine protease expressed in the liver, was also analyzed by using RT-PCR analysis.

Results. Both wild type and HGFA deficient mice were all alive for a week after hepatectomy, and there was no significant difference in the regenerated liver weight between the two groups. Hepsin and matriptase-2 were significantly upregulated in HGFA-deficient mice compared with wild type mice.

Conclusion. The results suggest that loss of HGFA is compensated for other functionally related serine protease gene products.

PP 34.03

DOES THE REMNANT LEFT LIVER SEGMENTAL REGENERATION AFTER RIGHT HEPATECTOMY DEPEND ON MIDDLE HEPATIC VEIN ANATOMY?

FAITOT, François¹; VIBERT, Eric¹; KOSKAS, Franck²; AZOULAY, Daniel¹; ADAM, René¹; BELLIN, Marie-France²; CASTAING, Denis³

¹Paul Brousse hospital (AP/HP), Centre Hepato Biliaire, VILLEJUIF, France; ²Paul Brousse hospital (AP/HP), Radiology department, VILLEJUIF, France; ³Paul Brousse hospital (AP/HP), Centre Hepato Biliaire, 94804, France

Introduction. Hepatic surgery is based on liver anatomy but few anatomic studies have been conducted on operated livers. The aim of this study was to describe and assess segmental volumetric variations and their anatomic determinants focusing on middle hepatic vein (MHV) anatomy. Material and method: Pre- and 1-month post-operative CT scan of 9 patients with normal liver operated of a right hepatectomy (RH) with conservation of MHV (living donors (n = 6), HCC (n = 1), cholangiocarcinoma (n = 1) and colo-rectal cancer metastasis (n = 1)) were analysed. Left liver segments, their proportions to the left liver and spleen volumes were calculated. They were compared one to each other using a Student t-test. MHV anatomy before RH was analysed using the depth of middle hepatic vein confluence and Nakamura's classification of inter-segmental area. We looked for correlation between MHV anatomy and regeneration rate of left lobe (LL) and segment 4 (S4).

Results. Before RH, whole liver, segment 1, LL, S4 and spleen volumes were respectively 1482±246cc, 27±19cc, 257±121cc, 224±80cc and 241±104cc. After RH, these volumes were respectively 1125±235cc, 36±27cc, 772±181cc, 313±69cc and 346±170cc. Liver regeneration are more important for LL than for S4 (p = 0.001). There was no difference of whole liver regeneration rate according to MHV anatomy whatever classification was used. There was no difference neither for LL nor for S4 between the groups using Nakamura's classification (respectively p = 0.21 and 0.51). There was a significant difference of proportion variation of S4 and LL between the groups using depth of confluence: a later confluence of the segment 4a branch was associated with significantly lower regeneration of segment 4 (p = 0.0002) and a significantly higher LL regeneration (p = 0.0012) than an early confluence.

Conclusion. After RH, remnant liver regeneration seems to be more due to left lobe growth than to S4 growth. The depth of MHV confluence before RH plays a role in this inhomogeneous regeneration.

PP 34.04

SAFETY AND LIVER REGENERATION FOLLOWING HEPATIC TRISECTIONECTOMY FOR HEPATO-BILIARY MALIGNANCIES

Paik, Kwang Yeol¹; Chung, Jun Chul²; Lee, Hyung Geun¹; Ryu, Dong Do¹; Heo, Jin Seok¹; Choi, Seong Ho¹; Choi, Dong Wook¹

¹Samsung Medical Center, Surgery, Seoul, Korea, Republic of; ²Soon Chun Hyang Bucheon Hospital, Surgery, Bucheon, Korea, Republic of

Extensive liver resections such as right or left trisectionectomy ( RTS or LTS) are required more frequently for pathologically curative resection for various hepato-bilary malignancies. This study was conducted to evaluate the safety and to identify the factors to affect liver regeneration. Retrospective analysis of prospectively collected data for 12 patients who underwent RTS or LTS from May 2005 through June 2006 in Samsung Medical Center was performed. Preoperative portal vein embolization was applied if the future remnant volume will be less than 20%. In case of cholestatic liver, surgery was carried out if bilirubin level was below 3 mg/dl. Liver regeneration was estimated with volumetry by serially checked MDCT scan. There were 7 male and 5 female patients, whose median age was 54.8. 3 RTS, 7 RTS plus caudate lobectomy and 2 LTS plus caudate lobectomy were performed for 7 hilar cholangiocarcinoma, 2 intrahepatic cholangiocarcinoma and 3 others with 2 portal vein resection. Average operation time was 430 min and hospital stay was 18.3 days. 8 patients developed various complications including 1 biliary leakage without liver failure or mortality. Fortunately, we could achieve pathological curability for all cases. Average remnant liver volume was 32.7%, which increased to 46.9%, 61.7%, 76.0%, 76.5% and 76.6% after 1 week, 1 month, 3 months, 6 months and 12 months. Age and body surface area were statistically significant factors affecting postoperative liver regeneration. Conclusion; Further study should be followed to investigate the limit of maximal liver resection rate for advanced hepato-biliary malignancies.

PP 34.05

SEQUENTIAL RIGHT HEPATIC VEIN EMBOLIZATION AFTER RIGHT PORTAL VEIN EMBOLIZATION TO INDUCE LEFT LIVER HYPERTROPHY IN HILAR BILE DUCT CANCER PATIENTS

Hwang, Shin¹; Lee, Sung-Gyu¹; Ko, Gi-Young²; Ha, Tae-Yong¹; Song, Gi-Won¹; Lee, Kwang¹; Ryu, Je-Ho¹

¹Asan Medical Center, University of Ulsan, Department of Surgery, Seoul, Korea, Republic of; ²Asan Medical Center, University of Ulsan, Department of Radiology, Seoul, Korea, Republic of

Background. Preoperative right portal vein (RPV) embolization has been performed to induce contralateral hypertrophy for right liver resection, but the effect of ipsilateral atrophy-contralateral hypertrophy was not definite in a small proportion of our 500 patients.

Patients and Methods. We prospectively performed sequential right hepatic vein (RHV) embolization after right portal vein embolization to accelerate left liver hypertrophy in 6 hilar bile duct cancer patients undergoing right lobectomy. The indication of RHV embolization was insufficient regeneration of the left lobe (< 40% of whole liver volume after RPV embolization) and/or high operative risk (age > 65 years, major co-morbidity, low hepatic functional reserve and concurrent pancreatoduodenectomy). RESULT: RHV emolization was performed after determination of interlobar liver volumes using 2-week computed tomography volumetry after RPV embolization. RHV embolization was performed through internal jugular vein approach. Before RPV embolization, mean left lobe volume proportion to the whole liver volume was 34%; after 2 weeks, it increased to 39%; and 2 weeks after RHV embolization, it became 43%. No procedure-related complication occurred. All patients successfully underwent right lobectomy, caudate lobectomy and bile duct resection, and concurrent pancreatoduodenectomy was performed in 1 patient. All patients recovered uneventfully. Immunohistochemical studies revealed that apoptosis was definitely increased in the area of RPV and RHV embolization; proliferative index was higher in the left liver comparing with only RPV embolization group.

Conclusion. Sequential RPV-RHV embolization is a safe and effective tool to induce contralateral hypertrophy. The underlying mechanism of RHV embolization seems to be complete blockage of portal flow through interference of intrahepatic arterio-portal collateral flows.

PP 34.06

EFFECTS OF SIMULTANEOUS COLONIC RESECTION ON LIVER FUNCTION AND REGENERATION: AN EXPERIMENTAL STUDY IN RATS

Sasanuma, Hideki¹; Viborg Mortensen, Frank¹; Okada, Masaki¹; Yasuda, Yoshikazu¹; Funch-Jensen, Peter²; Nagai, Hideo¹

¹Jichi Medical School Hospital, Department of Surgery, Shimotsuke, Japan; ²Aarhus University Hospital, Department of Surgical Gastroenterology L, Aarhus, Denmark

Background. and AIMS: The surgical strategy for the treatment of colorectal cancer and synchronous liver metastases remains controversial. The effects of simultaneous colectomy on liver function and regeneration have yet to be identified. The aim of the present study was to investigate the effects of colonic resection on the liver function and regeneration in rat model.

Methods. One hundred-and-eight Sprague-Dawley rats were block-randomized into 6 groups: Group I had a laparotomy performed. Group II had 1 cm of the left sided colon resected and anastomosed. Additionally, 40% or 70% of the liver was resected in Group IV and VI, respectively. Group III had 40% of the liver resected. Group V had 70% of the liver resected. Body weight was recorded on POD 0, 3, 5 and 7. Rats were sacrificed on postoperative day 7 by rapid collection of blood from the inferior vena cava (IVC), and endotoxin levels were measured. Remnant liver function was evaluated by means of the rate of branched amino acids to tyrosine ratio (BTR). Liver regeneration was evaluated using hepatic regeneration rate (RR).

Results: Body weight changes were significantly affected by the colectomy. Higher plasma endotoxin levels of the IVC were found in simultaneous colectomy groups. BTR was significantly lower and RR was significantly higher in simultaneous colectomy groups.

Conclusions. Simultaneous colectomy induced a higher degree of endotoxemia and hepatic regeneration. Body weight changes and BTR were negatively affected by colectomy.

PP 34.07

ERYTHROPOIETIN IN LIVER SURGERY AND TRANSPLANTATION-TISSUE PROTECTION AND ENHANCED REGENERATION

Schmeding, Maximilian; Rademacher, Sebastian; Boas-Knoop, Sabine; Neuhaus, Peter; Neumann, Ulf

Charité University Hospital, General and Transplantation Surgery, Berlin, Germany

Background. It has been proven in various animal studies that recombinant human erythropoietin (rHuEPO) protects kidney and heart tissue from ischemia, and promotes regeneration of adult CNS neurons. Recently protective effects of rHuEPO could be demonstrated in ischemia-reperfusion of the liver.

Aim. Regarding the limitations of hepatic surgery by impaired regeneration capacity of the remnant tissue after major liver resection we investigated the influence of pre- and perioperative rHuEPO treatment on liver regeneration. Furthermore the tissue-protective capacities of rHuEPO were evaluated in a small animal liver transplantation (LT) model.

Methods. Wistar rats undergoing 70% or 90% hepatectomy received an intraportalvenous administration (i.p.) of rHuEPO prior to resection or a subcutaneous injection (s.c.) for 3 days postoperatively, control animals were treated with surgery and saline injection only. Regeneration capacity of remnant livers was studied over 7 days by histology and immunohistochemistry (Ki67, PCNA). PCR was performed to measure TGF-ß, HIF, STAT-3 and VEGF. In a second study liver transplantation was performed in rats after 18 hours of cold ischemia, rats and transplanted grafts were either pre-treated with rHuEPO or saline injection. Liver enzyme levels were measured, apoptosis and necrosis rates as well as survival were evaluated (TUNEL, H/E).

Results. 10-day survival in rats undergoing 90% hepatectomy significantly increased in i.p. pretreated animals. After 70% hepatectomy the mitotic index was significantly increased in both rHuEPO treated groups, PCNA and Ki-67 expression displayed sign. enhancement in rHuEPO treated groups 24 h and 2 days after liver resection. After LT liver enzyme levels were significantly reduced in rHuEPO pre-treated animals with substantially lower rates of apoptosis and necrosis.

Conclusion. rHuEPO effectively enhances hepatic regeneration in rats after major liver resection. In LT rHuEPO contributes to minimalize ischemia-reperfusion injury and optimize initial graft function

PP 34.08

EXTENT OF HISTOLOGIC LIVER DISEASE IN HBEAG NEGATIVE CHRONIC HEPATITIS B PATIENTS WITH PERSISTENTLY NORMAL SERUM ALT AND LOW HBV DNA

Mahtab, Mamun¹; Rahman, Salimur¹; Khan, Mobin¹; Kamal, Mohammad²; Ahmed, Faroque¹; Hussain, Fawaz¹; Podder, Provat¹

¹Bangabandhu Sheikh Mujib Medical University, Department of Hepatology, Dhaka, Bangladesh; ²Bangabandhu Sheikh Mujib Medical University, Department of Pathology, Dhaka, Bangladesh

Background. It is not uncommon in our practice to come across patients with chronic hepatitis B (CHB) having persistently normal serum transaminase (ALT) and low HBV DNA level. The aim of this study is to see the Knodell and HAI scores in these patients to assess the severity of liver injury in them.

Methods. We did percutaneous liver biopsies of 42 consecutive CHB patients with persistently normal ALT and low HBV DNA (<100,000 copies/ml).

Results. 15/42 (35.7%) patients had mild to moderate chronic hepatitis (CH) (HAI score 4–12). Fibrosis score was >2 in 8/42 (19%) patients.

Conclusion. The study shows that pre-core/core promoter mutant CHB with persistently normal ALT and low HBV DNA produces significant histologic liver disease in a good proportion of patients.

PP 34.09

MEDICINE SPECIALISTS ARE LESS SUSCEPTIBLE TO HCV INFECTION COMPARED TO OTHER HEALTH CARE PERSONNEL IN BANGLADESH

Mahtab, Mamun

Bangabandhu Sheikh Mujib Medical University, Hepatology, Dhaka, Bangladesh

Introduction. Hepatitis C virus is not frequent in Bangladesh. The prevalence has been estimated at 0.8% in the general population (Mahtab et. al. unpublished data). Studies have shown that the prevalence of HCV in health care personnel in this country is 1.4% (Alam et. al. 2007). Since medicine specialists are less involved with invasive producers compared to surgeons or nurses, the aim of this study was to see whether they are less likely to be exposed to HCV.

Methods. Medicine specialists attending the 18th Annual Conference of the Association of Physicians of Bangladesh volunteered to get anti-HCV tests done during the conference. In all 400 medicine specialists from all over Bangladesh participated in the study.

Results. None of the 400 medicine specialists (0%) tested positive for anti-HCV.

Conclusion. The study shows that medicine specialists are much less susceptible to HCV infection compared to other health care personnel.

PP 34.10

REACTIVATION OF HBV VIRAL REPLICATION AFTER HEPATIC RESECTION

Lee, Hae Won; Suh, Kyung-Suk; Kim, Joohyun; Shin, Woo Young; Yi, Nam-Joon; Lee, Kuhn Uk

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. It has been reported that viral replication could accelerate after hepatic resection in HBV-positiv e patients. Reactivation of viral replication may be one of the significant prognostic factors in HBV-positive patients because it can aggravate hepatitis and cirrhosis. In this study, we investigated actual changing pattern of serum HBV DNA levels during the early postoperative period after hepatic resection.

Methods. Among HBV-positive patients who underwent hepatic resection for hepatocellular carcinoma at Seoul National University Hospital between February and July 2007, 26 patients who had available postoperative serum HBV DNA levels were enrolled. Eight patients underwent tumorectomy and the others underwent major resection more than segmentectomy.

Results. The mean preoperative serum HBV DNA level was 5.37¡¾0.37 Log10copies/mL. The DNA levels slightly decreased in 72% of patients on postoperative day (POD) 2 and the mean DNA level was 5.29¡¾0.33 Log10copies/mL although it was not significant change (p = 0.174). However, DNA level on POD 7 was 5.69¡¾0.35 Log10copies/mL, which was significantly increased level than on POD 2 (p < 0.001). This increasing pattern of DNA level was constant irrespective of resection type or preoperative DNA levels. At postoperative 1 month, DNA level slightly decreased again to 5.35¡¾0.38 Log10copies/mL (p = 0.447). Five (33%) of 15 patients who had DNA level more than 6 Log10copies/mL between postoperative 1 week and 1 month showed alanine aminotransferase (ALT) level elevation by more than two times of normal range although the others showed no elevation of ALT.

Conclusion. The early acceleration of HBV replication after hepatic resection, especially within 1 week, was a universal event and high DNA level affected postoperative hepatic function. Therefore, it might be necessary to check postoperative serum HBV DNA levels after hepatic resection in HBV-positive patients and early antiviral therapy should be considered if the DNA levels are high.

PP 35.01

MANAGEMENT OF BLEEDING PSEUDOANEURYSMS IN PATIENTS WITH PANCREATITIS

venu, thummanims, hyderbad, India

Background. Bleeding pseudoaneurysm is a rare but frequently fatal complication in patients with pancreatitis Methods. The details of 9 patients who presented with pseudoaneurysm associated with pancreatitis between 2000 to 2006 were reviewed.

Results. Five patients had pseudoaneurysms associated with acute pancreatitis, and four with chronic pancreatitis. The splenic artery was involved in seven cases, and the gastroduodenal artery in two cases. Four patients had prior intervention pigtail(2), cytogastrostomy(1), necrosectomy(1). Evidence of haemorrhage(2 with bloody drain,3 with UGI bleed) was present on admission in all patients with acute pancreatitis.2 of 4 patients with chronic pancreatitis presented with haemosuccus pancreaticus. Angiography was done in eight patients. One patient underwent surgery without previous arteriography because of haemodynamic unstability. Angiogram was done during the episode of bleed and could localize the lesion in all the patients. Doppler could localize the lesion in only 1 of 4 patients. Two of four patients with chronic pancreatitis underwent primary surgery(distal pancreatectomy and splenectomy) one as an emergency and one within 48 hrs of bleed. The remaining patients had transcatheter arterial embolization with microcoils. Control of bleeding was successful in all patients treated by surgery, but one patient treated by embolization required a second intervention (splenectomy, distal pancreatectomy and necrosectomy) in acute pancreatitis group. There was one mortality in chronic pancreatitis group (patient with alcoholic cirrhosis with portal hypertension and splenic artery aneurysm developed renal failure and sepsis post embolisation) Conclusion: CT is not accurate in the diagnosis of pseudoaneurysms complicating acute pancreatitis. Primary resection of the pseudoaneurysm, which frequently requires pancreatic resection, is the treatment of choice in patients with chronic pancreatitis.

PP 35.02

ENDOSCOPIC PANCREATIC SPHINCTEROTOMY FOR PROLONGED PANCREATIC FISTULA AFTER DISTAL PANCREATIC SURGERY

Goasguen, Nicolas¹; Lesurtel, Mickaël¹; Bourrier, Anne²; Ponsot, Philippe³; Prat, Frédéric²; Dousset, Bertrand⁴; Sauvanet, Alain¹; Belghiti, Jacques¹

¹Hospital Beaujon, HPB Surgery, Clichy, France; ²Hospital Cochin, Gastroenterology, Paris, France; ³Hospital Beaujon, Gastroenterology, Clichy, France; ⁴Hospital Cochin, Digestive Surgery, Paris, France

Background. Pancreatic fistula (PF) is a frequent complication of distal pancreatectomy (DP) or enucleation (E). Usually, PF closes spontaneously but complete healing can need several weeks with a mean time for PF closure ranging from 21 to 35 days. Preoperative endoscopic pancreatic sphincterotomy (EPS) has been proposed to prevent PF before DP but its routine use is debatable due to its own morbidity. We report herein 8 consecutive patients who were successfully treated by EPS for a prolonged PF following DP or E. STUDY DESIGN: From 2004 to 2006, 8 patients with intraductal papillary mucinous tumor (n = 5), endocrine tumor (n = 2) and corticosurrenaloma invading the distal pancreas (n = 1), treated by DP (n = 4), medial pancreatectomy (n = 2, with PF from the cephalic remnant) and E (n = 2), experienced prolonged PF. All 8 underwent attempt to EPS for PF ongoing for a mean delay of 35 days (range: 19–114). Median PF daily output was 80 ml (range, 50–250).

Results. EPS was performed in all patients and was associated with pancreatic stent insertion in 3. No additional mortality or morbidity was observed. PF healed within a median delay of 4 days (range, 1–12) after EPS, including one patient who had a second endoscopic procedure for stent malposition. No patients developed any abscess nor recurrent PF, including 2 who susbsequently stent removal. All patients were discharged within a median delay of 13 days (range, 8–15) after EPS.

Conclusions. These encouraging results suggest that EPS should be performed in patients with prolonged PF following DP or E. In this indication, EPS seems highly feasible, allows to shorten the duration of PF healing, and do not induce a specific morbidity.

PP 35.03

RISK OF PANCREATITIS AFTER ERCP AND EBD

Matsubayashi, Hiroyuki¹; Ono, Hiroyuki¹; Fukutomi, Akira²; Otake, Yosuke¹; Yamaguchi, Yuichiro¹; Hasuike, Noriaki¹; Ikehara, Hisatomo¹; Takizawa, Kohei¹; Uesaka, Katsuhiko³; Maeda, Atsuyuki³; Matsunaga, Kazuya³; Kanemoto, Hideyuki³

¹Shizuoka Cancer Center, Division of Endoscopy, Suntogun, Shizuoka, Japan; ²Shizuoka Cancer Center, Division of GI Oncology, Suntogun, Shizuoka, Japan; ³Shizuoka Cancer Center, Division of Hepatopancreatobiliary Surgery, Suntogun, Shizuoka, Japan

Background. Pancreatitis is a complication, which occurs in 5–15% after ERCP. EBD (endoscopic biliary drainage) is a therapeutic technique for the obstructive jaundice before surgery or during chemotherapy. So far, several risk factors of post-ERCP pancreatitis had been assessed, however not on post-EBD pancreatitis.

Aim and Method. During 2002, Oct.-2007. April, 654 consecutive patients who underwent ERCP associated procedures at Shizuoka Cancer Center were entered and analyzed for the risk factors of post-ERCP and -EBD pancreatitis. For biliary drainage, we used 7–10 French (Fr.) of EBD and 5–7.2 Fr. of ENBD (naso-biliary drain). For the initial drainage, we chose 8.5 Fr. or smaller in more than 80% of cases to prevent the obstruction of pancreatic juice exclusion, but after second time, 10 Fr. in more than 60% of cases. Cotton[Otilde]s criteria were used for diagnosis of pancreatitis.

Results. Of 654 ERCP procedures, 406 were with drainage and 165 were for diagnostic examination using at least one of the following modalities: biopsy or brushing of the duct, IDUS, and POPS or POCS. Overall incidence of post-ERCP pancreatitis was 4.0% (26/654). There was a modest trend of higher rate in female (6.3%) than in male (3.0%)(P = 0.055), but no trend by age. Incidence of pancreatitis was similar between cases with (3.7%) or without (4.4%) drainage, but was significantly higher in initial drainage (6.7%) than in ³2nd time (0.5%)(P = 0.001). Six cases of EBD-pancreatitis recovered after replacement with downsized drain or additional EST. Pancreatitis was recognized more often in examination group (9.1%) to compare with the rest of group (2.2%)(P = 0.0001). No pancreatitis occurred after therapeutic procedures such as papillectomy and choledocal stone removal, or with EPD (pancreatic duct drainage) insertion after ERCP.

Conclusion. Not only diagnostic examination, but also biliary drainage may occasionally cause pancreatitis. Endoscopists have to keep in mind of the risk and management for post-ERCP and post-EBD pancreatitis.

PP 35.04

8 CASES OF LIVING DONOR PANCREAS TRANSPLANTATION IN KOREA

Han, Duckjong; Park, Kwan Tae; Shin, Haengchul; Kim, Songchul

Asan Medic al Center, Surgery, Seoul, Korea, Republic of

Introduction. Cadaveric pancreas transplantation(PT) has become a widely accepted treatment option for the type 1 DM patients. But the living donor pancreas transplantation(LD PT), an attractive alternative that can give recipients the benefits of better immunologic match, reduced ischemic time, better timing of transplantation, has not been done widely. So, the purpose of this study is to report our experiences of eight LD PT.

Methods.) From August of 2005 to July of 2007, 5 PTA(pancreas transplant alone) and 3 SPK(simultaneous pancreas kidney transplant) from living donors were performed in Asan Medican Center. Donors underwent standardized metabolic workup such as insulin secretion test, HgbA1C, glucose tolerance test and abdominal CT. Distal pancreatectomy at the level of superior mesenteric vein with splenectomy was done for organ procurement. Also, functionally inferior kidney was harvested together in case of SPK. Seven doses of thymoglobulin induction therapies and tacrolimus and mycophenolate mofetil maintenance were used. Six doses of steroid were administrated and eliminated in early postoperative days.

Results. Five patients were female and three were male. Median age was 31 (20–46) and all the donors were family members (mother:3, siblings:3, spouse:2). Exocrine bladder drainages were done for 5 PTA and 2 SPK and enteric drainage for 1 SPK. One patient had graft thrombosis at the 5th day and the graft was removed. In 2 SPK recipient, solitary pancreas rejection was developed and one of them was successfully rescued by steroid pulse and thymoglobulin. Another 1 PTA patient lost pancreatic function from incompliance to tacrolimus. Finally, 5 out of 8 recipients are doing well and euglycemic without insulin. All the donor are also doing well and had no postoperative DM.

Conclusions. LD PT can be done safely and effectively as an alternative to cadaveric PT with strict selection of donors. To prevent graft thrombosis in LD PT, anticoagulation should be used cautiously.

PP 35.05

EXTRAPERITONEAL PANCREAS TRANSPLANTATION WITH SYSTEMIC-ENTERIC DRAINAGE: EARLY SURGICAL COMPLICATIONS AND OUTCOME

Kocik, Matej¹; Lipar, Kvetoslav¹; Adamec, Milos¹; Saudek, Frantisek²; Boucek, Petr²

¹Institute for Clinical and Experimental Medicine, Transplant Surgery Department, Prague, Czech Republic; ²Institute for Clinical and Experimental Medicine, Diabetes Center, Prague, Czech Republic

Background. A variety of techniques for pancreas transplantation (PTx) is used in different centers and intraperitoneal placement of the graft has remained a cornerstone of the operation technique. Despite improving results over the last years, there is still a significant number of surgical complications. We describe a single center experience with extraperitoneal placement with systemic venous and enteric exocrine drainage of the pancreas graft. The aim of this study was to evaluate early surgical complications and outcome in the first 3 months after PTx.

Methods. Between March 2001 and May 2007, a total of 126 PTx were performed in our institution of which 17.5% as an isolated PTx. In all transplants pancreas graft was placed extraperitoneally in the right iliac fossa and the vessels of the graft were joined to iliac vessels of the patient. Duodenum was joined in a side-to-side fashion to an adjacent small bowel loop after an incision of the peritoneum.

Results. A total of 39 patients (31%) had a surgical complication reguiring repeat laparotomy. Indications were: bleeding (7.9%), venous thrombosis (6.3%), duodenal anastomotic leak (1.6%), bowel obstruction (0.8%), peripancreatic abscess (1.6%), impaired wound healing with fluid secretion (12.7%). 3-months patient and pancreas graft survival rates were 96.8% and 86.5%. Indications for graft removal were: portal vein thrombosis (6.3%), otherwise uncontrollable bleeding (1.6%) and duodenal anastomotic leak (1.6%).

Conclusions. Our data confirm that PTx with extraperitoneal placement and systemic – enteric drainage brings comparable results with other techniques when pancreas graft is placed intraperitoneally. Extraperitoneal placement eliminates intraperitoneal infection and bleeding and allows easy ultrasound examination of the graft including its biopsy and early rehabilitation and oral nutrition. A drawback is more frequent incidence of impaired wound healing above the pancreas. It may lead to prolonged hospital stay but has no effect on long term survival.

PP 35.06

COMPARISON OF PANCREAS TRANSPLANTATION OUTCOMES BY DRAINAGE TYPE: A SINGLE CENTER'S EXPERIENCE

McHugh, Patrick P; Johnston, Thomas D; Jeon, Hoonbae; Gedaly, Roberto; Ranjan, Dinesh

Transplant Center, University of Kentucky, Surgery, Lexington, Kentucky, United States

Background. Pancreas allografts are transplanted by anastomosing donor duodenum to recipient urinary bladder or jejunum, facilitating exocrine drainage. Enteric drainage (ED) is more common, thus avoiding local complications associated with bladder drainage (BD). However, we observed a higher rate of major complications at our center, especially allograft venous thrombosis, using ED. After performing only ED since early 1998, we returned to using only BD in February 2005.

Objective. To compare outcomes in pancreas transplants at our center, by drainage method used.

Methods. We reviewed outcomes in patients who received simultaneous pancreas-kidney (SPK) or pancreas-after-kidney (PAK) transplant, or pancreas transplant alone (PTA) at our center.

Results. Between January 1996 and July 2007, we performed 104 SPK, 13 PAK, and one PTA, in 112 patients; since return to BD in February 2005, 12 SPK and 5 PAK have been performed. None of 27 total BD-SPK allografts has thrombosed, compared to 12 of 77 ED-SPK (p = 0.02). Among 14 PAK/PTA cases, one BD graft and 2 ED grafts thrombosed (p = n/s). All thrombosed grafts required emergent pancreatectomy. Of all BD-SPK, one patient developed bowel ischemia with survival of allograft function. 5 ED-SPK patients had major complications such as graft leak, necrosis, hemorrhage, jejunal volvulus, and bladder fistula; 2 required pancreatectomy. BD-related complications such as severe acidosis (9 total patients), cystitis (5 patients), and reflux pancreatitis (3 patients) occurred but were successfully managed, though 6 BD-SPK required ED-conversion, 2 of which within 1 year.

Conclusion. BD-SPK appears superior to ED-SPK performed at our center, with fewer major technical complications. A similar trend exists among PAK/PTA, but the small number of patients limits statistical analysis. Complications unique to BD are comparatively minor and rarely compromise long term allograft survival – overall an acceptable tradeoff for fewer postoperative thromboses.

PP 35.07

PANCREAS ISLET AUTOTRANSPLANTATION-AN UNCOMMON SOLUTION FOR SEVERE PANCREATIC FISTULA POST HEMIPANCREATODUODENECTOMY

OLIVERIUS, Martin¹; Girman, Peter²; Adamec, Milos¹; Saudek, Frantisek³

¹Institute for Clinical and Experimental Medicine, Transplant Surgery Department, Prague, Czech Republic; ²Institute for Clinical and Experimental Medicine, Department of Diabetology, Prague; ³Institute for Clinical and Experimental Medicine, Department of Diabetology, Prague, Czech Republic

Background. pancreatic leak represents the most serious complication of pancreatosurgery. Some of those cases can be solved conservatively but some of them need a surgical treatment with total pancreatectomy.

AIM(S)/OBJECTIVE(S): The major morbidity following total pancreatectomy is diabetes mellitus with its associated complications. Islet autotransplantation can be considered as a useful therapeutic option serving to prevent the occurrence of surgically-induced diabetes.

Methods. in a series of the 87 hemipancreatoduodenectomies with a total of 9, 1% leaks during 2004/2007 two patients underwent a total pancreatectomy with islet autotransplantation for severe leak. Islets were prepared in laboratory by digestion of the excised pancreas, and infused unpurified into the portal vein through an operatively placed catheter during one procedure.

Results: postoperative course was uneventful in both cases and their C protein was positive during the follow up. Owing to the moderate fasting hyperglycemia, postoperative exogenous low dose insulin therapy was necessary. During follow-up the fasting C-peptide level was positive, and an oral glucose tolerance test and an intravenous glucagon stimulation showed functioning engrafted islets.

Discussion. total pancreatectomy is mutilating procedure with lifelong defect of the exo- and endocrine functions. While the first one could be easily substitute the second one results of serious instable diabetes. Pancreas islet autotransplantation usually does not achieve insulin independence but improved control of glycated HbA1c. Reduced risk of recurrent hypoglycemia is a great benefit. The procedure is now associated with low morbidity and mortality.

Conclusion. In our opinion, islet autotransplantation should be offered to any patient needing to undergo total pancreatectomy for severe leak. In cases in which insulin independence is not achieved, the potential beneficia l effects of C-peptide make the procedure worthwhile.

PP 35.08

TECHNICAL PROCEDURES OF PANCREAS TRANSPLANTATION

Sabino, Gustavo B; Brabo, Janaina L.; Iida, Diego F.; Ribeiro Junior, Marcelo A. F.; Subero, Lídia L.; Saad, William A.

Universidade Cidade de São Paulo-UNICID, São Paulo, Brazil

Introduction. Due to the evolution in the surgical techniques as well as the imunosuppression drugs, the pancreas transplantation (PT) has been increased for the treatment of the Diabetes Mellitus (DM) throughout the world. The Simultaneous Kidney and Pancreas Transplantation (SKPT), is the modality of transplant more used in the entire world following by Pancreas Transplantation after Kidney (PTAK). This last one, is indicated to patients who had made the renal transplant from a living donor and are still waiting the pancreas from a deceased donor to get the benefits of the glicemia levels. Normally the PTAK is carried through after the stabilization of the graft kidney. The Isolated Pancreas Transplantation (IPT) is the less common modality, corresponding 5% of the transplants. It is indicated for severe metabolic disturbance.

Objective. A review of the literature about the subject.

Methods. Research of articles and specialized books from the English and Portuguese literature.

Results. It can be verified that, despite the survival of the patient to be similar in all the categories of receivers, the functional graft's result after one year is significantly superior in the SKPT when compared with PTAK and IPT (P = 0.0001). However, recently the group of Minnesota has demonstrated that, following some guidelines, they could get similar results of survival grafts in these two last categories of patients when compared with the SKPT.

Conclusion. According to the reviewed literature, the final results of the PT depends of a lot of factors, mainly related of the receivers and technical procedures. Evidences in literature suggest a beneficial effect of the PT on the metabolic disturbance and the evolution of the secondary complications of the illness.

PP 35.09

PANCREAS TRANSPLANTATION: BLADDER VS. ENTERIC DRAINAGE.

Brabo, Janaina L; Sabino, Gustavo B.; Iida, Diego F.; Ribeiro Junior, Marcelo A.F.

Universidade Cidade de São Paulo-UNICID, São Paulo, Brazil

Introduction. Several series have compared bladder drainage (BD) versus enteric drainage (ED) of pancreas secretions for differences in long-term survival. The most recent UNOS/IPTR registry reports no difference in patient, kidney graft or pancreas graft survival between the techniques.

Objective. A review of literature about the subject.

Methods. Research of articles and specialized books in English and Portuguese literature.

Results. Recent individual center reports demonstrate no difference in long-term survival between the techniques. This is in contrast to reports from the early 1990's that reported increased infections (mainly intra-abdominal), increased technical failure, and worse graft outcome for ED compared to BD. Sollinger et al. demonstrated no difference if graft survival in BD versus ED. However, of the 388 BD grafts, 62.5% had urinary tract infection (UTI), 17.7% had hematuria, 15.4% had duodenal segment/bladder leak, 2.8% had urethral stricture and 2.5% had urethral disruption. By comparison, only 8% of the ED grafts suffered from leak and only 11.7% had urinary tract infections.

Conclusion. With current techniques and immunosuppression, patient and graft survival appears equal with either BD grafts or ED grafts. However, BD grafts appear to have a higher incidence of metabolic abnormalities, urologic complications, and infectious complications. The latter may play a role in the increased death from infectious causes in pancreas recipients. ED grafts appear to have a higher rate of intra-abdominal infections and hypertension. BD pancreas patients need to be monitored long-term for infections, metabolic abnormalities, and urologic complications including tumors. Patients who develop these manifestations may safely undergo conversion to ED without compromising graft or patient survival.

PP 35.10

LAPAROSCOPIC CHOLECYSTECOMY USING FLEXIBLE GASTROSCOPE-THE FIRST STEP ON THE WAY TO NOTES

Starkov, Yury¹; Shishin, Kirill¹; Solodinina, Elena²; Alekseev, Konstantin²

¹A.V.Vishnevsky Institute of Surgery, Surgical Endoscopy, Moscow, Russian Federation; ²A.V.Vishnevsky Institute of Surgery, Endoscopic Surgery, Moscow, Russian Federation

Introduction. Natural Orifice Translumenal Surgery is the latest trend of endoscopic surgery. Availability of this kind of surgical approach in treatment of different surgical diseases, e.g. calculous cholecystitis, was shown by good results of experimental operations in animals. Hybrid operations with using of flexible and laparoscopic endoscopy are transitional stage of application NOTES to clinical practice.

Methods. 30/05/07 a 46-years-old man, with clinically and instrumentally confirmed diagnosis of chronic calculous cholecystitis was operated with using of combined surgical approach. Gastroscope was inserted into abdominal cavity after creation of the pneumoperitoneum in umbilical point. Further during the operation pneumoperitoneum was maintained through trocar 5 mm inserted in the right hypohondrium region in the mid axillary line. Consecutive dissection of the cystic duct and cystic artery was made with the using of hot biopsy forceps and coagulation probe. Cystic duct and cystic artery were cut after clipping with endoscopic clips (2 clips were left on cystic duct stump and 2 – on cystic artery stump). Following evacuation of gall-stone gall-bladder was dissected with the help of coagulation probe and IT-knife and removed from abdominal cavity. Gall-bladder bed was coagulated. The operation time was 2 hours 15 minutes. There was no hemorrhage during the operation. Postoperative period was without any complications. Abdominal ultrasound did not reveal any pathological changes. The patient was discharged two days after operation, his status was satisfactory. Follow-up for three month after operation did not reveal any peculiarities of the postoperative period.

Conclusion. This case report shows the ability of cholecystectomy performance with the instruments conducted through the gastroscope channels. It is our first step on the way to translumenal endoscopic surgery – the next stage of minimally invasive surgery development.

PP 36.01

THREE CASES OF ISOLATED SPLENIC METASTASIS

Cho, Chol Kyoon¹; Koh, Yang Seok¹; Kim, Hyun Jong¹; Kim, Jung Chul¹; Hur, Young Hoi¹; Lee, Wan Sik²; Park, Chang Hwan²; Choi, Sung Kyu²; Kim, Seok Mo³; Jeong, Yong Yeon⁴; Shin, Sang Soo⁴; Lee, Jae Hyuk⁵

¹Chonnam National University Medical School, Surgery, Gwangju, Korea, Republic of; ²Chonnam National University Medical School, Internal Medicine, Gwangju, Korea, Republic of; ³Chonnam National University Medical School, Gynecology, Gwangju, Korea, Republic of; ⁴Chonnam National University Medical School, Radiology, Gwangju, Korea, Republic of; ⁵Chonnam National University Medical School, Pathology, Gwangju, Korea, Republic of

Background. Splenic metastases from solid tumors are unusual and detected with a state of multiple metastasis of many organs in far advanced stage. Cancers of ovary, lung, breast, stomach, colon and skin are known to metastasize to spleen. Isolated splenic metastasis without a evidence of metastasis to other organ is very rare and the exact pathomechanism of metastasis remains unknown even though hematogenous metastasis supposed to be related. AIM/ OBJECTIVE We present three cases of splenectomy for isolated splenic metastasis and evaluate the significance of splenectomy in such clinical situation.

Methods. The first case is a 36-year-old female who underwent left oophorectomy for ovarian mucinous cancer. Follow up CT 1 year after operation showed 9¡¿8 cm sized multi-septated cystic lesion with internal calcification in spleen. The second case is a 47-year-old female who has been treated with chemo-radiotherapy for endocervical cancer. Follow up CT after 10 months showed 2.3¡¿1.9 cm sized low attenuated mass in spleen. The third case is a 55-year-old female who received a chemo-radiotherapy for cervix cancer. Follow up CT after 10 months showed 2¡¿1.1 cm sized low attenuated mass in spleen. All cases were treated with splenectomy by open method in the first case and by laparoscopically in the other cases.

Results In microscopic examination of the resected specimen, the first case was metastatic mucinous cystadenocarcinoma from ovary, and the second case was metastatic adenocarcinoma from cervix, and the third case was squamous cell carcinoma from cervix. All three cases recieved chemotherapy or chemo-radiotherapy after splenectomy and are alived without a evidence of recurrence in follow up periods of 7 years, 21 months and 26 months respectively. DISCUSSION Splenectomy appears to be an appropriate therapy and confers a substantial survival benefit to patients with isolated splenic metastasis.

PP 36.02

SAFETY OF GASTROGRAFIN IN THE EFFECTIVE MANAGEMENT OF ADHESIVE SMALL BOWEL OBSTRUCTION

Dash, Nihar Ranjan¹; Sharma, Aribam D²; Kulkarni, Mukund¹; Pal, Sujoy¹; Sahni, Peush¹; Chattopadhyay, Tushar Kanti¹

¹AIIMS, GI Surgery and LTx, New Delhi, India; ²

Background. Adhesive small bowel obstruction (ASBO) is a problem following abdominal surgeries including the HPB. Gastrografin is being increasingly advocated in the diagnosis as well as therapy despite the concerns over its use.

Objective. To asses the effectivity and safety of Gastrografin in the management of ASBO.

Patients and Methods. During Feb04 to Nov05, all patients of clinically and radiologically diagnosed cases of uncomplicated ASBO, who failed to improve by bowel rest regimen, were prospectively studied. 100ml of undiluted Gastrografin was administered either through oral or enteral route. Abdominal X rays were taken at 8 hrs and 24 hrs. RESULT: Thirty patients were studied. The median age was 37.5 years. (11–74). Majority(13/30) of them were following colorectal surgeries (43%).Six (20%) were following HPB surgery.10% ASBO occurred during first week and 40% within 3 weeks following surgery. Complete relief occurred in 25(83%) cases. Median time for passage of flatus was 24 hours (4–120 hours).Median time for oral intake was 1 day (1to 8 days).Five (17%) cases required surgery in the form of adhesiolysis. None had strangulation. Only one had a localized small perforation at an anastomosis site. The median hospital stay following Gastrografin was 5 days (3–40).There was no mortality. Recurrence occurred in 13%( 3/25) cases with in 6 months. All were managed conservatively The presence of contrast at the stoma (at 8 hrs) or in the rectum (24 hrs) correlated significantly with the need for surgery. The sensitivity, specificity, overall accuracy, PPV and NPV for continuation of non operative management in stoma patients were 100% each. No patient had allergic or anaphylactic reaction. None had any problem like nausea abdominal pain; vomiting or aspiration following contrast ingestion. There was no deterioration in the renal parameters.

Conclusion. Gastrografin is safe to use in the effective evaluation and therapy of post operative ASBO after other causes of obstruction have been reasonably ruled out.

PP 36.03

COMPARISON OF GASTRIC ACIDITY BETWEEN PANCREATICOGASTROSTOMY AND PANCREATICOJEJUNOSTOMY FOLLOWING PYLORUS-PRESERVING PANCREATICODUODENECTOMY

Shinchi, Hiroyuki¹; Takao, Sonshin²; Maemura, Kosei¹; Noma, Hidetoshi¹; Mataki, Yukou¹; Kurahara, Hiroshi¹; Maeda, Shinichi¹; Ueno, Shinichi¹; Sakoda, Masahiko¹; Kubo, Fumitake¹; Aikou, Takashi¹

¹Kagoshima University Graduate School, Department of HBP Surg, Kagoshima, Japan; ²Kagoshima University Graduate School, Frontier Science Research Center, Kagoshima, Japan

Background. In general, pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) has been performed after Whipple resection or pylorus-preserving pancreaticoduodenectomy (PPPD). Although the physiologic alteration in the stomach is important for the correlation between gastric and pancreatic functions, the actual intragastric pH profile after PG or PJ is still unclear. This study was conducted to investigate the physiologic changes in gastric pH and serum gastrin and secretin levels before and after PPPD reconstructed with PG or PJ in humans.

Methods. Twenty-four hour continuous intragastric pH and serum gastrin and secretin levels in the fasting state were examined in 13 patients who had undergone PG and 10 patients with PJ.

Results. No peptic ulcer was detected in either group after the operation. After PPPD, in both PG and PJ patients, median pH and percentages of time that the gastric pH was less than 4 (% pH < 4) and more than 6 (% pH > 6) did not change in comparison with preoperative data, and circadian pH patterns also remained unchanged. Each data showed no significant differences between PG and PJ patients. Serum gastrin and secretin levels in the fasting state were also unchanged in both groups.

Conclusions. These results suggest that both PPPD-PG and PJ present no problem to the intragastric pH milieu and that the neurohumoral relation between the stomach, duodenum, and pancreas is preserved, which seems to be due to the preservation of the antrum and duodenal bulb.

PP 36.04

PRESENTATION, MANAGEMENT AND OUTCOME OF PANCREATICO-BILIARY TUBERCULOSIS

Jain, Sundeep¹; Kalla, Komal²; Kalla, Mukesh³; Sharma, Jayant⁴; Sharma, Shyam Sunder⁵

¹S.K.Soni Hospital, Gastrointestinal & Laparoscopic Surgery, Sector 5, Vidhyadhar Nagar, Jaipur, India; ²S.R.Kalla Memorial Hospital, Pathology, Jaipur, India; ³S.R.Kalla Memorial Hospital, Gastroenterology, Jaipur, India; ⁴S.K.Soni Hospital, Gastroenterology, Jaipur, India; ⁵S.M.S. Hospital, Gastroenterology, Jaipur, India

Introduction. Isolated pancreatico-biliary involvement with tuberculosis (TB) is a rare entity. Its clinical, biochemical, radiological and endoscopic presentation mimics that of pancreatico-biliary malignancy. OBJECTIVE The aim of the present study was to evaluate the clinical, biochemical, radiological and endoscopic presentation, management and outcome in patients with histologically confirmed pancreatico-biliary TB.

Methods. We retrospectively analyzed the records of 5 patients managed for biliary obstruction and/or pancreatic mass due to TB, during January 2002 to July 2007.

Results The clinical presentation was with jaundice, cholestasis, pain abdomen and anorexia. Three patients had LFTs suggestive of biliary obstruction. On radiological and endoscopic evaluation, 1/5 had hilar block, 2/5 had lower CBD stricture with peripancreatic lymphadenopathy and 2/5 had pancreatic head mass with peripancreatic lymphadenopathy. Histopathologically, 4/5 patients revealed caseating granulomas and 1/5 patient had acid fast bacilli. Patient with hilar block underwent laparotomy with the diagnosis of hilar cholangiocarcinoma, however intraoperative histopathology of the hilar lymph-nodes revealed caseating granulomas. He was treated by Roux-en-y hepatico-jejunostomy and antitubercular treatment (ATT). Patients with lower CBD stricture were treated with CBD stenting and ATT. Two patients with pancreatic head mass responded to ATT and on imaging showed significant reduction in size. The total follow-up of 4/5 patients is 3 months to 5 years. One patient was lost to follow-up.

Conclusions. There should be high index of suspicion for pancreatico-biliary TB in patients residing in endemic areas. If the diagnosis is confirmed histopathologically it can be treated without surgery. In case of doubt surgical exploration should be performed.

PP 36.05

NON-NEOPLASTIC CYSTIC AND CYST LIKE LESION OF PANCREAS

Vyas, Frederick¹; Joseph, Philip²; Sanghi, Ravish²; Eapen, Anu³; Sitaram, Venkatramani²

¹Christian Medical College Hospital, Department of General Surgery, Ida Scudder road, Vellore, India; ²Christian Medical College Hospital, Department of General Surgery, Vellore, India; ³CHristian Medical College Hospital, Department of Radiodiagnosis, Vellore, India

Background. Because of increasing use of cross sectional imaging, cystic lesions of pancreas are increasingly diagnosed. Many patients with cystic lesions of pancreas are asymptomatic. Pancreatic pseudocysts and cystic neoplasms are common. Non neoplastic pancreatic cystic and cyst like lesions are extremely rare.

Methods. Medical records of all patients who underwent surgical exploration for excision of cystic lesions of pancreas were retrospectively reviewed. Five patients had a final diagnosis of non neoplastic pancreatic cystic or cyst like lesion. These five patients are the focus of this study.

Results. There were 4 females and 1 male with a median age of 38 years (range 28–47). Three patients presented with abdominal pain and epigastric fullness. One patient presented with a discharging sinus following percutaneous drainage of hydatid cyst of liver in another hospital when he was also detected to have multiple cystic lesions in the tail of pancreas. One patient was asymptomatic. Two patients had palpable mass. Pre-operative radiological diagnosis included mucinous cystadenoma, pseudopancreatic cyst (2), hydatid cyst and dermoid cyst. Surgical procedures performed were pancreaticoduodenectomy (1), distal pancreatectomy with splenectomy (2), and excision of cyst (2). The final diagnoses on histopathology were lymphangioma, hydatid cyst of pancreas, mature cystic teratoma, benign epithelial cyst and degenerated parasitic cyst. Over a median follow up of 28 months, all patients are alive and well without any evidence of recurrent disease. Though 3 patients would have required surgery on the basis of signs and symptoms, there were 2 patients in whom surgical treatment could have been avoided.

Conclusion. Non-neoplastic, non-inflammatory lesions of pancreas are generally benign and do not require surgical treatment when asymptomatic. The pre-operative diagnosis is often unreliable. The challenge is to diagnose these lesions pre-operatively and avoid unnecessary operations.

PP 36.06

LYMPHOEPITHELIAL CYST OF THE PANCREAS —A RARE CYSTIC LESION THAT MIMICS CARCINOMA

Langan, Russell¹; Paragi, Prakash¹; Danieu, Linda²; Chamberlain, Ronald¹

¹Saint Barnabas Medical Center, Department of Surgery, Livingston, United States; ²Saint Barnabas Medical Center, Department of Oncology, Livingston, United States

Background. Lymphoepithelial cysts of the pancreas are rare lesions that mimic other cystic lesions such as pancreatic cystadenoma, cystadenocarcinoma and pseudocysts. Histogenesis of this lesion is not implicit, and differentiation from other cystic lesions of the pancreas is necessary to tailor the treatment.

Aim. We report a 59 year old male with lymphoepithelial cyst of the pancreas. A review of literature encompassing clinical presentation, diagnosis and management is presented.

Methods. An asymptomatic patient with a cystic lesion of the pancreas detected on routine workup was evaluated. Work up revealed a multi-cystic lesion in the head of the pancreas with no pancreatic insufficiency. Preoperative histopathology was inconclusive. Endoscopic ultrasound and fine needle aspiration revealed a non-serous, thick, yellow fluid with rare cellular atypia. No malignant cells were seen. Computer tomography revealed a 5.0×5.2cm multi-loculated cystic mass in the head of the pancreas extending into the uncinate process.

Results. The patient underwent a conventional Whipple procedure and pathological sections revealed a multi-loculated cyst lined by squamous epithelium and underlying lymphoid tissue consistent with a lymphoepithelial cyst.

Conclusion. True pancreatic cysts, which are distinguished by their epithelial lining, are the rarest form of cystic pancreatic lesions. The lymphoepithelial cyst of the pancreas is an extremely rare benign neoplasm of unknown etiology, and should be considered in the differential diagnosis of cystic lesions of the pancreas.

PP 36.07

TUBERCULOSIS OF PERIPANCREATIC LYMPH NODES CAN BE ASSOCIATED WITH OTHER PANCREATIC LESIONS- A RETROSPECTIVE STUDY

OV, Sudheer; Menon, Ramachandra; S, Sudhindran; Dhar, Puneet

Amrita Institute of Medical Sciences, Gastrointestinal Surgery, Kochi, India

Background. Peripancreatic lymph nodes with tuberculosis is not very rare where the disease is prevalent. This has importance in suspected pancreatic malignancy where the disease may be over staged by CT scan.

Materials and Methods. The cases of peripancreatic lymph nodes affected with tuberculosis during the period 2000–2006 were analyzed retrospectively from hospital data.

Results. During this period 10 cases of peripancreatic tuberculosis of lymph nodes were identified. The age group was 28 to 74 years. 5 out of the 10 patients were immunocompromised. (Diabetes mellitus 3, HIV positive 2) 5 cases were identified on evaluation of malignant obstructive jaundice. (2 in preoperative FNAC and 3 in Whipple's specimen associated with malignancy). 3 cases were found to have tuberculosis of peripancreatic lymph nodes associated with chronic calcific pancreatitis. Peripancreatic tuberculosis of lymph nodes was identified in one patient operated for solid and cystic tumour of pancreas. FNAC showed tuberculosis in another patient presented with anorexia, weight loss and peripancreatic lymph nodular mass on CT scan. In 5 out of 10 cases CT showed lymph nodes with central necrosis. FNAC was positive for tuberculosis in 5 out of 6 cases where it was done. All the 10 patients were treated with antitubercular treatment.

Conclusion. Peripancreatic lymph nodes with tuberculosis can be associated with other diseases. Large nodes with central necrosis in CT scan should raise a suspicion of tuberculosis. FNAC can give a diagnosis in majority of cases.

PP 36.08

INTRA-ABDOMINAL PRESSURE VARIATIONS AFTER LARGE PANCREATIC PSEUDOCYST TRANSCUTANEOUS DRAINAGE

Papavramidis, Theodossis S; Duros, Vassilios; Michalopoulos, Antonios; Papadopoulos, Vassilios N.; Paramythiotis, Daniel; Netta, Smaro; Harlaftis, Nikolaos

A.H.E.P.A. University Hospital, Aristotle's University of Thessaloniki, 1st Propedeutic Department of Surgery, Thessaloniki, Greece

Background. The intra-abdominal pressure (IAP) is the pressure existing in the abdominal cavity. The present study aims to investigate the IAP variations after large pancreatic pseudocyst transcutaneous drainage.

Material. In the present study participated 9 patients (6 males and 3 females) with large pancreatic pseudocysts that fulfilled the inclusion criteria: (i) volume greater than 1l, (ii) no signs of chronic pancreatitis, and (iii) no signs of acute pancreatitis for the last 2 months. The mean age of the patients was 72.2y (range 64 to 78y). The mean age was of 72.2 years. The BMI averaged 27.15 kg/m2. The mean volume of the initial pseudocyst fluid was 2300ml.

In order to measure IAP a Foley catheter was inserted into the urinary bladder using a standard sterile technique 6 hours before the transcutaneous drainage, with the patient at supine position. The measurements were taken 6 hours before the drainage and at 8 o'clock in the morning every morning for the 7 days following the drainage.

Results. The mean pre-drainage IAP was 12.6 cmH2O, while the first post-drainage day (PDD) it was 6.9 cmH2O. The second PDD IAP was 7.6 cmH2O, the third 8.7 cmH2O, the fourth 9.4 cmH2O, the fifth 10.8 cmH2O, the sixth 11.2 cmH2O, and finally the seventh 11.2 cmH2O.

Paired student's T-test showed statistically significant IAP differences between the pre- and all the post-drainage values. Furthermore, it is important to notice that IAPs seem to stabilize after the 5th post-drainage day since no statistical difference appears between 5th, 6th an 7th PDD.

Conclusion. The present study demonstrates that the drainage of large pancreatic pseudocyst reduces the intra-abdominal pressure both in an acute and in a chronic basis. Moreover, the IAP seems to rise shortly after the drainage again in a way that it remains at all time inferior to the initial value. More chronic changes to the IAP are related to abdominal cavity's properties which need more time to be altered, and have to be further studied.

PP 36.10

LARGE PANCREATIC PSEUDOCYSTS ALTER THE INTRA-ABDOMINAL PRESSURE IN A CHRONIC BASIS

Papavramidis, Theodossis S¹; Kotidis, Eustathios²; Duros, Vassilios¹; Michalopoulos, Antonios¹; Papadopoulos, Vassilios N.¹; Paramythiotis, Daniel¹; Papavramidis, Spiros T.²

¹A.H.E.P.A. University Hospital, Aristotle's University of Thessaloniki, 1st Propedeutic Department of Surgery, Thessaloniki, Greece; ²A.H.E.P.A. University Hospital, Aristotle's University of Thessaloniki, 3rd Department of Surgery, Thessaloniki, Greece

Background. Intra-abdominal pressure (IAP) is the pressure existing in the abdominal cavity. There is vast literature on the abdominal compartment syndrome and the different techniques for measuring the pressure. The present study aims to investigate whether the large pancreatic pseudocysts alter the IAP.

Methods. Two groups were formed. Group A consisted of 9 patients (6 males and 3 females) with pancreatic pseudocysts that fulfilled the inclusion criteria: (i) volume greater than 1l, (ii) no signs of chronic pancreatitis, and (iii) no signs of acute pancreatitis for the last 2 months. The mean age of the patients was 72.2y (range 64 to 78y). Group B consisted of 40 patients with type II, after Nyhus, inguinal hernia. The only condition that had to be fulfilled in forming this group was that the age of the patients had to be in the age range of Group A.

A Foley catheter was inserted into the urinary bladder of all patients using a standard sterile technique. The bladder was filled with 50 mL of saline using a previously described closed-system technique. The measurements were taken in the morning.

Results. BMI averaged 27.15 kg/m2 and 26.95 kg/m2 for groups A and B respectively. The mean IAP while supine was 12.6 cmH2O (range, 9–17 cmH2O) for group A, while for group B it was 11.1 cmH2O (range, 9–12.5 cmH2O). Student's T-test showed a statistically significant IAP difference between the two groups (p = 0.05).

Conclusions. The formation of the pseudocysts limits the abdominal volume occupied by the pancreatic fluids, and the exposure of the adjacent organs from the erosion of the pancreatic fluids. This study demonstrates that the presence of large pseudocyst sustains the IAP slightly elevated. This may have an effect mainly in pancreatic irrigation, but also other organs irrigation. Therefore, when large pancreatic pseudocysts are present, drainage of the cyst may importantly improve the condition of the pancreas, as well as the general condition of the patients.

PP 37.01

GASTRIC AND DUODENAL ULCERS IN PATIENTS WITH CIRRHOSIS AND NON- CIRRHOTIC PORTAL HYPERTENSION

Sinha, S K¹; Mehta, V K¹; Nada, R²; Prasad, K K¹; Rana, S V¹; Bhasin, D K¹; Singh, K¹

¹Post Graduate Institute of Medical Education & Research, Department of Gastroenterology, Chandigarh, India; ²Post Graduate Institute of Medical Education & Research, Department of Histopathology, Chandigarh, India

Introduction. Patients with cirrhosis have higher risk of peptic ulcer than general population. This may be related to either portal hypertension or hepatocellular dysfunction. The risk of peptic ulcer in non-cirrhotic portal hypertension (NCPHT) is not clearly defined. Comparing the risk in the two groups may also help in understanding the pathogenesis of these ulcers. AIMS & OBJECTIVES: To study the prevalence of gastric and duodenal ulcer in patients with cirrhosis and NCPHT, and assess their relation with H. pylori.

Methods. This prospective study was conducted on following three groups of patients: 84 patients with cirrhosis, 37 patiens with NCPHT (7 patients with non-cirrhotic portal fibrosis-NCPF and 30 patients with extrahepatic portal vein obstruction-EHPVO), and 50 patients with non-ulcer dyspepsia. Cirrhosis, EHPVO and NCPF were diagnosed on the basis of clinical, imaging and endoscopic findings. Informed consent was obtained from each patient. All patients underwent esophagogastroduodenoscopy and findings were recorded. Biopsies were obtained from gastric antrum and body for rapid urease test and histopathological examination to look for presence of H pylori.

Results. Out of 84 patients with cirrhosis (mean age 45.7 + 11.5 years), 29(34.5%) patients had evidence of peptic ulcer ( duodenal ulcer in 20, gastric ulcer in 7 and both in 2). Out of 37 patients with non-cirrhotic portal hypertension (mean age30.1 + 16.7 years), four (10.8%) patients had evidence of peptic ulcer (all duodenal ulcer). The difference in prevalence of ulcers was significant (p < 0.05). Helicobacter pylori was present in 12 out of 50 (24%) patients with non-ulcer dyspepsia (mean age 45.3 + 13.8 years), 16 out of 29 (55.1%) patients with peptic ulcer and cirrhosis and two out of four (50%) patients with peptic ulcer and non-cirrhotic portal hypertension.

Conclusion. Prevalence of peptic ulcer was significantly higher in patients with cirrhosis as compared to non-cirrhotic portal hypertension.

PP 37.02

LIVER FAILURE AFTER HEPATECTOMY: PREDICTIVE FACTORS OF MORTALITY

Vigano', Luca¹; Vellone, Maria²; Ferrero, Alessandro¹; Giuliante, Felice²; Nuzzo, Gennaro²; Capussotti, Lorenzo¹

¹Ospedale Mauriziano “Umberto I”, Surgery, Torino, Italy; ²Policlinico “A. Gemelli”, Surgery, Roma, Italy

Background. Liver failure is the first cause of death after hepatectomy. Few therapies are available with poor benefits.

Aim. To analyze predictive factors of mortality in patients with liver failure in order to define therapeutic suggestions.

Methods. Patients undergoing liver resection in Ospedale Mauriziano “Umberto I” in Turin and in Policlinico “A. Gemelli” in Rome between 1998 and 2006. Characteristics of patients with postoperative liver failure were analyzed as predictive factors of mortality.

Results. 1271 hepatectomies in 1153 patients were performed. Operative mortality was 1.7% (21). In 76.2% of cases mortality was associated with liver failure. Liver failure occurred in 57/1271 hepatectomies (4.5%), its related mortality was 28.1%. Four patients with liver failure due to vascular thrombosis were excluded from analysis. Mortality was significantively increased in patients with cirrhosis and diagnosis of HCC (54.5% vs 14.3%, p = 0.0045; 46.2% vs 15%, p = 0.020); it was decreased in case of colorectal liver metastases (0% vs 34.3%, p = 0.0044). Among postoperative data, sepsis and reoperation increased risk of mortality (46.7% vs 13.2%, p = 0.0087; 50.0% vs 14.6%, p = 0.010). Two independent risk factors of mortality were identified at multivariate analysis: cirrhosis (p = 0.0053) and sepsis (p = 0.0079). Fifteen patients with liver failure developed associated sepsis and their mortality rate was 46.7%. Comparing septic to non-septic patients, median bilirubin values were significantively higher only after sepsis onset.

Conclusions. Strict preoperative selection is mandatory in cirrhotic patients. Sepsis is often associated to liver failure and it has a key-role in its evolution toward death. Its early detection and aggressive treatment could reduce liver failure-related mortality.

PP 37.03

PREDISPOSING FACTORS AND SURGICAL OUTCOME OF COMPLICATED LIVER HYDATID CYSTS

Akcan, Alper¹; Sozuer, Erdogan¹; Akyildiz, Hizir¹; Yilmaz, Namik¹; Ozturk, Ahmet²; Yilmaz, Zeki¹

¹Erciyes University School of Medicine, Department of General Surgery, Kayseri, Turkey; ²Erciyes University School of Medicine, Departments of Biostatistics, Kayseri, Turkey

Background. The management and surgical outcome of complicated liver hydatid cysts remains controversial. The aim of this study was to evaluate the predisposing factors for peritoneal perforation and intrabiliary rupture and the effects of these complications on surgical outcome in liver hydatid disease.

Methods. A total of 372 patients with liver hydatid cysts who had undergone surgical treatment were evaluated retrospectively. Twenty eight patients with peritoneal perforation, 93 patients with spontaneous intrabiliary perforation, and 251 patients with noncomplicated hydatid cysts were treated in our clinics.

Results. Age and cyst diameter are important predisposing factors for both complications. Although complication rates were significantly different, recurrence, length of hospital stay, and mortality were not significantly different among the groups.

Conclusion. Our preferred surgical technique for liver hydatid cysts in complicated and noncomplicated patients is partial pericystectomy and drainage. In peritoneal perforated and intrabiliary ruptured cysts, the most important steps are irrigation of the peritoneal cavity with a sufficient amount of scolicidal agents, removal of all cystic contents from the peritoneum, and clearance of the cystic material from the biliary tree. Morbidity rates significantly increased in peritoneally perforated and intrabiliary ruptured cases.

PP 37.04

OPERATIVE APPROACH TO EXTENSIVE LIVER TRAUMA

Djukic, vladimir; Stepic, D.; Bumbasirevic, V.; Vujovic, S.; Jovanovic, B; Loncar, Z.; Popovic, N.; Karamarkovic, A.

KCS Belgrade, HPB and Emergency Surgery, Belgrade, Serbia and Montenegro

Background. Surgical strategy in the treatment of blunt and penetrating liver trauma has been dramatically redesigned since CT scan was applied in l981 tovards non operative. Extensive liver trauma grade IV and V with challenging juxtahepatic injuries are still matter of dramatic surgery with high comlication and mortality rate up to 65% Even liver transplant should be consider as an option of extreme surgery.

Material and Methods. 26 patients were operated in Emergency Centre Clinical Centre of Serbia Belgrade in a period ranging 01.01.2002–31.12.2006 Grade IV 18 patients and grade V remaining 8.Various surgical procedures and vascular isolation techniques were applied in order to achieve better results 1 atriocaval shunt completed with frormal right hepatectomy, 3 TVE total vascular exclusion/2 right hepatectomies and 1 patient right hepatectimy and suttures of left liver/, 4 left sectorectomies S 2,3, 6 patients wirh infrahepatic IVC repair,2 patients with caval repair and liver resection of 3 segments and more and nephrectomy, 3 patients with common bile duct and portal vein reconstruction, 6 atypical mayor liver resection/more than four segments/and 1 patient treated with perihepatic liver packing and modified Damage control surgey. Owerall mortality was 57% DISCUSSION High mortality rate and fatal triade as hypothermia, coagulopathy and acidosis due to severe haemorrhage in multiple injuried patients with bad prognostic ISS, TRISS, APACHE II an GLasgow Comma scale is reported in many Pub Med citated series from USA Canada and Europe. Unfortunatelly there is no magic alternative to demanding surgery with poor results in liver trauma grade IV and V Damage control surgery since Rotondo 1993 might be good initial option for bleeding problem but liver cell injury is still fatal

PP 37.05

LIVER TRAUMA

Frena, Antonio; Marinello, Peter; Ciola, Michele; Imperiale, Sandro; Ferrara, Roberto; Polato, Romano; Schellner, Michael Gerd; La Guardia, Giuseppe; Martin, Federico

Central Hospital of Bolzano, General Surgery, Bolzano, Italy

Background. liver injuries are the most frequent cause of death in the field of abdominal traumas. The increase in road accidents and sports injuries makes discussion of the treatment modalities increasingly relevant in this area.

Aim. In recent years we have witnessed an evolution in the therapeutic management of such injuries with the increasingly frequent use of non-operative procedures for the management of non-complex l esions.

Methods. a retrospective study was conducted in 111 cases of liver injuries observed in our department over a 20-year period (1985–2005). The mean age of the patients was 31 years. The most frequent causes were road accidents (48%), followed by sports injuries (23%) and occupational accidents (11%).

Results. 82 patients (74%) were treated surgically and 29 conservatively. In 58 cases (35 of which treated surgically), the liver injury was isolated, while in the other 53 cases lesions were also present in other abdominal organs. The liver injuries, classified according to the AAST, were grade I in 47 cases, grade II in 30 cases, grade III in 19 cases, grade IV in 5 cases, and grade V in 10 cases. Thirty-five percent of grade I-II lesions were treated conservatively, while 94% of grade III-IV-V lesions received surgical treatment. The overall operative mortality was 12.5%.

Conclusions. the evolution of the management of liver injuries has witnessed an increase in conservative treatment, particularly for grade I and II lesions. There is no alternative to surgical treatment when the injury involves the major hepatic vessels or substantial amounts of parenchyma. The mortality rate is high compared to that of elective liver surgery, but this is due to the frequent associated lesions in other organs and apparatuses.

PP 37.06

SPONTANEOUS CUTANEOUS FISTULA OF A LIVER HYDATID CYST: A RARE COMPLICATION OF HYDATID DISEASE

Martin-Perez, Elena; Gómez, Joaquín; Rubio, Inés; Rodríguez, Ana; Larrañaga, Eduardo

La Princesa Hospital, Dpt. of Hepatobiliopancreatic Surgery, Madrid, Spain

Background. Common sites of rupture of hepatic hydatid cyst are into the bile duct, bronchi, peritoneal and pleural cavity, and the gastrointestinal tract. However, rupture into the subcutaneous space is extremely rare.

Objectives. We report an unusual case of spontaneous cutaneous fistula into the abdominal wall of a hepatic hydatid cyst.

Case Report. An 87-year-old man presented to the emergency department with a slowly growing painless mass in his right hypochondrium for the past four years, without history of fever or jaundice. On physical examination, a well-defined and irreducible mass over the right flank was observed. A computed tomography (CT) scan revealed an 18×7 cm hypodense, well-defined cystic mass located in segment VIII of the liver causing compression of the left lobe to the midline. The lesion was seen to communicate with another cystic mass in the subcutaneous tissue through intercostal muscles. The patient refused to undergo surgery, and oral albendazole treatment was suggested as medical therapy. Ten months later he noticed a swelling in the abdominal wall over the right hypochondrium and a fistula draining a yellowish gelatinous material and whitish wrinkled cystic elements. At operation, the subcutaneous cystic lesion was totally resected and the liver cyst was treated by partial cystectomy. The residual cystic cavity was cleared of its contents, irrigated with diluted povidone iodine solution, and drained by a closed suction system. The postoperative course was uneventful. Follow-up abdominal CT scans showed no evidence of relapse.

Conclusion. Spontaneous cutaneous fistulization complicating liver hydatid disease is an extremely rare complication and is sparsely described in the literature. CT scan, in addition to clinical presentation, is essential for diagnosis. Surgery is usually required to achieve complete evacuation of the cyst contents. This pathology should be included in the differential diagnosis of an abdominal mass in endemic areas.

PP 37.07

HEPATIC TUBERCULOMA: A RARE MASS LESION OF LIVER

Pandey, Anshuman; Singh, Rajneesh K; Kapoor, Vinay K

Sanjay Gandhi Post Graduate Institute Of Medical Sciences, Surgical Gastroenterology, Lucknow, India

Background. Hepatic tuberculosis usually presents as miliary tuberculosis or granulomatous hepatitis. Hepatic tuberculoma presenting as a mass lesion is rare. We present a case of hepatic tuberculoma and the problems of diagnosis and management. Methods A middle aged female patient presented with low grade fever for 6 years. CT scan of the liver (picture for poster) showed a heterogeneously enhancing mass lesion of the left lobe of liver. The serum tumour markers (AFP, CEA, CA19-9) were within normal limits and preoperative FNAC was inconclusive. The routine LFT, chest X-ray and esophago-gastroscopy did not show any abnormality. At laparotomy there was a hard mass lesion in the left lobe of the liver with soft fleshy lymph nodes in the hepatoduodenal ligament. Frozen section of the nodes revealed granulomatous inflammation. The left lobe of the liver was resected along with the mass lesion (picture for poster). Histopathology showed multiple large epitheloid cell granulomas and was diagnostic of a tuberculoma of the liver.

Results. The patients did well after the surgery and the fever resolved. Thereafter she was given a 9 month course of 4 drug anti-tubercular therapy.

Discussion. Hepatic tuberculosis may present as one of three forms – (most common) diffuse miliary tuberculosis, diffuse hepatic infiltration (granulomatous hepatitis) or (the rarest) hepatic tuberculoma or abscess. Fever, weight loss and hepatomegaly are the common presenting symptoms. A raised ESR and mild derangement of LFT may be seen. CECT shows large discerete hypodense lesions with no pathognomonic features. MRI is of no added benefit. The final diagnosis rests on the histopathological evidence of caseating granulomas or demonstration of acid fast bacilli (AFB) on smear or culture of the specimen. The cornerstone of management is standard antitubercular drug treatment.

PP 37.08

RADIOFREQUENCY THERMAL ABLATION OF LIVER CARCINOMA. PROSPECTIVE STUDY OF 82 LESIONS.

Lermite, Emilie¹; MUCCI, Stéphanie²; TEYSSEDOU, Carlos²; BRACHET, Dorothée²; HAMY, Antoine²; AUBE, Christophe³; ARNAUD, Jean-Pierre²

¹Chirurgie viscérale. CHU, Angers, France; ²CHU, chirurgie viscérale, Angers, France; ³CHU, Radiologie, Angers, France

Objectives: The aim of this prospective study was to evaluate the feasibility of radiofrequency ablation of hepatic tumors. We studied the rates of mortality, morbidity, and recurrence and recorded overall and disease-free survival.

Methods. All patients aged over 18 years with histologically proven malignant liver disease inaccessible to surgical treatment (one to four tumor localizations) were eligible for inclusion in the study. Child-Pugh score > B9, platelets count 3 cm was correlated significantly with recurrence (P = 0.03). Actuarial 1-, 2- and 3-year survival rates in the hepatocarcinoma group (N = 31) were 84.7%, 57.7% and 34.6% respectively. Actuarial 1-, 2- and 3-year survival rates in the metastasis from colorectal adenocarcinoma group (N = 14) were 90%, 54% and 54% respectively (P = 0.72).

Conclusion. Radiofrequency thermal ablation is an effective treatment for hepatic tumors measuring less than 3 cm. There is a low risk of complications and open surgery can be associated. However in the absence of randomized studies comparing radiofrequency and surgery, respective indications cannot be defined in detail.

PP 37.09

BILE LEAKAGE AND ABDOMINAL BLEEDING AFTER HEPATIC RESECTION WITH BILIARY RECONSTRUCTION

Ferrero, Alessandro; Russolillo, Nadia; Vigano', Luca; Sgotto, Enrico; Lo Tesoriere, Roberto; Ribero, Dario; Amisano, Marco; Capussotti, Lorenzo

Ospedale Mauriziano- Umberto I, Department of Surgery, Torino, Italy

Background. Risks of conservative management of bile leakage after hepatectomy with cholangio-jejunostomy are not well defined.Aim. To evaluate the outcome of conservative treatment of bile leakage after liver resection with biliary reconstruction.

Patients and Methods. Prospectively collected clinical data of 1034 consecutive patients who underwent liver resection were reviewed. Bile leakage occurred in 25 out of 119 patients (21.0%) who underwent hepatectomy with biliary reconstruction (Group 1) and in 42 out of 915 patients (4.6%) without biliary anastomosis (Group 2) (p < 0.001). Serum albumin and bilirubin levels were the only factors significantly different between the two groups.

Results. Mortality rates were similar in the two groups (4% vs 2.3%). One or more postoperative complications occurred in 68% in Group 1 and in 40.4% in Group 2 (p 0.029). The incidence of sepsis (32% vs 7.1%, p 0.01), intra abdominal abscess (12% vs 0, p 0.04) and abdominal bleeding (28% vs 0, p 0.006) was significantly higher in Group1. Bile leak spontaneously healed in 52% of patients in Group 1 vs 76.2% in Group 2 (p 0.04). In order to identify independent predictive factors for abdominal bleeding we compared clinical data of patients with (7 patients) and without (18 patients) abdominal bleeding after hepatectomy and biliary reconstruction. The following variables were considered for multivariate analysis: arterial hypertension, cholangiojejunostomy on 3 ducts, left hepatectomy ±Sg1, intraoperative blood loss >300 mL and duration of postoperative bile leakage >10 days. Stepwise logistic regression a nalysis identified cholangiojejunostomy on 3 ducts as independent predictive factor of abdominal bleeding (p 0.02).

Conclusions. Conservative management of bile leakage after liver resection with biliary reconstruction is associated with higher rates of morbidity. The most severe complication is abdominal bleeding, which occurs more frequently after reconstruction of three ducts.

PP 37.10

PERI-OPERATIVE INDOCYANINE GREEN CLEARANCE IN LIVER RESECTION PATIENTS

Low, Jee¹; Mackillop, Andrew²; Clark, Debbie¹; Vadeyar, Hemant¹; Sherlock, David¹

¹North Manchester General Hospital, Surgery, Manchester, United Kingdom; ²North Manchester General Hospital, Anaesthesia, Manchester, United Kingdom

Introduction. Elimination of indocyanine green (ICG) from blood can be used to determine peri-operative hepatic function.

Aim. This technique was used to monitor the hepatic function of patients undergoing any form of liver resection.

Method. Sixteen patients scheduled for hepatic resection were studied. We used transcutaneous pulse densitometry for the assessment of liver function by measuring ICG plasma clearance (Limon ®). After an intravenous injection of 0.25mg/kg of ICG, we observed plasma disappearance rate (PDR) and retention rate extrapolated to 15 minutes (R15).

Results. Sixteen patients were studied, nine male and five female. The mean PDR before operation of all sixteen patients was 26.7%/min (19.3–40.2), on the first post-operative day 23.8%/min (7.9–40.1), one week later 23.4%/min (4.5–31.4) and beyond six weeks 21.0%/min (9.0–30.3) respectively. Of the six patients who underwent right hepatectomy, they had mean PDR of 29.8%/min, 13.9%/min, 17.3%/min and 18.9%/min respectively. The seven patients who underwent segmentectomy, had a mean PDR of 26.6%/min, 31.5%/min, 28.0%/min and 25.0%/min respectively. Three patients who had re-do hepatectomy had a mean PDR of 20.7 C, 25.4%/min, 24.8%/min and 19.9%/min respectively.

Conclusion. Measuring ICG clearance using Limon is practical, easy to use and a useful way of estimating hepatic dysfunction after surgery. There were clear differences in PDR between those patients who had right hepatectomy and those with segmentectomy

PP 38.01

THE EXPRESSION OF P15 AND P16 PROTEINS IN GALLBLADDER CANCER AND ITS CLINICAL SIGNIFICANCE

Sui, Chen-guang¹; Han, Yue²; Ren, Hong²; Ma, Qing-yong²; Shi, Jing-sen²

¹First Hospital of Xi¡^—an Jiao Tong University£¬Xi¡^—an 710061£¬China, Department of Oncology, Xi An; ²

Introduction. The gallbladder cancer is the most common malignant tumor in biliary tract system and its incidence takes the fifth or sixth position in all alimentary tract tumors in China. Gallbladder cancer is confirmed uneasily and with a poor prognosis. OBJECTIVE£°To evaluate the role of p15 and p16 in the occurrence and progression of gallbladder cancer and to make a understanding of their relationship and clinical significance.

Methods. Immunohistochemical techniques was applied on 30 cases of gallbladder cancer and 10 cases of cholecystolithiasis in order to detect the expression of p15 and p16 proteins.

Results. The expression of p15, p16 was correlated with clinical pathological stage, matastsis and prognosis in gallbladder cancer (P < 0.05). The p15 expression was positive correlation to p16 expression in gallbladder cancer (P < 0.05).

Conclusion. The reduced expression of p15 and p16 may participate in the occurrence and progression of the gallbladder cancer. Examination of expression of these two proteins may be helpful to judge biological behavior and prognosis of gallbladder cancer.

PP 38.02

INAPPARENT CARCINOMA GALLBLADDER: INAPPARENT OR INAPPROPRIATELY MANAGED?

Singhal, Dinesh; Chaudhary, Adarsh

Sir Ganga Ram Hospital, Surgical Gastroenterology, New Delhi, India

Background. Early gallbladder cancer (GBC) is difficult to differentiate from chronic cholecystitis on preoperative imaging and is often diagnosed at histopathology examination of the cholecystectomy specimen (‘inapparent GBC’). Our experience in the management of these patients indicated that all lesions might not have been truly inapparent. Hence we systematically investigated inapparent GBC patients for probable errors in the management and the lessons learnt.

Method. From 2003 –2007, 21 patients [13 females and 8 males, median age of 50 years (range 30 – 67 years)] referred to us for further management of ‘inapparent GBC’ were retrospectively analyzed for demography, presentation, preoperative imaging and surgical management. These characteristics were compared with those of 51 other patients managed by us as GBC during the same duration.

Results. Inapparent GBC patients were significantly younger than those with gallbladder mass lesions managed as GBC (50 versus 58 years, P = 0.017). Three patterns of management errors were identified: 1. Planning of laparoscopic cholecystectomy (LC) despite imaging suggestive of GBC (8 patients) 2. Persistence with LC in this group leading to bile leak in 5 patients and bleeding in 1 patient 3. Inappropriate postoperative management delaying definitive surgery (3 patients).

Conclusions. Mass lesions of gallbladder are more likely to be misinterpreted as benign in younger patients. Errors in the management of such patients are often avoidable.

PP 38.03

PRIMARY ADENOCARCINOMA OF GALLBLADDER WITH SOLITARY INTRAABDOMINAL METASTASIS FROM COLONIC ADENOCARCINOMA

Jacobs, Michael¹; Kansakar, Erina²; Chang, Jennifer²

¹Providence Hospital-St John Health System, Surgery, Southfield, United States; ²Providence Hospital, Surgery, Southfield, United States

Background. Carcinoma of the colon is one of the most common malignancies in the Western world; however, isolated peritoneal recurrence is rare. Primary gallbladder adenocarcinoma is also rare. OBJECTIVE The occurrence of primary adenocarcinoma of the gallbladder with a solitary intraabdominal metastasis from the colon is unusual and forms the basis of this report.

Methods and Results. A 90-year old man presented with jaundice and bloody stools five-years after surgery for colon cancer. The physical exam demonstrated jaundice with a microcytic anemia on complete blood count. The CEA and CA 19-9 were abnormal. A CT scan of the abdomen showed a right-sided mass anterior to Gerota's fascia free from adjacent organs and a mass in the neck of the gallbladder adjacent to the common bile duct. Colonoscopy revealed an intact ileocolonic anastomosis and no additional lesions. An ERCP showed a non-lithogenic filling defect at the junction of the CBD and cystic duct. Intraoperatively, the peritoneal mass was identified in Morrison's Pouch and was not attached to adjacent organs. A tumor was also seen in the infundibulum/cystic duct of the gallbladder with hemobilia. Intraoperative frozen section showed tumor free margins in the resected CBD. The patent underwent resection of the mass and common duct, cholecystectomy, and hepaticoduodenostomy. The histopathology was invasive poorly-differentiated adenocarcinoma of gallbladder (R0) and metastatic peritoneal moderately-differentiated adenocarcinoma of colonic origin. The patient did well postoperatively and was discharged after seven days.

Conclusion. Primary gallbladder cancer and isolated metastatic colorectal carcinoma is a unique rarity. Surgery offers both cure and palliation of jaundice and should be considered even at the extremes of age.

PP 38.04

STAGING LAPAROSCOPY PLAYS A DEFINITE ROLE IN THE PREOPERATIVE STAGING OF PATIENTS WITH RESECTABLE PROXIMAL BILIARY DUCT CANCERS

Hariharan, Deepak¹; Bhattacharya, Satyajit²; Abraham, Ajit²; Kocher, Hemant²

¹Barts & the London School of Medicine & Dentistry, Institute of Cancer, London, United Kingdom; ²The Royal London Hospital, Barts and the London HPB Centre, London, United Kingdom

Background. There exists a high incidence of occult metastases in patients diagnosed with proximal bile duct malignancies (gall bladder carcinoma, intra-hepatic carcinomas and hilar cholangiocarcinomas) despite extensive preoperative staging.

Aim. To determine the role of staging laparoscopy (SL) in association with laparoscopic ultrasound (LUS) in the management of patients with proximal biliary malignancies.

Methods. Studies using contemporary staging techniques and assessing the effect of SL/LUS in patients with potentially resectable proximal biliary malignancies with respect to alteration in surgical management were included. Surgical evaluation was considered the gold standard for staging and laparoscopy only, when obvious metastatic lesions were detected which precluded surgical exploration. Overall test characteristics and yield of SL/LUS in preventing unnecessary laparotomy was calculated.

Results. A total of 5 studies satisf ied our inclusion criteria and 420 patients were assessed laparoscopically. In 7 patients the laparoscopic assessment was incomplete due to adhesions. Additional metastatic disease precluding curative resection was identified in 170 patients. The sensitivity of SL/LUS for diagnosing unresectability was 57.2%, specificity 100%, positive predictive value of 100%, and negative predictive value of 49.2%. The true yield of SL/LUS in identifying inoperable disease was determined to be 41.1%.

Conclusion. Staging laparoscopy is a useful tool in predicting unresectability in patients with proximal bile duct malignancies, especially gall bladder carcinomas.

PP 38.05

NEUROENDOCRINE TUMOUR OF THE GALLBLADDER MIMICKING ADENOCARCINOMA

Shah, Sudeep¹; Deshpande, Ramesh²

¹PD Hinduja Hospital and MRC, GI Surgery, Mumbai, India; ²PD Hinduja Hospital and MRC, Pathology, Mumbai, India

Background. Carcinoma gallbladder is common in India and has a poor prognosis if there is extensive liver infiltration. Carcinoid tumour of the gallbladder is extremely unusual and presents in a similar fashion. As the prognosis is much better, this condition should not be overlooked.

Case Report. A 67 year old gentleman was incidentally detected to have a gallbladder mass on sonography, performed to evaluate prostatic symptoms. On subsequent CT, an 11×8×7 cm mass was seen engulfing the gallbladder, extensively infiltrating segments IVB, V and VI of the liver. There was no vascular or nodal involvement. CT chest and bone scan were negative. CA 19-9 was normal. The patient underwent resection of segment IVB, V and VI with the gallbladder and regional nodal clearance. Histopathology revealed neuroendocrine tumour. Nodes and margin was negative. The patient is asymptomatic 4 months after surgery

Discussion. Neuroendocrine tumours of the gallbladder are very rare and may mimic adenocarcinoma. Surgery should be offered for these as the prognosis is excellent.

PP 38.06

RESECTABILITY AND SURVIVAL IN CARCINOMA GALL BLADDER-OUR EXPERIENCE

KAPOOR, SANJAY¹; N, Kannan²; Gupta, Samir³

¹ARMY HOSPITAL, SURGICAL ONCOLOGY, (RESEARCH & REFERRAL), DELHI, India; ²Command Hospital(WC), Surgical Oncology, Chandigarh, India; ³Army Hospital (Research and Referal), Surgical Oncology, Delhi, India

Background. Cancer of the Gallbladder is very common in North India along the Ganges planes and majority of the cases present in advanced stage with obstructive jaundice and are inoperable. AIMS To study the impact of neoadjuvant chemotherapy in improving the possibility of resectability and the impact of neoadjuvant chemotherapy on improving survival.

Methods. All patients diagnosed as Carcinoma gallbladder were investigated for staging and to asses operability. Non metastatic cases were included in the study. Patients found operable were undertaken for Radical Cholecystectomy. Patients detected to have Cancer gall bladder after cholecystectomy for benign causes underwent completion radical cholecystectomy, after staging. Patients who were jaundiced but operable, were operated after biliary stenting Patients found to be inoperable were offered neoadjuvant chemotherapy. Those who had jaundice were stented before starting chemotherapy. These patients were evaluated after three cycles of chemotherapy and if found fit for surgery, they underwent radical cholecystectomy. If the desease was still unresectable, patients were given three more cycles of chemo therapy and then evaluated for operability, and those who responded underwent surgery at this stage. Chemotherapy was terminated if there was disease progression during chemotherapy. Patients who underwent surgery primarily or after three cycles of neoadjuvant chemotherapy were given adjuvant chemotherapy. More chemotherapy was given to patients who were found to have residual disease on surgery after six cycles of chemotherapy.

Results 124 patients were included in the study. Neoadjuvant Chemotherapy increased the number of resectabilty. Nodal metastasis was found in one case, who underwent completion radical cholecystectomy. Residual disease was found in all cases after three cycles, and in few cases after six cycles of chemotherapy.

Conclusion. Aggressive surgery with Neoadjuvant and Adjuvant chemotherapy can change the dismissal scenario of gall bladder cancer

PP 38.07

CLINICOPATHOLOGICAL STUDY ACCORDING TO DEPTH OF SUBSEROSAL INVASION IN PATIENTS WITH PT2 GALLBLADDER CARCINOMA

Yuko, Mataki; Hiroyuki, shinchi; Noma, Hidetoshi; Maemura, Kousei; Kurahara, Hiroshi; Maeda, Shinichi; Ueno, Shinichi; Sakoda, Masahiko; Kubo, Fumitake; Takao, Sonshin; Aikou, Takashi

Kagoshima University, Surgical Oncology, Kagoshima, Japan

Background. We examined whether depth of subserosal cancer invasion survival in gallbladder carcinoma (GBC) patients with pathological subserosal invasion (pT2).

Methods. Between 1987 and 2007, a total of 49 patients with GBC underwent a curative surgery at our department in Kagoshima University. Of these, subjects comprised 28 patients with pT2 GBC. We divided subserosal invasion into two categories corresponding to invasion of the shallower layer, ss1(n = 15) and deeper layer, ss2(n = 13). Relationships between subserosal classification, histopathological factors, and prognosis were examined.

Results. Positive rates of histopathologic findings, such as lymph node metastasis, lymphatic invasion, venous invasion, perineural invasion, hepatic invasion, and biliary infiltration, in ss1 GBC were lower than those in ss2 GBC(p = 0.26, p < 0.001, p = 0.006, p = 0.055, p = 0.06, p = 0.11, respectively). Overall five-year survival rate in pT2 GBC was 63.8%. The five-year survival of patients with ss1 GBC was significantly better than those with ss2 GBC(p = 0.033). Various hepatectomy for ss GBC was selected, such as cholecystectomy (n = 7), resection of hepatic bed (n = 14), S4a + S5 resection (n = 5), extended right lobectomy (n = 2). There was no significant difference in five-year survival among 4 types of hepatic resection. Only cholecystectomy provides five-year survival for 2 cases with ss1 GBC. Meanwhile, hepatectomy greater than gallbladder bed resection provides five-year survival for 4 cases with ss2 GBC. Recurrence of hepatic metastasis occurred in 6 cases. In two cases among them, S4a, S5 hepatic metastases occurred in half-year after first resection, and by additional resection of hepatic metastases they could get five-year survival.

Conclusions. In compliance with the extent of depth of subserosal invasion in ss GBC, hepatectomy should be selected.

PP 38.08

A RETROSPECTIVE ANALYSIS OF GALLBLADDER CANCER WITH SUBSEROUS INVASION (PT2) TREATED WITH SURGICAL RESECTION

Katagiri, Hiroyuki¹; Yoshida, Muneki²; Ishii, Kenichiro¹; Itabashi, Kouichi¹; Takahashi, Yoshihito¹; Furuta, Kazunori¹; Watanabe, Masahiko¹

¹Kitasato university, School of Medicine, Department of Surgery, Sagamihara, Japan; ²Sagamino Hospital, Department of Surgery, Sagamihara, Japan

Background. An appropriate procedure improves the outcome of long-term survival of patients of gallbladder cancer with subserous invasion (pT2). We had conducted the liver lobectomy, the central inferior (S4a + S5) hepatic subsegmentectomy, the gallbladder bed resection and the simple cholecystectomy in various cases of the pT2 cancer. Also such fundamental procedure has been done with regional lymphadenectomy, with or without extra hepatic bile duct resection. The prognosis of pT2 patients and the appearance of the recurrence were different among the procedure.

Aim. This study investigated which was most suitable procedure for pT2 cancer.

Methods. 34 patients with pT2 cancer who underwent the surgical treatment were reviewed. Prognostic factors of patients were evaluated by single or multivariate analysis.

Results. 14 patients had been underwent the radical operation (HPD). Seven patients, who had either pN0 disease and no infiltration of the cancer cells into the hepatoduodenal ligament, survived longer than 5 years. However the mean survival time (MST) of the other seven patients, who had carcinomatous invasion in the hepatoduodenal ligament, was only 7 months. Also patients with paraaortic lymphnodes metastasis, have not been survived beyond 12 months. In all cases of pT2 patients, that a tumor presented in the gallbladder neck (and/or extend to the cystic duct), the carcinomatous invasion in hepatoduodenal ligament were confirmed. Adjacent hepatic recurrence was most frequent mode in the case of the patients who underwent the simple cholecystectomy.

Conclusion. A radical surgery may not achieve a good outcome for all, and must be carefully considered to avoid surgical risk. Our results suggest that the gallbladder bed resection, combined with regional lymphadenectomy, is the most appropriate, and that the extra bile duct resection is reasonable for the tumor located on the gall-neck (and/or extend to cystic duct).

PP 38.09

GEMCITABINE BASED CHEMOTHERAPY IN GALLBLADDER CANCER

Kim, Hyungchul

Soonchunhyang University College of Medicine, Surgery, Bucheon, Korea, Republic of

Background. Gallbladder cancer is the most common malignancy of the biliary tract and the fifth most common gastrointestinal cancer. Unfortunately, patients with gallbladder cancer have advanced, unresectable tumor at the time of presentation and face a dismal prognosis in the absence of a standard chemotherapy regimen. This study was performed to evaluate the outcome of patients with gallbladder cancer who received postoperative chemotherapy. Methods and Materials: From 2001 through 2007, 23 patients with gallbladder cancer underwent surgical treatment in our institution. Most of patients were treated with a 3-week cycle gemcitabine (1000mg/m2) and 5-fluorouracil (200mg/m2) on day 1, 8, 15, 22, 29, 36, and 43. 4 patients with advanced gallbladder cancer (T3, T4) were treated with a 3-week cycle gemcitabine (1000mg/m2) on day 1, 8 and 5-fluorouracil (200mg/m2) on day 1.

Results. There were 1, 3, 13, 4, and 2 patients with T1a, T1b, T2, T3, and T4 disease, respectively. Radical cholecystectomy was the standard treatment of the respectable gallbladder cancer except T1a disease. The mean survival for the entire group was 36 months, and the overall 5-year survival rate was 62.5%, respectively. Results of survival analysis for patients who received chemotherapy for gallbladder cancer were 84.6% at 5 years postoperatively (p = 0.042).

Conclusions. Patients with completely resected (negative margins) gallbladder followed by adjuvant gemcitabine based chemotherapy had a relatively favorable prognosis, with a 5-year survival rate of 84.6%. This regimen warrants further evaluation in a phase II study including larger numbers of patients.

PP 38.10

DELAY IN GASTRIC EMPTYING IN CARCINOMA GALLBLADDER-A SCINTIGRAPHIC STUDY

pitchai, rajapandi; Yadav, THAKUR D; Wig, Jai D; Kudari, ashwinikumar; doley, rudra p; Gupta, rajesh; srinivasan, thiagarajan

PGIMER, Chandigarh, India, General Surgery, chandigarh, India

Background. AND AIM: Gastrtoparesis is characterized by delayed gastric emptying in the absence of mechanical gastric outlet obstruction. There is a strong association of gastroparesis with carcinoma gall bladder. About one third of patients with carcinoma gallbladder present with symptoms and signs suggestive of gastric stasis. The aim of this study is to find the incidence of delayed gastric emptying in carcinoma gallbladder without mechanical gastric outlet obstruction and its correlation with symptoms, stage of the disease.

Methods. Thirty patients diagnosed with carcinoma gallbladder and 20 normal controls were enrolled in this study. Patients with mechanical gastric outflow obstruction were excluded from the study. All patients underwent CECT abdomen & radiolabelled solid meal gastric emptying scintigraphy study. The upper limit of normal gastric emptying time was defined from the control group as mean + 2 SD. This value was applied to the study group to find out the delayed emptying in patients.

Results. Age and sex were comparable between the two groups. Upper limit of normal gastric emptying time is 55.09 (40.53 + 14.56) minutes. In our study, 5 (15.6%) patients of carcinoma gallbladder had symptoms suggestive of gastric stasis and 16 (53.3%) patients had delayed gastric emptying. The range is 23–127 (mean 66.72) minutes. Among the later 16 patients, only 2 (12.5%) patients had symptoms of gastric stasis. Other factors like age, sex, symptoms, duration of symptoms, associated gallstones, serum bilirubin and stage of the disease were also studied but these factors were found to have no affect on gastric emptying.

Conclusion. Significant percentage of patients with carcinoma gallbladder have delayed gastric emptying sub clinically. This delay does not correlate with symptoms and stage of the disease and not affected by associated gallstones or lymph nodal status.

PP 38.11

INCIDENTAL CARCINOMA OF THE GALL BLADDER- TO RE-OPERATE OR TO LEAVE ALONE?

IRPATGIRE, RAVINDRA¹; KANTHARIA, CHETAN²; PRABHU, RAMKRISHNA²; BAPAT, RAVINDRA²; SUPE, AVINASH²

¹KEM HOSPITAL & SETH GS MEDICAL COLLEGE, SURGICAL GASTROENTEROLOGY, PAREL, MUMBAI, India; ²KEM HOSPITAL & SETH GS MEDICAL COLLEGE, SURGICAL GASTROENTEROLOGY, MUMBAI, India

Department of Surgical Gastroenterology, Seth GS Medical College & KEMH, Parel

Background. Though the management of Ca GB is well established, ideal management of Incidental Ca GB still remains to be protocolised. The present study is to determine the whether patients with Incidental Ca GB need to be re-operated.

Methods. 48 cases of Ca GB were identified from our database, in last three years (2003–2006). 11 of these (8 females, age range; 29–80 years, median -54 years.) had Incidental Ca GB. All the 11 patients had undergone laparoscopic cholecystectomy. Following HP diagnosis of Ca GB, the patients were subjected to CECT Scan for staging. Two patients with liver infiltration and five with Lymphadenopathy without liver infiltration were detected. They were subjected to surgery. The median time from cholecystectomy to re-resection was 18 days. At the time of re-resection, wedge resection with LN clearance (three), tri-segmentectomy (two) and peridochal lymp node clearance (two) was performed. 4 were left alone and kept under surveillance. Pathology of the re-resection specimen noted residual disease in all 7. Specifically, carcinoma was found in the liver bed (4), lymph nodes (3). All the patients were monitored by doing USG and CT scan. The F/U ranged from 6 to 33 months. QOL (based on SF-36 criteria) and survival was assessed Results:

	Median Survival in months	QOL
Wedge resection with LN clearance (3)	30 (18–30)	8 (7–8)
segmental resection (2)	20 (14–26)	7 (6–8)
Peridochal LN exicision(2)	27 (24–30)	7 (6–8)
Left alone	12 (11–14)	5.5 (5–6)

Conclusions. Re-resection for incidental gallbladder carcinoma is warranted as the majority of patients have residual disease. They have acceptable mortality and offers better QOL.

PP 39.01

ROLE OF SPECT-CT ”FUSION IMAGING” IN NEUROENDOCRINE TUMOURS

Kumari, Saumya¹; Krishna, B. A.²; Ghule, Shwetal²

¹P. D. Hinduja National Hospital, Nuclear Medicine, and Medical Research Centre, Mumbai, India; ²P. D. Hinduja National Hospital, Nuclear Medicine, Mumbai, India

Background. The fusion imaging (CT and nuclear imaging) has enhanced the sensitivity of nuclear imaging in oncology practice. In the context of neuroendocrine tumours, the wholebody octreotide imaging is conventionally used pre and post operatively. However, lack of anatomical details reduced the clinical impact. The recently introduced fusion imaging technique – CT-SPECT- has enhanced its role in the treatment decision making process.

Aim. To demonstrate the improved localization and higher sensitivity of the SPECT-CT fusion imaging over planar or SPECT imaging alone in patients of neuroendocrine tumours.

Methods. Totally 13 patients with pathologically proven diagnosis of neuroendocrine tumours were included in this study. All patients were subjected to 111 Indium Octreotide imaging. Both whole body planar and CT-SPECT images were acquired.

Results. In 10/13 patients, the SPECT demonstrated additional lesions over the planar images and SPECT-CT further enhanced the spatial localization in 8 out of these 10 patients.

Conclusion. SPECT-CT fusion imaging using 111 Indium Octreotide is a sensitive and specific modality for the diagnosis and localization of the disease, thereby guiding the optimal management of these patients. The SPECT imaging diagnosed additional lesions in 77% of the patients and the SPECT-CT fusion imaging further enhanced the localization in 80% of these patients.

PP 39.02

IMPACT OF PREOPERATIVE POSITRON EMISSION TOMOGRAPHY ON PATIENT SURVIVAL IN COLORECTAL LIVER METASTASIS-10 YEAR CAMBRIDGE EXPERIENCE

Sadat, Umar; Jah, Asif; Kan, Yuk-Man; Paulvannan, Subramanian; Gibbs, Paul; Praseedom, Raaj K; Jamieson, Neville V; Huguet, Emmanuel L

Addenbrooke's Hospital, Hepatobiliary and Transplant Surgery, Cambridge, United Kingdom

Introduction. Postoperative survival after liver resection for colorectal liver metastases depends on good patient selection. PET scan is a useful radiological tool which increases the accuracy of preoperative disease staging.

Aim. To assess the impact of preoperative PET imaging on the survival of patients with colorectal liver metastasis.

Methods. All patients undergoing liver resection for colorectal liver metastases since 1997 were included, and divided into three groups: group 1, patients who had liver resection after PET scan, group 2 who had resection without PET and group 3 who were deemed inoperable on PET findings. Kaplan-Meier survival estimates and Log rank/Wilcoxin tests were used to quantify the median survival time, hazard ratio and equivalence of death rates respectively. The correlation between number of lesions on PET, CT scan and histology in operated cases was determined by Spearman's rank correlation.

Results. In the ten year period, 157 patients underwent liver resections for colorectal liver metastases (mean age: 61.5 yrs±7.3), males being predominant (36% females). 149 patients were included for analysis (8 records missing, 86 patients in group 1, 63 in group 2, and 30 patients in group 3). The median survival for the three groups was 2651 vs. 1338 (95%CI = 895–1729) vs. 679 days (95%CI = 676–1916) respectively (hazard ratio (95% CI):1.69 (0.85 -3.36) group1 vs. group 2, 0.44 (0.12–1.63) group 1 vs. group 3 and 0.26 (0.07–0.88) group 2 vs. group 3, equivalence of death rates:15.22, P = 0.0005). There was good correlation between findings on PET, CT and histology in the extent of intrahepatic disease (liver histology vs. liver CT: 0.55, liver histology vs. liver PET: 0.46, liver PET vs. liver CT: 0.58, P < 0.0001), but PET was more sensitive in the detection of extrahepatic disease.

Conclusions. As a result of detection of occult extrahepatic disease, preoperative PET scanning is associated with significantly improved patient survival, and thereby allows futile liver resections to be avoided.

PP 39.03

THE CLINICAL ROLE OF 18F-FDG PET-CT FOR PRIMARY EXTRAHEPATIC BILE DUCT CANCER

Jeong, Seok¹; Lee, Don Haeng¹; Kang, Hyo Seung²; Lee, Chung Hwon³

¹Inha University College of Medicine, Incheon, Korea, Republic of; ²Incheon Christian Hospital, Internal Medicine, Incheon, Korea, Republic of; ³Dongsuwon General Hospital, Internal Medicine, Suwon, Korea, Republic of

Background. In the primary extrahepatic bile duct (EHD) cancer, preoperative evaluation is important because only surgical excision is associated with improvement in 5-year survival. However, morphological imaging techniques, including CT, are still insufficient for accurate diagnosis and staging. We evaluate the sensitivity and specificity of PET-CT using 18F-FDG for diagnosis, differential diagnosis and staging of the primary EHD cancer. Subjects and Methods. Abdominal CT and PET-CT studies were performed on 27 patients (21 men, 6 women; mean age ¡¾ SD, 65 ¡¾ 10 y) with suspicious malignant EHD strictures on abdominal CT, MRI, endoscopic retrograde cholangiography, or percutaneous cholangiography. The final diagnosis of EHD cancer was made by pathologic exam after surgical resection or bile cytology, or by regular clinical and radiological follow-up for 12 months or more. The SUVmax was measured on the primary lesion.

Results. Final diagnosis was histologically or clinically proven to the primary EHD cancer in 22 cases and benign stricture in 5 cases. The sensitivity and specificity of FDG PET-CT for diagnosing the primary EHD cancer was 84% (21/25) and 50% (1/2), respectively. The sensitivity and specificity of FDG PET-CT for nodal staging in 12 patients who were surgically confirmed as the primary EHD cancer, was 40% (2/5) and 71% (5/7), respectively. The probability of localization of PET-CT for the primary EHD cancer was 100% (21/21). The SUVmax was 4.38 ¡¾ 2.38 (range, 1.69–11.1) in primary EHD cancer group, compared with 2.64 ¡¾ 0.42 (range, 2.03–3.2) in benign EHD stricture group (P = 0.029). The optimal cutoff value of SUVmax for detecting the primary EHD cancer (area under the curve 0.851, p < 0.029) was 3.22, obtained from analysis of receiver operator characteristics curve.

Conclusions. We suggest that 18FDG PET-CT may have some clinical roles in differential diagnosis of both the primary EHD cancer and benign stricture, and localization of the primary lesion.

PP 39.04

EVALUATION OF RESPONSE TO 90-YTTRIUM MICROSPHERE TREATMENT FOR COLORECTAL LIVER METASTASES USING FDG-PET SCAN: HISTOLOGICAL CORRELATION

Sommerville, Craig¹; Pai, Madhava²; Damrah, Osama²; Stamp, Gordon³; Jackson, James⁴; Tait, Paul⁴; Al- Nahas, Adel⁵; Habib, Nagy²; Jiao, Long²

¹Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, Du Cane Road, London, United Kingdom; ²Hammersmith Hospital, Imperial College, Hepatobiliary Surgery, London, United Kingdom; ³Hammersmith Hospital, Imperial College, Histopathology, London, United Kingdom; ⁴Hammersmith Hospital, Imperial College, Radiology, London, United Kingdom; ⁵Hammersmith Hospital, Imperial College, Nuclear Medicine, London, United Kingdom

Introduction. Selective Internal Radiation Therapy (SIRT) with 90Yttrium microspheres has emerged as a treatment option for patients with colorectal liver metastases. Positron emmision tomography (PET)has recently been advocated as an early metabolic marker of disease response to SIRT.

Methods. Two patients with colorectal liver metastases underwent surgery following successful downstaging therapy with SIRT. At surgery one patient had portal hypertension and the planned resection of a PET non-responsive metastasis was abandoned after a biopsy. The second patient underwent resection of the PET non-responsive metastasis and an excisional biopsy of a metastasis that had responded on PET imaging.

Results. The histological response was a central fibrovascular core containing microspheres with fibrosis, hyalinization and a reduction of viable tumour cells in the two patients. The biopsy of patient 1 showed a histological response to SIRT compared to his previous hepatectomy specimen and in patient 2 there was no difference between the metastases that had and had not shown a PET response although both had evidence of a histological response to the therapy. The result does demonstrate a pathological response to SIRT however the PET imaging does not correlate with the pathological response.

Conclusion. The imaging response to best assess response to treatment is not known and requires further investigation.

PP 39.05

EVALUATION OF MRI IN DIAGNOSING FOCAL HEPATIC LESIONS AND SUSPECTED CANCER: ITS CLINICAL UTILITY.

Shah, Ankur J¹; Parsons, Brian²; Callaway, Mark³; Finch-Jones, Meg¹; Finch-Jones, Meg¹; Thomas, Michael G²

¹Bristol Royal Infirmary, HPB surgery, Bristol, United Kingdom; ²Bristol Royal Infirmary, Surgery, Bristol, United Kingdom; ³Bristol Royal Infirmary, Radiology, Bristol, United Kingdom

Background. Detection and characterization of focal liver lesions (FHL) remains a challenge. MRI is frequently used for evaluation of focal hepatic lesions that are indeterminate with other imaging modalities.

Aims. To explore the clinical utility of contrast enhanced MRI in the characterization of FHL and to find out if it made a change in the staging of cancer.

Methods. This retrospective study looked at the results of 122 consecutive MRI scans over the last 2 years. This was compared to the previous radiological examination (Ultrasound-USS or multislice CT scan).The results were evaluated on the basis of utility of MRI to add/ confirm /negate the findings of the previous USS/CT scan for all lesions and specifically whether it changed the staging in suspected cancer.

Results. Out of the 122 patients who had a MRI; 86 had previous USS and 40 had a CT scan. For all FHL, MRI made a difference in 72% (62/86) of patients who had an USS. As compared to a CT scan, MRI made a difference in 47.5% (19/40) of patients. A cancer was suspected in 63 patients. MRI changed the diagnosis in 64% (23/36) of patients who had an USS only; whereas it altered the management in 44% (12/27) of patients who had a CT scan. In summary, MRI made a significant change in 55.5% of patients in whom a cancer was suspected.

Conclusions. MRI is superior to other non-invasive imaging modalities for lesion identification and characterization. It made a significant difference in the diagnosis and management of suspected cancer. This study supports the routine use of contrast enhanced MRI for undiagnosed focal liver lesions.

PP 39.07

A CASE OF AN OBSTRUCTING DUODENAL EMBRYONAL CARCINOMA

Smith, Marty; Abraham, Ajit

Royal London Hospital, HPB Surgery, London, United Kingdom

We present a case report of an embryonal cell carcinoma originating in the second part of the duodenum, mimicking a primary duodenal carcinoma and causing obstruction. The patient was a 39 year old man who was otherwise fit and well but under investigation epigastric pain, vomiting and weight loss. There was no history of a mass or back pain. He underwent upper GI endoscopy which revealed a circumferential tumor, biopies were consistent with a poorly differentiated adenocarcinoma of duodenal or pancreatic origin. Staging CT revealed a bulky tumor without vascular involvement but local lymphadenopathy particularly a large nodal mass in the aorto-caval groove. PET scans confirmed no other focii of FDG avid disease. An aggressive approach of surgery followed by chemotherapy was set upon and a Whipples Pancreato-duodenectomy with clearance of regional lymph nodes was performed. The patients recovery was complicated by a pancreato-jejunostomy leak but has made a good recovery and is now receiving chemotherapy. Histo-pathological examination of the specimen has revealed a completely resected Embryonal Cell Carcinoma. This was supported by immunohistochemistry; MNF 116, CD 30, PLAP and AFP positive, CD 31, CD 117, CD 56, Chromogranin and Desmin negative. Of the resected lymph nodes one of fifteen (from the aorto-caval groove) was involved The retroperitoneum is the second most common site for Extra-Gonadal Germ Cell Tumors (EGGCT) that are known to arise at any point in the midline between pineal gland and sacro-coccyx. Most of these are metastatic with a testicular primary however a diligent search revealed no primary site hence we conclude that this has originated in or immediately around the duodenum. The usual mode of presentation for these tumors in the adult is back pain, a mass or bleeding, an advanced tumor causing gastric outlet obstruction in an adult has not previously been reported.

PP 39.08

CHOLEDOCHAL CYST IN NEONATES

paraian, ioan¹; budusan, anca²; ordeanu, calin²

¹University of medicine, surgery, cluj-napoca, Romania; ²university of medicine, cluj-napoca, Romania

Aim. Choledochal cyst is an uncommon cause of neonatal jaundice and a rare biliary disease mostly presenting during childhood. The aim of this study is to present our experience in diagnosis and treatment of choledochal cyst in neonates.

Material and Methods. We retrospectively analysed files of the patients admitted in our clinic between 2000 and 2007. During a seven years period 4 children were diagnosed and treated with choledochal cysts in our clinic. The patients were newborns, 2 girls and 2 boys. They presented with prolonged jaundice after birth. Laboratory findings revealed elevated levels of serum transaminases and direct bilirubin. Ultrasound revealed a cystic mass close to gall-bladder.

Results All patients underwent surgery and dilatation of the common bile duct with distal obstruction was noted during surgery in all cases. We performed cyst excision with Roux-en-Y hepaticojejunostomy and cholecystectomy. The postoperative course was uneventful with administration of antibiotics.

Conclusions. early diagnosis and treatment oc choledochal cyst in neonates are important for preventing serious complications of biliary obstruction – progressive damage to the bile ducts and to the liver parenchyma. Ultrasound of the abdomen should be performed in cases of prolongued jaundice in all neonates.

PP 39.09

COMPOSITE LARGE CELL NEUROENDOCRINE CARCINOMA AND ADENOCARCINOMA OF THE AMPULLA OF VATER

Lee, Keun Ho; Lee, Jin A; Park, Il Young

The Catholic Univ of Korea, SURGERY, Seoul, Korea, Republic of

Neuroendocrine tumor of the ampulla of Vater is rare, and large cell neuroendocrine carcinoma (LCNEC) is extremely rare among neuroendocrine tumors. This report dercribes composite LCNEC and adenocarcinoma of the ampulla of Vater. A 60-year-old man presented with fever, chill and jaundice. We found a periampullary ulcerative lesion and performed radical pancreatoduodenectomy. Histopathologically the tumor consists of a LCNEC component and a poorly differentiated adenocarcinoma component. Immunohistochemical stain showed the tumor cells are reactive for chromogranin, synaptophysin, neuron-specific endolase and CD56. Five months after operation, the patient underwent PET-CT scan and it showed multiple metastatic lymphadenopathy. He received radiation therapy. LCNEC is very rare in this location and highly aggressive with a poor prognosis.

PP 39.10

CLINOCOPATHOLOGICAL ANALYSIS OF LYMPH NODE METASTASES IN CASES OF THE CANCER OF THE MAJOR DUODENAL PAPILLA

Nagaike, Koki; Chijiiwa, Kazuo; Uchiyama, Shuichiro; Nagano, Motoaki; Hiyoshi, Masahide; Ohuchida, Jiro; Kai, Masahiro; Kondo, Kazuhiro

MIyazaki University, School of Medicine, Surgical Oncology and Regulation of Organ Function, Miyazaki, Japan

Background. Pancreaticoduodenectomy or pylorus preserving pancreaticoduodenectomy has been applied for cancer of the major duodenal papilla as a standard surgical approach. Although the less invasive surgery such as ampullectomy including endoscopic approach is sometimes chosen for early ampullary cancer, its indication is still vague.

Aim. To clarify the suitable surgical procedure, we performed clinocopathological analysis of the patients with ampullary cancer treated by curative resection.

Methods. Between 1986 and 2006, twenty-two patients (eight women and fourteen men, range 43–85 years old)with ampullary cancer were treated. The survival rates with respect to various clinicopathologic factors were analyzed retrospectively.

Results. The overall rate of lymph node metastases was 36.4%, and all metastases were located at the regional lymph nodes. Cases without lymph node metastasis showed better prognosis than those with lymph node metastases statistically (p < 0.05). The analysis of lymph node metastases with respect to the depth of tumor invasion revealed that when tumor was limited in the mucosal layer, no lymph node metastasis was observed. One of five cases (20%) with invasion into the sphincter of Oddi showed lymph node metastasis, and this case also showed intraductal spreading into the lower bile duct. However, in cases with invasion over the sphincter of Oddi, 46.1% (7/15) showed lymph node metatases. The 3-year survival rates of the patients limited to the mucosal layer or the sphincter of Oddi were significantly higher (100%) than those with invasion over the sphincter of Oddi (45.4%).

Conclusions. When the tumor is limited to the mucosal layer, ampullectomy can be applied. Pancreaticoduodenectomy with lymph nodes dissection is required in cases with invasion over the sphincter of Oddi.

PP 39.11

CLINICOPATHOLOGICAL ANALYSIS OF AMPULLARY LESIONS TREATED BY WIDE AMPULLECTOMY

Uchiyama, Shuichiro; Chijiiwa, Kazuo; Hiyoshi, Masahide; Imamura, Naoya; Nagano, Motoaki; Ohuchida, Jiro; Nagaike, Koki; Kai, Masahiro; Kondo, Kazuhiro

Miyazaki University School of Medicine , Surgical Oncology and Regulation of Organ Function, Miyazaki, Japan

Background.: Although benign and malignant tumors of the major duodenal papilla can be detected endoscopically, definitive diagnosis of cancer by histologic examination using biopsy specimens and of the depth of invasion are sometimes difficult. If apparent invasive growth is observed by imaging modalities including endoscopic ultrasonography and intraductal ultrasonography, pancreaticoduodenectomy is chosen as the standard treatment. We have applied wide ampullectomy to only the patients who have been diagnosed as high grade adenoma or suspicious of a small focus of malignancy.

Aim. To clarify the significance of wide ampullectomy in such patients, we performed clinicopathological analysis of the cases treated by wide ampullectomy.

Results. From 1995 to 2007, six cases were treated by wide ampullectomy. Among them, four were diagnosed as adenomas, and two as carcinoma in adenoma. Among the latter 2 cases, one showed a small focus of carcinoma and carcinoma in adenoma was diagnosed, but the resected edges were free from cancer cells and neither vessel nor lymphatic peameation was seen. In another one case, intraductal spreading into the lower common bile duct was observed at the resected edge, and pancreaticoduodenectomy was added later. In all cases, there was no severe crash damage, and precise histologic diagnosis could be easily performed. All cases were alive without recurrence.

Conclusion. Wide ampullectomy is an adequate treatment in cases of high-grade adenomas or high-grade adenoma with a small focus of carcinoma.

PP 40.01

LAPAROSCOPIC CHOLECYSTECTOMY FOR GALLBLADDER LESIONS IN PATIENTS WITH CARDIOVASCULAR DISEASE

Lee, Chen-Fang; Yeh, Chun-Nan; Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung University, Department of General Surgery, Taipei, Taiwan

Background. Cardiovascular disease (CVD) and gallstone are reported strongly associated because both diseases are frequently involved as part of the metabolic syndrome. Laparoscopic cholecystectomy (LC) has become them standard treatment for gallbladder lesions over the world. CVD is considered as an absolute or relative contraindication to LC, however, clinical information on LC for gallbladder lesions in patients with CVD is lacking. This study aims to assess feasibility of LC for gallbladder lesions in CVD patients.Method.: From 1996 to 2005, the medical records of 66 CVD patients (including valvular heart disease, ischemic heart disease, and heart failure) with gallbladder lesions undergoing LC (CVD-group) were retrospectively reviewed. Furthermore, the clinical features and outcomes of 8834 patients with gallbladder lesions without CVD undergoing LC (NCVD-group) were also summarized for comparison.

Results. Of 8900 patients with gallbladder lesions that had undergone LC, 66 (0.74%) had CVD. Overall, CVD patients undergoing LC clearly exhibited older age, male predominance, higher BUN level, and longer hospital stay when compared with those without CVD. Longer hospital stay and higher percentage of acute cholecystitis and chronic cholecystitis were the independent factors to differentiate between patients with open heart surgery and NCVD-group patients. Anticoagulant adjustment not post-operative complications contribute to longer hospital stay. Older age and male predominance were the independent factors to differentiate between patients with ischemic heart disease with intervention.

Conclusions. LC is a feasible procedure for selected CVD patients with gallbladder lesions. Applying LC to treat selected CVD patients with gallbladder lesions could achieve similar operative morbidity and mortality rate to patients with gallbladder lesions without CVD. Appropriate preoperative preparations and experienced operative techniques are still mandatory.

PP 40.02

USE OF PEROPERATIVE CHOLEDOCHOSCOPY IN MANAGING CHOLEDOCHOLITHIASIS

Damodaram, Srikumari¹; Naganath Babu O L, ¹; Selvaraj T, ¹; Raghumani P, ¹; Berty A, ²; Lakshmanan, Anand³

¹Govt. General Hospital, Dept. of SGE, MMC, Chennai., chennai; ²; ³Madras Medical college, Dept. of Surgical Gastroenterology, Chennai

Introduction. Common bile duct exploration is an important surgical intervention when endoscopic retrograde pancreatography fails to extract calculi. Direct visualization of biliary tree using choledochoscopy reduces the incidence of retained biliary calculi and is an opportunity to detect other pathologies missed during initial evaluation. AIM To assess the value of choledochoscopy in lowering the incidence of retained stones in the common bile duct following choledocholithotomy.

Methods. From July 2004 to May 2007,44 patients underwent exploration of common bile duct specifically for calculous disease at the Department of Surgical Gasteroenterology, Madras Medical College. 6 patients had prior cholecystectomy, hence underwent common bile duct exploration alone.38 patients underwent cholecystectomy with common bile duct exploration. Choledochoscopy was done for all the cases.

Results. In 20.5% (9/44) patients stones which had been missed by preoperative evaluation was detected. In 2 patients (5.45%) intrahepatic calculus was detected and extracted using choledochoscopy. The distal CBD stones were removed by Dormia basket and in one patient the stone was pushed into the duodenum. Primary closure of choledochotomy was done in 36 patients(81.8%).T Tube drainage was done in 2 patients(4.55%).5 patients (11.4%)underwent choledochoduodenostomy 1 patient(2.3%) underwent choledochojejunostomy. In 2 cases stricture was detected. Biopsy revealed inflammatory fibrous disease. There was no mortality or morbidity in this series.

Conclusion. Per-operative choledochoscopy is an effective method in preventing retained ductal stones during common bile duct exploration and should be used in patients with suspected choledocholithiasis, to ensure removal of all calculi.

PP 40.03

ADVANTAGES OF LAPAROSCOPIC CHOLECYSTECTOMY FOR CEREBROVASCULAR ACCIDENT PATIENTS WITH GALLBLADDER LESIONS

Lee, Hsiang-Lin; Yeh, Chun-Nan; Liu, Yu-Yin; Chen, Miin-Fu; Jan, Yi-Yin

Chang Gung Memorial Hospital Chang Gung University, Department of General Surgery, Taipei, Taiwan

Background. Since 1987, laparoscopic cholecystectomy (LC) has become the treatment of choice for gallbladder lesions over the world. However, no information is reported on gallbladder lesions in patients with cerebrovascular accident (CVA). This study aims to assess feasibility of LC when compared with open cholecystectomy (OC) in CVA patients with gallbladder lesions. Method: From January 1994 to June 2005, 104205 CVA patients treated at our hospital, among them, 696 (0.67%) had gallbladder lesions. 172 of the 696 CVA patients (24.7%) with gallbladder lesions undergoing cholecystectomy were reviewed. Among them, 100 patients undergoing LC were classified as LC-CVA group, while the remaining 72 patients receiving OC were classified as OC-CVA-group. The clinical features and outcomes between LC-CVA and OC-CVA group patients were compared. Result: Gallbladder stone with acute cholecystitis was the most common cause for CVA patients undergoing cholecystectomy (78/172; 45.3%). The LC-CVA group patients had similar demographic and laboratory data to OC-CVA patients. However, LC-CVA patients experienced less blood loss, shorter operation time, and shorter hospital stay. Applying LC or OC to treat CVA patients with gallbladder lesions could achieve similar operative morbidity and mortality rate.

Conclusions. Gallbladder lesions seem to be uncommon in the CVA patients, however, gallbladder stone with acute cholecystitis is the most common cause for CVA patients undergoing cholecystectomy either by open or laparoscopic approach. Applying LC or OC to treat CVA patients with gallbladder lesions could achieve similar operative morbidity and mortality rate. LC had significant advantages for CVA patients with gallbladder lesions with less blood loss, shorter operation time, and shorter hospital stay. Appropriate preoperative preparations and experienced operative techniques are still required to prevent morbidity and mortality in the specific subtype of patients.

PP 40.04

A REVIEW OF AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IN A SINGAPORE TEACHING INSTITUTION: ARE WE READY FOR DAY-CASE LAPAROSCOPIC CHOLECYSTECTOMY

Kow, Alfred Wei-Chieh¹; Ho, Choon-Kiat¹; Tan, Amanda Pei-En¹; Chan, Siew-Pang²; Lee, Sow-Fong³

¹Dept of General Surgery, Tan Tock Seng Hospital, Center for Advanced Laparoscopic Surgery, Singapore, Singapore; ²Tan Tock Seng Hospital, Clinical Research Unit, Singapore; ³Tan Tock Seng Hospital, Operating Theatre Management, Singapore

Background. Day-Case laparoscopic cholecystectomy (LC) is practiced in many countries. However, this has yet been accepted in Singapore.

Aim. This study aims to determine the potential success rate of day-case LC in our institution and hence the feasibility of starting this programme locally.

Patient and Methods. We retrospectively assessed the proportion of our Ambulatory Surgery 23 hour (AS23) LC patients that met discharge criteria. Our porposed same-day discharge criteria include minimal pain, ability to tolerate feeds, ambulate independently and void spontaneously after 6–8 hours of monitoring.

Results. From 2005 to 2006, of 405 patients listed for elective LC, 339 patients were admitted to our AS23 ward. The other 66 were admitted as inpatient. Of these, 41 patients were admitted because of conversion to open surgery. A history of cholecystitis or cholangitis was a significant predictor of conversion to open surgery (OR = 5.73 and 5.74 respectively, P < 0.001). However, if the gallbladder of such patients can be successfully removed laparoscopically, then these patients have an equal chance of fulfilling all the discharge criteria as those who had no past history of cholecystitis or cholangitis. Of the 339 patients, 221 of them fulfilled all 4 criteria by the 8th hour of monitoring. Therefore, based on an intention-to-treat analysis, 51.2% fulfilled all 4 criteria and could potentially be discharged the same day if we had day-case LC. No predictor for failure was identified, including presence of co-morbidities, duration of operation, surgeon's grade and additional procedures like laparoscopic common bile duct exploration.

Conclusion. We can expect a potential success rate of at least 50% if we offer day-case LC. With the attendant advantages of cost-savings and reduced resource utilization, it is therefore worthwhile to start it in Singapore.

PP 40.05

MULTIPLE LINEAR REGRESSION ANALYSIS OF HOSPITAL CHARGE IN ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY

Chuang, Shih-Chang; Lee, King-Teh

Kaohsiung Medical University Hospital, Surgery, Kaohsiung, Taiwan

Background. Laparoscopic cholecystectomy is the standard method in the surgical treatment of gallbladder stone and becomes an item of case payment system in many developed countries. The aim of this study is to delineate the impact of clinical factors on the total hospital charge.

Methods. The patients who underwent elective laparoscopic cholecystectomy were retrospectively studied during January 2003 to April 2006 at Kaohsiung Medical University Hospital. Clinical and economic information were abstracted from medical charts and the financial division, that included the demographics (age, gender), clinical manifestations (acute inflammation), admission status, age adjusted Charlson comorbidity index, pre-operative waiting days, operative time, complications and length of hospital stay.

Results. Nine hundred and twenty-one consecutive patients include 555 man and 366 women, mean age 52.8 ¡Ó 12.9 years old. The mean length of hospital stay was 4.7 days, and the mean total hospital charge was USD 1,526. From multiple linear regression analysis, the length of hospital stay, acute inflammation, operation time, admission status, age (P < 0.001) and complication (P = 0.035) was associated with significantly cost. While, the age adjusted Charlson comorbidity index did not significantly influence total hospital charge. As a result, we created the linear regression formulas: THC = 18013+ 3654×(length of stay) + 5142×(acute inflammation) + 49×(operative time) + 3966×(admission status) + 82×(age) + 4578×(complication) Conclusions: This study demonstrates that multi-factors affect the total hospital charge, while length of hospital stay plays the most important role.

PP 40.06

A CASE OF BILOMA FORMATION IN THE INTRAMUSCULAR LAYER AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Lee, Daesung

Sunlin Hospital, Pohang, Korea, Republic of

Symptomatic bile leak and biloma formation occur sometimes after laparoscopic cholecystectomy. Localized collection of bile occurring usually after postcholecystectomy is intraperitoneal cavity. I experienced a rare case of intramuscular biloma formation after laparoscopic cholecystectomy through barovac drain. Case: A 58-year-old male was admitted to our hospital with a history of intermittent right upper quadrant pain from 1 year. Ultrasound showed diffuse gallbladder wall-thickening with stones. I performed laparoscopic cholecystectomy with infrahepatic drainage for treatment. Only diffuse thickening of the gallbladder was seen during the operation. Multiple dark colored stones were in the gallbladder. Unusual abdominal pain was present in the postoperative 2nd day. I didn't detect bile discharge from an infrahepatic drain, so I performed immediate computer tomography on him. I detected large biloma in the intramuscular layer on the computer tomography. Biloma resolved and bile leakage was treated by replacement of a drain. On the postoperative 15th day, he showed no event of bile leakage and had normal finding on the cholescintigraphy. On the postoperative 22th day, he was discharged without any other problems. I report a rare case of intramuscular biloma occurred by a drain after laparoscopic cholecystectomy with infrahepatic drainage.

PP 40.07

XANTHOGRANULOMATOUS CHOLECYSTITIS: P53 AND PCNA EXPRESSION IN COMPARISON TO CHRONIC CHOLECYSTITIS AND GALLBLADDER CANCER

Ghosh, Mila¹; Sakhuja, Puja²; Singh, S.¹; Agarwal, Anil¹

¹G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ²G. B. Pant Hospital and Maulana Azad Medical College, Pathology, New Delhi, India

Background. Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis which often mimics a gallbladder carcinoma. Pre-operative and intra-operative diagnosis is usually difficult and it may coexist with GBC and lead to diagnostic dilemma. Furthermore the premalignant nature of this entity is controversial.

Aim. To study the p53 and PCNA expression in XGC in comparison to gallbladder cancer and chronic inflammation.

Materials andMethods. Sections were obtained from paraffin embedded blocks of surgically resected specimens of gallbladder cancer (29 cases), XGC (44 cases), chronic cholecystitis (16 cases), Normal gall bladder (10 cases). Immunohistochemistry with the monoclonal antibody p53 (DakoCytomation), and monoclonal antibody PCNA(Diagnostic Biosystem) was performed in all cases. The results were scored semiquantitavely and statistical analysis performed. p53 expression was scored as percentage of the nuclei stained. PCNA expression was scored as the product of percentage of nuclei (0–100) stained and intensity of the staining(1–3). Thus a maximum Quick score of 300 can be obtained. A cut off value >30 for Quick score was taken as a positive result. Result: p53 mutation was positive in 82% (24 out of 29) GBC cases. p53 expression was positive in 9% (4 out of 44) in XGC cases, 6%( 1 out of 16) in chronic cholecystitis, and 0%( 0 out of 10) in normal cases. p53 expression in XGC was significantly lower than in GBC (p < 0.0001). But there was no significant difference of p53 expression in XGC with chronic cholecystitis and normal gallbladder. PCNA expression was 97%(28 out of 29 cases) in GBC, 27% (12 of 44) in XGC, 6%(1 of 16 cases) in chronic cholecystitis, and 0% (0/10) in normal. PCNA expression was significantly higher in GBC than XGC (p = 0.004)but there was no significant difference in PCNA expression in XGC in comparison to chronic cholecystitis and normal gallbladder.

Conclusion. There is significant less expression of p53 and PCNA in XGC than in GBC but statistically no difference with chronic inflammation. This result supports the inflammatory nature of XGC and does not support a premalignant nature of the disease.

PP 40.08

HOW TO AVOID BILIARY DISASTERS IN LAPAROSCOPY-SINGLE SURGEON'S EXPERIENCE

Singh, Kuldip; Ohri, Ashish

Dayanand Medical College, Department of Surgery, Ludhiana, India

In the era of laparoscopy when laparoscopic cholecystectomy has become the ‘gold standard’ for the treatment of gallstone disease, the incidence of bile duct injuries is still higher than open cholecystectomy. These biliary disasters entail a great morbidity for the patient and also put excessive burden on the health service providers. The subgroup of patients which are more prone to these disasters are patients having undergone previous abdominal surgery with gallstone disease, patients having complicated cholecystitis like empyema GB, gangrenous GB, cholecystoenteric fistula and patients having abnormal anatomy like mirizzi syndrome. For patients with suspected adhesions like those undergone upper abdominal surgery, one should have a pre-operative evaluation with CT scan of abdomen and choose a safe option while creating pneumoperitoneum like insertion of veress needle in the left hypochondrium, use of open technique with Hasson canula or use of Endotip or optiview to make a safe entry into the peritoneal cavity. In cases of anomalous anatomy or complicated disease, adherence to the basic rules of surgery and step by step dissection following the landmarks like staying close to the liver margin, defining the gall bladder neck, defining the junction of gall bladder with cystic duct, identifying the cystic lymph node, displaying the calot's triangle, staying antero-superior to the Rouviere's sulcus can make most of the difficult situations possible laparoscopically. In our own experience of 6780 cases, we had to convert 31 patients to open surgery with a conversion rate of 0.45% and the most common complication was a bile duct injury which lead to four conversions. All the converted cases were complicated. From our experience, we emphasize that the experience of the surgeon and meticulous technique are the most important factors to achieve a low complication rate.

PP 40.09

POST CHOLECYSTECTOMY SECTORAL BILE DUCT INJURY

Yadav, Abhishek; Gupta, Vishal; Singh, Shivendra; Agarwal, S.; Agarwal, Anil

G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India

Background. Sectoral duct injury/Type 5 benign biliary strictures (BBS) are uncommon bile duct injury sustained after cholecystectomy. The management and outcome of this subgroup of patients are reviewed.

Methods. Retrospective analysis of the records of patients referred to a tertiary care center for the management of post cholecystectomy bile duct injury from January 2000 to December 2006.

Results. Total 302 patients of bile duct injury were treated during this period, including 183 patients who underwent surgical repair. Nine patients had sectoral duct injury constituting ∼3% of total cases. Median age was 28 years (range 18–55 years) with most (6/9) injuries sustained after open cholecystectomy. Two patients presented with biliary peritonitis and were managed with laparotomy lavage and drainage while remaining 7 patients underwent surgical repair of stricture, hepaticojejunostomy. Liver resection was not required in any case. Right anterior sectoral duct injury was seen in 4 patients while remaining 3 patients had right posterior sectoral duct injury. Atrophy was seen in 3 patients. Median hepaticojejunostomy stoma size was 28 mm (range: 25–33mm). Access loop was constructed in 5 patients while stented anastomosis was performed in 5 patients. Postoperative mortality was none and no major morbidity was seen. Median postoperative hospital stay was 7 days (range 5–13 days).

Conclusion. Type 5 BBS/ sectoral duct injury are an uncommon and complex biliary injury. Successful repair, however, can be achieved in specialized center with minimal morbidity and mortality.

PP 40.10

MIRIZZI SYNDROME TYPE II – LAPAROSCOPIC APPROACH.

Bregante, Mariano; Ardiles, Victoria; Salceda, Juan; Fernandez, Diego; Pfaffen, Guillermo; Pekolj, Juan; de Santibañes, Eduardo

Hospital Italiano de Buenos Aires, HPB Surgery and Liver Transplant Unit, Buenos Aires, Argentina

Background. Common hepatic duct obstruction secondary to compression by gallstones impacted at the gallbladder neck or cystic duct could induce a cholecystobiliary fistula or “Mirizzi Syndrome” (MS) type II which is a rare complication of prolonged cholelithiasis. Its laparoscopic treatment seems controversial at present.

Aim. To show a health center experience in HPB surgery and laparoscopic treatment for MS type II Design: Retrospective analysis. Material and method: Between November 1999 and December 2004, 6107 laparoscopic cholecystectomies for gallstones were performed. Estimated biliary fistula incidence, in particular cholecystobiliary fistula(MS type II), its laparoscopic treatment, conversion incidence, resolution, morbidity and mortality were assessed. All the patients underwent preoperative laboratory test and two or more imaging studies. Intraoperative cholangiography was perfomed in all cases.

Results. Biliary fistula, 38 patients (0.6%); MS type II,0.2% with common hepatic duct gallstones in 58.3%. Female patients:76.3%, mean age: 68 years. Laparoscopic treatment resolution in MS type II: 66.7%. Conversion rate:33.3%. Morbidity: 25%. Mortality: 0%.

Conclusion. Mirizzi Syndrome is a rare and major complication of prolonged cholelithiasis. The use of the laparoscopic or the open approach depends on the surgeon's experience. Its diagnostic presumption is an important issue regarding its resolution, since patients'referral to specialized centres has resulted in lower short-term and long-term morbidity and mortality rates

PP 40.11

SEVERITY AND OUTCOME OF MANAGEMENT OF GALLSTONE DISEASE IN ELDERLY PATIENTS

Jain, Sundeep¹; Sharma, Jayant²; Kalla, Mukesh³; Sharma, Bharat⁴; Sharma, Shyam Sunder⁵

¹S.K. Soni Hospital, Gastrointestinal & Laparoscopic surgery, sector-5, Vidhyadhar Nagar, Jaipur, India; ²S.K. Soni Hospital, Gastroenterology, Jaipur, India; ³S.R. Kalla Memorial Hospital, Gastroenterology, Jaipur, India; ⁴S.K. Soni Hospital, Gastrointestinal & Laparoscopic Surgery, Jaipur, India; ⁵S.M.S. Hospital, Gastroenterology, Jaipur, India

Introduction. Gallstone disease in elderly population is associated with higher perioperative morbidity and mortality. OBJECTIVE This study was undertaken to determine the relationship between the age of the patients, severity of the disease, and the outcome of treatment in these patients.

Methods. The study was prospectively conducted in 150 patients during August 2005 to July 2007. All patients were divided into three groups. Group I- age <50yrs, Group II- age 50–69yrs, and Group III- age >70 yr. A comparative analysis was done between them in terms of clinical presentation, presence of gallstone related complications, comorbid conditions, and overall outcome of treatment.

Results The three groups had 80, 54, and 16 patients respectively. The incidence of CBD stones was maximum in the IIIrd group (37.5%), with the successful endoscopic CBD clearance rate of 100%, 71.4% & 0% in the three respective groups. Laparoscopic surgery was successful in only 37.5% patients in group III. All of the group III patients had comorbid conditions in comparison to 38.8% and 6.25% in group II & I patients. Group III patients had maximum postoperative complications (18.7%) and mortality (18.7%). All 3 patients who died in group III were having CBD stones along with the stent. The median hospital and ICU stay in the three groups were 1–0, 1–0 & 5–5 days, respectively.

Conclusions. Gallstone disease in elderly population is associated with higher perioperative morbidity and mortality due to the presence of more comorbid conditions, and septic complications. Higher incidence of gallstone related complications in them are an important determinant of conversion of laparoscopic procedure into an open surgery. Elderly patients are more commonly associated with CBD stones which are multiple and big in size making their endoscopic removal difficult.

PP 41.01

ROLE OF MULTIDETECTOR ROW CT IN ASSESSING RESECTABILITY OF PERIAMPULLARY CARCINOMA

yadav, Thakur D¹; venkatesan, ragavendran¹; Kang, Mandeep²; Wig, Jaidev¹

¹PGIMER, Chandigarh, India, department of general surgery, chandigarh, India; ²PGIMER, Chandigarh, India, department of radiodiagnosis, chandigarh, India

Objective. Periampullary carcinoma exhibit poor prognosis due to early spread to surrounding vessels and organs. Proper assessment of resectability is important to avoid unnecessary laparotomy. We tried to evaluate the accuracy of Multidetector row helical CT angiography in assessing the resectability of periampullary carcinoma and defining vascular anomalies.

Methods. Thirty three patients with clinical features and imaging suggestive of periampullary carcinoma were studied prospectively. All of them underwent MDCT preoperatively while 24 patients underwent surgery. Intraoperative findings were correlated with preoperative CT findings with respect to tumour, vascular invasion and vascular anomalies.

Results. Thirty three patients were studied, 23 were male and 10 were females. Mean age was 52 years. Twenty four patients underwent surgical exploration, 17 had curative resection and 7 had palliative surgery. MDCT yielded sensitivity, specificity, PPV, NPV and accuracy of 100%, 75%, 98.9%, 100% and 98.97% respectively for determining resectability with respect to vascular invasion. For predicting resectability, a sensitivity, specificity, PPV, NPV and accuracy were 94.1%, 71.4%, 88.8%, 83.3% and 87.5%. Of the eighteen patients (n = 18) concluded by CT as resectable, on surgery 16 patients were found to be resectable (n = 16) and two patients were unresectable (n = 2). The causes of unresectability were Grade III vascular invasion in one case (n = 1) and liver metastases in one case (n = 1). Vascular anomalies were detected in seven patients and were confirmed in five patients who underwent surgery.

Conclusion. MDCT significantly improves the prediction of resectability of periampullary carcinoma and also provides an adequate overview of vascular anatomy.

PP 41.02

INDICATION FOR ORGAN-PRESERVING SURGERY FOR TREATMENT OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS (IPMN) OF THE PANCREAS: AN INSTITUTIONAL EXPERIENCE

Vashist, Yogesh; Link, Bjoern; Schurr, Paulus; Bogoevski, Dean; Gawad, Karim; Reichelt, Uta; Izbicki, Jakob; Yekebas, Emre

University Clinic Hamburg-Eppendorf, General, Visceral and Thoracic Surgery, Hamburg, Germany

Objective. Surgical management of intraductal papillary mucinous neoplasms (IPMN) remains a topic of considerable dispute.

Background. IPMN are divided into adenomas (IPM-A), borderline tumors (IPM-B), non-invasive and invasive carcinomas (IPM-C). In non-invasive IPMN, reported 5-year survival rates range from 77–100%. Surgical procedures vary considerably between different institutions.

Methods. 32 patients with pancreatic IPMN were included into this institutional study between 1997 and 2004. Re-classification of specimens was performed based on the WHO nomenclature (2002). Surgical technique, tumor-staging and pattern of recurrence were related to survival.

Results. 22 non-invasive IPMN (4 IPM-A, 15 IPM-B, 3 non-invasive IPM-C) and 10 invasive IPM-C (all of the colloidal non-cystic type) were identified. Median disease-specific survival for invasive IPM-C and non-invasive IPMN was 12 and 46 months, respectively (p < 0.001). All patients with invasive IPM-C (n = 10) were treated by radical pancreaticoduodenectomy. Out of 19 patients with IPM-A and IPM-B, 9 were treated with duodenum-preserving pancreatic resection (DPPR) and 9 with radical pancreaticoduodenectomy. The remaining patient with IPM-A in which a diagnostic laparoscopy was performed, died perioperatively. In type A and B lesions, except one patient, no tumor relapse was observed. In 2 out of 3 patients with non-invasive IPM-C treated by DPPR, local recurrence occurred after 46 and 49 months, respectively. The remaining patient was treated by left splenopancreatectomy and is still relapse-free since 56 month.

Conclusion. Radical resection is indicated in IPM-C irrespective of invasiveness. Organ-preserving surgery such as DPPR is the surgery of choice in IPM-A and IPM-B.

PP 41.03

OUTCOMES IN ELDERLY PATIENTS WITH A PANCREATIC ANASTOMOTIC LEAK

Mukherjee, Samrat; Hutchins, Robert R; Bhattacharya, Satyajit; Kocher, Hemant M; Abraham, Ajit T

Barts and the London HPB Centre, London, United Kingdom

Background. Major pancreatic resections can be performed for the elderly with acceptable outcomes. However, pancreatic anastomotic leak remains the major cause of morbidity and mortality in patients undergoing pancreatico-duodenectomy (PD).

Aims. To evaluate the incidence and outcome of pancreatic anastomotic leak in elderly patients undergoing PD.

Methods. Patients undergoing PD were extracted from a prospectively maintained pancreatic database. Data was analysed for patients aged 70 years and above versus those less than 70 years, in terms of the incidence of pancreatic leaks and related mortality.

Results. From 1999 to 2007, 49 patients aged 70 or above (median, 75 (range 70–84) years) underwent a PD as compared with the 117 patients aged less than 70 (median 59 (range 31–69). 3 patients (6.1%) in the elderly group developed a pancreatic anastomotic leak, of whom 2 died as a consequence compared to 12 patients (10.2%) in the younger group of whom 1 patient died as a consequence. (Fisher's exact test, p = 0.55 for likelihood of leak: p = 0.08 for the likelihood of mortality following a pancreatic leak).

Conclusion. Following PD in the elderly, their likelihood of developing a pancreatic leak or dying as a consequence is not significantly different from a younger sub-group of patients.

PP 41.04

PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY: IS THE INTERNATIONAL STUDY GROUP OF PANCREATIC FISTULA (ISGPF) DEFINITION USEFUL?

Martin-Perez, Elena; Gómez, Joaquín; Bermejo, Elena; García, Rubén; Martin-Alvarez, José Luis; Larrañaga, Eduardo

La Princesa Hospital, Dpt. of Hepatobiliopancreatic Surgery, Madrid, Spain

Background. One of the most common complications of pancreaticoduodenectomy (PD) is pancreatic fistula (PF) with a reported rate highly variable (from 2% to 30%). This variability depends on the lack of consensus on the definition of this complication.

Objectives. To validate the International Study Group of Pancreatic Fistula (ISGPF) definition and analyze the risk factors for PF in a group of patients undergoing PD.

Methods. Between November 2001 and March 2007, 50 consecutive patients with periampullary neoplasms underwent PD. PF was defined by ISGPF criteria. Patients were divided into four categories: no fistula, grades A, B, and C. Collected data included: pathological diagnosis, diameter of pancreatic duct, texture of the remnant pancreas, amylase levels from drains, symptoms, therapeutic and diagnostic strategies, incidence and type of complications, readmission, reoperation, and mortality.

Results. There were 32 men and 18 women, with a mean age of 66,6 + 14,26 years (range 41 to 84 years). Final pathology: adenocarcinoma: 43 (86%); cystic neoplasms: 2 (4%); neuroendocrine: 2 (4%); GIST: 1 (2%); other: 2 (4%). Pancreatico-jejunal anastomosis: end-to-side with ductal stent: 39 (78%); end-to-end: 11 (22%). 32 patients (64%) had no evidence of fistula. There were 8 (16%) grade A fistulas, 6 (12%) grade B fistulas, and 4 (8%) grade C fistulas. Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Clinical outcomes of the main features of each fistula grade are presented.

Conclusions. This classification can provide comparison of surgical outcomes among different centres and treatments. Biochemical fistulas (grade A) have no clinical significance, but grade B and C fistulas negatively impact patients with higher rates of complications, hospital stays and costs. Further studies are warranted in large well controlled trials to definitively validate this definition.

PP 41.05

AMYLASE CONCENTRATION OF DRAINAGE FLUID AFTER PANCREATICODUODENECTOMY AS PREDICTIVE FACTOR OF PANCREATIC FISTULA

Martin-Perez, Elena; Gómez, Joaquín; Zapata, Camilo; Martin-Alvarez, José Luis; Sánchez-Urdazpal, Luis; Larrañaga, Eduardo

La Princesa Hospital, Dpt. of Hepatobiliopancreatic Surgery, Madrid, Spain

Background. Pancreatic fistula (PF) is a serious complication of pancreaticoduodenectomy (PD). The correlation of the amylase value in drains with the development of PF is still unclear.

Objectives. The aim of this study was to assess if the volume and amylase content of the effluent from surgical drains predict PF after PD and to determine the factors affecting the drainage amylase level.

Methods. From November 2001 to March 2007, 50 consecutive patients underwent PD. Data included age, gender, diagnosis, type of anastomosis, complications, mortality, length of stay, need for postoperative percutaneous drainage, reoperation, and readmission. The consistency of the pancreas and the diameter of the pancreatic duct were also evaluated. The volume and amylase concentration of the drainage fluid were measured from postoperative day (POD) 3 and POD 7. The upper limit of normal of the serum amylase value in our hospital is 110 U/L. The criteria for leak were met if >50 ml/day of drainage was observed and if that drainage contained an amylase-rich fluid (greater than 3 times the upper limit of normal of the serum amylase value) on or after POD7.

Results. Data were compared between patients with no fistula (n = 39) and with fistula (n = 11). On POD 3, the drainage fluid amylase was more than three times the normal serum amylase in 52%, with a median of 548 U/L (range 30–16.363 U/L). On POD 7 the median drainage fluid amylase was 136 U/L but ranged from 30 to 26000 U/L, with 22% with amylase greater than 3 times the upper limit of normal of the serum amylase value. Soft pancreatic parenchyma and a nondilated pancreatic duct were significantly associated with higher drainage amylase levels.

Conclusion. Although determination of volume and drainage fluid amylase levels may be useful for early detection of a leak that will have clinical impact and to plan appropriate management, other factors such as consistency of the pancreas and diameter of the pancreatic duct must be evaluated.

PP 41.06

GRANULOCYTIC SARCOMA OF THE PANCREAS

Martin-Perez, Elena; Gómez, Joaquín; Martin-Alvarez, José Luis; Rodríguez, Ana; Rubio, Inés; Larrañaga, Eduardo

La Princesa Hospital, Dpt. of Hepatobiliopancreatic Surgery, Madrid, Spain

Background. Granulocytic sarcoma (GS) is a rare extramedullary soft-tissue tumour that is composed of immature cells of the myeloid series. It commonly presents as bone, soft tissue, or lymph node tumours.

Objectives. To describe a case a GS of the pancreas, who presented initially with obstructive jaundice without evidence of bone marrow disease.

Case report. A 41-year-old man presented with a 6-month history of painless jaundice and 5 kg weight loss. Computed tomography scan showed dilated intrahepatic bile ducts with no masses in the pancreas. Magnetic resonance cholangiopancreatography revealed an irregular narrowing of the distal common hepatic duct suggestive of a cholangiocarcinoma or pancreatic carcinoma. The patient underwent surgery and frozen section biopsy specimen showed a malignant tumour, compatible with poorly differentiated carcinoma. A duodenopancreatectomy was performed. However, histological examination of the resected specimen revealed that the tumour was characterized by an extensive infiltrate of polimo rphic cells with irregular nuclear contours, vesicular chromatin, prominent nucleoli and various stages of maduration with characteristic eosinophilic granules consistent with GS. Immunohistochemical examination: positive for myeloperoxidase, muramidasa, CD34 and CD68, and negative for CD3, UCHL-1, and CD56, a profil consistent with a myeloid phenotype. A bone marrow biopsy was normal. The patient received combination therapy (idarubicin and AraC). Ten months after operation the patient remained well and had not developed acute myelogenous leukaemia.

Conclusion. In patients who develop GS before leukaemia, the diagnosis is difficult to make by radiographic examination only, and it may be confused with adenocarcinoma or lymphoma because of the non-specific necrotic nature of the tumour. The presence of GS is associated with a poorer outcome and a shorter overall survival. An early and intensive chemotherapy may improve the prognosis and avoid systemic involvement.

PP 41.07

PYLORUS-PRESERVING PANCREATODUODENECTOMY WITH GASTROINTESTINAL RECONSTRUCTION BY THE IMANAGA METHOD

Kitago, Minoru¹; Matsui, Junichi²; Omagari, Kenji¹; Matsubara, Kentaro¹; Akiyama, Yoshinobu¹; Hattori, Hiroaki¹; Yamamoto, Tatsuya¹; Suzuki, fumio¹; Otaka, Hitoshi¹; Ogata, Yoshiro³

¹Kyosai Tachikawa Hospital, Surgery, Tachikawa, Tokyo, Japan; ²Saitama city hospital, Surgery, Saitama, Saitama, Japan; ³Tochigi Cancer Center, Surgery, Utsunomiya, Tochigi, Japan

Background. Pylorus-preserving pancreatoduodenectomy (PPPD) have been performed for disorders of the pancreatic head and periampullary region. The most commonly used reconstructive technique anastomose the duodenum end-to-side to the jejunum, with pancreatic and biliary anastomoses placed proximally to the end-to-side duodenojejunostomy. In contrast, we have favored PPPD with gastrointestinal reconstruction by the Imanaga method (PPPD-Imanaga), which consists of end-to-end duodenojejunostomy, end-to-side pancreatojejunostomy, and choledochojejunostomy, performed in that order, because the PPPD-Imanaga provides a physiologic mixture of food, pancreatic juice, and bile in the upper portion of the jejunum and pancreatojejunostomy and choledochojejunostomy are observed by endoscopy after PPPD-Imanaga. We present our PPPD-Imanaga and evaluate anastomoses of pancreatojejunostomy and choledochojejunostomy by endoscopy.

Methods. From April 2007, 2 patients underwent PPPD-Imanaga at Tachikawa Hospital. As part of the PPPD-Imanaga, the pancreatic duct was sewn directly to the jejunal mucosa and lost tube stent was inserted. Outer layer sutures were placed between the pancreas and seromuscular layer of the jejunum after spraying of fibrin glue on the pancreatic stump. Choledochojejunostomy was done with single layer sutures without biliary drainage tube. End-to-end duodenojejunostomy was anastomosed by layer-to-layer anastomosis.

Results. No complication correlated with PPPD-Imanaga was shown in pancreatic head cancer patient(TNM Stage‡V) and cholangiocarcinoma patient(TNM-Stage‡UA). The average duration of hospital stay after operation was 25 days. Follow-up endoscopic examination in 3 months since operation showed pancreatojejunostomy and choledochojejunostomy were opened and stent tube was lost. Conclusion□FImanaga method is a favorable complement to PPPD.

PP 41.08

MESENTERICOPORTAL VEIN RESECTION FOR PANCREATIC HEAD CARCINOMA

Kostov, Daniel; Ivanov, Valkan

Naval Hospital, Clinic of General Surgery, Varna, Bulgaria

Introduction. Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. However, this procedure can only be performed in a few cases due to presentation of the tumor in advanced stages.

Objective. An aggressive surgical approach remains the best palliation and chance for five-year survival in the treatment of locally advanced pancreatic cancer. Increasingly this approach has involved partial or total resection of the portal vein (PV) or superior mesenteric vein (SMV) in combination with pancreaticoduodenectomy.

Methods. We are presenting three patients with pancreatic head carcinoma, operated by different types of techniques, different resection volume and mesentericoportal vein reconstruction. One of the patients with two-third of cross-sectional circumference of the lower PV or SMV resection, and a SMV diameter of 0.5 cm will result with primary venous re-anastomosis, primary closure is preferred technique of reconstruction. When a large amount of the cross-sectional venous diameter was resected we use of an on-lay patch or interposition graph of autogenous vein – used in the second patient. The third patient was put under total resection of the portal-mesenterial venous confluence along 2 cm, which allowed termino-terminal venous anastomosis.

Results. In our series all patients underwent partial or total vein resection with minimal additional blood loss, operative time, or post-operative complications including pancreatic fistulae. Postoperative portography had showed preserved anatomical relationship of the vessels, without kink or rotation of the portal-mesenteric confluence.

Conclusion. Pancreatic resection is currently the only treatment offering the possibility of long-term survival for patients with pancreatic cancer. Mesentericoportal vein involvement used to be considered a contraindication to pancreatic resection, but recent advances in vascular surgery have gradually extended the indications of curative pancreatic resection in such cases.

PP 42.01

CHOLANGIOCELLULAR CARCINOMA PRESENTING AS BUDD-CHIARI SYNDROME: A CASE REPORT AND LITERATURE REVIEW

Korita, Pavel¹; Wakai, Toshifumi¹; Shirai, Yoshio¹; Sakata, Jun¹; Muneoka, Katsuki²; Hatakeyama, Katsuyoshi¹

¹Niigata University Graduate School of Medical and Dental Sciences, Division of Digestive and General Surgery, Niigata City, Japan; ²Niitsu Medical Center Hospital, Department of Surgery, Niigata City, Japan

We herein report the case of a patient with cholangiocellular carcinoma presenting as Budd-Chiari syndrome. A 63-year-old man presented with shortness of breath and abdominal distention. Thoraco-abdominal CT and inferior vena cavography revealed the obstruction of the inferior vena cava, and Budd-Chiari syndrome was diagnosed. As it could not be denied that soft tissue density around the obstruction on CT showed a malignant tumor, exploratory laparotomy was performed, which revealed a tumor measuring 5 cm arising in the segment VIII of the liver with direct invasion to the inferior vena cava. Histologic examination of excisional biopsy specimen revealed moderately to poorly differentiated adenocarcinoma. It was considered that extrahepatic stromal invasion involved the inferior vena cava led to Budd-Chiari syndrome. Radical resection was abandoned because of distant nodal disease and peritoneal metastases. Immunohistochemical study confirmed a diagnosis of cholangiocellular carcinoma, because the tumor cells were diffusely positive for cytokeratin 7, which is a marker for biliary epithelium. He received systemic chemotherapy with gemcitabine (250mg/m2/day) and irinotecan (25mg/m2/day). No adverse effects were noted. Eight months after the initiation of chemotherapy, he died of disease. In the literature, we found only 5 cases (including the present case) of cholangiocellular carcinoma presenting as Budd-Chiari syndrome. This case and a review of the literature suggest that patient with cholangiocellular carcinoma arising in the liver adjacent to the inferior vena cava may present as Budd-Chiari syndrome and clinicians should take it into consideration in differential diagnosis of a cause disorder of Budd-Chiari syndrome.

PP 42.02

PANCREATIC AND DUODENAL INVASION IN DISTAL BILE DUCT CANCER: PARADOX IN THE TUMOR CLASSIFICATION OF THE AMERICAN JOINT COMMITTIEE ON CANCER

EBATA, Tomoki; NISHIO, Hideki; IGAMI, Tsuyoshi; YOKOYAMA, Yukihiro; NIMURA, Yuji; NAGINO, Masato

Nagoya University Graduate School of Medicine, Disision of Surgical Oncology, Nagoya, Japan

Background. Distal bile duct cancer often invades the pancreas and/or duodenum; invasion of the pancreas is defined as a T3 and that of the duodenum as a T4 tumor, in the T classification of the American Joint Committee on Cancer (AJCC).

Objective. The aim of this study was to assess whether this T classification is rational from the viewpoint of prognostic power.Method.: Ninety-five patients with distal bile duct cancer were retrospectively analyzed, according to the current T classification of the AJCC.

Results. The main determinant of pT3 (n = 32) and pT4 (n = 30) was pancreatic and duodenal invasion, respectively, and the survival for patients with pT3 and pT4 are similar (P = 0.595). Duodenal invasion was present in 39% of the patients with pancreatic invasion, whereas pancreatic invasion was observed in 86% of those with duodenal invasion. The survival for patients with pancreatic invasion was not significantly different (P = 0.283) whether or not there was concomitant duodenal invasion (n = 19 and n = 37, respectively). Multivariate an alysis identified venous invasion, distant metastasis, histologic grade, and pancreatic invasion as independent prognostic factors.

Conclusion. Although duodenal invasion usually occurs after pancreatic invasion, it is not a significant prognostic factor while pancreatic invasion is. The current T classification should be revised since it expresses tumor extension but does not reflect a survival in distal bile duct cancer.

PP 42.03

AGGRESSIVE INDICATION OF LOBAR HEPATIC RESECTION AND VASCULAR RESECTION FOR HILAR CHOLANGIOCARCINOMA

Tanaka, Eiichi; Hirano, Satoshi; Suzuki, On; Sagawa, Noriaki; Ichimura, Tatsunosuke; Hashida, Hideaki; Suzuoki, Masato; Kondo, Satoshi

Hokkaido University Graduate School of Medicine, Surgical Oncology, Sapporo, Japan

Background. Hemihepatectomy combined with portal and/or hepatic arterial resection and reconstruction for hilar cholangiocarcinoma (HC) is a challenging issue, in both technical aspects and safety. Large amount of hepatic resection may result in negative hepatic ductal margin, however, increased risk in postoperative hepatic failure. Vascular resection, especially hepatic arterial resection has a serious risk of postoperative remnant liver ischemia and liver abscess.

Introduction. Standard operative procedure for HC except Bismuth type IIIb in our department is right hemihepatectomy with caudate lobectomy and extrahepatic bile duct resection in the condition of adequate remnant liver functional reserve. In addition, vascular resection such as portal and/or hepatic arterial resection is concomitantly performed with or without liver resection to keep surgical separation margin free. Recently, portal vein resection and reconstruction is routinely performed with right hemihepatectomy for en bloc resection of HC.

Materials andMethods. We experienced 100 surgically resected cases in our department since 1999, of which age are 68(45–81) on average, gender M/F = 81/19, and Bismuth classification I/II/III/IV = 18/20/31/31. Hepatic arterial resection (N = 18) was performed in the presence of temporal arterio-portal shunting and no direct arterial reconstruction in 17 patients, preserved left hepatic artery originated from left gastric artery and no arterial reconstruction in 1 patient.

Results. Respectability of our 100 cases are; R0/R1/R2 = 88/10/2. Cumulative 3 and 5 year survival rate on Kaplan-Meier method is; 49% and 29% in the case of portal vein resection(N = 39), 34% and 13% in arterial resection(N = 18), 51% and 34% in simultaneous arterial and portal vein resection(N = 9), respectively. There is no postoperative mortality in the case of combined arterial resection.

Conclusion. We believe lobar hepatic resection with vascular resection(s) is a safe and potent surgical procedure to improve surgical outcome of HC.

PP 42.04

HILAR CHOLANGIOCARCINOMA: SURGICAL TREATMENT

Mega, Raquel; Oliveira, Paulo; Nobre, Ana Marta; Rocha, Vitorino; Coelho, João; Moniz, Luisa; Pereira, José A.; P. Marques, Hugo; Filipe, Edite; Mira, Paulo; P. Pereira, Jorge; Martins, Américo; Barroso, Eduardo

H. de Curry Cabral, Centro Hepatobiliopancreático e de Transplantação, Lisboa, Portugal

Background. Hilar cholangiocarcinoma is a frequent cause of obstructive jaundice. Curative treatment is only possible with complete resection, which sometimes demands large hepatic resections. This treatment should be done in hospitals with large experience in hepatic surgery and with possibility of multidisciplinary approach.

Objectives. To study patients who underwent surgery for carcinoma at the hilar confluence of the hepatic ducts. To define age, sex, type of tumor, pre-operative drainage, type of surgery, complications, pos-operative mortality, staging and presence of positive nodes, margins of resection, survival rates and disease-free survival rates. To study prognostic factors to survival and disease-free survival rates.

Methods. Retrospective study, with consultation of clinical process. Survival analysis by Kaplan-Meyer Curves, and prognostic factors with Long-Rank test.

Results. From 2004 to June 2007, 39 patients (71,8% male, aged 35–81, average 63,25) underwent surgery, in our HBP center. Curative resection was possible in 64% of the cases, either local or hepatic resection. About 50% involved the left or right hepatic duct (Bismuth type IIIa or IIIb). The pathological classification showed 40% of IIa tumors by the TMN staging. In 8 patients lymph node involvement was present. The 33 months survival rates for 25 patients undergoing curative resection were 25%.

Conclusion. Surgery is the only curative treatment for cholangiocarcinoma. When resection with free margins is possible, the results are better in long term survival, with a relatively low complications rate.

PP 42.05

TRENDS IN SURGICAL MANAGEMENT OF NO-KLATSKIN BILE DUCT CANCER

Frena, Antonio

Central Hospital of Bolzano, General Surgery, Bolzano, Italy

Introduction. carcinoma of the mid or distal third of the common bile duct is a fairly rare nosological entity in the West, accounting for 13–23% of tumours of the extrahepatic bile ducts. The surgical treatment varies in relation to the site: in the case of carcinomas of the distal common bile duct the operation of choice is duodeno-pancreatectomy, whereas for tumours of the mid common bile duct there is still no unanimous consensus of opinion regarding the type of surgery.

Aim. The prognosis of these tumours is better than that of carcinomas of the proximal choledochus.

Methods. we retrospectively assessed 37 patients with non-hilar extra-hepatic bile duct tumours observed in our department from 1985 to 2005. The presenting symptom was jaundice in 95% of cases. In 23 cases the carcinoma affected the distal common bile duct and in 14 cases the mid common bile duct.

Results. 15 patients were treated with a radial intent by either duodenopancreatectomy (13 cases) or by resection of the common bile duct (2 cases). Twenty-two patients with local inoperability or liver metastases were treated with a palliative operation or endoscopically. Postoperative staging identified 1 patient as stage Ia, 2 patients as stage Ib, 8 patients as stage IIa, 3 patients as stage IIb, and 1 patient as stage III according to the new TNM classification. There was no operative mortality. Survival at 1, 2 and 5 years was 51%, 27% and 14%, respectively.

Conclusions. carcinoma of the mid or distal portion of the common bile duct is a tumour that offers fairly good prospects of survival. Surgical radicality is achieved by obtaining ductal and radial margins which are free of microscopic infiltration and by means of a thorough lymphadenectomy. These conditions can be achieved more easily in carcinomas of the distal portion of the duct owing to the extent of duodeno-pancreatectomy they require. In carcinomas of the mid common bile duct the anatomical contiguity with the portal vein is responsible for a lower resectability rate

PP 42.06

SURGICAL TREATMENT OF HILAR BILE DUCT CARCINOMA --MY PERSONAL EXPERIENCE WITH 25 CONSECUTIVE HEPATECTOMIES--

Kawarada, Y¹; Tabata, M²; Taoka, H²; Isaji, S³

¹Mie University School of Medicine, 1st Department of Surgery, Tsu-City, Japan; ²; ³Mie University School of Medicine, Department of Surgery( Hepatobiliary pancreas), Tsu, Japan

Background.To evaluate our recent surgical policy regrding hilar bile duct carcinoma, we evaluated 62 cases treated between 1976 and 1993, and 25 cases treated between 1944 and 2000. Hepatectomy was performed in a totl of 65 (74.7%) of the 87patients. 40(64.5%) in the early period, and all 25 in the late period, and thus 100 percentage of patients treated by hepatectomy was significantly highr in the late period. Hepatectomy �{total caudate lobectomy that included the paracaval portion (S1�{S9) were performed in all patients in the late period. Also, S4a�{S5�{S1 (so called Taj Mahal hepatectomy) hepatectomies were performed in old patients and patients with poor liver function, and only in the late period. The curative resection rate was significantly higher in the late period. We reported 3-and 5-year survival rates in the late period of 59.9% and 49.9%, respectively, compared with 27.1% and 20.2%, respectively, in the early period in 2001 in the J. Gastrointestinal Surgery (2002). However, some may feel that 2001 was too early to judge our data for the late period or to evaluate the 3-year and 5-year survival rates.<Aim > I retired from Mie University School of Medicine but continued to follow up my 25 cases until the end of 2006.<Results > At the end of 2006, the 3-and 5-year survival rates in the late period (my cases) were 59.1% and 46.4%, respectively. Also, seven of the 25 patients had survived recurrence-free for more than 5 years after surgery.<Conclusion > Between 1994 and 2000, I performed 25 hepatectomies for hilar bile duct carcinoma. After I retired, but continued to follow up my 25 cases for 6 years between 2001 and 2006. The small number in this study may explain the number of positi ve Results. However, my data revealed good results and proved the effectiveness of our procedures for hilar bile duct carcinoma.

PP 42.07

DIFFERENTIATION OF MALIGNANT AND BENIGN PROXIMAL BILE DUCT STRICTURES

Kloek, Jaap¹; van Delden, OM²; Erdogan, Deha¹; ten Kate, Fibo³; Rauws, Eric¹; Busch, Olivier¹; Gouma, Dirk¹; van Gulik, Thomas¹

¹Academic Medical Center, Department of Surgery, Amsterdam, Netherlands; ²Academic Medical Center, Department of Radiology, Amsterdam, Netherlands; ³Academic Medical Center, Department of Pathology, Amsterdam, Netherlands

Background. The main etiology of proximal bile duct strictures is hilar cholangiocarcinoma (HCCA). However, the differentiation of benign and malignant strictures at the liver hilum remains difficult despite extensive diagnostic work-up. The aim of this study was to assess whether preoperative criteria were able to differentiate HCCA from benign proximal bile duct strictures.

Methods. A total of 68 patients underwent resection on the suspicion of HCCA between 1998 and Jan 2007. In these patients, collected data included laboratory investigations, combination of imaging studies (including cholangiography, CT, MRCP and duplex ultrasound) and brush cytology. These findings were analyzed in regard with the final histopathological outcome.

Results. Histopathological examination of the resection specimens confirmed HCCA in 58 patients (85%, group I) whereas 10 patients (15%, group II) were diagnosed with benign strictures. Benign strictures mainly consisted of sclerosing cholangitis (including autoimmune cholangitis) and chronic fibrosing inflammation. The most common presenting symptom was obstructive jaundice in 77% of patients (79% in group I vs. 60% in group II, respectively, P = 0.23). Laboratory findings showed significantly elevated transaminase levels in group I compared to group II (P < 0.05). The various imaging modalities showed a higher incidence of a mass lesion in group I (97% in group I vs. 70% in group II, respectively, P < 0.05). Vascular involvement was exclusively found in group I (36% P < 0.05). Brush cytology was positive for malignant cells in 50% of the patients in group I, whereas none in group II showed malignant cells (P < 0.05).

Conclusions. Despite improved imaging techniques, the differentiation of HCCA from benign proximal bile duct strictures remains difficult. Although specific features, such as vascular involvement and the presence of a mass lesion support malignancy, these findings are inconclusive. Therefore, in case of a suspicious lesion in the liver hilum, surgical excision should be pursued.

PP 42.08

POSTOPERATIVE LIVER FAILURE RATE AFTER LIVER RESECTION FOR HILAR CHOLANGIOCARCINOMA IN THE ABSENCE OF PREOPERATIVE BILIARY DRAINAGE

RAJAN, RAMESH; NATESH, BONNY; KUMAR, ARUN; R S, SINDHU; A, SYLESH; N, SUBHALAL; A P, KURUVILLA

Medical College Hospital, Surgical Gastroenterology, Trivandrum, India

Background. Meta-analyses of controlled trials have not shown preoperative biliary drainage to be beneficial in malignant lower biliary obstruction although isolated reports have shown benefit. However, resection of malignant hilar obstruction often involves resection of cholestatic liver with higher rates of postoperative liver dysfunction/failure. The role of preoperative drainage in this setting is less clear.

Objective. To assess the postoperative liver failure rate after liver resection for hilar cholangiocarcinoma in the absence of preoperative biliary drainage.

Materials and Methods. Operative morbidity and mortality was evaluated from a prospectively held database in patients undergoing liver resection for hilar cholangiocarcinoma over a four year period from July 2003 to June 2007. Preoperative biliary drainage was performed in none.

Results. There were 12 resections in all out of a total of 38 patients with hilar cholangiocarcinoma. 9 patients needed liver resections. There were 5 (L) hepatectomies, 3 ( R) hepatectomies and 1 Parenchyma conserving liver resection. Morbidities noted were minor bile leaks (3), major bile leak with biliary peritonitis (1), ascitic leak (3), hemobilia (1), pleural effusion needing paracentesis (1). Postoperative liver failure occurred in none although there was reversible liver dysfunction in 3. There was 1 mortality due to sepsis from biliary peritonitis. The median preoperative Total Bilirubin level in those who underwent liver resection was 18 mg/dl.

Conclusion. Absence of preoperative biliary drainage is not necessarily associated with a high postoperative liver failure rate in liver resections for hilar cholangiocarcinoma.

PP 42.09

IS THE LEVEL OF TOTAL BILIRUBIN IN THE BILE A SIMPLE INDICATOR FOR EVALUATION OF FUNCTIONAL LIVER RESERVE IN OBSTRUCTIVE JAUNDICE PATIENTS?

Ota, Takehiro¹; Araida, Tatsuo²; Hamano, Mie¹; Takeshita, Nobuhiro¹; Yazawa, Takehisa¹; Tezuka, Tohru³; Yagawa, Yohsuke³; Yasuda, Hideki³; Yamamoto, Masakazu¹; Higuchi, Ryota⁴

¹Tokyo women's Medical University, Surgery, Tokyo, Japan; ²Tokyo Women□fs Medical University Yachiyo Medical Center, Surgery, Chiba, Japan; ³Teikyo University Chiba Medical Center, Surgery, Chiba, Japan; ⁴Tokyo Women's Medical University, Teikyo University Chiba Medical Center, Surgery, Tokyo, Japan

Objective. This prospective study was performed to investigate whether monitoring the level of total bilirubin in the bile from a predicted remnant liver (LTB) can assist in predicting functional liver reserve in obstructive jaundice patients undergoing major hepatectomy. Summary Background Data: Accurate evaluation of functional liver reserve before hepatectomy in patients with obstructive jaundice is sometimes difficult. Method: In 118 patients (45 hilar bile duct and 73 gallbladder cancer) who underwent surgery in our institution, 24 consecutive patients with jaundice scheduled to receive major hepatectomy, in whom all bile from the predicted remnant liver could be collected were included in this study. We measured bile volume, density and LTB preoperatively from the predicted remnant liver. We judged the safe zone to be over 80 mg/day, and the risky zone, from 60 to 80 mg/day.

Results. Mean bile volume, total bilirubin density and LTB from the predicted remnant liver were 3.4□}1.7dl, 51□}26 mg/dl and 153□}72 mg/day, respectively. Of 21 patients with LTB over 60 mg/dl, who underwent major hepatectomy as planned preoperatively, one died of liver infarction, sepsis and DIC from obstruction of the reconstructed hepatic artery, but no patient died of liver failure from hepatic insufficiency. Two patients whose LTB was under 60 mg/dl barely tolerated major hepatectomy, and long postoperative management was needed because of postoperative liver failure.

Conclusion. LTB is a simple indicator for evaluation of functional liver reserve in obstructive jaundice patients who are candidates for major hepatectomy.

PP 42.10

HORIZONTAL EXTENT OF EXTRAHEPATIC BILE DUCT CANCER ACCURATELY DIAGNOSED BY INTRADUCTAL ULTRASONOGRAPHY: A CASE REPORT

Sadakari, Yoshihiko¹; Ienaga, Jun²; Tanabe, Reiko²; Nakamura, Masahumi²; Yamaguchi, Koji²; Tanaka, Masao²

¹Graduate School of Medical Sciences, Department of Surgery and Oncology, Kyushu University, Fukuoka City, Japan; ²

Background. Bile duct cancer often extends intraluminally. The proper diagnosis concerning about the horizontal extent is important to determine the treatment strategy. We report bile duct cancer of which extent diagnosed correctly using intraductal ultrasonography (IDUS).

Case Report. A 59-year-old Japanese man consulted his personal doctor for jaundice. Serum chemistry suggested obstructive jaundice and ultrasonography revealed dilatated intrahepatic bile ducts. Therefore, the patient was referred to our hospital for the further examination and treatment. Computed tomography, magnetic resonance imaging and endoscopic retrograde cholangiography detected bile duct tumor localized in the extrahepatic bile duct below primary confluence, and diagnosed bilateral hepatic ducts were intact. However IDUS only revealed the papillary change in the left hepatic duct and intrahepatic duct which suggested cancer invasion. Extended left lobectomy with caudate lobectomy and pylorus-preserving pancreatoduodenectomy were performed. The resected specimen showed that the tumor extended to the left hepatic duct and surgical margin was free. 18 months after the operation, the patient is alive without recurrence.

Conclusion. IDUS is one of the useful modalities to determine horizontal extent of bile duct cancer in some cases.

PP 42.11

CARCINOMA OF THE PROXIMAL AND MID BILE DUCT: IS BILE DUCT SEGMENTAL RESECTION AND LYMPH NODE DISSECTION APPROPRIATE?

Lee, Hyung geun¹; Choi, Sung-Ho²

¹Samsung Medical Center, Sungkyunkwan University School of Medicine, seoul, Korea, Democratic People's Republic of; ²Samsung Medical Center, seoul, Korea, Republic of

Background/aims. Bile duct segmental resection with lymph node dissection (radical BDSR) is a procedure done for the Bismuth type I of proximal bile duct cancer (PBD-1) and mid bile duct cancer (MBD) when proximal and distal resection margins are negative and there is no local invasion to surrounding vascular structures, duodenum, pancreas or liver. Although BDSR is performed by many surgeons in select cases, clinical studies on the adequacy of this procedure is scarce. In this study, clinical observation and prognostic factor analysis is done for patients receiving radical BDSR for PBD-1 or MBD. To validate the adequacy of radical BDSR for PBD-1 or MBD, comparison of survival and postoperative complication and hospital stay is made between radical BDSR for PBD-1 or MBD and pancreaticoduodenectomy (PD) for distal bile duct cancer (DBD). Result: Retrospective analysis was conducted for 45 cases of radical BDSR for PBD-1 or MBD and 149 cases of PD for DBD. 3- and 5-year survivals were 51.7% and 36.6% for the radical BDSR group. T-stage and lymph node invasion were significant prognostic factors. 3- and 5-year survivals of patients in the PD group were 55.7% and 34.2%, respectively. Radical BDSR group and PD group did not show significant difference in survival when adjusted for TNM stage. Postoperative complications were significantly less in the radical BDSR group (20.0% vs. 40.9%, p = 0.01). Postoperative hospital stay was significantly shorter in the radical BDSR group (mean 16.62 vs. 28.39 days, p = 0.035).

Conclusions. Bile duct segmental resection with lymph node dissection is justified as a radical operation for PBD-1 or MBD when there is minimal local invasion and negative bile duct resection margin and radial margin is ensured.

PP 43. 03

LAPAROSCOPIC RIGHT HEPATECTOMY PRESERVING MIDDLE HEPATIC VEIN TRIBUTARIES IN ADULT-TO-ADULT LIVING DONOR LIVER TRANSPLANTATION

Yi, Nam-Joon¹; Suh, Kyung-Suk¹; Kim, Juhyun¹; Shin, Woo Young²; Lee, Hae Won¹; Lee, Kuhn Uk¹

¹Seoul National University College of Medicine, Surgery, Seoul, Korea, Republic of; ²

This is the first report of a totally laparoscopic right hepatectomy preserving middle hepatic vein tributaries in a live donor. A 25-year-old lady volunteered to be a live donor to her farther who has suffered from recurrent hepatic encephalopathy associated with hepatitis B related liver cirrhosis and hepatocellular carcinoma. A totally laparoscopic procedure was performed using a hand port device and additional 5 ports. The hepatic parenchyma was dissected using laparoscopic ultrasonic aspirator under pneumoperitoneum. After then, the right bile duct stump was intracorporeally over-sewn using 6–0 prolene. The right hepatic artery, right portal vein, and middle hepatic vein tributaries were divided using hem-o-lock clips. The right hepatic vein was divided using endovascular GIA stapler. The operation time of the donor was 765 minutes including 218 minutes for parenchymal transaction and 150 minutes for meticulous wound closure. She was discharged on postoperative day (POD) 10 without complication. The recipient recovered well but unfortunately experienced cerebral infarction on POD 10. He was discharged POD 32 after recovery from sequela of cerebral infarction. In this case, a totally laparoscopic modified right hepatectomy was technically feasible and may improve the quality of life of live liver donors as well as cosmetic effect.

PP 43.01

LIVING DONOR LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA IN PATIENTS BEYOND THE MILAN BUT WITHIN THE UCSF CRITERIA

Park, Jeong-Ik; Lee, Sung-Gyu; Hwang, Shin; Kim, Ki-Hun; Ahn, Chul-Soo; Moon, Deok-bog; Ha, Tae-Yong; Song, Gi-Won; Jung, dong-hwan

University of Ulsan College of Medicine and Asan Medical Center, Department of Surgery, Seoul, Korea, Republic of

Background. Liver transplantation is accepted as one of the curative treatments for patients with the diagnosis of hepatocellular carcinoma(HCC). The Milan criteria have remained the standard inclusion criteria for over a decade. Nevertheless, no much is known regarding the results of liver transplantation in patients with tumors outside of the Milan criteria. The aim of this study was to analyze the patient¡^—s survival and post-transplant disease-free survival comparing HCC meeting the Milan and meeting the UCSF but exceeding the Milan criteria.

Patients and Methods. Between February 2000 and June 2006, 329 cases of living donor liver transplantation(LDLT) for patients with HCC were performed at Asan medical center. We excluded 13 hospital mortalities and 17 salvage LDLT. Among the patients, 15 patients exceeding the Milan but meeting the UCSF criteria and 226 patients meeting the Milan criteria were identified. Male to female sex ratio was 245/54 and mean age was 52.3 years old.

Results: The overall 1- and 3-year survival rates of patients who meeting the Milan criteria were 95.1%, 86.7%, respectively, whereas those of patients who exceeding the Milan but meeting the UCSF criteria were 93.3%, 74.7%, respectively. The 1- and 3-year disease-free survival rates of patients who fulfilled the Milan criteria were 94.7%, 89.0%, respectively, whereas those of patients who exceeded the Milan but meeting the UCSF criteria were 86.7%, 71.1%, respectively.

Conclusions. This study shows that the 3-year survival and disease free survival rate was lower in the beyond Milan-within UCSF criteria compared to within the Milan criteria patients. However, only small percentage of transplanted HCC patients can be classified as beyond Milan within UCSF criteria, so more large volume patients¡^— study is needed.

PP 43.02

LIVING-DONOR LIVER TRANSPLANTATION WITH SIDE-TO-END RENO-PORTAL ANASTOMOSIS FOR PATIENTS WITH OBLITERATED PORTAL VEIN AND LARGE SPLENORENAL SHUNTS

Moon, Deok-Bog; Lee, Sung-Gyu; Ahn, Chul-Soo; Kim, Ki-Hun; Hwang, Shin; Park, Kwang-Min; Kim, Kwan-Woo; Ko, Kyoung-Hoon; Choi, Nam-Kyu; Ha, Tae-Yong

Asan Medical Center, Seoul, Hepato-Biliary Surgery & Liver Transplantation, Seoul, Korea, Republic of

Background. End-stage liver disease patients with obliterated portal vein(PV) and large spontaneous splenorenal shunts(SRS) often need renoportal anastomosis(RP-A) during liver transplantation as one of the solutions. At our institution, RP-A in living-donor liver transplantation(LDLT) was successfully performed by using different method from the previous end-to-end anastomosis.

Methods. We performed four LDLT with RP-A for the treatment of obliterated PV and large spontaneous SRS between 2005 and 2006. We reviewed the two different methods of RP-A, and also evaluated outcomes of RP-A.

Results. End-to-end RP-A was performed in one patient by interposing cadaveric iliac vein graft between native renal vein and graft portal vein. It had several problems causing difficult and insecure anastomosis. Other three patients underwent side-to-end RP-A that could make us to perform easy and secure anastomosis. Except one patients who died from cerebral hemorrhage, other three patients who underwent LDLTs with RP-A are alive with normal graft function and a patent RP-A.

Conclusion. LDLT with side-to-end RP-A for the treatment of obliterated PV and large spontaneous SRS in patients with end-stage liver disease is an easy and safe life-saving portal reconstruction technique.

PP 43.04

TEMPORARY PORTO-CAVAL SHUNT(TPCS) DURING LIVING DONOR LIVER TRANSPLANTATION(LDLT)

Goja, Sanjay; Kakodkar, Rahul; Kumaran, Vinay; Nundy, S; Soin, Arvinder

Sir Ganga Ram Hospital, Gyan Burman Liver Surgery Unit, New Delhi, India

Background. Temporary porto-caval shunt can resolve the problems associated with portal vein clamping during the anhepatic phase of liver transplantation. Its advantages include avoidance of bowel edema, reduction in transfusion requirements and avoidance of fluid overload which in turn may translate into reduction in artificial ventilation time and the shorter intensive care and posttransplant hospital stay. AIM To study the indications and utility of temporary porto-caval shunt in our series of LDLT.

Methods. All the 148 LDLTs performed between Jan 2002 to July 2007 were analysed. An end-to side TPCS was done in 13 patients with one or more of the following: a) Fulminant liver failure or patients who had no spontaneous portocaval shunts (5) b) Benching time unexpectedly prolonged (4) c) Excessive portal hypertensive bleeding during hepatectomy (6) d) Variceal bleeding during recipient hepatectomy (1).

Results. Among the TPCS patients, 10 were males and 3 females. Their age ranged from 17 to 58years (mean 39.7). Three patients had FHF, 2 HCV induced cirrhosis, 4 cryptogenic cirrhosis,1 PSC, 1 Hepatitis B induced cirrhosis, 1 alcoholic cirrhosis and 1 autoimmune cirrhosis. Their MELD scores were between 22 to 38 (mean 28). The average time taken for the TPCS was 5 minutes and there was no loss of portal vein length in any patient. Portal vein clamping time was 64–104 minutes in FHF patients and 80–201 minutes in the others. There was appreciable decrease in blood loss after TPCS in all patients. In one patient intra-operative variceal bleeding was immediately controlled with TPCS. In this high risk group of patients, 10 out of 13 (77%) survived and are currently well 1–38 months after transplant. Our overall current (last 100 patients) patient and graft survival rate at 1 year is 92%.

Conclusion. In selected high risk patients, temporary TPCS is an easy and efficacious method of reducing problems due to portal vein clamping during the anhepatic phase of living donor liver transplantation.

PP 43.05

EFFECTS OF ISCHEMIC PRECONDITIONING OF THE GRAFT IN ADULT LIVING RELATED LIVER TRANSPLANTATION

azoulay, DANIEL; castaing, denis; andreani, paola

APHP hopital paul brousse, cHB, Villejuif, France

Background. Ischemic preconditioning of the liver graft in the donor has not yet been studied in clinical adult to adult living related right liver transplantation (LRRLT). OBJECTIVE To compare the results of LRRLT with and without ischemic preconditioning of the graft in the donor.

Patients and Methods. Alternate patients were transplanted with right liver grafts from living donor that had (n = 22, Group Precond) or had not (n = 22, Group Control) been subjected to IPC of the graft in the donor. Liver ischemia-reperfusion injury, liver and kidney function, morbidity and mortality were compared in the two groups of recipients. Predictive factors of the peak AST level and the minimum value of prothrombin time were assessed by uni-and multivariate analysis. The outcome of the two groups of donors were compared.

Results In the recipients, the postoperative peaks of AST (IU/L) and ALT (IU/L) were similar (307 + 189 and 437 + 302, p = 0.8, vs 290 + 146 and 496 + 343, p = 0.6, respectively) in Group Precond and Group Control. In univariate analysis, only the preoperative value of AST in the recipient was significantly associated with the postoperative peak of AST. The rate of technical morbidity and the incidence of acute rejection were similar in both groups. Primary non function occured in 1 and 0 case of Group Precond and Group Control respectively (p = 0.9). In multivariate analysis, the graft to recipient weight ratio (p = 0.003) and the preoperative value of bilirubin (p = 0.004) were significantly predictive of the post-transplant minimum value of PT. Hospital mortality rates were similar in the two groups. IPC had no impact in the donor on postoperative peak of AST, liver and kidney function tests, morbidity and duration of hospital stay.

Conclusion. Compared to standard LRRLT, ischemic preconditioning of the liver graft in the donor does not trigger any benefit neither for the recipient nor for the donor. Until further studies are available, the clinical value of preconditioning liver grafts remains uncertain.

PP 43.06

RESULTS OF HEPATIC ARTERY ANASTOMOSIS USING LOUPE MAGNIFICATION IN LIVING DONOR LIVER TRANSPLANTATION

Goyal, Neerav; Vij, Vivek; Sahani, Riti; Wadhawan, Manav; Srivastava, Ajitabh; Kumar, Abhay; Gupta, Subash

Indraprastha Apollo Hospital, Liver Transplant and Surgical Gastroenterology, New Delhi, India

Background. Hepatic artery thrombosis (HAT) occurs in 1.6 to 8% of Liver recipients and has high morbidity and mortality. Amongst other factors, using operating microscope is said to decrease incidence of HAT, but it prolongs operative time. We use 3.5x loupe for our hepatic arterial anastomosis (HAA) and describe our center's experience with it.

Material and Methods. Seventy patients underwent Living Donor Liver Transplantation from January 2004 to August 2007 with Right lobe grafts in 63 and Left lobe in 7 patients. Donors had preoperative evaluation by MDCT Angiography. HAA was carried out with 7–0 prolene, using 3.5x Loupe. Recipient's post transplant vascular perfusion was evaluated per-operatively with Doppler Ultrasonography (DU) by a single ultrasonologist. Post operatively, DU was done for five consecutive days and then as required. Hepatic arterial peak flow velocity, type of flow and resistive indices were evaluated. Hemoglobin was kept < 10gm%, patients with INR < 1.7 received low molecular weight heparin, and Ecosprin once platelet count rose to > 30,000/cumm. Diagnosis of HAT was made on basis of DU and confirmed by MDCT Angiography.

Results. Mean diameter of hepatic artery in 70 patients was 2.8mm. Redo HAA was done in 4 patients for unsatisfactory flow at per-operative DU. One patient developed HAT on post operative day 3. Redo anastomosis with an arterial conduit was attempted because of intimal dissection of hepatic artery, but was unsuccessful. Another patient had late HAT due to persisting bile leak. Incidence and mortality due to HAT was 2/70 (1.4%). Overall survival was 59/70 (81.9%).

Conclusion. A meticulously done Hepatic arterial anastomosis under loupe magnification, avoiding kinking, looping or twisting of anastomosis, can keep the incidence of HAT low. Hepatic arterial anastomosis should be redone unless a satisfactory per-operative DU result is achieved, which goes a long way in reducing incidence of post operative HAT.

PP 43.07

TIPS FOR TRANSPLANT IN LIVING DONOR LIVER TRANSPLANT-ROLE IN DECREASING PERIOPERATIVE RISK

Wadhawan, Manav¹; Vij, Vivek²; Kumar, Ajay¹; Gupta, Subash²; Gupta, Subash²

¹Indraprastha Apollo Hospital, Gastroenterology & Hepatology, Liver Transplant, New Delhi, India; ²Indraprastha Apollo Hospital, Liver Transplantation and Surg Gastro, New Delhi, India

Background. Role of TIPS to reduce perioperative risk in liver transplant is controversial. Anecdotal studies have reported decreased intraoperative blood loss if TIPS is done prior to transplant, but evidence is equivocal. We report a very high-risk case for transplant that had multiple abdominal surgeries in the past and underwent successful liver transplant after a TIPS procedure.

Case report. A 55 yr old lady, suffering from HCV related end stage liver disease, presented to us in grade IV encephalopathy for consideration of liver transplant. She had a history of multiple abdominal surgeries in the past – Tubal ligation in 1985, open cholecystectomy in 1992, incisional hernia repair in 1992 and repeat repair of incisional hernia in 2002. After initial stabilization, TIPS procedure was performed on her prior to the transplant. She tolerated the procedure well, had no encephalopathy post TIPS and ascites disappeared. She underwent a right lobe LDLT 10 days after TIPS. There were dense adhesions between the liver, stomach, duodenum and colon, which took 3.5 hours to separate. Despite extensive adhesions due to previous surgeries, patient had minimal blood loss and required only 2 packed red cell transfusions. Of this one unit was transfused during reperfusion, where we flush the liver with portal blood and suck this out through an IVC vent. It was relatively simple to retrieve the stent at operation by dividing the stent with scissors at the right portal vein level. She had an uneventful postoperative recovery and was discharged on 20th post op day.

Conclusion. TIPS may have a role before transplant to reduce blood loss during surgery. TIPS does not hinder surgery or postoperative survival and may reduce morbidity and mortality in sick patients for liver transplant with a high risk of intraoperative bleeding.

PP 43.08

HEPATIC ARTERY RECONSTRUCTION IN LEFT LOBE LIVER TRANSPLANTATION: DIFFICULTIES AND OUTCOMES

Soliman, Hossam Eldeen; Ibrahiem, Tarek; Soliman, Bassem; Hegazy, Osama; Marwan, Ibrahiem

National liver institute, Menoufia University, Department of Hepatobiliary and liver transplantat, Egypt

Background. Hepatic artery reconstruction is an essential step during liver transplantation. The use of micro9surgical techniques had minimized the rate of hepatic artery complications to below 2%. Left lobe grafts are commonly used in pediatric transplants and less commonly in adults.

Aims. We present our experience in in hepatic artery reconstruction in a mixed pediatric and adult living donor transplantation governmental program in Egypt. mes.

Patients and Methods. We had performed 16 left lobe livibg donor liver transplantation for pediatric patients that will be compared to 23 right lobe grafts for adults in the department of Surgery, National Liver institute, Menoufia University starting from 28th of April 2003 to the end of September 2007. We reviewed the preoperative patients data, graft characteristics, operative data, postoperative details including hospital stay, the in-hospital complications and early follow.

Results. There were no cases of Hepatic artery thrombosis in left lobe grafts compared to two cases in the adult series. Hepatic artery steal phenomena occurred in each group. The operative time was 60± 30 minutes for left lobe grafts while 45±10 in Right lobe grafts. What is unique in our series is that reconstruction of hepatic arteries arising from the left gastric artery was done in 3 cases and was associated with more operative time and all has biliary complications and leak. All died later from these biliary complication.

Conclusions. Hepatic artery reconstruction for left lobe grafts is technically more difficult but with low thrombosis rate. We don't recommend reconstruction of accessory arteries arising from the left gastric artery because of the high rate of biliary complications in theses cases in our series.

PP 43.09

USE OF THE NATIVE LIVER VEINS AS A SOURCE FOR VEIN GRAFTS IN LIVING DONOR LIVER TRANSPLANTATION: TECHNIQUE, DIFFICULTIES AND COMPLICATIONS

Soliman, Hossam Eldeen; Ibrahiem, Tarek; Soliman, Bassem; Hegazy, Osama; Marwan, Ibrahiem

National liver institute, Menoufia University, Department of Hepatobiliary and liver transplantat, Egypt

Background. LIVING DONOR liver transplantation is a good alternative in areas where cadaveric transplants. Variation of the hepatic veins and portal vein are important factor in determining suitability of grafts for living donation especially as regard donor safety and difficulty in outflow reconstruction due to the lack of suitable vein grafts.

Aims. We present our experience in vascular reconstruction of living donor transplants using vein grafts from the native liver of the recipient.

Patients and Methods. We had performed 39 living donor liver transplantation in the department of Surgery, National Liver institute, Menoufia University starting from 28th of April 2003 to the end of September 2007. They 16 pediatric patients and 23 adult patients. We reviewed the preoperative patients data, graft characteristics, operative data, postoperative details including hospital stay, the in-hospital complications and early follow. And accordingly, we excluded 7 patients with tumors and two patients with portal vein thrombosis.

Results. There were one case of use of portal confluence for reconstruction of double portal veins in left lobe group graft in pediatric cases. While in right lobe grafts we used vein grafts in 13 out of 16 patients. We tried to minimize the number of hepatic veins to a maximum of two anastomsies by this technique. Long grafts were obtained from the portal system and the hepatic veins in reconstruction of V5 in 4 patients, V8 in 2 cases, middle hepatic vein in 5 cases, inferior hepatic vein in 2 cases and anterior patch for the right hepatic vein in 8 cases. In one case we used a canalized umbilical vein to reconstruct two inferior veins in one patient. In one case the long grafts were thrombosed postoperatively but the rest were functioning postoperatively.

Conclusions. The native liver of the recipient is a good source for vein grafts in livind donor liver transplants in absence of portal vein thrombosis and malignancy.

PP 43.10

EXTENDED LEFT HEPATECTOMY INCLUDING MIDDLE HEPATIC VEIN ACCOMPANIED BY V5 AND V8 RECONSTRUCTION FOR A LIVING-RELATED DONOR

Hyodo, Masanobu; Yasuda, Yoshikazu; Fujiwara, Takehito; Sakuma, Yasunaru

Jichi Medical University Hospital, Department of Surgery, Shimotsuke, Japan

Background. In case of extended left hepatectomy including middle hepatic vein (MHV), anterior segment is subject to congestion due to dissection of V5 and V8.Aim. We have introduced V5 and V8 reconstruction in extended left hepatectomy for a living-related donor to prevent anterior segment from congestion.

Methods. We expose suprahepatic vena cava (IVC) distinctly. After left hepatic artery and portal vein are secured, we transect liver parenchyma along right side of MHV intermittently clamping anterior segment portal pedicle, taking care of preserving V5 and V8. After the confluence of MHV and IVC is completely exposed, V8-IVC anastomosis is performed at first, and V5-IVC anastomosis is made by interposed a 3–4cm venous graft. If the surgical space is too small, we dissected left hepatic duct and hilar plate prior to venous reconstruction. Finally, we take out the graft after dissection of left hepatic duct, artery, portal vein, and both middle and left hepatic vein.

Results. We have performed this procedure for living-related donor operation□@in three cases without any complications.

Conclusions. Left extended hepatectomy accompanied by V5, V8 reconstruction is a feasible procedure for a safe living-related donor operation to preserve functional liver volume as much as possible.

PP 44.01

HEPATOPULMONARY SYNDROME ASSOCIATED WITH EXTRAHEPATIC PORTOSYSTEMIC SHUNT IMPROVES AFTER RADIOLOGICAL CLOSURE

Zachariah, Uday¹; Shyamkumar, NK²; Surendra Babu, SRN²; Moses, Vinu²; Eapen, C E¹; Kurian, George¹; Sitaram, V³

¹Christian Medical College, GI Sciences, Vellore, India; ²Christian Medical College, Radiodiagnosis, Vellore, India; ³Christian Medical College, Hepatopancreatobiliary Surgery, Vellore, India

Background. Hepatopulmonary syndrome (HPS) secondary to extrahepatic portosystemic shunt (EPS) is rare. Congenital EPS can be Type I or Type II depending on the absence or presence of a patent portal vein (PV). Of only 2 reported cases of EPS with HPS, both below 5 years of age, one had surgical shunt ligation. We report a case of HPS associated with a mesocaval shunt in an adult male, with significant improvement after radiological intervention.

Case report. A 41 year old male was evaluated for progressive exertional dysnoea and cyanosis over 5 years. He had a normal chest radiograph, echocardiogram, CT thorax and pulmonary angiogram with blood gases demonstrating orthodeoxia and contrast echo suggesting an extra cardiac shunt. CT abdomen revealed a small, symmetric liver, small caliber PV (6mm) and the superior mesenteric vein draining into infrarenal inferior vena cava via a large collateral vein. He had normal liver function. A diagnosis of HPS possibly secondary to EPS was made. Treatment options considered were liver transplantation, surgical ligation and radiological shunt closure. Following temporary balloon occlusion of the shunt, radiological coil embolization was planned at a later date. Meanwhile, he noticed marked improvement in his effort tolerance. Doppler and CT abdomen revealed shunt thrombosis with increase in PV caliber (12.6mm). Follow up at 2 months confirmed improvement in his oxygenation.

Discussion. EPS must be considered in any patient presenting with HPS without hepatic dysfunction. Portal venous blood may contain gut derived pro-angiogenic factors that are modified by hepatic anti-angiogenic factors. Any extrahepatic shunt may therefore contribute to pulmonary arteriolar proliferation and HPS. We believe spontaneous shunt thrombosis was precipitated by endothelial injury during balloon occlusion.

Conclusion. In this case of Type II EPS, shunt closure after radiological intervention resulted in improvement of HPS.

PP 44.02

HEPATOPANCREATIC TUBERCULOSIS MASQUERADING MALIGNANCY

Varma, Vibha¹; Gandhi, Vidhyachandra²; Nagari, Bheerappa³; Regulagadda, Adikesava Sastry⁴

¹Nizam's Institute of Medical Sciences, Department of Surgical Gastroenterology, Panjagutta, Hyderbad, India; ²Nizam's Institute of Medical Sciences, Department of Surgical Gastroenterology, Hyderbad, India; ³Nizam's Institute of Medical Sciences, Department of Surgical Gastroenterlogy, Hyderabad, India; ⁴Nizam's Institute of Medical Sciences, Department of Surgical Gastroenterology, Hyderabad, India

Background. Hepatopancreatic tuberculosis, a curable disease can have protean manifestations. It may mimic malignancy on clinical and radiological grounds.

Objective. We present our experience of this rare entity in five patients.

Methods. Between June 2000 -2007, we treated three patients of hepatic tuberculosis and two of pancreatic tuberculosis. Their demographic details, clinical presentation and management were studied.

Results. Four patients were males and one female with age range of 16–58 years. Presentation of hepatic tuberculosis was in the form of obstructive jaundice in two patients and hepatomegaly with an abdominal lump in the other. Imaging revealed dilated intra and extrahepatic biliary system with a mass lesion in bile duct (1), periampullary lesion (1) and a space-occupying lesion (SOL) in the liver (1). All were explored for suspected malignancy. Bilobar SOL's in liver with pericholedochal lymphadenopathy (1), with periampullary lesion (1) and large SOL in right lobe with omental nodules & abdominal lymphadenopathy (1) was found at laparotomy. Whipple's with metastatectomy was performed for periampullary carcinoid, other two had biopsy from liver and omental nodules. Histology confirmed tuberculosis. Periampullary carcinoid had associated hepatic tuberculosis. Presentation of pancreatic tuberculosis was with obstructive jaundice and pancreatic head mass in both. One patient had para-aortic lymphadenopathy and image guided cytology from head mass confirmed the diagnosis. Second patient underwent Whipple's procedure for suspected head malignancy. Histology confirmed tuberculosis. All four responded dramatically to antituberculous chemotherapeutic regimen.

Conclusion. Hepatopancreatic tuberculosis, a rare and curable entity should be thought of as a differential diagnosis in mass lesion of liver and pancreas, in endemic areas. Laparotomy may be required to confirm the diagnosis, although targeted fine needle aspiration cytology may avoid laparotomy in some.

PP 44.03

LEIOMYOSARCOMA OF THE INFERIOR VE NA CAVA (IVC): THE EXTENDED ROLE OF THE HPB SURGEON

Sitaram, Venkatramani¹; Joseph, Philip²; Vyas, Frederick²; Sanghi, Ravish²; Cherian, Verghese³; Eapen, Anu⁴; Thomas, Susanna⁵; Samuel, Rekha⁵

¹Christian Medical College Hospital, Department of General Surgery, Ida Scudder Road, Vellore, India; ²Christian Medical College Hospital, Department of General Surgery, Vellore, India; ³Christian Medical College Hospital, Department of Anaesthesia, Vellore, India; ⁴Christian Medical College Hospital, Department of Radiodiagnosis, Vellore, India; ⁵Christian Medical College Hospital, Department of Pathology, Vellore, India

Background. Leiomyosarcoma of the IVC is a rare malignant tumor. Though rare it is still the most common tumor of the IVC. The experience worldwide is limited. The HPB surgeon is ideally suited to manage these patients.

Objective. To share our experience of 8 patients with leiomyosarcoma of the IVC during the period 2003–07.

Methods. The case records of 8 patients with leiomyosarcoma of the IVC seen in our unit from January 2003 to date were analyzed.

Results. Eight patients (6 females and 2 males) were diagnosed to have IVC leiomyosarcoma. Their mean age was 48.4 years (range 38–58). The commonest symptom was right upper abdominal pain (6); two patients had back pain. The duration of symptoms ranged from 1–76 months (mean 19.6 months, median 6 months). An abdominal mass was palpable in 4 of them. None of the patients had symptoms or signs of IVC obstruction. Seven patients were diagnosed by computed tomography and one by magnetic resonance imaging. One patient with type III IVC tumor refused treatment. Complete excision of the tumor was done in 7 patients with type II IVC tumor. A prosthetic graft was used in 5 patients to reconstruct the excised IVC. Of these, one patient underwent autotransplantation of the liver. One patient had local excision and primary closure of the IVC and another had patch closure of the IVC defect. Five patients needed renal vein reconstruction. Postoperative complications include transient renal failure (5), graft thrombosis (1), systemic inflammatory response syndrome (3), ventilator associated pneumonia (1), fungal septicemia (1). There was one perioperative death. Two patients are lost to follow-up. One patient died during follow-up.

Conclusion. Although these tumors appear formidable at the time of presentation, an attempt at complete excision should be made. Radical excision still remains the major therapeutic option in the treatment of leiomyosarcoma of the IVC.

PP 44.05

LIVER LESIONS IN A GENERAL HOPSITAL: AN AUDIT

Patil, Bhushan; Bhange, Snehal; Adhikari, Devbrata; Singh, Rajinder; Shetty, Tilakdas; Joshi, Rajeev

T.N. Medical College & B.Y.L. Nair Ch. Hospital, General Surgery, Mumbai, India

Background. Liver lesions often pose a diagnostic and therapeutic dilemma. Some rare lesions of the liver mimic common clinical conditions, adding to the confusion.

Objective. To profile liver lesions, to diagnose them accurately after a proper clinico-radiologico-pathological co-relation, to assess the lesions amenable to surgical intervention and to formulate a diagnostic and therapeutic algorithm.

Methods. 604 patients were analysed from February 1999 to July 2007. Diagnosis was based on clinical assessment, USG, CT scan, biochemical investigations, FNAC and MRI in select cases. The lesions were classified as solid and cystic. Of the 324 cystic lesions seen, 248 were amoebic liver abscesses, 34 parasitic cysts, 27 pyogenic abscesses, 7 simple hepatic cysts, 5 hepaticolithiasis, 2 polycystic liver disease and one each of biliary cystadenoma, embryonal sarcoma and cystic cholangiocarcinoma. Of the 228 solid lesions, 116 were metastases, 68 were HCC, 34 hemangiomas, 6 focal nodular hyperplasia and 4 hepatic adenomas.

Results. A few uncommon liver pathologies masquerading as some common clinical entities led to confusion. Majority of the cystic lesions of the liver were amoebic or pyogenic abscesses. 4 patients with amoebic abscesses and 1 with pyogenic abscesses required exploration. 24 patients of hydatid cysts, 1 with simple cyst and 1 with biliary cystadenoma were subjected to surgery. All 5 patients of hepaticolithiasis underwent hepatic resection. Only six of the HCC patients could be resected while 10 underwent chemo-embolisation. One case of hemangioma underwent liver resection in view of rapid increase in size. All the remaining cases were managed conservatively.

Conclusion. Amoebic abscesses are common among the lower socio-economic strata and pyogenic abscesses are showing an increasing incidence, related to the increasing incidence of HIV. Majority of the HCC cases present late in the course of the disease and hence are not amenable to surgery.

PP 44.07

SPONTANEOUS HAEMORRHAGE OF THE LIVER; A MANAGEMENT ALGORITHM

Silva, Michael A¹; Mehat, Manjit²; Pissanou, Theodora²; Coldham, Christopher²; Mayer, David²; Bramhall, Simon R²; Buckels, John A C²; Mirza, Darius F²

¹University Hospital Birmingham NHS Trust-Queen Elizabeth, The Liver Unit, Edgbaston, Birmingham, United Kingdom; ²University Hospital Birmingham NHS Trust-Queen Elizabeth, The Liver Unit, Birmingham, United Kingdom

Background. Spontaneous liver bleeds (SLB) are relatively uncommon. We review the management of SLB referred to a single centre in the UK.

Methods. Review of a prospectively recorded database, between 1995 and April 2007. The majority of patients were stabilised with transfusions and optimization of clotting at the referral centre. Those requiring transfer were then managed at our centre.

Results. 52 patients (37 female), median age 47(21–84) years. Bleeding into a liver adenoma (n = 15), focal nodular hyperplasia (n = 4), hepatoma (n = 11), simple cyst (n = 1), HELLP syndrome of pregnancy (n = 3) were underlying causes for 34 (65%). In 18 (35%) patients no aetiology was found. 37 (71%) presented with abdominal pain, 5 (10%) in haemodynamic collapse. Sixteen (31%) had intraperitoneal bleeds, the remainder subcapsular haematomas. 6 were explored at the local hospital with two procedures attended by one of our surgeons. Three of these required packing. 43 (83%) were transferred to our centre in the acute phase or following MDT review. Two were operated acutely for rupture following pregnancy which was packed the other a ruptured hepatoma requiring liver resection. Both died along with another patient with HELLP syndrome. 16 underwent re-imaging at our centre. 5 required angiography and embolization for continued bleeding at our centre. 44 (85%) were managed non operatively following the acute bleed. 21 (40%) underwent surgery for underlying lesions > 6 weeks later. 6 patients with hepatoma died during follow up. Aetiology and intraperitoneal bleeding was not correlated to requirement for interventional radiology or surgery (P > 0.05;NS) Conclusion: Resuscitation and correction of clotting deficit is paramount with cross-sectional imaging and liaising with a HPB centre. Majority can be managed non operatively in the acute phase followed by further imaging, with interval resections where indicated. Surgery in the acute phase has a high mortality. In a significant proportion (35%), cause for the bleed remains elusive.

PP 44.09

OUR RESULTS IN BILIARY ATRESIA-A REALISTIC ASSESSMENT

Kannaiyan, Lavanya; Sen, Sudipta; Chacko, Jacob; Thomas, Gordon; Karl, Sampath; Kumar, Jyothish

Christian Medical College and Hospital, Paediatric Surgery, Vellore, India

Background. Results of Biliary Atresia leave much to be desired. Outcome depends on how early the patients are operated. We present our results.

Aim. To study the outcome of Kasai's Procedure in patients with Biliary Atresia.

Materials andMethods. Retrospective Study of the patients with Biliary Atresia who underwent Kasai's Procedure at CMC, Vellore.

Results. A total of 44 patients underwent Kasai's Procedure from 1995– 2005. The average age of presentation was 74 days. 17 females and 27 males.13 patients had liver cell failure at the time of presentation. 4 patients had Biliary Splenic Malformation Syndrome. The mean age of surgery was at 87 days. 13 patients underwent surgery beyond 100 days of age. The average follow up was 180 days. 9 patients are lost to follow up. 20 patients had follow of at least 3 months (ranging from 3 months to 5 years). Of the patients with adequate follow up, 3 patients have expired, 3 patients with worsening liver failure refused further treatment. 8 pts have serum bilirubin less than 2 mg%. (40% have successful outcome).

Conclusion. The results appear to correlate to reported success of Kasai's. And with Liver transplant being increasingly available for children, Kasai's can act a bridge till the pt is old enough to under go liver transplantation,

PP 44.10

UNUSUAL CAUSES OF EXTRAHEPATIC BILIARY OBSTRUCTION IN CHILDREN- A SINGLE CENTER EXPERIENCE

Ravula, Phan i Krishna¹; Lal, Richa²; Sikora, Sadiq S²; Yacha, Surender K³; Pal, Lily⁴

¹Sanjay gandhi post graduate institute of medical sciences, Surgical gastroenterology, Lucknow, India; ²Sanjay gandhi postgraduate institute of medical sciences, Surgical gastroenterology, Lucknow, India; ³Pediatric gastroenterology; ⁴Pathology

Background. While biliary atresia and choledochal cyst are the two most common causes of surgical obstructive jaundice in children, other rare causes of biliary obstruction are infrequently reported in literature.

AIM. This paper highlights the etiology, diagnosis, management and outcome in 9'rare' cases of extrahepatic biliary obstruction in children.

Methods. Retrospective review of medical records of patients managed between March 2000 and March 2007 at the reporting centre.

Results. Extrahepatic biliary atresia and choledochal cyst constituted 93% (127/136) of all pediatric surgical biliary disorders However, 9 children (aged 1.5–15 years) presented with uncommon causes of biliary obstruction. These were: i) idiopathic benign non-traumatic inflammatory stricture (n = 3), ii) idiopathic fibrosing chronic pancreatitis (n = 2), iii) post cholecystectomy type benign biliary stricture (n = 1), iv) post acute pancreatitis pseudo cyst of pancreas (n = 1), v) non-Hodgkin's lymphoma (NHL) with extramural common bile duct compression and gall bladder perforation (n = 1) and vi) Langerhan cell histiocytosis (LCH, n = 1). The clinical features and the diagnostic work up of each group are discussed. A preoperative endoscopic/percutaneous biliary drainage was required in 4 children because of cholangitis at presentation. A biliary-enteric anastomosis was performed for all 7 children in groups (i) to (iv). The patients with NHL and LCH were referred for chemotherapy after establishing tissue diagnosis at laparotomy. With a follow up period of 3 months-7 years, 7 children (with the exception of patients with NHL and LCH) are currently anicteric.

Conclusion. This paper draws attention to some infrequently discussed causes of extrahepatic biliary obstruction in children. The management entails a carefully planned combination of endoscopic interventions, interventional radiology and surgery. The outcome in benign cases is usually satisfactory.

PP 45.01

RUPTURED HEPATOCELLULAR CARCINOMA: AGGRESSIVE MANAGEMENT FOR INITIAL SURVIVORS

Leung, Kam Fung; Cheung, Chin Cheung; Lau, Kwok Wai

Tuen Mun Hospital, Hepatobiliary Surgery, Tuen Mun, Hong Kong

Background. Ruptured hepatocellular carcinoma (HCC) is a life-threatening disease associated with high mortality of 50%. It has been labeled as terminal event with malignant dissemination. AIM We want to study whether the recent advance in interventional radiology and liver resection can befit the patients who survive after the incident of rupture.

Method. We retrieve the patients with spontaneous rupture of HCC from hospital database in the past 4 years and study the survival outcome after intervention. We exclude those with in-hospital mortality because of terminal malignancy and decompensated liver function.

Results. There were 11 patients (9 men and 2 women; average age 51, range 39– 76) who responded well to transcatheter arterial embolization (TAE) and they were worked up for subsequent management. 6 patients were deemed inoperable and they received a series of transcatheter arterial chemoembolization with average overall survival of 7 months (range 3–8 months). 5 patients underwent operation (3 resection, 2 open radiofrequency ablation) with average survival of 32 months (range 12– 48 months; 2 still alive in 32 and 36 months). DISCUSSION We show that patients who recovered from rupture of HCC could be benefited by aggressive treatment. One half had survival benefit of about 7 months with TAE alone while the other half had much better survival of about 32 months by surgical resection or ablation.

Conclusion. It is worthwhile to workup for aggressive radiological or surgical intervention for patients who recover from the rupture of HCC.

PP 45.02

A CASE OF HEPATOCELLULAR CARCINOMA WITH REPEATED BILE DUCT METASTASIS

Takahashi, Yutaka; Yamamoto, Masakazu; Katagiri, Satoshi; Kotera, Yoshihito; Ariizumi, Shun-ichi; Okano, Yusuke

Tokyo Women□fs Medical University, Dept. of Surgery, The Institute of Gastroenterolog, Tokyo, Japan

The patient is a 73-year-old man with hepatocellular carcinoma (HCC). He underwent transarterial chemoembolization□iTACE□jfor HCC twice. He presented with tarry stool and upper abdominal pain. Total bilirubin was 5.0mg/dl. Upon admission, he underwent endoscopic retrograde biliary drainage (ERBD). During the ERBD a hemorrhage and an impacted tumor thrombus were seen macroscopically on endoscopy. Ultrasonography and CT scan revealed a tumor about 25 mm in diameter in segment 8. Cholangiography did not show the bile duct of the anterior segment of the liver, and showed a filling defect in the common bile duct. Angiography showed tumor stains in segment 8 and 4. We diagnosed of HCC with bile duct tumor thrombus and we performed central bisegmentectomy of the liver in December 2004. The result of pathology revealed moderately differrentiated HCC (vp1, vv0, b3, fc(+), fc inf(+)). After surgery in August 2005, he had jaundice and fever. He admitted to our emergency department due to acute cholangitis and obstructive jaundice. Cholangiography showed a filling defect in the common bile duct. Based on a diagnosis of recurrence of HCC into the bile duct, we performed endoscopic retrograde cholangiography (ERC). The tumor was removed by endoscopic balloon catheter. After discharge, the tumor thrombus recurred 3 times and was removed repeatedly by endoscopy in the same way. We suspected that the tumor thrombus was growing out of the choledochal mucosa of the anterior bile duct stump, and the performed radiation therapy (total 50 Gry). After radiation therapy, the tumor maker AFP decreased and the tumor thrombus disappeared in June 2006.

PP 45.04

HEPATOCELLULAR CARCINOMA AND COMPENSATED CIRRHOSIS: RESECTION AS A SELECTION TOOL FOR LIVER TRANSPLANTATION

Scatton, Olivier¹; Zalinski, Stéphane¹; Terris, Benoit²; Lefevre, Jeremie¹; Cassali, Alessandra¹; Massault, Pierre- Philippe¹; Conti, Filomena¹; Calmus, Yvon¹; Soubrane, Olivier¹

¹Hôpital Cochin, hepato biliary surgery and liver transplantation, Paris, France; ²Hôpital Cochin, pathology, Paris, France

Objective. To evaluate histological profile obtained from primary resection of hepatocellular carcinoma as a selection tool for LT.

Background. Experience of resection prior to LT has been reported with conflicting results. Interestingly, histological data of the primary tumor and its recurrence have never been compared.

Methods. Between 1987 and 2006, 20 patients underwent a resection prior to LT. Feasibility, morbidity and mortality of LT following primary resection were analysed. Long term survival of these 20 patients was compared to the survival of 73 patients who underwent primary LT. Histological features of the resected specimen were compared to those of the recurrences.

Results. mortality and morbidity of LT following resection were 10% and 55%. Mean operation time was 8±2 hours. After a mean follow up of 3.8±4.4 years and 2.7±4.5 years from resection and LT respectively, 6 patients died; 4 from recurrence, 1 from severe cholangitis and 1 from HCV recurrence. Mean -1, -3, -5, -10 years overall survival rates in patients treated with transplantation and resection prior transplantation were 71%, 61%, 55%, 45% and 74%, 66%, 66%, 40%, respectively (ns). Fourteen patients had a recurrence at the time of LT. For two patients histological study of the recurrent tumors was not possible due to complete necrosis of the lesion. For 9 patients (75%), histological features of the recurrent tumor were exactly similar to those of the initial nodule. Four patients experienced recurrence following LT, in each case primary and recurrent nodules shared the same histological markers of poor prognosis.

Conclusion. Primary resection before LT seems feasible and has no deleterious consequence in term of morbidity, mortality and survival of LT. In addition, we showed for the first time that the primary resected tumor and its recurrence share the same histological profile in most of the cases. The histological features obtained from the primary resected specimen may be used as a selection tool for LT.

PP 45.05

HEPATOCELLULAR CARCINOMA ARISING FROM AUTOIMMUNE HEPATITIS

Abe, Akihito; Kubota, Keiichi

Dokkyo University Hospital, Department of Gastroenterological Surgery, Tochigi, Japan

Autoimmune hepatitis (AIH) is a disorder of unknown etiology, which often progresses to cirrhosis and carries a high mortality, even though its treatment with corticosteroids has become common. Hepatocellular carcinoma (HCC) has been reported as a rare complication of AIH. We describe an operative case of a 70-year-old woman with HCC associated with AIH during a 15-year follo w-up. She took steroid therapy (predonin 5mg/day) after AIH diagnosis. In 2006, Alpha-1-fetoprotein (AFP) was elevated and abdominal CT, US, Angiogram revealed a 3.5cm in diameter lesion in the S7. We diagnosed as a primary HCC in an AIH. We performed subsegmentectomy of the S7. Histological examination showed that tumor was a moderately differentiated HCC and liver tissue was an AIH. Post operative couse was an eventful and she was doing well without any reccurence. Patients with AIH were not recognized to be a high-risk group for developing HCC because HCC occasionally occurred even in patients with long-standing cirrhosis in the absence of hepatitis B virus and hepatitis C virus infection.

PP 45.06

FATE OF REMAINED FLOATING BILE DUCT TUMOR DEBRIS AFTER CURATIVE RESECTION IN HEPATOCELLULAR CARCINOMA WITH BILE DUCT TUMOR THROMBOSIS

Yun, Sung Su¹; Lee, Dong Shick²; Kim, Hong Jin²

¹Yeungnam University Hospital, Department of Surgery, 317–1 Daemyung Dong, Nam-Gu, Taegu, Korea, Republic of; ²Yeungnam University Hospital, Department of Surgery, Taegu, Korea, Republic of

Background./AIMS: Eventhough common causes of jaundice in patients with hepatocellular carcinoma(HCC) are underlying liver cirrhosis and/or extensive parenchymal destruction, occasionally, jaundice can be caused by bile duct tumor thrombi. We can have good outcome after curative hepatectomy with extrahepatic bile duct resection if the disease is still localized. But we do not know the fate of remained floating tumor debris after curative resection, whether it is viable or not. We reviewed our treatment experience of floating bile duct tumor debris in patients with HCC with bile duct tumor thrombosis to clarify the viability of floating tumor debris.

Methods. We experienced 17 cases of HCC with bile duct tumor thrombi for recent two decades. Among them, we had 8 patients with floating bile duct tumor debris remote from main bile duct tumor thrombus. We performed curative hepatectomy with extrahepatic bile duct resection in these 5 patients and reviewed recurrence pattern.

Results. Two patient are alive until now and 2 patients had recurrence in their liver those were not different from usual recurrence pattern of HCC. One patient had recurrence in remnant intrapancreatic bile duct. The patient was 46 years old female who had 9 cm HCC in the left lobe of liver with tumor thrombus extended to main confluence of hepatic duct. We did left lobectomy and extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy. Careful review revealed that, at the time of surgery, we did not remove all of the floating bile duct tumor debris in remnant intrapancreatic bile duct. Two year later, we found recurrence in remnant intrapancreatic bile duct and consequently the patient was dead due to multiple tumor recurrence 29 months after operation.

Conclusion. We think that floating bile duct tumor debris is viable and can be source of recurrence, unless we remove it completely.

PP 45.07

SIGNIFICANCE OF SURGICAL TREATMENT FOR PATIENTS WITH HEPATOCELLULAR CARCINOMA EXCEEDING MILAN CRITERI

Amano, Hironobu¹; Itamoto, Toshiyuki²; Oshita, Akihiko²; Tanimoto, Yoshisato²; Ushitora, Yuichirou²; Ohdan, Hideki²; Tashiro, Hirotaka²; Asahara, Toshimasa³

¹Hiroshima University Hospital, Surgery, Hiroshiam, Japan; ²Hiroshima University Hospital, Surgery, Hiroshima, Japan; ³Hiroshima University Hospital, Surgery, Japan

Background. The appropriate treatment strategy for patients with hepatocellular carcinoma (HCC) exceeding Milan criteria (MC) is not unclear. The aim of this study is to clarify the significance of the surgical treatment for those patients.

Methods. From January 1990 to December 2006, 134 patients with HCC diagnosed as exceeding MC underwent curative surgical treatment. Survival rates and prognostic factors were analyzed retrospectively.

Results. The overall 5-year and disease-free survival rates of the patients with platelet counts of more than 100.000 /mm,R(n = 100) were 65% and 38%, whereas those with platelet counts of less than 100.000 /mm,R(n = 34), were 26% and 6%, respectively. These results suggest that platelet counts can be significant prognostic factor for better overall and disease-free survival. Moreover, among patients with platelet counts of more than 100.000/mm,R, 57% (57 of 100 cases) of the case revealed recurrence with median interval of 15.7 months (range 1–144), although in 25% (19 of 57 cases) of the cases, recurrent pattern showed within MC, indicating those patients can be rescued by following liver transplantation.

Conclusions. Among HCC patients diagnosed exceeding MC, platelet count of more than 100.000 /mm,R can be good prognostic factor after operation both in overall and disease-free survival. In these patients hepatectomy may contribute to suboptimal patient selection for liver transplantation.

PP 45.08

CLINICOPATHOLOGICAL CHARACTERISTICS OF HEPATOCELLULAR CARCINOMA WITH BILE DUCT INFILTRATION

Ikenaga, Naoki; Chijiiwa, Kazuo; Otani, Kazuhiro; Uchiyama, Shuichirou; Kondo, Kazuhiro

Miyazaki University, Surgery Oncology and Regulation of Organ Function, Miyazaki, Japan

Introduction. Although vascular invasion in hepatocellular carcinoma (HCC) has been well documented, characteristics of HCC involving bile duct are not clear.

Objective. To reveal clinicopathological characteristics of HCC with bile duct infiltration.

Methods. From 1990 to 2006, 271 patients with HCC were surgically treated at our institute. Macroscopic or microscopic bile duct infiltration was found in 15 cases (5.5%). We compared these 15 cases (b+ group) with the other 256 without bile duct infiltration (b- group).

Results. In the b+ group, 27% of patients showed obstructive jaundice and dilated intrahepatic bile duct was detected in 47%. The levels of serum bilirubin (2.39 mg/dl vs. 0.78 mg/dl, p < 0.0001) and serum alkaline phosphatasehigher (478 IU/l vs. 291 IU/l, p = 0.001) were significantly higher in the b+ group than those in the b- group. With respect to the macroscopic type, confluent multinodular type (40% vs. 12%) and infiltrative type (20% vs. 5%) were predominant in the b+ group (p = 0.002). Microscopically, infiltration of tumor capsule was found in all cases of b+ group (100% vs. 73% in b- group, p = 0.0399). The portal vein infiltration was significantly associated in the b+ group (86% vs. 44%, p < 0.004); however, the frequency of hepatic vein invasion was similar (p = 0.0956). The median survival after surgery was significantly shorter in the b+ group than b- group (11.4 months vs. 56.1 months, p = 0.0022) and the main recurrence site was the remnant liver.

Conclusion. HCC with bile duct infiltration has its own characteristics resulting in the poor outcome.

PP 45.09

LIVER TRANSPLANTATION VS RESECTION FOR PATIENTS WITH HCC WITHIN MILAN CRITERIA.

Luigi, Lupo¹; Carbotta, Giuseppe²; Panzera, Piercarmine²; Memeo, Riccardo³; Tandoi, Francesco²; Tedeschi, Michele²; Vittore, Francesco²; De Blasi, Vito²; Memeo, Vincenzo³

¹Policlinico Universitario, Emergency and organ translantation, Bari, Italy; ²Policlinico, Emergency and Organ transplant, Bari, Italy; ³Policlinico, Emergency and organ transplantation, Bari, Italy

Background. Debate is going on the optimal strategy of the management of HCC balancing resources and results. Resection allows only short term good results but it's followed by recurrence. Liver transplantation allows long term result but is limited by shortage of organ. Aim To compare results of Liver resection (Res) and liver transplantation (LTx) in a cohort of patients with HCC within Milan criteria in a single centre.

Patients and Methods. Between 2001 and 2007 58 patients ( Age median 54, range:48 – 64, M 53, F 59 with HCC within the Milan Criteria ( Mc), underwent LTx (29) or Res ( 29). The two groups had similar distribution by cancer stage, [n°1 (1–3) vs 3 ( 1–5)] and size [2.8 (2–4.5) vs 2.8 ( 2–5)] and liver disease etiology ( HBV: HCV: ALD: 10:16:3 vs 9:18:2), but at different stage ( C-P: A:B:C: 3, 15,11 vs 12,13,4; p < 0.001).Data were compared with parametric and non parametric tests; Survival and DFS were analyzed by life tables and log rank test. Results Two deaths occurred only in the LTx group. The overall survival (OS) at the 1st, 3rd and 5th year after LTx and Res was respectively: 80%, 72.2% and 72.2% and 88.9%, 72.7% and 57%. The disease free survival (DFS) in the LTx group at the 1st year was 92% and remains stable for the following four years and was statistically longer than in the Res ( 88.9% at the 1st year, 72.7% at the 3rd y and 57% at the 5th y (P < 0.01) Transplanted patients seem to have better 5 year survival rate even if it was not statistically validated because of the shortage of the cohort of patients. Conclusion Liver transplantation offers better results than Liver resection in the treatment of HCC within Milan cr iteria. Considering good results of liver resection in the short term, and according to Markow analysis of Majno and Sarasin, liver resection may be offered as first option and liver transplantation as rescue therapy.

PP 45.10

PREOPERATIVE TACE AND PVE PLUS RFA EXTEND LIMITS OF SURGICAL MANAGEMENT OF LARGE HCC ON CIRRHOSIS

Lupo, Luigi; Panzera, Piercarmine; Carbotta, Giuseppe; Tedeschi, Michele; De Blasi, Vito; Vittore, Francesco; Bizzoca, Cinzia; Memeo, Vincenzo

Policlinico universitario, Emergency and organ transplantation, Bari, Italy

Background. Liver Resection (Res)and transplantation (LTx) currently offer the optimal therapy for HCC but are limited by the extension of cancer and/or the poor liver function. Aim A prospective study was undertaken to evaluate the impact of arterial chemioembolization (TACE), portal vein embolization plus radio frequency ablation (PVE + RFA) before surgery, on improving suitability for surgical treatment of large HCC on cirrhosis.

Patients and Methods. From Sept 2002 to June 2007 14 patients (Age median 62 range 52 –78; with HCC (n° median 1, range 1–4; median diameter 7cm, range 3–12)) on cirrhosis (HBV 5, HCV 8, ALD 1; CP: A8, B6) underwent sequential TACE and PVE + RFA 4–6 weeks later. fp determination. Results AfterαPatients were followed up by US and CT scan and TACE and PVE + RFA no deaths but 3 abscesses occurred. Eight patients underwent Res after controlateral hypertrophy and 1 LTx at an internal of 2–8 months. Three patients did not require further treatment and survived without evidence of cancer 30, 38 and 46 months, but 2 experienced rapidly progression of cancer disease and died. Histology of surgical specimens revealed residual cancer or new lesions on 6/9. During follow up 4 patients died in the Res group from liver failure (2) and cancer (2) at an interval ≥ 3 years. Conclusion This limited experience shows that combined TACE, PVE + RFA allow surgical treatment of advanced HCC with improved outcome.

PP 46.01

LAPAROSCOPIC MANAGEMENT OF SYMPTOMATIC CONGENITAL LIVER CYSTS

Daskalakis, Kritolaos¹; Daskalaki, Despoina²; Paraskakis, Stefanos²; Anastasiou, Anastasios²

¹General Hospital of Rethymno, Surgery Clinic, Rethymno, Greece; ²

Background. Laparoscopic management is the gold standard for treating selected symptomatic congenital liver cysts ( CLC). In contrast, the laparoscopic approach is not indicated for patients suffering from adult polycystic liver disease (APLD) except for APLD type I with large multiple cysts of the liver.

AIM. The aim of this study is to evaluate the advandages using laparoscopic approach in the management of symptomatic congenital hepatic cysts.

MATERIAL: During the period 2004 – 2006, 5 patients with symptomatic congenital hepatic cysts treated laparoscopically in our institution. There were 3 patients with CLC and 2 ( brother and sister) with APLD type I. One was male and 4 females, mean age 68,5 years ( range 56 – 86 years). The wide fenestration technique by deroofing the cyst wall was applied in all patients. Cholecystectomy was added in 4 patients, in 2 for gallstones and in 2 because of proximity of the hepatic cyst with gallbladder. Drainage of the residual cavity/ies was inserted in all patients.

Results. There were no intraoperative complications ( haemorrhage, bile leakage, hepatic or biliary injury etc) and no conversions. Mortality was nil. There were no postoperative complications. Mean hospital stay: 3,9 days. Follow – up range from 4 to 31 months. Clinical observation, laboratory investigations and abdominal ultrasound (every six months) confirmed the absence of both the symptomatology and the relapse of the disease. The histological results on the segments of the excised cystic wall, established the diagnosis of CLC.

Conclusion. Laparoscopic approach can be considered as a safe and efficacious method in the management of symptomatic CLC and APLD type I.

PP 46.02

LAPAROSCOPIC TREATMENT OF BILE PERITONITIS FOLLOWING BLUNT HEPATIC TRAUMA

Pilgrim, Charles¹; Usatoff, Val²; Evans, Peter²; Burton, Paul²

¹The Alfred Hospital, Commercial Road, Melbourne, Australia; ²The Alfred Hospital, Melbourne, Australia

Minimally invasive techniques have gained widespread acceptance and are indeed standard of care for many hepatobiliary problems. Their application in the trauma setting remains to be defined so clearly. Conservative management of blunt hepatic trauma has become mainstream and is successful in avoiding laparotomy in most cases. As a result however, biliary tree injuries are not being recognised or repaired until later in the hospital admission. Delayed presentation bile leak in this setting is well treated with laparoscopic washout and drainage, and we present four cases successfully managed in this manner. This technique sits along side endoscopic and percutaneous drainage, but offers advantages over both, and should be considered part of the armamentarium for surgeons dealing with hepatobiliary trauma.

PP 46.03

RADIOFREQUENCY ABLATION OF HEPATIC METASTASES: OWN EXPERIENCE.

Shabunin, Alexey¹; Bedin, Vladivir²; Tavobilov, Michael¹; Lukin, Andrey¹; Grekov, Dmitryi¹; Shikov, Dmitryi¹

¹Botkin, s Memorial Hospital, HPB-surgery, Moscow, Russian Federation; ²Botkin, s Memorial Hospital, Cief of HPB-surgery, Moscow, Russian Federation

Background./AIMS: Radiofrequency ablation (RFA) has been shown to be one of the promising new modalities to treat or to palliate metastatic liver tumors. Method. OLOGY: We present a series of 19 patients, 5 females and 14 males with a age ranging from 43 to 78 years, treated since October 2006 to July 2007, the RFA has been used either by laparotomy (3 patients) or percutaneously (16 patients) to treat 32 lesions. There were 15 patients with metastases of colorectal cancer, 2 patients with metastasis of pancreastic cancer and the other 2 had a breast cancer metastasis. The RFA was performed after the primary tumor resection was done. Pre- and post-treatment evaluation was performed with contrast-enhanced computed tomography, ultrasonography (US) and fine-needle biopsy.

Results. The total number of lesions treated were 32 with a size range of 18 to 49 mm. Two patients had 4 and 5 lesions, accordingly. All lesions were treated by 21 RFA procedures (from 12 to 28 min. long). Three patients had a postablative complications such as fatigue, flabbiness, fever and hepatic enzymes elevation. All complications were managed by intravenous infusion therapy in three days period. None of the patients died. Long-term results (up to 9 months) showed 0% morbidity rate and lowered level of contrast intake in RFA underwent lesions.

Conclusion. RFA is an effective method to treat liver metastases. Survival is improved and the rate of complications is low.

PP 46.04

GLYCINE PROTECTS LIVERS FROM REPERFUSION INJURY DUE TO PNEUMOPERITONEUM

Al-Saeedi, Mohammed¹; Nickkholgh, Arash¹; Flechtenmacher, Christa²; Zorn, Markus³; Liang, Rui¹; Buechler, Markus W¹; Gutt, Carsten N¹; Schemmer, Peter¹

¹Ruprecht-Karls University, Dept. of General Surgery, Heidelberg, Germany; ²Ruprecht-Karls University, Dept. of Pathology, Heidelberg, Germany; ³Ruprecht-Karls University, Central Laboratory, Heidelberg, Germany

Background. Experimental pneumoperitoneum induces ischemia/reperfusion injury (IRI) in liver most likely via activation of Kupffer cells. Glycine has been shown to ameliorate reperfusion injury in various animal models. Thus, this study was performed to assess the effects of glycine to liver tissue after pneumoperitoneum.

Materials and Methods. Sprague-Dawley rats (200–230 g) underwent CO2 pneumoperitoneum (12 mmHg) for 90 minutes. Some rats received i.v. glycine (1.5 ml, 300 mM) 10 min before pneumoperitoneum. Controls were given the same volume of Ringer's solution. Subsequently, transaminases, hepatic microcirculation, and latex beads phagocytosis to index both liver injury and Kupffer cell activation were investigated. Analysis of variance (ANOVA) followed by t test or ?2 (or Fisher's exact) test were performed as appropriate. Results are presented as mean±SEM.

Results. Glycine significantly decreased AST, ALT, and LDH at 1 hr after desufflation from 145±19 U/L, 53±5 U/L, and 500±58 U/L in controls to 94±4 U/L, 40±2 U/L, and 334±27 U/L, respectively (p < 0.05). In parallel, glycine significantly blunted the permanent adherence of leukocytes to the endothelium by up to 35% of controls (p < 0.05). Furthermore, glycine decreased the rate of phagocytosis significantly more than 50%.

Conclusion. Glycine decreased IRI after CO2 pneumoperitoneum most likely via inactivation of Kupffer cells and an improved hepatic microperfusion.

PP 46.05

SECURE AND RAPID PROCEDURE ON IMPLANTATION OF DENVER PERITONEOVENOUS SHUNT

Oida, Takatsugu¹; Mimatsu, Kenji¹; Kawasaki, Atsushi²; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi³; Amano, Sadao⁴

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Social Insurance Yokohana Central Hospital, Surgery, Yokohama, Japan; ³Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ⁴Nihon University School of Medicine, Surgery, Tokyo, Japan

Background./AIM. Ascites often contributes to patient morbidity and discomfort. Peritoneovenous shunt is a suitable alternative treatment, obviating both the problem of fluid intraperitoneal accumulation and continuous loss of proteins. Denver peritoneovenous shunt is one of the treatments for refractory ascites. The purpose of this study was to analyze our technique of implant of Denver shunt.

Patients and Methods. Fourteen shunts (Denver-PAK, Denver Biomaterials Inc.) were implanted in 14 patients with hepatic failure-related ascites. All the procedures were performed in the operating suite under general anesthesia with the patients laying supine. In all patients the shunts were percutaneously placed through the left subclavian vein under digital fluoroscopic guide. Ultrasound (US)-guided puncture of peritoneal cavity ipsilateral to side of venous puncture (left side). The ascitic fluid is slowly drained in order to avoid that a great amount of fluid reverses into the circulatory system the shunt is operating. A subcutaneous pocket, lateral to the nipple line on the costal border, is then made by cutaneous incision. The venous access is obtained by percutaneous US-guided approach to left subclavian vein. The introducer and the wire are removed, and the venous end of the Denver shunt, which has been cut to the proper length, is passed through the sheath, which is then stripped away. Once the vein and peritoneal cavity have been accessed and the pump chamber pocket fashioned, the subcutaneous tunnels are created.

Results. No complications directly related to the procedure occurred. The shunt was successfully positioned in all patients in 44 min average time.

Conculusions. Denver peritoneovenous shunt is a useful in resolution of refractory ascites, reducing symptoms, and allowing effective palliation. Left subclavian approach is a relatively easy, rapid, and secure procedure on implant of Denver shunt.

PP 46.06

SURGICAL CORRECTION OF PORTAL HYPERTENSION BY METHOD OF HEPATIC TUNNELING IN COMBINATION WITH ENDOSCOPIC LIGATION OF ESOPHAGEAL VARICOSE VEINS

Mugatarov, Ildar¹; Zarivchatskiy, Mikhail²; Ishenin, Yuriy¹; Mugatarov, Ildar¹; Kamenskikh, Ekaterina³; Smolentsev, Sergey¹; Smetanin, Denis¹

¹Center of Hepatology, Medicosanitary Hospital N1, Perm, Russian Federation; ²Center of Hepatology, Medicosanitary Hospital N1, Academy of Medicine named after Acad. E. Wagner, Perm, Russian Federation; ³Academy of Medicine named after Acad. E. Wagner, Perm, Russian Federation

Introduction. Prophylaxis of varicose veins hemorrhage of cardioesophageal zone in patients with cirrhosis promotes introduction of new methods of portal hypertension correction.

Objective. Intrahepatic portosystem shunting by tunneling method according to Ishenin was used from May 2005 up to July 2007 in 10 patients aged 43 – 62 suffering from cirrhosis with 2–4 times esophageal hemorrhage in anamnesis. Among them there were 7 (70%) females and 3 (30%) males. Triple tunneling of liver was fulfilled in 60% of cases, only double tunneling-in 20%, single tunneling-in 20%.

Results. Intraoperative hemorrhage was equal to 150 – 2500 ml. Two patients died: 1 – from thrombohemorrhagic syndrome, 1 – from hepatic deficiency. Endoscopic ligation of esophageal varicose veins was fulfilled to 5 patients. Degree of varicose veins was equal to F3.

Results. Stenosis of portal vein from 18–20 mm up to 9–12 mm in 7 patients and up to 14 mm – in 1 patient was observed 1–3–6–12 months after the operation in sonography of liver. Blood flow in tunnels remains. Increase of blood flow volume in portal vein from 287±14 ml/min to 970±11 ml/min (normal blood flow is equal to 850 ml/min) was observed in duplex scanning. Hepatic encephalopathy doesn't increase, patients are able to work, no relapses were fixed. Results of endoscopic picture are rated as good in 3 patients (form of veins F2), as excellent (form of veins F1-F0) – in 2 patients.

Conclusion. The methods permitted to decrease pressure in portal vein and increase its volume blood flow, they decreased risk of hemorrhage relapses.

PP 46.07

CENTRAL HEPATECTOMY-AN ALTERNATIVE TO EXTENSIVE LIVER RESECTIONS IN SELECTED CASES

Govil, Sanjay; Chepudira, Vikram Belliappa

Narayana Hrudayala Institute of Medical Sciences, Surgical Gastroentrology, Bangalore, India

Introduction. Many tumors due to their central location will require extensive resections. In few patients a central hepatectomy is a viable option to get adequate clearance and save functioning liver parenchyma.

Methods. At our center two patients underwent central hepatectomies for centrally located hepatocellular carcinomas. One patient had a background of cirrhosis. In both cases hepatic veins were controlled extra-hepatically. Intermittent inflow occlusion was used in one case. Transection of the liver parenchyma was done using crushing technique with a hemostat clamp. Resection of segments 4, 5 and 8 was carried out in both patients.

Results. The mean postoperative stay in hospital was ten days. The patient with background cirrhosis required two units of blood transfusion. Both patients had postoperative ascitis which resolved on conservative measures. Both patients had resected margins which were free of tumor.

Conclusion. Central hepatectomies are a viable alternative to extensive liver resections in selected patients. These resections help in preserving maximum amount of functional liver tissue and prevent postoperative liver failure in patients with background liver disease.

PP 46.08

MANAGEMENT OF EXCLUDED BILE DUCT LEAKAGE AFTER HEPATIC RESECTION. REPORT OF FOUR CASES.

HONORE, Charles; VIBERT, Eric; AZOULAY, Daniel; ADAM, René; CASTAING, Denis

Paul Brousse Hospital, Centre Hepato Biliaire, 94804, France

Background. Post-operative bile leakage is a common complication after hepatic surgery. Nagano and al. classified this situation in four different sub-types. Leakage due to bile duct exclusion is the rarest and remains problematic for two reasons: difficult diagnosis and unclear treatment. The aim of this study was to report our management of this situation.

Methods. We reviewed 2254 hepatectomies performed between April 1992 and June 2007. Four presented an excluded bile duct fistula following a right hepatectomy for patient 1 and 3, a right hepatectomy extended to segment 4 for patient 2 and a right hepatectomy extended to the segments 1, 5 and 8 for patient 4.

Results. Symptoms were permanent bilious leak or recurring abdominal bilious collection for which multiple percutaneous drainages were required. A preoperative vascular embolization was tried in one but was only able to decrease the drainage. Definitive treatment consisted in a resection of the right half of segment 4, resection with a new bilio-digestive anastomosis for patient 1, a removal of the incomplete remains of segment 6 for patient 2 and the completion of segment 8 and 5 resection for patient 3. Patient 4 has not been operated yet. Patient 3 evolved uneventfully. Patient 1 developed a biliary fistula on the bilio-digestive anastomosis which eventually closed after 3 months of drainage. Patient 2's initial evolution was initially satisfactory but he later developed a main bile duct stenosis which required a percutaneous trans-stenotic drain. Patient 4 is being prepared for surgery.

Conclusion. operative treatment of excluded segmental bile leakage is efficient. In our experience, conservative treatment was deceptive because incomplete.

PP 46.09

SYSTEMATIC EXTENDED RIGHT LATERAL SECTIONECTOMY: AN ALTERNATIVE TO RIGHT HEPATECTOMY

Donadon, Matteo; Marconi, Matteo; Botea, Florin; Palmisano, Angela; Del Fabbro, Daniele; Procopio, Fabio; Montorsi, Marco; Torzilli, Guido

University of Milan, Istituto Clinico Humanitas IRCCS, Third Department of General Surgery, Rozzano (MI), Italy

Background. A surgical approach based on ultrasound-guided hepatectomy might minimize the need for major resection, whose rates of morbidity and mortality are not negligible. Right hepatectomy (RH) is traditionally performed in cases of vascular invasion of the right hepatic vein (RHV) with multiple tumors in the right lateral section, and/or of the right lateral portal branch (P6–7) with tumor in contact with right paramedian portal branch (P5–8). We herein describe an alternative approach to RH consisting in ultrasound-guided systematic extended right lateral hepatic sectionectomy (SERLS).

Methods. Among 207 consecutive hepatectomies, 21 (10%) underwent SERLS. Median age was 67 years (range 48–79). There w ere 13 men and 8 women. Ten (48%) patients had HCC; 11 (52%) had colorectal liver metastases. Median tumor number was 2 (range 1–15); median tumor size was 4.5 cm (range 2.5–20). Ten (48%) patients had cirrhosis, 8 (38%) had steatosis, and 3 (16%) had normal liver. Surgical strategy was based on tumor-vessels relationship at intraoperative ultrasonography (IOUS) and on findings at color-Doppler IOUS.

Results. In-hospital and 90-days mortality were nil. Major and minor morbidity occurred in 3 (14%) and 2 (9.5%) patients respectively. No patients were reoperated because of complications. Blood transfusions were given to 2 (9.5%) patients. After a median follow-up of 21 months no local recurrence was observed.

Conclusions. IOUS guided SERLS is feasible, safe, and effective. It should be applied whenever possible as alternative resection to RH to maximize liver parenchymal sparing

PP 46.10

TWO-HUNDRED HEPATECTOMIES WITHOUT MAJOR MORBIDITY: THE 50-7 RULE

Del Fabbro, Daniele; Marconi, Matteo; Donadon, Matteo; Botea, Florin; Palmisano, Angela; Spinelli, Antonino; Montorsi, Marco; Torzilli, Guido

University of Milan, Istituto Clinico Humanitas IRCCS, Rozzano, Milan, Italy, Third Department of General Surgery, Rozzano (MI), Italy

Objectives. Reoperation for major morbidity, and bile leakage are two factors which still impair results of liver surgery. To limit their occurrence, we adopt a well established policy comprehensive of careful intraoperative control of the liver cut surface, and of the long-term drain maintenance. The aim of this study was to validate this policy on a large series of consecutive patients.

Materials andMethods. A prospective cohort study enrolling 200 consecutive patients with liver tumors has been carried out. All patients underwent liver resection. Wound closure was never started prior to 50 minutes since resection was ended, and abdominal drains were always positioned and maintained for at least 7 postoperative days (pod). Intraoperative cholangiography was never carried out. The bilirubin concentration in serum and drain discharge was sampled on the 3rd, 5th and 7th pod.

Results. Peroperative mortality was 0.5%, and no reoperation were carried out. Drains were removed in 7th pod in all but 2 patients in whom were removed in 12th pod. The median bilirubin level in drain discharge was significantly higher on the 5th postoperative day than on the 3rd and 7th pod. Percutaneous drainages of fluid collections were never needed.

Conclusions. The policy summarized in the two rules of 50 minutes of liver cut surface control and 7 days postoperative drain maintenance proved to be effective in limiting morbidity and in particular biliary fistulas after hepatectomies in a large series of consecutive patients.

PP 47.01

DONOR SPLENIC VEIN GRAFT TO IMPROVE THE PATENCY OF PORTAL VEIN IN PEDIATRIC LIVER TRANSPLANTATION

Sakuma, Yasunaru; Fujiwara, Taketo; Hyodo, Masanobu; Mizuta, Koichi; Kawano, Yoichi; Egami, Satoshi; Hishikawa, Shuji; Kawarasaki, Hideo; Yasuda, Yoshikazu

Jichi Medical University, Department of surgery, Shimotsuke, Japan

In pediatric living donor liver transplantation (LDLT), the patients□f portal veins (PV) are sometimes complicated by sclerosis or stenosis due to cholangitis or previous laparotomies. The liver grafts from adult donors have larger vessel compared with those of small pediatric patients, and the size mismatch of PV and short pedicles demands the usage of vein grafts. In addition, the option to obtain vessel grafts is limited, and gonadal vein, inferior mesenteric vein, and colic vein are commonly used. These veins were too small in some cases, and therefore the donor splenic vein (SV) was introduced to adjust them in three cases. Case 1) One yr old girl who diagnosed as congenital absence of portal vein received LDLT. The SV graft from her paternal donor was 40×14mm in diameter and interposed between the donor PV and native superior mesenteric vein (SMV). Case 2) Ten month old boy who diagnosed as congenital biliary atresis had narrowing PV (3mm) and received LDLT. The SV graft from her paternal donor was 30×12mm in diameter, and anastomosed to the confluence of SMV and SV. Case 3) Ten month old boy who diagnosed as congenital biliary atresis had narrowing PV (3mm) and received LDLT. The SV graft from his maternal donor was 35×10mm in diameter, and anastomosed to the confluence of SMV and SV. All SV grafts were taken out from the distal side of the union of SV and SMV. No complication was observed in donors, and the post operative courses of the recipients were fine. There was no need of radiological and/or surgical intervention after transplantation. Here, we introduced the method of donor splenic vein graft especially from the point of donor harvest and recipient portal reconstruction.

PP 47.02

POST-TRANSPLANT PULMONARY ARTERY EMBOLIZATION IN A PATIENT WITH SEVERE HEPATOPULMONARY SYNDROME

Lee, Hae Won; Suh, Kyung-Suk; Kim, Joohyun; Shin, Woo Young; Yi, Nam-Joon; Lee, Kuhn Uk

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. Hepatopulmonary syndrome (HPS), one of the most serious complications of the liver disease may be improved after liver transplantation (LT). However, post-transplant mortality has been reported to be much higher in patients with severe HPS than in patients without HPS. The purpose of this report was to introduce our experience of post-transplant pulmonary artery embolization (PAE) performed in a patient who had suffered from sustained dyspnea after LT.

Methods. A 10-year-old male patient who had undergone Kasai operation for biliary atresia at 3 months after birth was referred for LT. He had recurrent variceal bleeding and severe HPS. His arterial O2 pressure (PaO2) and saturation (SaO2) was only 40mmHg and 70–75% in room air. A diffuse pulmonary ateriovenous shunt was identified by saline contrast echocardiography and pulmonary arteriography. The calculated amount of the shunt fraction was 63% on macroaggregated albumin scan. He received extended left liver graft including middle hepatic vein from his father.

Results. Hypoxemia and dyspnea remained and he was still bed-ridden till post-LT one month. We performed PAE for tortuous and dilated vascularity in left upper lung field on post-LT 30th day. The abnormal vascularity markedly decreased and oxygen saturation increased by about 10% right after PAE. The second PAE was performed in right lower lung field on 37th day. His activity got better and better and he showed some active movements such as wheel-chair ambulation at the time of discharge, 40th day. His PaO2 and SaO2 increased up to 65mmHg and 93% 3 months after LT and he showed the same activity as children in his age group.

Conclusion. A patient with severe HPS may suffer from sustained hypoxemic symptoms for a long time even after LT. We found that PAE improved these symptoms by reducing the amount of the shunt. Therefore, we think that post-transplant PAE might be useful to reduce the risk of postoperative mortality and morbidity and to accelerate the recovery in a patient with severe HPS.

PP 47.03

HISTORY OF LIVER TRANSPLANTATION;ITS EVOLUTION AND PRESENT SCENARIO.

Shah, Niraj¹; Dhumane, Parag¹; Mansukhani, verushka¹; Bharucha, Manoj²

¹LILAVATI HOSPITAL, General Surgery., Mumbai, India; ²LILAVATI HOSPITAL, G I Surgery, Mumbai, India

Introduction. History of transplantation goes way back in 12th century B.C., power of lord shiva who xenotransplanted head of an elephant over a boy to produce an Indian God, “Ganesha”. Egyptian and Greco-Roman mythology provides us with countless examples of metamorphoses sung by Homer and Ovid. History of Transplantation: Liver has been the organ of life from time immemorial-Leber in German, derived from verb to live. Replacing a diseased organ with a healthy one from another individual, dead or alive, to enable a human to survive, considered most stirring event in field of medicine. Welch (1955) and Cannon (1956) attempted liver transplantation in dogs. Starzl (Denver) performed first liver transplant in humans (1/03/1963). 3 year child with biliary atresia, received liver from child who died from brain tumour & survived for five hours, succumbing to complications of coagulation and haemostasis. 2nd liver transplantation performed (May 5, 1963), was more successful. Patient died on 22nd postoperative day from pulmonary embolism, with a normal liver. Starzl achieved first long-term survival in 1967. (1960–1970) one year patient survival only 35%. In 1980's immunosuppressive therapies helped to increase graft and patient survival by treating acute and chronic rejection effectively. Survival rose from 47% (1968–1988) to 67% (1988–1996). Further advance was improvement of liver preservation by the introduction of Viaspan solution (1987). Present scenario:Research in Domino transplant, lab grown (stem cell) liver transplant, xenotrnsplant and advances in transplant immunology assure of promising future.

PP 47.04

PATIENTS’ ECONOMIC IMPACT OF ORTHOTOPIC LIVER TRANSPLANT IN ATLANTIC CANADA

Molinari, Michele; Gillis, Amy; Walsh, Mark

Dalhousie University, Surgery, Halifax, Canada

Background. Data on the impact of OLT on the patients’ and their families’ financial status are lacking. Primary aim of this study was to assess the personal and familiar annual income changes occurring after OLT.

Methods. From September 2006 to January 2007, a cross sectional study was performed using a validated Societal Reintegration Questionnaire. Participants were interviewed by phone or during follow-up visits and were adults at least 3 years post OLT, without communication impairments. All data were prospectively collected. Chi-Square was used to analyze categorical data and Student's t test for continuous variables; P values < 0.05 with two tail distribution were considered significant.

Results. Among 158 eligible patients, 47 were randomly selected. 45 (95%) participated and 2 declined for personal reasons. 15 patients (33%) were full time employed and 12 (52%) were employed in the same position as before OLT. 13 individuals (28%) were on disability while the remaining were students or housekeepers. 11 patients (24%) had retired. The overall annual personal income of patients undergoing OLT decresed from $ 28,300 to 26,500 (p = ns) and the houshold annual income from $ 44,000 to 43,700 (p = ns) despite the expected 3% national discount rate. 35 individuals (77%, p < 0.05) reported that OLT had a negative impact on their personal and familiar finances due to the increased expenses for medical therapy and 12 (26%) had to borrow money for medicine costs or travel expenses related to OLT. Among them 42% had to interrupt immunosuppression medications against medical advice because of financial restriction.

Conclusion. Although OLT provides better survival and quality of life to patients with liver failure, the financial impact of this procedure on patients and their families is significant. For low income patients, better financial support should be considered to prevent suboptimal care and risks of chronic graft rejection.

PP 47.05

BILE DUCT INJURIES AND LIVER TRANSPLANTATION

Ardiles, Victoria; Bregante, Mariano; Pekolj, Juan; Ciardullo, Miguel Angel; de Santibañes, Eduardo

Hospital Italiano de Buenos Aires, HPB Surgery and Liver Transplant Unit, Buenos Aires, Argentina

Background. Bile duct injuries constitute a severe complication during the treatment of a benign disease. Several surgical, endoscopic and percutaneous procedures are required to repair the lesion and to treat concomitant complications. In spite of the procedures applied, a significant percentage of cases develop end-stage liver disease and liver transplant arises as the sole solution.

Objective. To analyse the indications and results of liver transplant as a treatment bile duct injuries. DESIGN: Retrospective cohort study.

Materials and Method. Twenty patients on liver transplant waiting list between January 1988 and April 2003 with end-stage liver disease secondary to a bile duct injury. Retrospective charts and office visits analysis. Survival was estimated with Kapplan Meir test.

Results. Four patients died on the waiting list and 16 were transplanted. The lesion occurred during a cholecystectomy in 81% of patients. Lesion mechanism included resection in 4 patients, burn in 3, ligature in 3, section in 6, post T-tube placement stenosis in 2 and formol injection in 1. All patients had undergone previous repair attempts of the lesion. Transplant was performed with cadaveric donor in all patients. Intraoperative mortality was 0%. Hospital morbidity and mortality were 12.5% and 56.2%, respectively. Follow-up ranged between 24 and 152 months. One, 5 and 10-year survival rates were 81%; 75% and 50%, respectively.

Conclusions. Complex bile duct injuries and those with previous repair attempts can lead to- end stage liver disease. In these cases, liver transplant provides good quality of life and long- term survival.

PP 47.06

LOW ASPARTATE TO ALANINE AMINOTRANSFERASE RATIO IS AN INDICATOR OF LATE CELLULAR REJECTION IN PEDIATRIC LIVER TRANSPLANTATION PATIENTS

Kim, Joohyun¹; Suh, Kyung-Suk²; Yi, Nam-Joon²; Lee, Hae Won²; Shin, Woo Young²; Lee, Kuhn Uk²

¹Seoul National Universiy College of Medicine, Surgery, Seoul, Korea, Republic of; ²Seoul National Universiy Hospital, Surgery, Seoul, Korea, Republic of

Background. Some serum markers have been proven to be indicators of the fibrosis in adult liver diseases, but their role in the pediatric liver transplantation patients were not have been determined. Because invasiveness and longterm-safety are particularly concerned in this age group, it is important to identify high-risk groups for appropriate management.

Objective. To evaluate simple serum tests as predictors for the pathologic results of the pediatric liver transplantation patients.

Methods. Seventy consecutive pediatric liver transplantation patients undergoing a liver biopsy between October 1999 and July 2006 were retrospectively reviewed, and pathologic findings of the liver biopsy was systemically re-interpreted. Nine patients underwent deceased liver transplantation (DDLT), and 61 patients underwent living donor liver transplantation (LDLT).

Results. LDLT patients showed a tendency of the lower AAR (P = 0.056). Twenty-one (30%) of 70 patients had early cellular rejections during follow up, and 10 (14%) patients showed late cellular rejections. Aspartate to alanine aminotransferase ratio (AAR) of the late cellular rejection patients during the first postoperative year was significantly lower than those of the early rejection patients (P = 0.045). Moreover, the patients who had fibrosis in their liver biopsy specimen showed a tendency of higher AAR (P = 0.057).

Conclusions. Simple, noninvasive serum tests including AAR might be a valid predictor for late cellular rejections in pediatric liver transplantation patients, and some pathologic backgrounds of them could be identified.

PP 47.07

GUILLAIN-BARRÉ SYNDROME AFTER LIVER TRASPLANTATION: A CASE REPORT

Bilbao, Itxarone¹; Sapisochin, Gonzalo¹; Dopazo, Cristina¹; Len, Oscar²; Escartin, Alfredo¹; Castells, Luis³; Lazaro, Jose Luis⁴; Lopez, Iñigo⁴; Balsells, Joaquin⁴

¹Hospital Vall d′Hebron, Surgery Department, Barcelona, Spain; ²Hospital Vall d′Hebron, Infectious Service, Barcelona, Spain; ³Hospital Vall d′Hebron, Hepatology Department, Barcelona, Spain; ⁴

Background. Guillain-Barré syndrome (GBS) is characterized by acute paralysis and ascending neuropathy. Although its pathogenesis is not fully established it is well known its association to cytomegalovirus (CMV) and Campylobacter jejuni infection. AIMS: To asses a single case experience of a GBS after liver transplantation (LT). CASE: A 61 years old man received a LT for hepatocarcinoma and hepatitis C (HCV). Initial immunosuppressive therapy consisted in Tacrolimus (Tac) and mofetil mycofenolate (MMF). Both donor and recipient were CMV negative and the patient did not receive prophylaxis with ganciclovir. One and a half months later, he was admitted with a history of fever and diarrhea; pp65 antigenemia and polimerase reaction chain (PCR) for CMV were positive. He was diagnosed of disseminated CMV infection and was treated with ganciclovir (5mg/kg/12h) for 17 days and afterwards with valganciclovir (900mg/12h) for 4 days. MMF was stopped and Tac decreased to through levels between 3–5 ng/ml. Both, antigenemia and PCR became negative. Fifteen days later, he developed bilateral symmetric leg weakness. Neurological examination revealed absence of muscle stretch reflexes in all extremities. Cerebrospinal fluid (CSF) showed absence of cells and a total protein concentration of 103mg/dl. Shortly after readmission he developed acute respiratory failure and was admitted in intensive care unit. Treatment with intravenous immunoglobulin (0,4mg/kg/day) was started for 5 days. Tac was stopped and everolimus was initiated in monotherapy at low dose to reach levels around 3. Antigenemia and PCR for CMV were negative. He was discharged from hospital 10 days after the treatment was started.

Conclusions. GBS has been associated to CMV infection in non-transplant population. Evidence of CMV in our patient suggests that CMV may have a role in triggering this illness. However Tacrolimus with its known neurotoxicity may also be involved. In such case everolimus (m-Tor inhibitor) may be useful to protect the patient from rejection.

PP 47.08

OUTCOME OF LIVER TRANSPLANTATION FOR HEPATITIS C IN HAEMOPHILIC PATIENTS CO-INFECTED WITH HIV

Sapisochin, Gonzalo¹; Bilbao, Itxarone¹; Escartin, Alfredo¹; Dopazo, Cristina¹; Castells, Luis¹; Lazaro, Jose Luis¹; Altisent, Carmen²; Balsells, Joaquin¹

¹Hospital Vall D′Hebron, HBP and Liver Transplantation Unit, Barcelona, Spain; ²Hospital Vall D′Hebron, Haemphilia Unit, Barcelona, Spain

Background. Prior to the introduction of hepatitis C virus (HCV) screening, many patients with haemophilia developed chronic viral hepatitis due to transfusion and some of them progressed to cirrhosis and hepatocarcinoma. AIMS: To assess our experience in liver transplantation for HCV cirrhosis in haemophilic patients co-infected with HIV.

Results. We present two patients with haemophilia A co-infected with hepatitis C and HIV, with end stage liver disease, who received liver transplantation. Both of them received transfusion in their childhood, before 1980. One patient was diagnosed of severe haemophilia (factor VIII < 1%) and the other, mild haemophilia (factor VIII 7%). At the time of surgery one patient was 26 years old and the other was 37. Perioperatively factor concentrate replacement was administrated using continuous infusion regimen following initial bolus dosing. Postoperatively clotting factor levels were normalized and concentrate infusion discontinued 55 hours post transplant in both cases. Transfusion requirements during surgery and the immediate post-transplant period were similar to non-haemophilic transplanted patients; 4 red blood cells (RBC) units and 13 plasma units in the mild haemophilia and 8 RBC units, 14 plasma units and 15 platelet units in the severe case. No complications were seen. Antiretroviral treatment was started on day 7 after LT and patients received the same HAART regimen administered before LT. HIV viremia remained negative and CD4 levels were above 200 cells/mL. Actually, both patients have developed a HCV recurrence, and received early treatment with interferon and ribavirin with no response and have developed liver cirrhosis after a mean follow-up of 24 months. Actually their clotting factors and coagulation is completely normal.

Conclusions. Liver transplantation can be considered as definitive therapy for haemophilic patients with transfusion-related cirrhosis and is associated with similar morbidity than patients with no clotting factor disorders.

PP 47.09

GRAFT VERSUS HOST AFTER LIVER TRANSPLANTATION

Bilbao, Itxarone¹; Dopazo, Cristina¹; Len, Oscar²; Castells, Luis³; Lazaro, Jose Luis¹; Lopez, Iñigo¹; Escartin, Alfredo¹; Sapisochin, Gonzalo¹; Balsells, Joaquin¹

¹Hospital Vall d′Hebron, Surgery Department, Barcelona, Spain; ²Hospital Vall d′Hebron, Infectious Service, Barcelona, Spain; ³Hospital Vall d′Hebron, Hepatology Department, Barcelona, Spain

Introduction. Graft versus host disease (GVHD) is extremely rare after liver transplantation (LT). Management and treatment is not stablished.

Aim. To present a single case experience of a GVHD after LT. CASE. A 56 years old male, submitted to renal transplant 20 years previously, was taken inmunosuppression with azatioprina and steroids. He was operated 3 years ago for hepatocellular carcinoma in cirrhosis HBV and HCV positive. He was submitted to liver transplantation on April 2007 due to multifocal recurrence of HCC (segments IV, VII, VIII). He received triple therapy with Tacrolimus (around 8ng/ml), MMF and steroids. During the second week post-transplant, he presented high fever without focality (toraco-abdominal scan, ultrasound, urine and blood culture, CMV, Epstein-Barr and Herpes virus negative). In the third week post-trasplant a maculopapular cutaneous rush involving palms and soles, appeared. Skin biopsy revealed graft versus host. Therapy with steroid pulses was started, MMF was stopped and tacrolimus was converted to everolimus. Donor lymphocyte chimerism reached 12%. Patient ameliorated and was discharged on steroids 30 mg/day and everolimus (3 ng/ml). Fifteen days later he was readmitted with fever and cutaneous rush. Ebstein-barr, CMV and herpes virus 6 were positive. Everolimus was stopped and steroids tappered to cero. He was treated with IV ganciclovir. Peak chimerism increased to 15%. After 4 weeks of treatment he was discharged, but 15 days later he has been readmitted for fever, pancitopenia, and extreme astenia. A bone marrow biopsy revealed medular aplasia. The patient is currently under teatment with Basiliximab.

Conclusion. There are conflicting opinions on wether to increase or decrease immunosuppression in the face of GVHD. In the first episode we increased immunosuppression, in the second episode we chose to withdraw therapy in order to allow patient′s immune system to fight against infections, but now in a last attempt to resolve the situation we have decided to administer Basiliximab.

PP 47.10

EXPRESSION AND INDUCTION OF CYTOCHROME P450 ACTIVITY IN CRYOPRESERVED PORCINE HEPATOCYTES

Cursio, Raffaele¹; Baldini, Edoardo¹; De Sousa, Georges²; Margara, Andrea¹; Honiger, Jiri³; Saint-Paul, Marie-Christine⁴; Bayer, Pascale¹; Raimondi, Vincent¹; Rahmani, Roger²; Mouiel, Jean¹; Gugenheim, Jean¹

¹Univ. de Nice Sophia Antipolis, Laboratoire de Recherches Chirurgicales, Nice, France; ²INRA, Lab. Pharma-Toxicologie Cellulaire, Antibes, France; ³Univ. de Paris V, INSERM U420, Paris, France; ⁴Univ. de Nice Sophia Antipolis, Service d'Anatomo-Pathologie, Nice, France

Background./AIMS: Hepatocyte transplantation may be useful as a bridge for patients to whole organ transplantation, and it may provide metabolic support during liver failure. However, the availability of human hepatocytes is limited and the maintenance of primary culture is possible for only a few weeks. Cryopreservation may be a way to preserve hepatocytes for a longer periode, but the isolation may modify their function represented by cytochrome P450 enzyme activity. The aim of this study was to assess the cytochrome P450 enzyme activity and the effects of its induction in long-term cryopreserved porcine hepatocytes.

Methods. Isolated porcine hepatocytes were cryopreserved for 1 month, thawed and cultured for 3 days. During medium culture, the hepatocytes were exposed to the following cytochrome P450 inducers: dimethyl sulphoxide, rifampicin, phenobarbital, 3-methylcholantrene and dexamethasone. Cytochrome P450 enzyme activities were determined by immunoblotting and EROD assay.

Results. Basal expression of Cytochrome P450 activity was maintained in cryopreserved porcine hepatocytes. CYP1A2 protein levels were significantly increased in cryopreserved porcine hepatocytes when exposed to 3-methylcholantrene compared to other cytochrome P450 inducers. CYP34A protein levels were significantly increased by rifampicin and phenobarbital, whereas no cytochrome P450 inducer modified CYP2E1 protein levels. EROD activity was significantly increased in cryopreserved porcine hepatocytes when exposed to phenobarbital and 3-methylcholantrene compared to other cytochrome P450 inducers.

Conclusions. Cytochrome P450 activity in long-term cryopreserved porcine hepatocytes was maintained and could be increased when exposed to several cytochrome P450 inducers.

PP 48.01

REMOTE ISCHEMIC PRE-CONDITIONING IMPROVES HEPATIC TISSUE OXYGENATION AND ACIDOSIS FOLLOWING LIVER ISCHEMIA REPERFUSION INJURY

Kanoria, Sanjeev¹; Jalan, Rajiv²; Davies, Nathan A.³; Fusai, Giuseppe⁴; Quaglia, Alberto⁴; Seifalian, Alexander M.⁴; Williams, Roger²; Davidson, Brian⁴

¹Royal Free Hospital and RFUCSM, Pond Street, London, United Kingdom; ²The UCL Institute of Hepatology, Division of Medicine, London, United Kingdom; ³The UCL Institute of Hepatology, Division of Medicine, Londoan, United Kingdom; ⁴Royal Free Hospital and RFUCSM, London, United Kingdom

Introduction. Hepatic ischemia reperfusion injury (IRI) lowers hepatic oxygenation and induces hepatic tissue acidosis affecting the outcome of major liver surgery. Remote ischemic pre-conditioning (RIPC) has been shown to reduce the adverse systemic and local effects of liver IRI.

Objective. This is the first study to investigate the effect of RIPC on improving liver tissue oxygenation and acidosis following liver IRI non-invasively through near infra-red spectroscopy (NIRS).

Methods. 24 New Zealand rabbits were grouped into four groups: sham, RIPC, IRI alone, RIPC + IRI. RIPC was induced through 3 cycles of 10 minute ischemia and reperfusion to the limb. Total hepatic ischemia was produced by complete portal inflow occlusion for 25 minutes. Serum transaminases, bicarbonate and hepatic venous nitrite/nitrate (NOx) levels were measured 2 hours post-reperfusion. Hepatic oxygenation was monitored with NIRS.

Results. At 2 hours post reperfusion, IRI alone resulted in reduced mitochondrial oxygenation (CytOx CuA Redox), serum bicarbonate, hepatic venous NOx and an increase in serum transaminases and hepatic deoxyhemoglobin levels. RIPC before IRI caused significant improvement in mitochondrial oxygenation (P = 0.01), increased serum bicarbonate (P = 0.02), hepatic venous NOx (P = 0.025) levels and a decrease in serum transaminases (P = 0.04) and hepatic deoxyhemoglobin levels (P = 0.03). There was a positive correlation (P = 0.02) between hepatic venous NOx levels and mitochondrial oxygenation.

Conclusion. RIPC before IRI reduces hepatic injury, acidosis and improves mitochondrial oxygenation. This is associated with increased Nitri c Oxide bioavailability in the liver. RIPC has potential for clinical application in reducing the adverse effects of liver IRI following major liver surgery.

PP 48.02

CYTOKINES IN THE PIG LIVER DURING WARM ISCHEMIA, PRECONDITIONING AND REPERFUSION

Kannerup, Anne-Sofie¹; Grønbæk, Henning²; Jørgensen, Rasmus Langelund¹; Funch-Jensen, Peter¹; Tønnesen, Else³; Mortensen, Frank Viborg¹

¹Aarhus University Hospital, Department of Surgery L, Aarhus, Denmark; ²Aarhus University Hospital, Department of Medicine V, Aarhus, Denmark; ³Aarhus University Hospital, Dept. of Anesthesiology Medicine, Aarhus, Denmark

Aim: Hepatic ischemia-reperfusion injury induced by Pringles manoeuvre during liver surgery is a well known cause of morbidity and mortality. The aim of this study was to monitor serum interleukins (IL-6, IL-8 and IL-10) and tumor necrosis factor (TNF) during warm ischemia, preconditioning and reperfusion in the pig liver.

Methods. Sixteen landrace pigs (60 kilos), eight in each group, underwent laparotomy followed by 60 minutes of total ischemia with or without prior ischemic preconditioning (10 minutes of ischemia followed by 10 minutes of reperfusion) followed by 3 hours of reperfusion. Before ischemia, at the end of ischemia and during reperfusion serum interleukins (IL-6, IL-8 and IL-10) and TNF were measured as well as serum alanine aminotransferase.

Results. Before ischemia and during the following 60 minutes of total ischemia no differences in pro- and anti-inflammatory cytokines (IL-6, IL-8, IL-10 and TNF) were observed. Thirty minutes after reperfusion all three cytokines started to increase in both groups, especially IL-6. TNF increased only in the ischemic group. IL-6 increased significantly in the group with ischemic preconditioning compared with the non-preconditioned group. IL-8 and IL-10 increased more in the ischemic group compared with the preconditioned group. A minor increase in alanine aminotransferase was observed.

Conclusion. Warm liver ischemia with or without ischemic preconditioning activates the pro- and anti-inflammatory cytokines. Especially IL-6 increased when the liver was exposed to preconditioning.

PP 48.03

EFFICACY OF HEAT SHOCK PROTEIN TO RFA FOR LIVER

KAWASHIMA, YUSUKE; UCHIDA, SHINJI; SHIROUZU, KAZUO

KURUME University Hospital, Surgery, KURUME, Japan

Background. In order to reduce postoperative complication, preservation of liver function and reduction of operative stress are important in treatment of hepatocellular carcinoma(HCC). Therefore, liver radiofrequency ablation therapy (RFA) is prevailing as the local treatment in Japan. HSP is composed quickly to fever and various kinds of stress in cytoplasm. HSP control quality of protein in cytoplasm and has strongly resistance to stress. Geranylgeranylacetone:GGA(Esai Co. Ltd Tokyo Japan) is a antiulcer drug that protects gastric mucosa without affecting gastric acid or pepsin secretin. It make clear that GGA guides HSP70(molecular weight 72kDa) selectively by activation of transcriptase of HSP70.

Purpose. Using rats RFA model, we confirm a state of liver damage after liver RFA and review the influence of GGA.

Methods. Using Wistar rats (male 10weeks 300g), we divide into three groups:GGA treated group (NG +), non-treated group(NG□[) and GGA + Quercetin(an inhibitor of HSP70) treated group(GQ). GGA were given at a dose of 200mg/kg body weight in 24 and4 hours before RFA. Quercetin were given at a dose of 100mg/kg body weight in4 hours before RFA.□@RFA were performed about 15% of liver under general anesthesia with diethylether.□@We measured ALT, AST, TB, LDH, TNFa, IL -6 by ELISA method at preoperation, 6, 12, 24, 48 hours after RFA. We measured expression of HSP70 in the liver using western blotting.

Results. AST, ALT, TB, LDH peak occurred within 6hours after RFA. GGA treated group had a significantry lower peak compared with non-treated group and GGA + Quercetin treated group.□@TNF-a, IL -6 peak occurred within 6 and12hours after RFA too, and GGA treated group had a significantry lower the peak. GGA treated group showed high expression of HSP70 compared with non-treated group until 48 hours after RFA. Western Blotting showed inhibition of HSP70 by medication of Quercetin.

Conclusion. Administration of GGA induce HSP70 and HSP70 relived liver damage.

PP 48.04

DECREASED SERUM INSULIN-LIKE GROWTH FACTOR I (IGF- I) IN HEPATOCELLULAR CARCINOMA: A CORRELATION STUDY WITH CLINICAL DATA

Wang, Shen-Nien¹; Lee, King-Teh²

¹Kaohsiung Municipal Hsiao-Kang Hospital, Surgery, Kaohsiung, Taiwan; ²Kaohsiung Medical University Hospital, Surgery, Kaohsiung, Taiwan

Background. Experimental studies have demonstrated that deregulated serum IGF- I levels play an important role in hepatocarcinogenesis. Our study aims to explore the correlation of clinical data with serum IGF- I levels in patients with hepatocellular carcinoma (HCC).

Methods. A radioimmunoassay was used to determine serum IGF- I levels in 60 HCC patients and 160 healthy subjects. The data was further correlated with their clinical and biochemical characteristics.

Results. The mean IGF- I level was significantly decreased in HCC patients in comparison with healthy subjects (158.46¡Ó105.07 vs. 247.63¡Ó149.96 ng/mL; P <0.001). Homeostasis model assessment-insulin resistance (HOMA-IR) index of HCC patients was significantly higher than that of healthy subjects (5.35¡Ó8.82 vs. 2.53¡Ó6.90; P = 0.027). Moreover, the positive correlation of HOMA-IR with serum IGF- I, which appeared in healthy subjects, was not noted in HCC patients. Intriguingly, in HCC patients, the mean IGF- I level of HCV subgroup was significantly reduced than that of HBV subgroup (113.14 ¡Ó71.28 vs. 180.14 ¡Ó105.10 ng/mL, P = 0.006).

Conclusion. Serum IGF- I level is reduced in HCC patients. Insulin resistance and HCV infection may play some important roles in this deregulation.

PP 48.05

FROM SIMPLE STEATOSIS TO NASH-RELATED HEPATOCELLULAR CARCINOMA (HCC): AN UPDATE ON THE MOLECULAR GENETICS

Stefano, Jose T¹; Oliveira, Claudia Cpm²; Correa-Giannella, Maria Lucia³; Kubrusly, Marcia S²; Privato, Marta²; Mello, Evandro S⁴; Alves, Venancio AF⁴; Bacchella, Telesforo²; Machado, Marcel C C²; Carrilho, Flair J²

¹School Of Medicine São Paulo University, Department of Gastroenterology, São Paulo, Brazil; ²School of Medicine University of São Paulo, Department of Gastroenterology, São Paulo, Brazil; ³School of Medicine University of São Paulo, Departament of Endocrinology, São Paulo, Brazil; ⁴School of Medicine University of São Paulo, Department of Pathology, São Paulo, Brazil

Introduction. Although the risk factors for nonalcoholic fatty liver disease (NAFLD) are well established, its natural history is still uncertain. Studies suggest that the progression from one stage to the next can be triggered by genetic and environmental factors alone and also through their interaction.

Aim. To identify molecular processes involved in NAFLD progression, from simple hepatic steatosis to NASH-related hepatocellular carcinoma (HCC) using microarray analysis.

Methods. Liver tissues from 12 patients with NAFLD diagnosis [3 affected by simple steatosis grade II (STEAT), 3 NASH grade I (NASH), 3 NASH-related cirrhosis (CIR) and 3 NASH-related HCC (HCC)] and 3 non-diseased tissues (CTRL) were evaluated for differentially expressed mRNAs by using CodeLink™ Human Whole Genome Bioarrays with ∼57,000 human transcripts. Data were analyzed by MAPPFinder, which works with the annotations from GO to identify global biological trends in gene expression data and biological pathways.

Results. Using filtering criteria of 2.0-fold-change in expression and a t-test where p < 0.05, the number of differentially expressed genes among all conditions is shown on Table 1. Considering the 866 genes modulated at least in one NAFLD-related condition, the pathways identified as significantly disturbed included: Fatty acid beta oxidation, Synthesis and degradation of ketone bodies, Fatty acid biosynthesis; Triacylglyceride synthesis; Steroid biosynthesis; Inositol metabolism; Heme biosynthesis; Eicosanoid synthesis; Translation factors; Acyltransferase activity; Complement and coagulation cascades; Alpha6-Beta4-Integrin NetPath; Oxidative Stress; Prostaglandin synthesis regulation; Inflammatory response pathway; p38 MAPK signaling pathway and TGF beta signaling pathway.

Conclusions. This study reveals significant gene expression alterations in key biological process and the pathways modulated between the different stages of progression of NAFLD were identified. Table 1. Differentially expressed genes among all conditions

COMPARISON	GENES	UP-REGULATED	DOWN-REGULATED
CIR×CTRL	91	39	52
NASH×CTRL	248	30	218
HCC×CTRL	249	20	229
STEAT×CTRL	113	24	89
NASH×CIR	220	32	188
HCC×CIR	181	4	177
STEAT×CIR	107	8	99
HCC×NASH	452	53	399
STEAT×NASH	237	113	124
HCC×STEAT	305	33	272

PP 48.06

TRANS-PAPILLARY PANCREATIC DUCTAL STENT PLACEMENT IN THE THERAPY OF PANCREATIC DUCT DISRUPTION

Carter, R; McKay, C.J.; Murray, W.R.; Imrie, Clem

Glasgow Royal Infirmary, Department of Surgery, Glasgow, Scotland, United Kingdom

Introduction. Pancreatic duct(PD)disruption usually presents as a consequence of chronic (CP)or acute pancreatitis(AP)in the form of a pseudocyst or ascites. Traditional therapy involves surgical or endoscopic pseudocyst drainage. We describe our experience with PD stenting as part of a multi-modality management algorithm for pancreatic pseudocyst and ascites.

Methods. A prospectively collated database of endoscopic findings was supplemented by retrospective record review. Between April 1996 and November 2006, 9485 ERCP's were performed, 818 procedures were on 416(4.5%) patients for the investigation of “cysts”. A median of 2.36 (range 1– 4) procedures were performed per patient. In 182(1.9%) patients a radiological PD disruption was identified. This occurred in 125 male and 57 female patients, median age 51(range 10–82)).Only 14(8%) had ascites or a pancreatico-pleural fistula. The disruption was in the pancreatic head in 35(19%), neck 58(32%), body 35(19%) and tail 54(30%). CP was present in 97(54%), AP in 79(43%) and 6(3%)involved trauma/ tumour/auto immune pancreatitis. Treatment success was defined as radiological resolution of the fistula, and any associated cyst. The median follow-up 55 months (range 1–118).

Results. Trans-papillary stenting was technically successful in 162/182 patients (89%). Presence of a PD stricture significantly reduced the likelihood of initial stent placement (16/98 vs. 4/84;p = 0.03). Of 162 successful stents, treatment is ongoing in 6, leaving 156 on which to assess the short/medium term success of therapy. Overall resolution occurred in 68%(119/176) of all disruptions and 76% (119/156) of those with successfully placed stents. Resolution was unaffected (p > 0.05) by the site of the disruption (head 25/32(78%)), neck (36/47(77%)), body (18/28(64%)) and tail (40/49(82%)); etiology (AP-58/71(82%)); CP- 58/60(73%)); stent diameter (5FG – 47/61(77%)); 7FG- 72/95(76%)); or whether the stent crossed the disruption (44/61–72%); was short of the disruption 66/86(77%) or into the cyst 9/9 (100%). The presence of an established duct stricture significantly reduced the success of treatment (44/79(58%) vs. 73/77(95%) p < 0.05).

Conclusion. Trans-papillary PD stenting is effective in controlling duct disruption. Pancreatic duct stricture adversely affects outcome.

PP 48.07

PYLORIC EXCLUSION IN THE MANAGENET OF BLUNT DUODENAL TRAUMA.

Morales, Dieter¹; Garcia de Polavieja, Manuel²; Casanova, Daniel²; Seco, Isabel²; Ortega, Carlos²; Marton, Paula²; Naranjo, Angel²

¹University Hospital “Marqués de Valdecilla”, Department of Surgery, Santander, Spain; ²

Introduction. Blunt injuries to the duodenum are uncommon and preoperative diagnosis is difficult. We report the case of a blunt duodenal trauma successfully managed with pyloric.

Case Report. 47 year old white man with history of alcoholism and gastric surgery due foreing body swallowing. He was admitted at hospital drunk. Clinical exploration showed pain and tenderness at right hemiabdomen. Laboratory examination showed leucocytosis with normal amylasa. Ultrasonography showed free fluid at Douglas and CT scan showed retroperitoneal free air (Fig. 1). A median laparotomy was performed. There was a perforation at second part of duodenum (grade III) and biliary peritonitis. A pyloric exclusion, vagotomy and gastrojejunostomy were performed (iconography). The postoperative period was uneventful.

Conclusions. 1.- Preoperative diagnosis of duodenal perforations is difficult.2.- Pyloric exclusion provides an valuable alternative of management of this injuries in order to shorten the operative time and make the procedure reversible.3.- To practise vagotomy remain controversial.

PP 48.08

INTERRUPTED HORIZONTAL MATTRESS SUTURES PLUS CROSS DOUBLE “U” PANCREATICOJEJUNAL ANASTOMOSIS PREVENT PANCREATIC FISTULAS

Chen, Yifa; Chen, Xiaoping

Tongji Hospital, Hepatic Surgery Centre, Wuhan, China

Background. Pancreaticoduodenectomy(PD) has become an increasingly common and safe operation for most patients with benign and malignant periampullary tumors. However pancreatic fistula (PF) is still the most problematic common complication after PD. Especially the pancreaticojejunal anastomostic leakage is a major cause of morbidity and mortality post-pancreaticoduodenectomy.

Methods. We designed a new technique of pancreaticojejunal anastomosis to prevent the development of pancreatic Fistulas. The procedures of this new technique included pancreatic remnant interrupted horizontal mattress sutures(see figure1) and cross double “U” pancreaticojejunal anastomosis(two sutures)(see fugure2). Mattress sutures shoud avoid main pancrea duct ligament and the double cross “U” pancreaticojejunal anastomosis made the pancreatic remnant in the jejunal lumen sheath at least 3 cm.

Results. From May 2006 to May 2007, a total of 52 periampullary malignant tumor patients were operatived with this type of pancreaticojejunostomy, None of the patients developed pancreatic fistulas.

Conclusion. Pancreatic remnant interrupted horizontal mattress sutures plus cross double “U” pancreaticojejunal anastomosis can prevent pancreatic fistulas after pancreaticoduodenectomy.

PP 48.09

CHRONIC VENTRAL PANCREATITIS WITH PANCREAS DIVISUM

Tanabe, Reiko¹; Takahata, Syunichi²; Konomi, Hiroyuki³; Sadakari, Yoshihiko²; Ienaga, Jun²; Yamaguchi, Koji²; Tanaka, Masao²

¹Kyushu University Hospital, Department of Surgery and Oncology, Fukuoka, Japan; ²Graduate School of Medical Sciences of Kyushu University, Department of Surgery and Oncology, Fukuoka, Japan; ³Kitakyushu Municipal Medical Center, Kitakyushu, Japan

Background. Pancreas divisum is one of the anatomical variant, results from the deficiency of fusion of the dorsal and ventral pancreatic duct. Sometimes it causes dorsal pancreatitis because of the insufficient drainage via minor papilla but scarcely ventral pancreatitis. We report a case of chronic ventral pancreatitis with pancreas divisum successfully treated by pancreas head resection. CASE: A 57 year old woman had abdominal pain after drinking. Computed tomography showed the stone of pancreas head. First she was treated by medication, but the pain wasn□ft improved. ERCP studies could not show the Wirsung duct but showed the dilation of dorsal pancreatic ducts and branches. We performed EST and stenting for dorsal pancreatic duct via minor papilla. However, the pain slowly emerged two years later, she underwent pancreaticoduodenectomy. The resected specimen showed chronic pancreatitis localized to the ventral pancreas and there is no connection dorsal and ventral pancreatic duct. After the operation, she recovered from the pain.

Conclusion. Pancreas divisum is found about 3% in Japan, and known to bring about chronic dorsal pancreatitis. This case, however, was seemed to be caused by insufficient drainage of ventral pancreas induced by drinking, and was cured by pancreaticoduodenectomy. There is possibility to be a ventral pancreatitis in pancreas divisum, and if it were, it was effective to resect the ventral pancreas such as pancreaticoduodenectomy.

PP 48.10

ANALYSIS OF CHEMORADIATION THRAPY FOR UNRESECTABLE STAGE IV PANCREATIC CANCER

Otani, Satoshi; Takeda, Shin; Yamada, Suguru; Sugimoto, Hiroyuki; Nomoto, shuji; Kasuya, Hideki; Kanazumi, Naohito; Nakao, Akimasa

Nagoya university graduate school of medicine, Surgery II, Nagoya, Japan

Background. Pancreatic cancer has an extremely poor prognosis. The benefit of chemotherapy, radiotherapy or both as a palliative treatment of unresectable pancreatic cancer is uncertain. OBJECTIVE To assess the effects of chemotherapy (CHT) and/or intraoperative radiotherapy (IORT) in the management of unresectable pancreatic cancer. SUBJECTS AND

Methods. Between October 1981 and August 2007, 167 patients with unresectable pancreatic cancer were treated at our institution. According to the treatment modality, the study population was classified by (with/without) IORT, CHT, locally advanced and/or distant metastasis. We evaluated median survival and the 0.5 and 1-year survival rates of the each group retrospectively. Kaplan-Meier analysis was used to calculate the actuarial rate of the overall survival (OS) rate. Results Median survival of the 0.5-year (and 1.0-year) survival rates in the group with CHT + IORT (n = 39), with IORT alone (n = 55), with CHT alone (n = 18) and no treated (n = 55) were 6.7 months, 52.6(23)%, 6.6months, 55.6(20.4)%, 8.1 months, 72.1(19%), 3.2months, 24.1(3.7)%, respectively. In the 39 patients with chemoradiation, the median survival in the GEM-based group (n = 18) were significantly better than in the other agents-based group (n = 21) (P = 0.02). Median survival amounted to 3.16 months (95% CI: 2.2–4.1 months) for the patients without CHT (n = 110) while it was prolonged to 6.6 months (95% CI: 5.4 □∣7.9 months) for undergoing IORT.

Conclusions. Prolongation of the survival period was shown by concomitant IORT and administration of GEM for unresectable pancreatic cancer. Thus, attempting to combine chemotherapy with IORT and giving additional consideration to the administration method was shown to provide adjuvant therapy that can be expected to be effective against stage IV unresectable pancreatic cancer.

PP 49.01

KRUKENBERG′S TUMOR AS A FIRST MANIFESTATION OF FIBROLAMELLAR HEPATOCARCINOMA

Bilbao, Itxarone¹; Vilallonga, Ramon¹; Dopazo, Cristina¹; Allende, Elena²; Viladomiu, Luis³; Quiroga, Sergi⁴; Margarit, Carlos¹

¹Hospital Vall d′Hebron, Surgery Department, Barcelona, Spain; ²Hospital Vall d′Hebron, Pathology Department, Barcelona; ³Hospital Vall d′Hebron, Hepatology Department, Barcelona; ⁴Hospital Vall d′Hebron, Radiodiagnostic Department, Barcelona

Introduction. Fibrolamellar carcinoma (FL-HCC) is a rare subtype of hepatocellular carcinoma (HCC) with distinctive clinical and histological features and better prognosis than HCC.Aim. To present a single case experience of a Krukenberg′s tumor as a first manifestation of FL-HCC. CASE. A 45 years old woman presented inferior abdominal pain and swelling during the last 5 months. Abdominal exploration revealed left hepatomegaly and masses in both iliac fossa. Ultrasound and CTscan revealed an 8×12 cm mass in left hepatic lobe, bilateral ovarian masses and peritoneal implants in great omentum, perihepatic, right parietocolic and minor pelvis peritoneum. Citology by ovarian PAAF was positive for malignant cells of hepatic morphology. Inmunohistochemistry was positive for keratine A7 and negative for keratine AE1 /AE3, alpha fetoprotein, citokeratine 20, HMB-45 and plap. Liver enzymes revealed: AST = 163 UI/L, ALT = 80UI/L, Alkaline phosphatase = 888UI/L GGT = 177UI/L. HBV and HCV serology were negatives. Left hepatectomy with doble anexectomy, omentectomy and partial peritonectomy was done. Histopathologic characteristics showed a well diferentiated FL-HCC (pT2, N1, M1). Postoperative course was uneventful and she was discharged 12 days after surgery. She received chemotherapy with gemcitabine 1000 mg/m2 the first day followed by oxaliplatino 100 mg/m2 the second day, each two weeks. She received a total of 4 cycles, with bad tolerance and respond. Six months after operation an abdominal TAC revealed peritoneal recurrence. Two years after surgery she is still alive with bad general status and palliative treatment.

Conclusion. FL-HCC is variety of hepatocallular carcinoma appearing more frequently in young adults. The presentation as a Krukenber tumour is very rare but has been previously reported. The best treatment is surgical resection. In cases of diseminated disease, citoreduction can be tried in order to prolonge survival.

PP 49.02

LAPAROSCOPIOC HEPATECTOMY FOR CILIATED HEPATIC FOREGUT CYST

Kawasaki, Atsushi¹; Oida, Takastugu¹; Mimatsu, Kenji¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Inami, Makiko²; Mtsuoka, Shun-ichi²; Fijikawa, Hirotoshi³; Amano, Sadao⁴

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Social Insurance Yokohama Central Hospital, Gastroenterology, Yokohama, Japan; ³Social insurance Yokohama Central Hospital, Gastroenterology, Japan; ⁴Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. Ciliated hepatic foregut cyst (CHFC) is rare benign, solitary cyst consisting of ciliated pseudostratified columnar epithelium, subepithelial connective tissue, smooth muscle layer, and an outer fibrous capsule. However, ciliated cysts commonly arise from the tracheal bronchial tree and esophagus, they could also be found in the liver with rare incidence. Therefore, we present a case of 57-year-old woman who underwent laparoscopic hepatectomy for CHFC. CASE REPORT: A-57-year-old woman with a liver tumor was admitted to our hospital. The tumor was cystic with calcification. Fine needle aspiration biopsy underwent for the cystic lesion, and diagnosed CHFC. The cystic tumor slightly enlarged at 7 months later after the diagnosed. We performed a laparoscopic hepatectomy. The HE-stained sections showed an epithelial lining of ciliated pseudostratified columnar cells with occasional goblet cells. Niether signs of squamous metaplasia nor signs of malignancy could be pbserved in the epithelium.

Conclusion. When squamous epithelium is identified in a liver cyst, an extensive sampling is recommended to identify possible foci of squamous carcinoma and to classify more precisely the histological type of the lesion. Laparoscopic surgical removal of the lesion may be appropriated as a minimally invasive procedure.

PP 49.03

SMALL CELL CARCINOMA LIVER – A CASE REPORT

Kanchustambam, subba rao; Darmender, MS

Apollo health city, HPB & Liver transplant surgery, hyderabad, India

Introduction. Small cell carcinoma is one of the commonest malignant tumors of Lung. Extra pulmonary primary small cell carcinoma is rare. We herein report a case of small cell carcinoma of Liver CASE HISTORY The patient is a 73 yr old female presented with right upper quadrant pain with fever 6 months following Lap cholecystectomy. CT abdomen showed well defined hypo dense lesion at the junction of segment 5 and 4 whose FNA (thought to be abscess) suggested Hepatoma. Her AFP was 24ng/ml. The other tumor markers CEA, Ca 19-9 were normal. She has no underlying liver disease. She underwent Diagnostic laparoscpy followed by segment 4 and 5 resection. Recovery was uneventful. HISTOLOGY Histopathology revealed small cell carcinoma (High grade endocrine tumor) of liver. The resected margin is free. Adjoining liver and omentum are free of tumor. On immuno histochemistry, tumor cells show diffuse and strong positivity for NSE and negative for CYTOK-7&CYTOK-20. DISCUSSION: Extra pulmonary Small cell carcinoma (EPSCC) is an entity different from that of lung. Of all EPSCC, one third is from uterine origin. EPSCC other than uterus are usually aggressive. The median survival from the time of diagnosis is about 9 to 14 months. The prognosis is dependent on the stage and primary location of the tumor. Multimodal treatment improves survival both in local and extensive disease.

PP 49.04

DIAGNOSIS OF INFLAMMATORY PSEUDOTUMOR OF THE LIVER

Kuboi, Youichi¹; Oida, Takatsugu¹; Mimatsu, Kenji¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. AND AIM: Inflammatory pseudotumors are uncommon mass lesions arising most typically in the lungs of young adults. Hepatic inflammatory pseudotumors (HIPT) are rare focal lesions of the parenchyma, accompanied by fever, malaise, abdominal pain and mass effect, and therefore are commonly misdiagnosed as malignant tumors or liver abscesses. Routine imaging techniques are not specific and do not reach a definitive preoperative diagnosis between a benign and a malignant tumor. We studied three patients with HIPT to determine what examination can aid in its diagnosis.

Patients and Method. One patient underwent lateral hepatic segmentectomy as a cholangiocellular carcinoma. We performed repeat ultrasonography in one patient, and diagnosed as a hepatocellular carcinoma. One patient underwent ultrasonography-guided percutaneous liver biopsy because of difficulty in definitive preoperative diagnosis, and the histological finding was consistent with HIPT.

Results and Conclusion. Repeat US findings are useful to diagnosis as HCC or HIPT, however, in the difficulty of preoperative diagnosis, preoperative histological confirmation is necessary to avoid unnecessary surgery.

PP 49.05

FIBROLAMELLAR HEPATOCELLULAR CARCINOMA AND LARGE FOCAL NODULAR HYPERPLASIA: A CASE REPORT AND REVIEW OF THE LITERATURE.

Sapisochin, Gonzalo; Dopazo, Cristina; Escartin, Alfredo; Lazaro, Jose Luis; Bilbao, Itxarone; Balsells, Joaquin

Hospital Vall D′Hebron, HBP Surgery and Liver Transplant, Barcelona, Spain

Introduction. Focal nodular hyperplasia (FNH) is the second most common benign liver tumor after hemangioma. The potential for malignant transformation has not been demonstrated, however some authors have suggested a direct link between FNH and fibrolamellar hepatocarcinoma (FL-HCC). OBJETIVES: To describe a case report of a liver tumor that was a FNH with focus of FL-HCC. CASE: A 47-year-old man was referred to our outpatient clinic in April 2003 with mild abdominal pain and fatigue. An abdominal ultrasound was then performed and reve aled a 6×5 cm liver mass in the left lobe. A CT scan showed this mass with a central scar and was described as a FNH, which was confirmed with a fine needle biopsy that didn't show atypical cells, and an MRI that showed a typical FNH image. From July 2003 to December 2006 the patient was controlled in the clinic and different image examinations were done revealing a progressive increase in the size of the mass but with the same FNH characteristics. Laboratory exams were normal. The patient referred increase in the pain. A new CT scan was repeated and showed that the liver mass had a 10 cm diameter now, and still had FNH characteristics. Due of the great increase of pain and the increase in size, the patient was operated on March 2007. The surgical procedure involved a left hepatectomy. Macroscopically it had a yellow–white cut surface and a central scar. Microscopic examination revealed a FNH with focus of FL-HCC. The postoperative period was uneventful. Actually, 6 months after surgery the patient is asymptomatic and free of disease.

Conclusions. FL-HCC have a relatively indolent tumor biology and it may be difficult to differentiate it from a FNH with imaging techniques. To find an association between FNH and FL-HCC is rare, and so, it becomes difficult to draw conclusions for both the pathology of this tumor and the optimal management of these patients.

PP 49.06

THE BENEFITIAL EFFECT OF ICK(INCHIN-KO-TO) IN LARGE VOLUME HEPATECTOMY IN AN ICTERIC LIVER WITH HILAR CHOLANGIOCARCINOMA: REPORT OF A CLINICAL CASE

Nishi, Masaaki; Ikegami, Toru; Imura, Satoru; Morine, Yuji; Kanemura, Hirofumi; Arakawa, Yusuke; Mori, Hiroki; Shimada, Mitsuo

The University of Tokushima, Department of Surgery, Tokushima, Japan

Background. ICK (inchin-ko-to), an herbal medicine, is known to have various hepatotrophic effects including hepatocytes protection, prevention of hepatic fibrosis, and promoted bile excretion by hepatocytes. Therefore, possible improvement in liver functions of an icteric liver is anticipated, even in a surgical setting. We herein report a case with hilar cholangiocarcinoma (HC). With the aid of ICK, the patients underwent extended right lobectomy with complete caudate lobectomy. A case report. The case was a female patients aged 70's. She admitted in our ward for HC with prominent jaundice and malaise. The radiological works-ups showed that the invasive tumor was located on the confluence of hepatic ducts, with dilatation of the intrahepatic bile ducts in the both lobes. Liver function test were as follows; Total bilirubin(T-bil) 17.3mg/dl, direct bilirubin 13.1mg/dl, type?collagen 241ng/ml, hyaluronic acid 119ng/ml, CEA1.0ng/ml and CA19–9 733U/ml. The plan for curative resection was extended right lobectomy with complete caudate lobectomy followed by bile duct reconstruction. The patient underwent percutaneous trans-hepatic biliary drainage through the B3, followed by the administration of daily ICK. Two weeks later, T-bil was still 4.9mg/dl with ICG15 value of 32%. The volumemetry analysis showed that the expected remnant liver was 29.2% of her total liver volume after the planned surgery. The planned curative surgery was conducted under continuous administration of ICK. Although she had some signs of hepatic failure with elevated total bilirubin of 10.4mg/dl, her condition improved within 10days, followed by the discharge on 44days after surgery.

Conclusion. We reported a case with a successful large-volume hepatectomy under administration of ICK, even though the hepatic icterus was not fully ameliorated. ICK may prevent hepatic failure in large volume hepatectomy in a marginally icteric liver.

PP 49.07

HEPATECTOMIES FOR NON-MALIGNANT AND NON-INFECTIOUS LIVER MASSES.

Sapisochin, Gonzalo; Dopazo, Cristina; Bilbao, Itxarone; Escartin, Alfredo; Lazaro, Jose Luis; Balsells, Joaquin

Hospital Vall D′Hebron, HBP Surgery and Liver Transplant, Barcelona, Spain

Introduction. Non-malignant and non-infectious liver masses, are increasingly being recognized with the widespread of better and more accurate imaging techniques. Hepatectomies are usually performed with suspicion of malignancy or because patients become symptomatic.

Aim. To describe our experience on hepatectomies for these masses.

Results. Between 1989–2006, 695 hepatectomies have been performed in our unit, 68 (9,8%) for these masses. Mean age of patients was 50 years (r 22–80); 46% males and 54% females. The majority of these masses were cavernous hemangioma 15 (22%) and focal nodular hyperplasia 13 (19%) while the rest of the diagnosis were a miscellanea. Fifteen percent were cirrhotic patients of whom 50% were HCV positive and 10% HBV positive. There was a unique mass in 80% of the cases and more than one in 20%, and were located on the left lobe in 53%, 42% on the right lobe and 5% were bilobar. Mean size of the biggest mass was 6 cm (r 0,4–18), 58% were encapsulated. Indications for treatment were the suspicion of malignancy, size or symptoms. Surgical procedures included 18 left lateral segmentectomies (26,5%), 14 segmentectomies (20,5%), 14 tumorectomies (20,5%), 10 right hepatectomies (14,7%), 6 left hepatectomies (8,8%), 3 amplified left hepatectomies (4,4%), 2 right lateral hepatectomies (2,9%) and 1 central hepatectomy (1,5%); mean time for surgery was 154±68 minutes with need of blood transfusion in 24%. There was 1 case (1,5%) of postoperative mortality due to acute liver failure. Morbidity was observed in 18%; 15% infections, 7,4% biliary leak, 8,8% acute liver failure and 1,5% re-laparotomy for hemoperitoneum. Patients were followed-up a minimum of 6 months and no mortality was observed.

Conclusions. Non-malignant and non-infectious liver masses may be resected with safety by expert liver surgeons and it is associated with a low mortality and morbidity. We think that surgery is feasible and needed in cases were the non-malignant nature of the mass cannot be confirmed or when symptoms appear.

PP 49.08

RESULTS FOLLOWING SURGICAL RESECTION FOR PERIPHERAL CHOLANGIOCARCINOMA

Pissanou, Theodora; Silva, Michael A; Attia, Magdy S; Manzia, Tomasso; Coldham, Christopher; Mayer, David; Bramhall, Simon R; Buckels, John A C; Mirza, Darius F

University Hospital Birmingham NHS Trust-Queen Elizabeth, The Liver Unit, Birmingham, United Kingdom

Background. Peripheral cholangiocarcinoma (PC) is the second most common primary bile duct cancer and constitutes 10% of primary liver malignancies. Surgical resection presently offers the only prospect of long term survival. We present the experience of managing PC at a tertiary referral centre in the UK.

Methods. This is a retrospective analysis of a prospectively maintained database from 1988 to January 2007. Patients with peri-hilar lesions and gall bladder cancer were excluded.

Results. There were 103 patients (58 female), median age 64 (41–81) years; 42 (41%) underwent surgical exploration with 29 (28%) undergoing curative resection including portal lymph node clearance. All these patients presented late with vague symptoms without jaundice. Postoperative morbidity and 30 day mortality were 52% and 10% respectively. R0 clearance was achieved in 22 (76% of resected) with 4 having R1 clearance. The median survival following R0 resection was 16.4 (0.2–98) months and for R1 was 1.5 (0.3–32) months respectively (P = 0.001). The median survival of non resectable and those managed non operatively was 4.8 (0–56) months (P = 0.001). Tumour size >5cm, vascular and lymph node invasion were significantly associated with for tumor recurrence post resection and survival (P < 0.05). R0 resection of tumours classified as advanced according to UICC staging however achieved longer survival compared to in operable and those managed non operatively.

Conclusions. R0 resection resulted in significantly prolonged survival, with tumour size, vascular and lymph node invasion being prognostic factors for tumor recurrence and survival. R0 resection can provide prolonged survival, even in patients with advanced PC.

PP 49.09

RUPTURED HEPATIC ANGIOSARCOMA: A CASE REPORT

Sonawane, Rajendra

Medical Trust Hspital, Surgical Gastroenterology, M G Road, Cochin, India

Introduction. Rupture is a common and fatal complication of Hepatic Angiosarcoma (HA). Management of ruptured HA is addressed in anecdotal reports worldwide. Hitherto it is unreported from India. CASE REPORT: A 65 year old male with 6 cm tumor in segment II and III was referred to us for liver resection with histological diagnosis of hemangioendothelioma. The patient opted for alternative medicine and was lost to follow up. Four months later he was readmitted with hypovolemic shock and acute abdomen. On assessment he was found to have hemoglobin of 4 gm%, hemoperitoneum and 16 cm mass in liver. After resuscitation and transfusion of activated factor VIIa, triphasic CT was done which revealed multiple space occupying lesions in right lobe besides an exophytic 16 cm. mass from the left lobe. Left lateral segmentectomy and partial caudate lobe resection was performed 48 hours after admission. Barring transient nonoligouric renal failure the recovery was uneventful. Patient was discharged on 14th day. Histology revealed HA. At 8 month follow up patient is alive and asymptomatic with disease in right lobe.

Conclusion. This cas e report highlights aggressive nature of HA. Resection is feasible in ruptured HA after optimization. Critical risk/benefit assessment should be done, as resection is often non-curative. Angiographic embolization has been reported either as an alternative modality or as an adjunct to surgery. Role of factor VIIa in such situations is evolving and randomized trials do not support its routine application yet.

PP 50.01

FLEXIBLE APPROACH IN MANAGEMENT OF NECROTIZING PANCREATITIS

Shabunin, Alexey¹; Bedin, Vladimir²; Shikov, Dmitryi³; Tavobilov, Michael³; Lukin, Andrey³; Grekov, Dmitryi³

¹Botkin, s Memorial Hospital, Prof. The cief surgeon, Moscow, Russian Federation; ²Botkin, s Memorial Hospital, The cief of HPB-surgery, Moscow, Russian Federation; ³Botkin, s Memorial Hospital, HPB-surgery, Moscow, Russian Federation

Background. It's obvious that degree of pancreas gland and parapancreatic fat damage plays the leading role in determination of surgical approach, which cosequently influences on the outcome.

AIM. to assess the role of Dynamic Contrast Enhancement Computed Tomography (DCECT) in combination with ultrasound (US) monitoring and MR-tomography in defining the surgical management. MATERIALS/ Methods. 277 patients with NP, which were presented of two groups, have been analyzed during 2002 to 2006. All patients had the same clinical data (Ranson > 3, APACHE > 9) on admission. Group 1–125 patients (2002–2003), group 2 – 152(2004–2006). In group 1 the main role in diagnostic algorythm were US monitoring and native CT. All patients from group 2 underwhent CECT on 3–5 days from the onset of desease or on the admission case of delay hospitalization with following CECT monitoring and MRT to detect latest complications. The choice of way and kind of surgery based on clinical data and results of CECT or MRT. Patients which had CT index of C and D and volume of necrosis (VN) < 30% were underwent endoscopic surgery and US guided percutaneus drain, in cases with peripancreatic fluid collections > 50 ml. In some cases these methods were performed like a first step with following open surgery. If CT index was grade E (VN – 30–50%, >50%) such patients were mainly underwent open surgery.

Results. Endoscopic surgery and US-guided drain were performed as a first and final stage of treatment in 41 (32,8%) cases of group 1 and in 106 (69,7%) of group 2. Endoscopic surgery and US-guided drain with following open surgery were performed in 39 (31,1%) cases of group 1 and in 32 (21,1%) cases of group 2. Open surgery, as a single surgical method, was performed In 45 (36,1%) cases of group 1 and in 14(9,2%) cases of group 2. The mortality range in group 1 was 35,2% and 16,4%-in group 2 (p = 0.005).

Conclusion. DCECT and MRT are the most effective diagnostic methods in management of necrotizing pancreatitis.

PP 50.02

THE ANTIOXIDANT STATUS OF AN INFLAMMATORY DISEASE AS MEASURED BY CYCLIC VOLTAMMETRY: A RODENT STUDY TO ASSESS THE SEVERITY OF ACUTE PANCREATITIS

Anubhav, Mittal¹; Flint, Richard²; Fanous, Medhat³; Delahunt, Brett³; Killmartin, Paul³; Cooper, Garth JS³; Windsor, John A¹; Phillips, Anthony⁴

¹University of Auckland, Surgery, Auckland, New Zealand; ²University of Auckland, Surgery, Auckland; ³; ⁴University of Auckland, Surgery

Objective.To determine whether serum antioxidant capacity measured by the electrochemical technique of cyclic voltammetry (CV) could resolve differences in severity of the inflammatory disease acute pancreatitis. Methods-Experimental animal study using male Wistar rats. Rats from 5 groups were studied. Group 1 (baseline), immediate euthanasia with no surgical interventions; Group 2 (sham), identical surgical procedures to the pancreatitis groups but no intraductal infusion; Groups 3 – 5, acute pancreatitis induced by intraductal infusion of 3%, 4% or 5% sodium taurocholate respectively. Terminal blood and pancreatic tissue samples for CV, biochemistry and histology were collected at 12 h (Groups 2–5). Results-There was a significant positive correlation of the first serum cyclic voltametric peak current maxima (CVi1) with pancreatic histological severity (Spearman r = 0.51, p = 0.007) as well as with a number of other markers of systemic disease severity, notably bicarbonate (r = − 0.57, p = 0.002), base excess (r = − 0.65, p <0.001) urea (r = − 0.68, p < 0.001) and calcium (r = − 0.60, p = 0.008). Uric acid and ascorbic acid, two circulating low molecular weight antioxidants, were calculated to contribute a maximum of 57±12% and 19±4% respectively, to the serum CVi1 peak current. CVi1 was superior at indicating the severity of the disease state compared to a standard method of total antioxidant capacity measurement (ABTS.+ based assay). Conclusions-CV was found to be a simple, technique that could differentiate between the physiological and histological severities of acute pancreatitis. Further clinical studies are now justified to determine if point-of-care CV offers prognostic and treatment-monitoring advantages for severe acute pancreatitis within the critical care setting.

PP 50.03

EXPERIENCE OF THE TREATMENT OF EMPHYSEMATOUS NECROTIZING PANCREATITIS

Ðileikis, Audrius; Beiða, Virgilijus; Jurevièius, Saulius; Zdanytë, Elena; Strupas, Kæstutis

Vilnius University hospital Santariðkiø klinikos, Abdominal surgery department, Vilnius, Lithuania

Background. Emphysematous pancreatitis is a life-threatening condition that ordinarily requires surgical management. Four cases of emphysematous pancreatitis including successful medical treatment without any surgical interventions are described in this article.

Methods. Retrospective review of case records of patients with emphysematous pancreatitis, who have been treated by different methods.

Results. Four patients had pancreatic necrosis with retroperitoneal and intrapancreatic gas trapping for more than 3 years. Retroperitoneal and intrapancreatic gas trapping was found for all of them during the first week of their illness. Two of them underwent immediate surgery after the confirmation of the diagnosis (necrosectomy and open packing), the third patient was operated (necrosectomy and closed lavage) on the 9th day after medical treatment, and the fourth patient recovered after conservative treatment without any surgery.

Conclusions. If the patient's condition is stable antibiotic treatment could be undertaken without any surgical intervention despite the evidence of pancreatic infection. General physical condition of the patient is an important factor for choosing a treatment rather than bacteriological or radiological findings of the infection.

PP 50.04

ALCOHOL-METABOLIZING ENZYME GENE POLYMORPHISMS AND ALCOHOL CHRONIC PANCREATITIS AMONG POLISH INDIVIDUALS

Lach, Halina; Celiñski, Krzysztof; S³omka, Maria

Medical University of Lublin, Department of Gastroenterology, Lublin, Poland

Background. Chronic pancreatitis develops in 5–10% of alcohol-addicts. In developed societies alcohol is the cause of chronic pancreatitis, at least in 70–80%. Genetic polymorphism of enzymes involved in alcohol metabolism plays relevant role in etiopathogenesis of chronic pancreatitis.

Aim. The aim of the study was to find, in the Polish population, the ADH, ALDH2 and CYP2E1 alleles and genotypes that are likely to be responsible for higher susceptibility to chronic alcohol pancreatitis.

Methods. We determined the allele and genotype of ADH2, ADH3, ALDH2 and CYP2E1 in 141 subjects: 44 with alcohol chronic pancreatitis, 43 “healthy alcoholics” and 54 healthy nondrinkers as the controls. Genotyping was performed using PCR-RELP methods on white cell DNA.

Results. ADH2*1, ADH3*1 alleles and ADH2*1/*1, ADH3*1/*1 genotypes were statistically more frequent among the patients with alcohol chronic pancreatitis in comparison to the controls. ADH3*2/*2 genotype was more frequent among “healthy alcoholics” and in the controls than among those with alcohol chronic pancreatitis. In the studied group only ALDH2*1 allele was detected, all patients were ALDH2*1/*1 homozygotic. Differences in the CYP2E1 allele and genotype distribution in the examined groups were not significant.

Conclusion. In the Polish population examined ADH3*1, ADH2*1 allele may be risk factors for developing alcoholism. ADH3*2/*2 genotype may confer protection against alcohol chronic pancreatitis. CYP2E1 gene polymorphisms are not related to alcoholism and alcohol chronic pancreatitis. Examined Polish population is ALDH2*1/*1 homozygotic.

PP 50.05

GROOVE PANCREATITIS SUCCESSFULLY TREATED BY PANCREATICODUODENECTOMY

DeOliveira, Michelle L¹; Benini, Bárbara²; Triviño, Marcelo²; Apodaca-Torrez, Franz R.²; Artigiani-Neto, Ricardo³; Triviño, Tarcisio²

¹University Federal of Sao Paulo-Division of Gastrointestinal Surgery, Surgery, Sao Paulo, Brazil; ²University Federal of Sao Paulo-Division of, Surgery, Sao Paulo, Brazil; ³University Federal of Sao Paulo, Pathology, Sao Paulo, Brazil

Background. Groove pancreatitis is a rare subtype of chronic pancreatitis where the fibrotic tissue involves the groove between the pancreatic head and duodenum, and common bile duct. It is a tumor-like lesion that often mimics pancreatic carcinoma. There are different choices of treatment for groove pancreatitis described in the literature, mainly due complications from such uncommon disease.

Aim. The aim of this study was to report three cases of groove pancreatitis with duodenal stenosis.

Methods. Three male patients with an average age of 49 years, presenting severe upper abdominal pain, post-prandial vomiting and weight loss associated to remarkable history of alcohol abuse were evaluated.

Results. All patients underwent pancreaticoduodenectomy (with pylorus preserving in two cases and partial gastrectomy in one case). After surgical treatment, there was no related mortality and patients evolved with symptoms relief and weight gain. The final diagnosis was confirmed by histological findings.

Conclusion. These cases illustrate pancreaticoduonectomy as favorable treatment choice for groove pancreatitis leading to duodenal stenosis.

PP 50.06

FREY'S PROCEDURE-EXPERIENCE OF A TERTIARY CARE CENTER

Yadav, Thakur Deen; Wig, Jai Dev

PGIMER, General Surgery, Chandigarh, India

Background. Debilitating abdominal pain remains the most common indication for surgery in patients with chronic pancreatitis. In 1987 Frey and Smith described a new procedure designed to decompress a hypertensive ductal system more completely in patients with chronic pancreatitis. The aim of this study is to evaluate the safety and outcome of Frey's procedure.

Patients and Methods. All patients of chronic pancreatitis where Frey's procedure was offered; were included in this study. The study period was from June 2003 to May 2007.

Results. During this period, 28 patients affected by chronic pancreatitis were subjected to the Frey's procedure. Seventeen patients were male and etiology included alcohol abuse in 12, idiopathic in 10 patients. Pancreas divisum was found in 2 patients. Preoperative selection criteria included confirmed diagnosis of chronic pancreatitis. Preoperative pain was present in 27 cases, 7 patients were diabetic, left sided portal hypertension was found in 4 patients. Frey's procedure was done in 24 patients, Frey's procedure with hepaticojejunostomy in one patient, Frey's with gastrojejunostomy in two patient and Izbicki's procedure in one patient. Postoperative gastrointestinal and intraabdominal bleed occurred in one patient and small leak from the pancreaticojejeunal anastomosis in one patient. Both these patients were successfully managed on conservative line using octreotide in both. Mortality was nil. All patients were pain free in the immediate post operative period. After surgery, in two patients the diabetes stabilized and the insulin requirement decreased. None of the patients developed diabetes in the post operative period. The body mass index and quality of life showed significant improvements in the follow up.

Conclusion. With limited follow up, the outcomes confirm that Frey's procedure is a safe procedure in experienced hands.

PP 50.07

SURGICAL CONSIDERATIONS IN THE MANAGEMENT OF FAILED PANCREATIC ENDOTHERAPY (PANCREATIC STENTING) IN CHRONIC PANCREATITIS

Joshi, Mukund

Joshi Clinic, Janardan Sadan, 1194/23, Ghole Road, Pune, India

Introduction. Endoscopic pancreatic stenting is quite commonly practiced in cases of chronic Pancreatitis. Often it is followed by Pancreatic lithotripsy for easier extraction. We have presented 14 cases in which pancreatic endotherapy was advocated which failed on various accounts and needed surgical exploration. The paper contains illustrations with intra-operative photographs.

Methods. We selected cases of chronic pancreatitis who had undergone pancreatic endotherapy, who presented with abdominal pain, sepsis or Jaundice. 4/14 cases had undergone pancreatic stenting alone, 8/14 had undergone stenting with Lithotripsy, 2/14 had undergone ERCP where stenting had failed. All patients underwent CT scan evaluation, biochemical work up and were started on IV antibiotics 24 hours prior to surgery.

Results. All cases underwent Laparotomy. Identification of pancreatic duct was found to be difficult secondary to “Edematous Fibrotic pancreas”. In majority of cases stones were seen around the stent and 10/12 stents were all blocked. All patients underwent PJ after successful removal of stent. Average blood loss was 650cc. Requiring Blood transfusions. Average time was 4.30hrs. There was no mortality. DISCUSSION: Surgical exploration of pancreas becomes difficult due to edematous pancreas which spreads to nearby tissues making the dissection difficult. Stent could never be palpable on the surface of pancreas due to edematous pancreas. One needs to be extremely gentle while performing pancreatic anastomosis as sutures can give way secondary to pancreatic tissue edema. Stents need careful pulling as it can lead to severe bleeding and duodenal injury.

Conclusions. Pancreatic endotherapy is not without complications. Lithotripsy does not necessarily lead to duct clearance. Careful dissection is priority. Adequate blood transfusions should be reserved. Overall post-operative recovery appeared delayed as compared to Pancreatico-jejunostomies done without pre-operative pancreatic endotherapy.

PP 50.08

ROLE OF FREY'S PROCEDURE FOR CHRONIC PANCREATITIS IN INDIAN SCENARIO – INITIAL RESULTS

Joshi, Mukund¹; Dadu, Anurag²; Dube, Sudhir²; Jamkar, Arun²; Joshi, Manohar²

¹Joshi Clinic, Janardan Sadan, 1194/23, Ghole Road, Pune, India; ²

Introduction. In India we have a mixed spectrum of tropical calcific Pancreatitis & Alcoholic Pancreatitis. We selected Frey's head coring procedure for the patients with predominant disease in head of Pancreas.

Methods. Frey's procedure was performed in 32/46 cases since Feb. 2002. Frey's procedure involves coring of the pancreatic head along with laying open of the pancreatic duct & lateral anastomosis. Male to female ratio was 3:1. Age group ranged from 9 to 60 years. The main complaint was epigastric pain referred to back, and significant weight loss, for over 5 years. 10/32 cases were those of Tropical calcific pancreatitis (TCP)with no history of Alcoholism, while the rest (22/32) gave h/o alcoholism ranging from 5 to 11 years. Out of these 22 cases, 15 patients had features of tropical calcific pancreatitis. Six patients were diagnosed to have diabetes. & six were known diabetics. Ultrasonography and CT scan were performed in all patients. 21/46 cases were shown to have complicated disease in the head. Selection of patients was made by radiological assessment ( 21/46) & by intra-operative assessment (11/46). Average blood loss is around 350cc. Mean operation time was 4:30 hrs.

Results. There was no mortality. 2 patients had superficial wound infections. Two patients experienced malaena for 6 days. Mean post-operative hospital stay was 9 days. 24/36 patients had excellent pain relief in the early post-operative period. Pain relief was greater in the alcoholic group. DISCUSSION: The Frey's procedure is more elaborate than classical lateral pancreatico-jejunostomy. Pain relief in the alcoholic group was remarkable. The diabetic status remained unchanged.

Conclusion. Frey's procedure offered better pain relief than with lateral pancreatico-jejunostomy alone and appears less cumbersome than Beger's procedure. Advantage of Frey's procedure in the TCP group of patients needs to be assessed further. Frey's Procedure seems ideal for the disease predominantly in the head of pancreas with H/O alcoholism.

PP 50.09

COMMON BILE DUCT (RE)STENOSIS AFTER SURGERY FOR CHRONIC PANCREATITIS

Van der Gaag, Niels A; Boermeester, Marja A; Hemmes, Sabrine; Busch, Olivier RC; Van Gulik, Thomas M; Gouma, Dirk J

Academic Medical Center, Surgery, Amsterdam, Netherlands

Background. Controversy exists whether surgical drainage alone (pancreaticojejunostomy) treats chronic pancreatitis (CP) sufficiently or should always be combined with (limited) resection (Frey/Beger procedure), to decrease the risk of local symptoms such as common bile duct (CBD) stenosis.

Aim. To evaluate in patients with CP the occurrence of benign symptomatic CBD stenosis after surgical drainage alone or after combined drainage/resection.

Methods. Records of 146 drainage and 46 drainage/resection patients with CP, operated between Jan-1992 and Sep-2006 for intractable pain, were reviewed to assess symptomatic CBD stenosis rate. Rates were compared with the results after pure resection procedures, i.e. tail resection (38 patients) and pancreatoduodenectomy (PD) (68 patients; including 63 CP patients operated for a m ass lesion). Treatment of stenosis was also evaluated.

Results. 2 patients died postoperatively, 4 were lost to follow-up. Median follow-up was 60 months. Symptomatic CBD stenosis occurred significantly less after drainage compared to drainage/resection: 8% (12/144) vs. 24% (11/45), respectively (P = 0.004). Concomitant biliodigestive anastomosis reduced symptomatic CBD stenosis to 3% (1/35) after drainage (P = 0.29) and to 6% (1/18) after drainage/resection (P = 0.031). After pure resection procedures symptomatic CBD stenosis rate was 5% (2/38) for tail resection and 6% (4/67) for PD. Overall, patients received conservative treatment in 14%, endoscopy/PTC in 75% and reoperation in 41% (NS different among procedures).

Conclusion. Symptomatic CBD (re)stenosis rate was higher after drainage/resection for CP than after drainage alone, showing that, in the absence of pancreatic head involvement in CP, surgical drainage alone carries no increased risk of CBD stenosis.

PP 50.10

MESENTERIC INFLAMMATORY PROCESS IN EXPERIMENTAL ACUTE PANCREATITIS: ROLE OF TNF-ALPHA IN LEUKOCYTE–ENDOTHELIUM INTERACTION

Matheus, Andre S.¹; Jukemura, Jose¹; Coelho, Ana Maria M.¹; Sannomiya, Paulina²; Nakagawa, Naomi K.²; Machado, Marcel C.C.¹; Cunha, Jose Eduardo M¹

¹University of Sao Paulo, Dept. of Gastroenterology, Sao Paulo, Brazil; ²University of Sao Paulo, Research Division-Heart Institute (InCor)

Background. Leukocyte–endothelium interaction is known to be a remarkable event at the beginning of systemic inflammatory response syndrome. Leukocyte activation and infiltration are believed to be critical steps in the progression from mild to severe pancreatitis and responsible for many of its systemic complications. The aim of this study was to evaluate leukocyte–endothelium interactions in mesenteric postcapillary venules and cytokines serum levels in experimental acute pancreatitis followed by inhibition of TNF-á prodution.

Methods. Severe pancreatitis was induced in Wistar rats with a injection of 0.5ml of 2.5% sodium taurocholate into the pancreatic duct. Eighteen rats were divided in 3 groups: Sham (surgical procedure without AP induction), Pancreatitis (AP Induction), and Pentoxifylline (AP induction plus administration of 25 mg/kg pentoxifylline). Intravital microscopy was used to observe inflammatory leukocyte rolling, adhesion, and transendothelial migration in small venules in vivo (venule diameter, 15–25 ìm). TNF-á, IL-6, and IL-10 levels were measured by ELISA.

Results. Inhibition of TNF-á by pentoxifylline shows beneficial effects in this experimental model. The Pentoxifylline group had a statistically significant reduction of leukocyte rolling, adhesion, and transendothelial migration in vivo and a statistically significant reduction of inflammatory cytokines levels (IL-6, IL-10, and TNF-á).

Conclusion. Inhibition of TNF-á reduced systemic inflammatory response in this experimental model. Moreover, our data suggest that TNF-á induce accumulation (adhesion, and transendothelial migration) of leukocytes in acute pancreatitis.

PP 51.01

IS LIVER RESECTION FOR COLORECTAL LIVER METASTASES SAFE AND FEASIBLE IN THE ELDERLY?

de Liguori Carino, Nicola¹; van Leeuwen, Barbara²; Wu, Andrew¹; Ghaneh, Paula¹; Audisio, Riccardo A.²; Poston, Graeme J.¹

¹University Hospital Aintree, Supra-Regional Hepato-Biliary Unit, Liverpool, United Kingdom; ²St. Helens & Knowsley Hospitals Trust, Prescot, United Kingdom

Introduction. Among all patients with a newly diagnosed colorectal tumour 76% are between 65 and 85 years old. A substantial proportion will develop colorectal liver metastases, for which resection is the only cure. This study was conducted to investigate the feasibility, short and long terms outcomes of liver resection for colorectal liver metastases in elderly patients.

Methods. Between 1990 and April 2007 data were prospectively collected on patients over 70 years old who underwent a liver resection for colorectal liver metastases in the Hepato Billiary Unit at the University Hospital Aintree, Liverpool, UK.

Results. 181 liver resections were performed in 178 consecutive patients. Median age was 74 years. 34 patients (18,8%) received neoadjuvant chemotherapy(FOLFOX) prior to liver surgery and a majority (57,5%) of liver resections involved more than three Couinaud's segments. Median in hospital stay was 13 days, 70 (38,5%) patients had perioperative complications and overall in hospital mortality was 4,9% (9 patients). Median follow-up was 17,5 months (range 1–120). Overall- and disease free survival rates at 1, 3 and 5 years were 86,1%, 43,2% and 31,5%, and 65,8%, 26% and 16% respectively. Neoadjuvant chemotherapy and hepatic pedicle clamping did not significantly influence overall and disease free median survival(p > 0.05). In multivariate analysis only the occurrence of postoperative complications was predictive of overall and disease free survival.

Conclusions. Liver resection for colorectal liver metastases in elderly patients is safe and may offer long time survival to a substantial percentage of patients. We strongly recommend considering senior patients for surgical treatment whenever possible.

PP 51.02

GROWTH FACTOR EXPRESSION FOLLOWING THERMAL ABLATION OF COLORECTAL LIVER METASTATIC TUMORS.

Fifis, Theodora; Amidjojo, Jason; Anggono, Beatrice; Malcontenti-Wilson, Caterina; Muralidharan, Vijayaragavan; Christophi, Christopher

University of Melbourne, Austin Health, Department of Surgery, Heidelberg 3084, Australia

Background. Thermal ablation is an alternative treatment for colorectal liver metastases in patients not eligible for liver resection. While some studies report lower tumor recurrence after thermal ablation compared to liver resection, recurrence still occurs in large number of patients. Growth factors which are upregulated during liver regeneration following hepatectomy, may also be upregulated after thermal ablation resulting in tumor recurrence. AIM: To investigate changes in growth factor expression after thermal ablation Methods. A murine colorectal liver tumor metastasis model was used. Thermal ablation of selected tumors was performed 21 days after tumor induction. Expression of EGF, HGF, TGF-β, VEGF and bFGF was assessed by immunohistochemistry and ELISA in thermal ablation and sham treated livers and tumors at the time of treatment and at several time points, for up to seven days after. Growth factors were also measured in livers of un-induced mice.

Results. The baseline expression of VEGF and TGF-β were significantly elevated in tumor bearing livers compared to that of un-induced livers. HGF was also increased but did not reach significance. No changes in EGF expression were observed. Expression of all growth factors decreased in the ablated tumour following treatment. In the liver tissue and at distant non ablated tumors VEGF and HGF showed a decreasing trend, while EGF showed a small increase and TGF-β showed a significant increase at the later time points.

Conclusion. The decrease in growth factors in the ablated tumors may be responsible for the reported lower tumor recurrence compared to resection. However the increases in EGF and TGFβ in liver and untreated tumors of the treated animals may contribute to tumor recurrence. Inhibition of these factors in combination with thermal ablation may improve the outcome for patients with unresectable liver metastases.

PP 51.03

DOES VASCULAR CLAMPING AFFECT LONG-TERM SURVIVAL FOLLOWING LIVER RESECTION FOR COLORECTAL METASTASES?

Nuzzo, Gennaro; Giuliante, Felice; Ardito, Francesco; Vellone, Maria; Giordano, Marco; Ranucci, Giuseppina; Giovannini, Ivo

Catholic University-School of Medicine, Hepato-Biliary and Digestive Surgery Unit, Rome, Italy

Background. Liver resection for colorectal metastases offers good long-term outcome. A controversial issue is that hepatic ischemia/reperfusion injury from vascular clamping might accelerate the outgrowth of residual micrometastases.

Objective. To evaluate the impact of liver ischemia on long-term outcome after hepatectomy.

Methods. Between 1992 and 2006, 216 patients had primary curative hepatectomy for metastases (colon/rectum 151/65; synchronous/metachronous 85/131; single/multiple 116/100). Outcomes were analyzed according to clinico-pathologic variables.

Results. There were 122 major and 94 minor resections, with hepatic pedicle clamping in 163 cases (in 78 with continuous clamping > 30 min or intermittent clamping > 60 min). Mortality was 0.9%, morbidity 24.3%, blood transfusion requirement 26.4%. Clamping vs. no clamping was associated with a higher rate of transfusion (39.6% vs. 22.1%, p = 0.02) and transfused units/patient. At a mean follow-up of 39 months, 117 patients (117/214, 54.7%) had recurrence, involving hepatic recurrence in 59 (27.6%). At univariate analysis, transfusion requirement, small surgical margin, preoperative CEA, primary tumor nodal status, synchronous metastases, R1-resection, m ajor resection, number, bilobarity and size of metastases (p from <0.001 to 0.03) were associated with lower disease-free survival. Five-year disease-free survival was higher in patients who underwent clamping (31.2 vs. 17.4%, p = 0.04). Liver-free survival was unrelated to clamping and to its duration. At multivariate analysis, transfusion requirement and surgical margin remained the strongest predictors of lower disease-free and overall survival (p < 0.002 for all), with clamping weakly associated with higher survival.

Conclusions. Blood transfusion and small surgical margin are powerful predictors of poor long-term outcome, with no similar impact of clamping, which indeed is protective against transfusion requirement.

PP 51.04

PROGNOSTIC FACTORS IN HEPATIC RESECTIONS FOR THE COLORECTAL CANCER METASTASES

Karamarkovic, Aleksandar¹; Blazic, Ivan²; Ivancevic, Nenad²; Mihailovic, Vojin²; Doklestic, Krstina³

¹University Center for Emergency Surgery, School of Medicine Belgrade, Surgiocal Dpt. III, Belgrade, Serbia and Montenegro; ²University Center for Emergency Surgery, School of Medicine Belgrade, Surgical Dpt. III, Belgrade, Serbia and Montenegro; ³University Center for Emergency Surgery, School of Medicine Belgrade, Surgical Dpt. III, Belgrade

Background. Liver resection currently serves as the only one curative therapy for liver metastases from colorectal carcinoma. Appropriate criteria for surgical resection are controversial.

Aim. The aim of this study was to determine the caracteristics of the disease which affected prognosis. Methodology: Between March 2002 and December 2006, 135 patients with hepatic metastases from colorectal carcinoma underwent anatomical liver resection at our institution. There were 77 men and 58 women, with a mean age of 56.9 years (range 22–74). The follow-up period ranged from 2 to 69 months. The survival rate was estimated by the Kaplan-Meier method and compared by log-rank test.

Results. 76 of the primary lesions were located in the colon and 59 in the rectum. There were 42 Dukes B, 54Dukes C and 39 Dukes D. Liver metastases were detected synchronously in 45 and metachronously in 90 patients at the time of diagnosis. The operative mortality rate within 30 postoperative days was 3.1%. During the follow-up period we registered tumor recurrence rate of 14.1%. The overall 5-year survival rate was 31.8%. Multivariate analysis shows a significant correlation between 5-year survival and solitary (p < 0.05) and unilobar (p < 0.01) metastases. The survival rate did not significantly correlate with gender, age, location of primary tumor, Dukes classification, time of diagnosis or CEA level.

Conclusions. According to our results, number and localization of metastatic liver lesions represents the prognostic factors of significant importance. Without an effective therapeutic alternative, liver resection is still recommended and represent a “gold” standard in the treatment of colorectal liver metastases.

PP 51.05

INTRA-OPERATIVE MEASUREMENT OF CARCINOEMBRYONIC ANTIGEN IN GALLBLADDER BILE AS A MARKER OF OCCULT HEPATIC METASTASIS IN COLORECTAL CANCER.

Hathurusinghe, Harsha; Holt, Adrian; Siriwardena, Ajith

Manchester Royal Infirmary, Hepatobiliary Surgery Unit, Manchester, United Kingdom

Aims. Carcinoembryonic antigen (CEA) – a 200,000 kilodalton glycoprotein has a high specificity for colon cancer and is used in post-resection surveillance. In patients with hepatic metastases, CEA is concentrated in bile and measurement of biliary CEA is reported to help predict metastases. This study undertakes a pooled analysis evaluating intra-operative measurement of biliary CEA during bowel cancer resection in order to ascertain optimum cut-offs and predictive values (sensitivity and specificity) for subsequent detection of hepatic metastases.

Methods. A computerized search of MEDLINE from January 1996 to June 2006 using the MeSH headings “carcinoembryonic antigen”, “Bile” and “colorectal-neoplasms” was undertaken. Only articles with original data were recruited. Pooled data were available on 203 patients with known hepatic metastases at the time of bowel resection and a further 602 undergoing colectomy without hepatic metastases. In all cases biliary CEA was obtained by intra-operative gallbladder aspiration.

Results. There were no reports of procedure-related complications. Paired (biliary CEA compared to serum CEA) data were retrieved for 203 patients. All studies report higher levels of CEA in bile than in serum. Modal biliary CEA in patients with known colorectal metastases was 612 ng/mL compared to a modal serum CEA of 89 ng/mL in matched series. Raised biliary CEA (with a cut-off set at 5 ng/mL) has a sensitivity of 75–100% and a specificity of 38–95% for prediction of subsequent development of liver metastases. Several studies report a correlation between hepatic tumour burden and biliary CEA (R 0.8–0.91) with linear regression demonstrating that metastases as small as 1 cm could be determined with raised biliary CEA.

Conclusion. There is evidence of a consistent trend that intra-operative measurement of biliary CEA during bowel cancer resection and the finding of elevated values helps in the identification of a subset of patients at risk for subsequent development of hepatic metastasis.

PP 51.06

A PRELIMINARY ANALYSIS OF COMBINED LIVER RESECTION AND NEW CHEMOTHERAPEUTIC AGENTS FOR SYNCHRONOUS COLORECTAL LIVER METASTASIS

Ng, Wilson WC; Lee, KF; Wong, John; Fok, KL; Ng, Nancy; Lo, Xina; Mak, OS; Ling, Eva; Lai, Paul BS

Prince of Wales Hospital, The Chinese University of Hong Kong, Department of Surgery, Hong Kong SAR, Hong Kong

Background. Liver resection in combination of new chemotherapy for colorectal liver metastasis can potentially prolong survival.

Aim. To evaluate the benefit of liver resection in combination with new chemotherapy (oxaliplatin, irinotecan, capecitabine, bevacizumab or cetuximab) for patients with synchronous colorectal liver metastasis.

Methods. Patients who followed the management strategy were retrospectively studied.

Results. Over a four-year period (2002–2006), we had 30 patients with synchronous colorectal liver metastasis (Dukes¡∣ D) undergoing hepatectomy. Twelve patients (40%) were initially unresectable either due to local extend of the disease or extrahepatic disease. Out of these 30 patients, 8 (26.7%) had received palliative liver resection. Concomitant intra-operative radiofrequency ablation (RFA) and pre-hepatectomy RFA was used in 5 and 2 patients respectively. Fifteen patients (50%) had received pre-hepatectomy chemotherapy (60% down-staging & 40% neoadjuvant) while 21 patients (70%) had post-hepatectomy chemotherapy (57.1% palliative & 42.9% adjuvant). Three patients (10%) developed post-operative complications but there was no in-hospital mortality. The median minimal histological tumor free margin was 10 mm. The median duration of follow up was 24.5months. Two patients (9.1%) developed recurrent liver metastasis after curative liver resection. The median overall survival and disease free survival were 33.8 and 7.3 months. The overall one- and two-year survival rates were 96.7% and 66.6% while those for disease-free survival rates were 45.6% and 28.1% respectively.

Conclusions. For patients with synchronous colorectal liver metastasis, liver resection in combination with new chemotherapy demonstrates satisfactory response rate and short-term survival outcome.

PP 51.07

CHEMOTHERAPY-ASSOCIATED HEPATOTOXICITY: IMPACT ON THE SURGERY FOR COLORECTAL LIVER METASTASES

Polishchuk, Lilia; Kozmin, Leonid; Sekatcheva, Marina; Skipenko, Oleg

Russian Research Center of Surgery, Moscow, Russian Federation

Background. Preoperative prolonged chemotherapy lead to liver resection in up to 10–13% of the patients with initially unrespectable disease. But the clinical effects of chemotherapy are associated with the chemotherapy-related hepatic injuries. Damages of parenchyma can lead to increase of postoperative morbidity and mortality.

Objective. To investigate the influence of chemotherapy on liver parenchyma.

Patients andMethods. 40 patients (24 received preoperative chemotherapy: C+ group; and 16 were without chemotherapy: C- group) were selected for detailed pathologic analyses. Histologic review of the nontumorous liver was performed using established criteria for steatosis, fibrosis, vascular lesions and surgical necrosis. The effect of different regimens of chemotherapy and associated liver injury on perioperative outcomes was analyzed.

Results. Chemotherapy consisted of 5-FU-based regimens: alone, 2 patients; plus irinotecan, 2 patients; plus oxaliplatin, 7 patients; hepatic arterial infusion with 5-FU, 2 patients; and other therapy, 3 patients. Clinical and operative factors were similar in both groups. On histological analysis, moderate and severe grade of steatosis had 11 cases, sinusoidal vasodilatation – 12, fibrosis – 7 cases. Necrotic lesions possibly induced by operative manipulation on liver were detected in 14 cases. There was no postoperative mortality. In 7 from 16 post-chemotherapy patients, peliosis developed but there was no correlation between postoperative morbidity and intraoperative RBC transfusion requirement. The rate of moderate to severe steatosis was similar (C+ group, 5; C- group, 6; p = 0,39). Fibrosis revealed more often in C+ group (1 in C- group vs. 6 in C+ group, p = 0,025), but it was not associated with increase of postoperative morbidity.

Conclusion. The main hepatic lesion induced by chemotherapy in patients with colorectal liver metastasis is moderate and severe forms of fibrosis. Even after prolonged chemotherapy, major liver resection could be performed without mortality

PP 51.08

SPLENIC METASTASES FROM COLORECTAL CANCER: TWO CASES

Bracco, Ricardo¹; Grondona, Jorge²; Moreno, Adrián³; Lo Veci, Juan⁴; Moreno, Adrián⁵

¹Clinica Pueyrredón, HPB unit, Mar del Plata, Argentina; ²Centro Médico Martín y Omar, HPB unit, San Isidro, Argentina; ³Clínica Pueyrredón, HPB fellow; ⁴Centro Médico Martín y Omar, HPB fellow, San Isidro, Argentina; ⁵Clínica Pueyrredón, HPB fellow, Mar del Plata, Argentina

Background. splenic metastases from colorectal cancer are very rare and there are only 13 cases reported in the English literature so far. Most cases are asymptomatic and the diagnosis is usually made by imaging studies during the evaluation of rising CEA level postoperatively.

Aim. to describe two cases of splenic metastases from colorectal cancer.

Methods. case 1: a 74 year old male patient underwent right hemicolectomy for a right colon cancer 27 months before that an elevation of the CEA level was observed. At the same time a ct-scan showed a 6 cm in diameter tumor in contact with the inferior part of the the spleen with no other evidence of metastasic disease. At laparotomy a tumor located in an accesory spleen was recognized. Splenectomy and remotion of the tumor was carried out and the patient survived for 3 years and 3 months. Case 2: a 72 year old female patient underwent a right hemicolectomy for a right colon carcinoma with 4 syncronous liver metastases. After a 6 months period of sistemic chemotherapy she was operated on again to treat the liver tumors. Beside this lesions a very small tumor of 0.5 cm on the small bowell wall and a cluster of small tumors at the anterosuperior edge of the spleen were founded also. A left hepatectomy, an atipical resection of the right liver, a wedge resection of the small bowell and a splenectomy were performed. Eighteen months later the patient died with cancer progression on lungs and bones.

Conclusions. splenic metastases are a very rare finding in the follow up of colorectal cancer patients and long term survival can be achieved with splenectomy.

PP 51.09

SYNCHRONOUS LIVER METASTASES RESECTED TOGETHER WITH PRIMARY COLORECTAL CANCER

Lipska, Ludmila; Visokai, Vladimir; Levy, Miroslav

Thomayer Teaching Hospital, Surgical Department, Prague 4, Czech Republic

Objectives: To review a single institution experience with simultaneous resections of primary colorectal carcinoma and liver metastases.

Background. Surgery remains the only option for curative radical treatment for liver metastases from colorectal carcinoma. The strategy for resection of synchronous liver metastases from colorectal carcinoma is still a question for discussion.

Methods. Aim of this lecture is to present our experience with simultaneous resections of synchronous liver metastases in one stage procedure with resection of colon or rectum. Since the year 1996 till 2006, 47 patient undewent such operation in our surgery. The primary tumor was located in colon in 27 patients (58%) and in 20 patients (42%) it was a rectal carcinoma. In 2 patients the subtotal colectomy was performed due to acute colon obstruction. Radical lymphadenectomy of the resected colorectal primary up to apical nodes was obligatory. Lymphadenectomy of the hepatoduodenal ligamnet was optional. Alltogether 90 metastatic lesions were removed, 2 right hepatectomies, 2 left hepatectomies, 1 extended right hepatectomy, 2 bisegmentectomies, 3 segmentectomies and 40 nonanatomical resections were performed. Two patients were operated urgently due to large bowel obstruction.

Results. The mean blood loss was 600 ml, postoperative morbidity was 25% and mortality 2,5%. Median survival was 2,4 year, median follow up 1,9 year, 3 year overall survival was 42% and 5 year overall survival was 30%. Multivariate analysis was done and the most important prognostic factor was N2 nodal status of primary colon or rectal cancer.

Conclusion. Simultaneous liver and colorectal resections are feasible. The benefit for patient is only one operation. In our institution we prefere nonanatomical parenchyma sparing resections.

PP 51.10

THE EFFECT OF MICROWAVE RADIATION (MWR) TREATMENT ON THE SUBCELLULAR ANATOMY OF NORMAL LIVER IN THE TREATMENT OF COLORECTAL LIVER METASTASES (CLM)

Pathak, Samir¹; Verghese, Miriam²; Poston, Graeme J¹; Foster, Christopher S³

¹Royal Liverpool University Hospital, Dept of Surgery, Liverpool, United Kingdom; ²Royal Liverpool University Hospital, Surgery, Liverpool, United Kingdom; ³Royal Liverpool University Hospital, Dept of Patholgy, Liverpool, United Kingdom

Background. Hepatectomy is the gold-standard treatment for CLM and should be achieved with >1cm margin because of the risk of satellite tumours. Destructive therapies are being used increasingly to treat CLM, particularly as not all patients are suitable for major, open surgery. Recent interest has focussed on the use of MWR. Little is known about the penetration depth of MWR beyond the visible macroscopic burn (B) in human liver OBJECTIVES-To investigate the effect of MWR on adjacent liver in patients undergoing evaluation of MWR for CLM.

Methods. Biopsies taken after MWR treatment (100W/120seconds, 3 cm diameter CLM) at edge of B, 1cm, 2cm, 3 cm and distant from B for light (H&E)(LE) and electron (osmium tetroxide fixation)(EM) microscopy. Observers were blinded to sample site.

Results.

Site	LM	EM
B edge	10% necrosis	Granulomatous cytoplasm, complete loss of intracellular architecture
1cm B	Scattered 10% necrosis	Significant mitochondria loss in all cells and loss of intracellular lipids
2cm B	Normal intracellular architecture	Variable mitochondria and intracellular lipid loss, endoplasmic reticulum undamaged
3cm B	Normal intracellular architecture	Random loss of intracellular architecture, decreased mitochondria in < 5% cells
Distant	Normal intracellular architecture	Normal intracellular architecture

Discussion. The limited changes seen on LM may in fact be due to the “freezing” effect of the microwave radiation, immediately after use. These cells do probably undergo severe damage as illustrated by EM. Future studies to confirm this would be ethically challenging as one would need to biopsy the same patient a few months post-operatively to ascertain the true extent of the burn. It remains to be proven whether MWR treatment is safe or effective when treating CLM. Our observations suggest that in normal human liver, the effect of MWR, at the dose tested, will be measurable up to 2cm beyond visible TB, which may be equivalent to the 1cm margin of conventional liver surgery. Long-term follow up of these patients is needed to determine the effectiveness of MWR as an alternative treatment to open hepatectomy.

PP 52.01

OUTCOME OF R1 RESECTION IN PATIENTS UNDERGOING PANCREATODUODENECTOMY FOR PANCREATIC CANCER

Fusai, Giuseppe¹; Pamecha, Viniyendra¹; Warnaar, Nienke¹; Sabin, Caroline²; Archibong, Samuel¹; Davidson, Brian¹

¹Royal Free Hospital, Liver Transplantation & Hepatobiliary Unit, London, United Kingdom; ²Royal Free and University College Medical School, Primary Care & Population Sciences, London, United Kingdom

Background. Pancreatico-duodenectomy (PD) is the only potentially curative treatment for cancer of the head of the pancreas. Its role is well established if complete tumour clearance is anticipated. However, with the decrease in perioperative morbidity and mortality, there might be a role for palliative resection in selected cases. AIMS: To define the outcome for microscopically incomplete PD in patients with pancreatic cancer.

Methods. 106 consecutive patients with pancreatic head cancer underwent exploratory laparotomy with the intention to perform PD. 67 patients were resected and 32 underwent palliative bypass (PSB) because of locally advanced disease. Perioperative status and complications were recorded and compared between the two groups. Survival was analysed between patients undergoing microscopically complete (R0) PD, incomplete (R1) PD and PSB.

Results. Groups were similar with regard to demographic and preoperative state. Of the 67 PD, 27 were classified as R0 and 40 as R1. Median survival for R0, R1 and PSB were 24, 18 and 9 months respectively. Survival in the PSB group was 34% at 1 year and 0% at 2 years. 1, 2 and 5 year survival in the R0 and R1 group was 79% and 70%, 48.3% and 39.1%, 21.5% and 9.9% respectively. There was a significant difference between the mortality curves in the three groups (p = 0.0002, log-rank test). Compared to those undergoing PSB, both other groups were less likely to die over follow-up (R0: Risk Hazard (RH) 0.29, 95% CI [0.15–055] p = 0.0002; R1: RH 0.41 [0.23–0.72], p = 0.002). Mortality was not different between the R0 and R1 groups (RH 1.52 [0.79–2.92], p = 0.21). Perioperative complications and hospital mortality were similar in the PD and PSB groups (29.9% and 3.0% vs 31.3 and 3.1% respectively, p = 1.00).

Conclusions. A better survival in the R1 PD than in the PSB group and a similar perioperative risk would support the decision to perform a PD even when there is the possibility of incomplete microscopic clearance.

PP 52.02

TUMOR INVASIVENESS IS THE STRONGEST PREDICTOR OF SURVIVAL FOLLOWING RESECTION FOR AMPULLARY ADENOCARCINOMA

Barauskas, Giedrius¹; Gulbinas, Antanas²; Sileikis, Audrius³; Pundzius, Juozas¹; Strupas, Kestutis³

¹Kaunas University of Medicine, Dept. of Surgery, Kaunas, Lithuania; ²Kaunas University of Medicine, Institute for Biomedical Research, Kaunas, Lithuania; ³Vilnius University Hospital Santariskiu Klinikos, Centre of Abdominal Surgery, Vilnius, Lithuania

Background. Adenocarcinoma is the most common malignant tumor of ampulla, but in general it is still rare. Therefore there are discordant data on factors affecting prognosis in in ampulla of Vater adenocarcinoma AIM. To evaluate long-term survival of patients surgically treated for pancreatic adenocarcinoma and to determine independent factors influencing survival.

Methods. We have prospectively investigated 52 consecutive patients with adenocarcinoma of the papilla of Vater at two HPB centers performing the vast majority pancreatic resections in Lithuania. Preoperative clinical data, pathology reports, UICC tumor stage and long-term follow-up results were evaluated.

Results. Overall 1-, 3-, and 5-year actuarial survival rates after resection were 83.2, 67.7, and 67.7 per cent respectively with mean survival time of 71 months (95% CI: 59–83) after resection. The survival rates of patients with stage I–II tumor was significantly better than with stage III–IV disease. Patients with T1–T2 and/or N negative tumors had significantly better survival comparing with patients with T3–T4 and/or N positive tumors. Patients who had ampullary tumors with high or moderate differentiation of cells (G1 and G2) survived better than patients with poor cell differentiation (G3). Presence of lymphatic invasion and blood vessel infiltration by malignant cells significantly worsened survival rates, whereas another tumour related factor – neural invasion had no significant influence to overall survival rates. Multivariate analysis revealed that lymphonode positivity ( Hazard ratio for N1-5.8) and blood vessel infiltration (Hazard ratio for V1 – 7,1) are the strongest independent predictors of survival.

Conclusion. Tumor invasiveness is the main predictor of survival after resection for ampullary adenocarcinoma.

PP 52.03

POPULATION-BASED STUDY ON SURVIVAL DETERMINANTS FOLLOWING PANCREATODUODENECTOMY FOR PANCREATIC CANCER

Barauskas, Giedrius¹; Gulbinas, Antanas²; Sileikis, Audrius³; Jurevicius, Saulius³; Strupas, Kestutis³; Pundzius, Juozas¹

¹Kaunas University of Medicine, Dept. of Surgery, Kaunas, Lithuania; ²Kaunas University of Medicine, Institute for Biomedical Research, Kaunas, Lithuania; ³Vilnius University Hospital Santariskiu Klinikos, Center of Abdominal Surgery, Vilnius, Lithuania

Background. Majority of studies that have analyzed the determinants of long-term survival in post resection pancreatic cancer patients, have been single-institutional chart reviews yielding inconsistent results. Therefore factors, influencing survival following radical operations due to pancreatic adenocarcinoma are still ill defined.

Objective. To analyze prognostic factors influencing pancreatic cancer survival following curative resection, using prospectively collected population-based data.

Methods. Data was prospectively collected from 199 consecutive patients being resected for pancreatic adenocarcinoma at two HPB centers performing the vast majority of pancreatic resections in Lithuania. Overall survival probabilities were calculated using Kaplan-Meier method. All factors likely to be predictive of survival after pancreatic resection were evaluated by univariate analysis (Log-rank test). Multivariate analysis using Cox model was completed for all factors with p value <0.1 at univariate analysis.

Results. Median survival of the patients was 15 months. Overall 1–, 3- and 5-year actuarial survival rates after resection for pancreatic adenocarcinoma were 56.3, 22.3 and 12.8 percent respectively with mean survival time of 26 months (95%CI: 21–31). Univariate analysis revealed that stage of the disease including T-stage and lymphnode positivity (N1), tumor differentiation grade and curative (R0) resection were main factors influencing survival for pancreatic cancer. Multivariate analyses through Cox proportional hazards survival analysis indicated that strongest predictors of survival were differentiation grade of the tumor (Hazard ratio 1.7 for less differentiated G3–G4 tumors) and curative resection (Hazard ratio 1.5 for R1).

Conclusion. Although biologic characteristics remain important predictors of survival for patients with resected pancreatic cancer the survival rate could be determined by the radicality of resection

pp 52.04

PANCREATICO-DUODENECTOMY WITH RADICAL LYMPHADENECTOMY IN PATIENTS WITH ESTABLISHED CHRONIC LIVER DISEASE AND PORTAL HYPERTENSION

Sethi, Harsheet; Marangoni, Gabriele; Srinivasan, Parthi; Prachalias, Andreas; Heaton, Nigel; Rela, Mohamed

Kings College Hospital, HPB Surgery and Liver Transplantation, London, United Kingdom

Background. Chronic liver disease has been considered a contraindication to radical surgery for intra-abdominal tumours because of the risk of decompensation. There are no established guidelines for the management of operable pancreatic tumours in patients with cirrhosis and portal hypertension.

Methods. A retrospective analysis of all patients undergoing pancreaticoduodenectomy for cancer from January 2000 to December 2006 at our centre identified 4 patients with operable pancreatic tumours and well-compensated chronic liver disease. Pre-operative staging, decompression of the biliary tree, liver biopsy and assessment of the Childs-Pugh and MELD scores was performed in all patients.

Results. All patients had successful pancreatico-duodenectomy with minimal blood loss, and no peri-operative blood transfusions or liver decompensation. There was no post-operative mortality. Two patients received adjuvant chemotherapy. One patient died with recurrent disease at 18 months, one is alive with disease at 22 months, and two patients are alive and disease free 8 and 11 months after surgery.

Conclusion. Patients with pancreatic cancer and well-compensated chronic liver disease should routinely be considered for radical surgery.

PP 52.05

A VERTICAL STOMACH RECONSTRUCTION AFTER MODIFIED SUBTOTAL-STOMACH PRESERVING PANCREATICODUODENECTOMY PREVENTING FOR DELAYED GASTRIC EMPTYING

Oida, Takatsugu¹; Mimatsu, Kenji²; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi³; Amano, Sadao⁴

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²; ³Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ⁴Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. AND AIM: Pylorus-preserving panpancreaticoduodenectomy (PPPD) has better results in operative mortality and morbidity and postoperative nutritional state than that of Whipple procedure. However, delayed gastric emptying (DGE) comprises one of the most troublesome complications of this procedure. Subtotal stomach preserving pancreaticoduodenectomy (SSPPD), in which duodenum and pylorus ring were removed, has been performed for the patients of periampullary and pancreas head tumors of malignancy.□@While a comparison between PPPD and Whipple procedure has been often reported, SSPPD has been evaluated as an alternative to PPPD only few. The aim of this study was to create a reconstruction method which preventing DGE with modified SSPPD.

Patients and Method. Eight patients (3 female, 5□@male) underwent SS,oPD. The mean age was 64 years (56□@to 78). The diagnosis was carcinoma of the pancreatic head in 3 patients, carcinoma of the ampulla of Vater in 3 patients, carcinoma of the lower bile duct in 2 patients. Gstrointestinal reconstruction after modified SSPPD was as followed. Modified pancreaticogastrostomy, end-to-side choledocojejunostomy, and end-to- side gastrojejunostomy have been performed, in that order. The major modification of our technique was as retrocolic reconstruction and setting the transverse colon between pancreaticogastrostomy and gastrojejunostomy.

Results. Hospital mortality was none. Postoperative morbidity was 12.5%. DGE and pancreatic leakage were observed in 12.5% and 0%, respectively. Nasogastric suction was required for 2.6□} 1.0 (2 to 5) days, and 11.8□}3.4 (9 to 20) postoperative days were needed until a solid diet was tolerated orally.

Conclusion. We consider that our reconstruction as one of the most favorable procedure in patients who undergone pancreaticoduodenectomy.

PP 52.06

DOES BILE CONTAMINATION DURING PANCREATICODUODENECTOMY INCREASE POSTOPERATIVE SEPTIC COMPLICATIONS?

Fuks, David; Mirre, Frantz; Riboulot, Michel; Moquet, Olivier; Delmas, Jerome; Delcenserie, Richard; Yzet, Thierry; Dupont, Hervé; Regimbeau, Jean-Marc

CHU Nord Amiens, Federation of Digestive Diseases, AMIENS, France

Background. Thirty percent of postoperative complications after pancreaticoduodenectomy (PD) are septic. This study aimed to determine if bile contamination during PD is an independent risk factor of postoperative septic complications (PSC).

Methods. We reviewed data of 51 patients with PD with pancreaticogastrostomy performed from 2002 to 2006. We distinguished patients with bile contamination (B + ) and patients with sterile bile culture (B − ). Among patients with B+ with PSC, we compared isolated microorganisms. Clinical, preoperative and PSC data were analysed using Mann-Whitney U-test and Pearson chi(2) tests.

Results. 51 patients were included. Age (66±15 years old vs 63±16), ASA > 3 (27% versus 20%), operative time (455±60min vs 450±97) and blood loss (650±500 ml versus 600±387) were similar in group B+ and B−. Median length of stay (30±17 days versus 21±18), ICU stay (2±3 versus 2±3), overall mortality (3% versus 0%) and pancreatic fistula (42% versus 48%; benign fistula 80%) were similar in both groups. 28 (55%) patients had one or more PSC: 15 (58%) patients were B+ and 13 (52%) were B− (p = 0,68). 16 patients (31%) had local PSC: 10 (38%) were in B+ group and 6 (24%) were in B− group (p = 0,26). 35 (67%) patients had distant PSC: 17 (65%) were in B+ group and 18 (72%) were in B− group (p = 0,61). 80% of local PSC were caused by same microorganism than in bile versus 47% in distant PSC. In B+ group, 17 patients had preoperative biliary drainage versus none in B− group ((p < 0.0001). We compared antibiotic prophylaxis (with or without enterococci coverage) by amoxicillin/clavulanic acid versus cephalosporin use. 8% of local PSC occurred with amoxicillin/clavulanic acid use versus 39% with cephalosporin use (p = 0.07).

Conclusion. Bile contamination during PD doesn't seem to increase PSC. Preoperative biliary drainage is a major risk factor of bile contamination. The use of prophylactic antibiotics with amoxicillin seems to decrease local PSC.

PP 52.08

NEOADJUVANT RADIOCHEMOTHERAPY FOR RESECTABLE ADENOCARCINOMA OF THE PANCREAS: HOPE AND DISAPPOINTMENT

Turrini, Olivier institut paoli calmettes, surgical oncology, marseille, France

Objective. To determine the real impact of neoadjuvant radiochemotherapy (RCT) on survival of patients with pancreatic adenocarcinoma (PA).

Methods. From 1996 to 2005, 114 patients were diagnosed with resectable PA. 82 patients received neoadjuvant RCT and 40 were resected (group 1) after restaging (49%). 32 patients underwent primary surgery and 25 (group 2) had curative resection (78%).

Results. a) Intend-to-treat survival: median survival of patients receiving neoadjuvant RCT (n = 82) or not (n = 32) was respectively 15 months and 14 months (p = 0.8); 5 year global survival was respectively 8%–19% (p = 0.01). b) Survival of resected patients: median survival for group 1 was 23 months compared with 14 months for group 2 (P = 0.04). 5 year survival of group 1 and group 2 was respectively 14% and 21% (p = 0.16). c) Disease-free survival: median disease-free survival for group 1 was 15 months compared with 10 months for Group 2 (p = 0.03). Disease-free survival of group 1and group 2 at 1, 3 and 5 years was respectively 57% and 47%; 27% and 18%; and 14% and 18% (p = 0.04). Local recurrences occurred in 2 patients (5%) in group 1 and 6 patients (24%) in group 2 (p = 0.02). General metastasis or carcinomatosis occurred in 26 patients (65%) in group 1 and 10 patients (40%) in group 2 (p = 0.04).

Conclusion. Impact on survival of neoadjuvant RCT is disappointing. However, we concluded that abandoning the use of preoperative radiotherapy is unjustified because it improves local control of the disease. Association with systemic chemotherapy should improve survival, controlling the metastatic part of the disease.

PP 52.09

POST PANCREATICODUODENECTOMY HEMORRHAGE: RISK FACTORS AND MANAGEMENT OPTIONS

Rajarathinam, G; Vimalraj, V.; Jeswanth, S.; Ravichandran, P.; Rajendran, S.; Balachandar, T.G.; Kannan, D.; Surendran, R.

Government Stanley Medical College and Hospital, Department of Surgical Gastroenterology, Chennai, India

OBJECTIVE. The aim of the present study was to analyse the presentation and management and risk factors of postoperative haemorrhage after pancreaticoduodenectomy in a single institution during the last ten years. MATERIAL AND Methods. Between Jan 1997 and Dec 2006 a total of 458 patients underwent Whipple's pancreaticoduodenectomy in our department were analyzed with regard to postoperative bleeding complications.

Results. Postoperative haemorrhagic complications occurred in 14 patients (3.1%) with a range of interval from 1 to 40 days after pancreaticoduodenectomy. Early haemorrhage was recorded in 5 (36%) patients, and delayed haemorrhage in 9 (64%) patients. Luminal bleed occurred in 6(43%) and intraabdominal bleeding in 8(57%) patients, 8 (57%) had sentinel bleeding, bleeding site identified in 13 (93%) patients. In 7 (50%) patients hemorrhage developed from pseudoaneurysms of the peripancreatic major arteries, 5 (36%) from pancreatic stump, 1(7%) at anastomotic site. Hemostasis was attempted by surgery in 10 (71%) patients; angioembolization was successful in 2 (14%) and endotherapy in 1(7%)patient. Overall, mortality is 36%(n = 5). Intraoperative vascular injury, pancreatic leak and sepsis were associated with increased risk of massive bleeding.

Conclusion. The surgeon should seriously consider the possibility of imminent massive hemorrhage in patients who had intraoperative vascular injury, pancreatic leak and sepsis. Emergency angiography and emboliz ation is the recommended treatment fails which surgery indicated. Identification of risk factors for massive bleeding and close observation postoperative leak and sepsis might prompt earlier diagnosis.

PP 53.01

A NEW RECONSTRUCTION USING DOUBLE INTESTINAL SEGMENT AFTER PANCREATICODUODENECTOMY

Oida, Takatsugu¹; Mimatsu, Kenji¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao²; Miyake, Hiroshi³; Amano, Sadao⁴

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Social insurance Yokohama Central Hospital, Surgery, Japan; ³Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ⁴Nihon University School□@,l … ‰, ‰,Z,…, Surgery, ,s,□,™,□, Japan

Background./AIM. Pancreaticoduodenectomy (PD) is commonly used for the surgical treatment of malignancies of the ampulla of Vater, duodenum, head of pancreas, and distal common bile duct. We have performed PD with pancreaticogastrostomy (PG) since 1999, no revealed pancreatic leakage, however, delayed gastric empting (DGE) occurred in 40% of all patients undergoing PD with PG. In this study we inroduced and evaluated our new surgical technique, modified Child□fs reconstruction with double intestinal segment and with PG to prevent DGE after PD. SURGICAL TECHNIQUE: PG implanted the pancreatic stump into the upper area of the stomach via a anterior gastrostomy. Interrupted sutures were placed circumferentially around 1 cm below from the stump of the pancreas and a full thickness of the posterior gastric wall through an anterior gastrostomy. The pacreatic duct tube was brought out through the upper anterior gastric wall. A double intestinal segment was prepared by means of an automatic instrument for enteroanastomosis. An opening was made in the jejunum and a double intestinal segment was produced by inserting the automatic instrument into the jejunum through the opening. The double intestinal segment was anastomosed to remnant stomach by side to end.

Results. No complications directly related to the procedure occurred. The smooth passage to the double intestinal segment was observed, and the DGE was short.

Conclusions. Modified Child□fs reconstruction with double intestinal segment and with PG useful procedure to prevent DGE without pancreatic leakage.

PP 53.02

LAPAROSCOPIC VERSUS OPEN APPROACH TO NEUROLYTIC CELIAC PLEXUS BLOCK IN INOPERABLE PANCREATIC CANCER

Tsimoyiannis, E.C¹; Zikos, N.²; Pappas-Gogos, G.¹; Tsimogiannis, K.E.¹; Benetatos, N.¹; Tsimogiannis, K.J.¹

¹G. Hatzikosta General Hospital, Surgery, Ioannina, Greece; ²Filiates General Hospital, Surgery, Filiates, Thesprotia, Greenland

Background. The cancer of pancreatic body and tail tends to be diagnosed at a relatively late stage of the disease when curative resection is precluded. Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control in such cases, while the diagnostic laparoscopy prevents aimless laparotomies in these severe ill patients.

Aim. We study the feasibility and effectiveness of the laparoscopic NCPB guided by laparoscopic ultrasound (LUS) versus open approach.

Methods. Eight patients (Group A) with cancer of the pancreatic body and tail underwent in diagnostic laparoscopy which revealed an inoperable pancreatic cancer. After tru-cut needle biopsy, under LUS guidance 40 ml of solution (20 ml of 95% ethanol mixed with 20 nl of xylocaine) was injected into either side of the para-aortic soft tissue, on the level of the celiac artery, via a percutaneously placed 18-gauge long length needle. The same solution was injected and in ten patients (Group B), with inoperable pancreatic cancer (body and tail) diagnosed during a laparotomy, under intraoperative ultrasound.

Results. There were no intraoperative or postoperative, NCPB related, complications. From the early postoperative period the patients in both groups, reported significant pain relief. Using the visual analogue scale preoperatively, in the 2nd postoperative day, 1st and 3rd postoperative month, in Group A the score was 3.9, 1.0, 1.5, and 2.3 respectively, and in Group B, 4.1, 0.8, 1.7 and 3.0 respectively (N.S. difference). In Groups A and B the mean hospital stay was 2.1 vs 5.2 days (P < 0.05) and the mean survival 8.4 vs 7.6 months (N.S.).

Conclusions. The NCPB is feasible under laparoscopic approach, during the diagnostic laparoscopy, and its effectiveness is about same as in open approach. The laparoscopic NCPB gives a shorter hospital stay than the open NCPB procedure.

PP 53.03

RISK FACTORS AFFECTING PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY

Jang, Yongsun; Lee, Joung-Bum; Ahn, Seung-Ik; Lee, Keon-Young; Oh, Cheong-Ah; Choi, Yun-Mee; Choi, Sun-Keun; Hur, Yoon-Seok; Kim, Sei-Joong; Cho, Young-Up; Hong, Kee-Chun; Shin, Seok-Hwan; Kim, Kyung-Rae; Woo, Ze-Hong

College of Medicine, In-ha University, Department of Surgery, Incheon, Korea, Democratic People's Republic of

Background. Pancreacticoduodenectomy is a procedure of choice for managing periampullary malignancy. But pancreatojejunostomy site leakage is so important and critical complication because of hardship of leakage prevention.

Objective. To analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy.

Methods. 172 consecutive patients were reviewed who had received pancreaticoduodenectomy at Inha University Hospital between Apr. 1996 and Mar. 2006. We analyzed pancreatic leakage rates according to clinical characteristics, pathologic findings, laboratory findings, and anastomosis methods retrospectively.

Results. There were differences in the mean age and pathologic findings between the two groups. Patients older than 60 years were 115 (66.9%) while other 57 patients (33.1%) were younger than 60 years. The incidence of developing pancreatic fistula in patients older than 60 years was 21.7% (25/115) while 8.8% (5/57) in younger patients, showing a significant difference regarding age(p = 0.03). The patients with dilated pancreatic duct showed lesser post-operative pancreatic fistula rate than the patients with non-dilated duct(p = 0.001). Other factors including anastomosis method and pathologic diagnosis dose not show any difference of statistical significance. According to the pathologic diagnosis, patients with pancreatitis and stomach cancer revealed pancreatic fistula to a smaller extent; among all cases- pancreatitis: 6 (3.5%), stomach cancer: 22 (12.8%). Among pancreatic fistula cases- pancreatitis: 0 (0%), stomach cancer: 2 (6.7%) But the difference was not statistically significant.

Conclusion. Our study demonstrated that pancreatic fistula is related to age and dilated pancreatic duct. Surgeon must take these risk factors into consideration when operating pancreaticoduodenectomy. We recommend surgeons to use oneself skilful technique to prevent pancreatic fistula.

pp 53.04

CELIAC AXIS STENOSIS AND LETHAL LIVER ISCHEMIA AFTER PANCREATICODUODENECTOMY

Visokai, Vladimir; Lipska, Ludmila; Trubac, Miroslav

Thomayer Teaching Hospital, Surgical Department, Prague 4, Czech Republic

Celiac axis stenosis can lead to a fatal hepatic ischemia after pancreaticoduodenectomy unless a simmultaneous revascularisation of the celiac circulation is performed. We report three cases of celiac axis stenosis, all of which had histologically confirmed periampullary cancer. Case 1: a 50-year-old male with a history of myocardial infarction and liver steatosis; visceral arteriography prior to the surgery demonstrated a celiac axis stenosis. Whipple operation was performed. After removing the specimen no signs of liver ischemia were found (liver was cholestatic) and pulsation of the hepatic artery was strong. Patient died on the second postoperative day after an abrupt irreversible cardiac arrest. Autopsy proved acute severe hepatic ischemia. Case2: a 64-year-old female. Preoperative visceral angiography showed significant celiac axis stenosis. As a first step of surgery the root of the celiac trunk was exposed, a fibrotic ring around it was divided. Standard D1 pylorus preserving pancreaticoduodenectomy was performed. Case 3: a 58-year-old female without preoperative angiography, indicated for surgery. After occlusion test of the gastroduodenal artery liver became ischemic. Division of the fibrotic ring around celiac axis was performed together with a standard D1 pylorus preserving pancreaticoduodenectomy. No postoperative complications were reported in both case 2 and 3. Our presentation is based on our background of experience and on study of literature. Few published articles on this topic what we found is in contradiction with frequence of this phenomenon and its potential danger of acute liver ischemia after pancreaticoduodenectomy.

PP 53.05

CONTINUOUS SUCTION DRAINAGE OF PANCREATIC JUICE AFTER PANCREATICODUODENECTOMY WITH SOFT PANCREAS

Oida, Takatsugu¹; Aramaki, Osamu¹; Mimatsu, Kenji²; Kawasaki, Atsushi³; Kuboi, Youichi²; Kanou, Hisao²; Miyake, Hiroshi⁴; Amano, Sadao⁵

¹S ocil Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ³Social Insurance Yokohma Central Hospital, Surgery, Yokohama, Japan; ⁴Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ⁵Nihon University School of Medicine, Surgery, Tokyo, Japan

Background./AIM. Pancreaticoduodenectomy (PD) is commonly used for the surgical treatment of malignancies of the ampulla of Vater, duodenum, head of pancreas, and distal common bile duct, however, leakage from pancreatic anastomosis still occurs and a serious problem. It has been proposed that a soft, friable, and normal pancreas with a normal size and thin-walled main pancreatic duct increases the risk of anastomotic leakage because of difficulties in anastomosis and the high output of pancreatic juice. To prevent the pancreatic leakage, the high output of pancreatic juice from soft remnent pancreas was contineous suction drainaged externally.

Patients and Method. Ten patients with soft pancreas underwent a PD. All patients had pancreaticogastrostomy with pancreatic duct tube (Sumitomo Bakelite Medical, Tokyo, Japan) connected to 200cc Silicone Bulb Evacuator® (Bard Medical Division, Georgia, U.S.A), which drained externally. The contineous suction pressure of Evacuator® is 20∼30mmHg. The daily pancreatic juice output was measured for 7 days after the surgery by using a pancreatic duct tube connected to Evacuator®. Drainage fluid amylase from the drainage tube near the pancreatic amnastomisis was measured on POD7. Anastomotic leakage was identified radiological by using contrast medium.

Results. The mean daily pancreatic juice output was 84±23 ml on POD1, 109±32 ml on POD 2, 152±49 ml on POD3, 180±59 ml on POD4, 207±44 ml on POD5, 250±61 ml on POD6, 275±75ml on POD7. The mean levels of drainage fluid amylase was 80±22 U/L. Pancreatic leakage and fistula were no revealed. CONCULUSIONS: Total external drainage with continuous suction of the pancreatic juice is useful to prevent pancreatic leakage in patients with a soft pancreas.

PP 53.06

MANAGEMENT OF TRAUMATIC PANCREATIC TRANSECTION, EXPERIENCE OF 6 CASES

Borgaonkar, Vijay, Seth Nandlal Dhoot Hospital, Surgery, A-1 Midc Chikalthana, Jalna Road, Aurangabad, India

Introduction. Traumatic transection of pancreas is relatively uncommon, but carries high morbidity & mortality if not treated appropriately. Pancreatic injuries are often missed on first clinical examination & need high index of suspicion & early diagnostic studies for diagnosis & proper treatment. MATERIALS: From the year 2002 to 2006, 6 patients of pancreatic transection following vehicular trauma were admitted in our institute. All were male patients, youngest 3 years & eldest 45 years. 2 presented within 2 hours of injury, one within 24 hours, 2 within 48 hours & 1 presented delayed 7 days. In all these cases diagnosis was established on computed tomography. 4 cases had pancreatic transection at midbody, 1 had transection at neck & 1 was with incomplete disruption of duct. Surgical management was performed in 5 patients & endoscopic management (pancreatic stenting) performed in 1. Out of these 6, 5 recovered well, 1 succumbed to ARDS on 15th post-operative day. This patient who succumbed had associated major injuries like # shaft femur, multiple # ribs & # pelvis. Amongst surgical options, distal pancreatojejunostomy Roux En Y anastomoses performed in 2. Distal pancreactectomy + splenectomy in 1, spleen preserving distal pancreactectomy & open drainage in 1 was performed. 1 patient had incomplete disruption of the duct & was managed by pancreatic stenting. In all these patients, peri- & post-operatively octeotrides were used. All patients treated surgically had feeding jejunostomy for enteral nutrition. Intensive surgical care & use of suitable antibiotic contributed for better results.

Conclusions. CT Scan is valuable imaging modality; MRCP is possible only in select patients, ERCP is often not possible due to acute morbid condition. Patients should be explored as early as possible, aims of exploration being assessment of injury, peritoneal toilet with drainage, whenever feasible perform definitive reconstructive procedure. In situations of high volume drainage, ERCP & Pancreatic Stenting is useful.

PP 53.07

PANCREATIC TRAUMA: AN INSTITUTIONAL EXPERIENCE

Nagari, Bheerappa¹; Regulagadda, Adikesava sastry²

¹Nizam's Institute of Medical Sciences, Surgical gastroenterology, Panjagutta, Hyderabad, India; ²Nizam's Institute Of Medical Sciences, Surgical gastroenterology, Hyderabad, India

Background. Diagnosis of blunt pancreatic trauma can be difficult. Delay in diagnosis may lead to high morbidity and mortality. AIM: To evaluate the investigative modalities, treatment options and their outcome following Pancreatic trauma.

Methods. 48 consecutive patients with Pancreatic trauma were treated between Jan.1990 and May 2007, of whom 33 had isolated pancreatic trauma.

Results. There were 46 males and 2 females with age range of 8–55 years. Grades of Injury were (AAST grading): Grade I- 6 patients, II – 8, III – 24, IV – 10. US Abdomen had poor correlation (9.3%) whereas CECT done in 38 patients had good operative correlation (80.7%). Out of 16 patients that presented early (less than 48 hrs), 13 underwent surgery (Laporotomy and drainage-6, distal Pancreatectomy-4, Pancreatic ductal drainage-2 for grade IV as a part of two stage procedure and Laporotomy and debridement-1). 32 patients presented late and 23 underwent surgery (10 Pancreatic necrosectomy, 6 Laporotomy and drainage, 2 distal pancreatectomy, 2 Cysto gastrostomy, 2 Pancreatico jejunostomy and one Whipples procedure.). Six had percutaneous drainage for fluid collection and 3 were managed conservatively. Ductal stenting was unsuccessful in 4 attempts in the late group. Two patients with grade IV injury had an innovative external ductal drainage initially followed by internal drainage three months later with good result. All the six deaths were in the late group (19.3%). Seven patients had complications-transient pancreatic fistula in two, bleeding, pancreatic ascites, subphrenic collection, colonic perforation and sepsis with multiorgan failure in one each.

Conclusion. Management should be individualized depending up on the grade of injury, timing of presentation and presence of associated injuries. Based on our experience we recommend conservative surgery that could be staged even in grade IV injuries.

PP 53.08

SPECTRUM AND OUTCOME OF PANCREATIC TRAUMA

Prabhu, Ramkrishna¹; Kantharia, Chetan²; Bapat, Ravindra³; Supe, Avinash³

¹Kem Hospital & Seth Gs Medical College, Surgical Gastroenterology, Mumbai; ²Kem Hospital & Seth Gs Medical College, Surgiacl Gastroenterology, Mumbai, India; ³Kem Hospital & Seth Gs Medical College, Surgical Gastroenterology, Mumbai, India

Introduction. Pancreatic trauma is associated with high morbidity and mortality. Its diagnosis is difficult, posing a formidable challenge.

Methods. Prospective analysis of data of 17 patients of pancreatic trauma was done with respect to the mode of injury, diagnostic modalities, associated injuries, grade of pancreatic trauma and its management. Pancreatic Trauma was graded as per Modified Lucas classification.

Results. Median age: 39 years (range 19–61). Etiology of pancreatic trauma was blunt trauma -14 and penetrating injury-3 cases. Bowel injury in 4 cases (3 penetrating injury and 1 blunt trauma) and one had associated vascular injury. Pancreatic Trauma graded as (Grade I- 5, Grade II- 3, Grade III- 7 and Grade IV -2). CECT scan was done for diagnosis in all patients with blunt trauma. Immediate diagnosis could be reached only in 4 (28.57%). Seven patients responded to only conservative treatment. Of ten patients operated, 6 required surgery for pancreas and duodenum. (distal pancreatectomy with splenectomy -3, PPPD -1, debridement with external drainage- 1, associated injuries -duodenum -1). Pancreatic fistula, recurrent pancreatitis and pseudo-cyst formation was seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patients respectively. Mortality was in 4 cases (23.52%), Grade IV-2, Grade III- 2.

Conclusions. CECT scans are useful in diagnosing and grading pancreatic trauma and in treatment and follow up of these patients. A repeat scan is indicated at times for evolving pancreatic injury. Though majority responds to conservative treatment, patients with penetrating trauma, higher grade pancreatic trauma and associated injuries require surgical interventions which carry higher morbidity and mortality.

PP 53.09

MULTIPLE ORGAN INJURIES TRIGGER WORSE OUTCOME IN PANCREATIC TRAUMA

DeOliveira, Michelle Lucinda¹; Del Grande, Leonardo Mello²; Arantes, Luiz Henrique²; Carvalho, Adilson Pimentel²; Triviño, Tarcisio²

¹University Federal of Sao Paulo, Surgery-Division of Gastrointestinal Surgery, Sao Paulo, Brazil; ²University Federal of Sao Paulo, Surgery, Sao Paulo, Brazil

Background. Traumatic injury to the pancreas is uncommon with a reported prevalence of only one out of 250,000 trauma admissions. Both the diagnosis and treatment of most pancreatic trauma represent major challenges for the surgeons. The most important determinant guiding management is the integrity of the main pancreatic duct. Because of the low prevalence, few surgeons or institutions have gathered sufficient experience to address the diagnostic and therapeutic issues.

Objective. The aim of this study was to evaluate in a single large trauma center the management, severity, and complications of pancreatic injuries.

Methods. We performed a retrospective analysis of 50 consecutive patients with pancreatic injuries admitted to a single trauma center over a 20-year period focusing on diagnosis, therapy and prognostic factors.

Results. The median age was 32 years and 84% of the patients were male. The mechanisms of injury were blunt trauma in 20 (40%) patients, gunshot wound in 22 (44%) and stab wound in 8 patients (15%). Injury to the pancreas was isolated in only 4 cases and combined with other organ injuries the other 46 patients. Accordingly to the Pancreas Injury Severity Score Criteria (AAST), there were 6 injuries Grade I, 21 Grade II, 17 Grade III, 5 Grade IV and one Grade V. The majority (66%) of pancreatic injuries was managed by drainage with or without suturing. Distal pancreatectomy was performed in 16 patients (%), and a Whipple procedure in one patient. Complications were graded according to a standardized severity grading system. Overall complications occurred in 70% of the cases and pancreas-related complications occurred in 56%. The overall mortality rate in this series was 34%, which closely correlated to the presence and number of extrapancreatic injuries. Mortality was also higher in gunshot and blunt trauma injury group.

Conclusion. Pancreatic trauma is associated with a high morbidity and mortality mostly due to associated injuries.

PP 53.10

PREDICTORS OF MORTALITY IN INJURIES TO THE PANCREATICO-DUODENAL COMPLEX

Gupta, Rajesh; Wig, Jai D; Kudari, Ashwini K; Doley, Rudra P; Ravella, Vishnu P; Yadav, Thakur D; Bharathy, Kishore GS

Postgraduate Institute of Medical Education and Research, Surgical Gastroenterology Unit, Dept Gen Surgery, Chandigarh, India

Background. Injuries to the pancreatico-duodenal complex are rare with high mortality.

Objective. To identify predictors of mortality in these difficult to manage injuries.

Patients and Methods. In this retrospective study, we analysed the results of management of these injuries at our Gastrointestinal Surgery unit.

Results. There were 37 cases of injury to pancreatico-duodenal complex (pancreatic 21, duodenal 11 and both 5) i.e., total of 26 pancreatic and 16 duodenal injuries. There were 35 males with mean age of 32.9 years. Blunt trauma accounted for 27 and penetrating in10. Nineteen patients arrived > 24 hours later. Associated intra-abdominal injuries were present in 62.1% and extra-abdominal injuries in 32.4%. Mortality was 10/37 (pancreatic 23.8%; duodenal 27.2%; combined 40%). Pancreatic injury group: Admission factors with significantly higher odds for mortality were age, hypotension, and hyperuremia. Tachypnea for > 48 hours postoperative and multiorgan failure had significantly higher odds. Duodenal injury group: Admission hypotension, associated chest abnormality and postoperative hypotension had nearly significant odds. Whole Cohort: Significantly higher odds were noted for age, associated chest injuries, hypotension, hypoxia, and hyperuremia amongst the admission parameters. Leucocytosis at admission had significantly lower odds. Postoperatively significantly higher odds were noted with systemic complications, tachycardia, tachypnea and hypotension.

Conclusions. AAST grade of organ injury and location of pancreatic or duodenal injury and the operative procedure were not significant factors affecting mortality. In pancreatic injury group, age, admission hypotension, hyperuremia, postoperative tachypnea and multiorgan failure had significantly higher odds. In duodenal injury, hypotension and associated chest trauma had nearly significant higher odds.

PP 54.01

MODIFIED RECONSTRUCTION OF MIDDLE HEPATIC VEIN OUTFLOW IN RIGHT LOBE LIVER TRANSPLANT WITHOUT INTERPOSITION GRAFT

Vij, Vivek¹; Srivastav, Ajitab¹; Goyal, Neerav¹; Govil, Deepak¹; Gupta, Subash²

¹Indraprastha Apollo Hospital, Liver Transplant and Surgical Gastroenterology, New Delhi, India; ²Indraprastha Apollo Hospital, Sarita Vihar, Liver Transplant and Surgical Gastroenterology, New Delhi, India

Background. Middle hepatic vein (MHV) outflow reconstruction with interposition graft in Right lobe liver transplant is a tedious and time taking process. Retrieval of MHV requires preserving the segment 4a branch in order to prevent congestion of remnant liver. Quite often this will require lengthening of MHV at the back table by an interposition graft obtained from recipient portal vein. This leads to prolonged cold ischemic time, anhepatic phase, portal clamping time leading to congestion of bowel and overall prolonged operative time for the recipient. To avoid these, we join the MHV of right lobe directly with carefully retrieved intrahepatic portion of the MHV of the recipient.

Methods. From January 2004 to August 2007, a total of 70 live donor liver transplants were done. 42 (60%) right lobes were retrieved with full or partial MHV. New technique was used in last 10 consecutive patients. Operative time was compared in 32/42 patients without this technique (group A) and 10/42 patients with this technique. During the terminal phase of recipient hepatectomy (after dividing portal structures and right hepatic vein) the long length of MHV was retrieved after splitting the liver parenchyma at the root of MHV. This stump of MHV was carefully checked and any holes were closed. MHV of the graft was directly joined to this stump maintaining a specific orientation.

Results. Anastomosis was technically successful in all the ten cases as documented on intraoperative Doppler study. None of the anastomosis required revision. The average time saved was 2.45 hours when compared to the group A. This led to shorter cold ischemia time, shorter anhepatic phase and shorter portal clamping time. The routine protocol Doppler's on first five days confirmed the triphasic flow and patency of MHV.

Conclusion. The technique of directly joining the MHV of the right lobe graft with carefully preserved MHV of the recipient is feasible & saves overall operative time. It also shortens cold ischemic time, portal clamping time & anhepatic phase.

PP 54.02

INFERIOR VENA CAVAL MOBILITY AND VENOUS OUTFLOW IN LIVING DONOR LIVER TRANSPLANT

Vij, Vivek; Goyal, Neerav; Srivastav, Ajitab; Gupta, Subash

Indraprastha Apollo Hospital, Sarita Vihar, Liver Transplant and Surgical Gastroenterology, New Delhi, India

Background. Proper venous outflow in living donor liver transplant is the key to avoid congestion and resultant graft dysfunction. Venous outflow is very sensitive to positional (rotation) changes of the graft as the graft swells up after reperfusion and may obstruct hepatic venous outflow. Further, the right hepatic vein- caval anastomosis is sometimes difficult due to less mobility of the posterior edge of the common orifice of right hepatic vein and IVC. We report a new technique to facilitate this anastomosis and prevent the effect of graft rotation after reperfusion. In this new technique, we completely free the cranial end of the IVC from the diaphragm by tying off the phrenic branches of the IVC.

Methods. From January 2004 to August 2007, a total of 70 live donor liver transplants were done. 63/70 (89%) of patients underwent right lobe liver transplant. The cranial side of the IVC was freed in the last 30 cases. After recipient hepatectomy without caval clamping, the phrenic veins draining into IVC were ligated and divided. IVC was then mobilized carefully circumferentially for a length of about 1.5–2.0 cm above the opening of the right hepatic vein. All the hepatic venous-caval anastomosis was done after cross clamping the supra and infra hepatic IVC.

Results. Freeing the IVC resulted in easier anastomosis as the IVC could be easily lifted up during the anastomosis. The analysis of waveforms of the Doppler USG after reperfusion of the graft revealed an interesting finding. 28/30 (100%) patients with this technique revealed triphasic waveform of outflow veins. None of the patients required positional adjustment of the graft after reperfusion. 5/33 (15%) of patients required major graft positional adjustments after reperfusion before adopting this technique and only 18/33 (55%) revealed triphasic flow in outflow veins and biphasic flow in the remaining.

Conclusion. This new technique helps in easing the anastomosis and leads to good outflow as documented by triphasic waveform on doppler examination.

PP 54.03

LONG TERM RESULTS FOLLOWING LIVING DONOR LIVER TRANSPLANTATION FOR NEONATAL HEPATITIS IN PEDIATRIC PATIENTS

Chan, Chung Yip¹; Chen, Chao-Long²; Wang, Chih-Chi²; Wang, Shih-Ho²; Liu, Yueh-Wei²; Yang, Chin-Hsiang²; Yong, Chee-Chien²; Concejero, Allan M²; Jordan, Amornetta²; Jawan, Bruno²; Cheng, Yu-Fan²; Eng, Hock-Liu²

¹Tan Tock Seng Hospital, Department of General Surgery, Singapore, Singapore; ²Chang Gung Memorial Hospital Kaohsiung Medical Center, Liver Transplantation Program, Kaohsiung, Taiwan

Introduction. Liver transplantation is indicated in patients with end-stage liver disease due to neonatal hepatitis.

Objective. We present our institutional experience with living donor liver transplantation in children with neonatal hepatitis.

Patients and Methods. 310 patients underwent LDLT at our institution from June 1994 to May 2007. Ten children (5 male, 5 female) were diagnosed with neonatal hepatitis. We reviewed and analyzed the clinical records of these patients retrospectively.

Results. The median age at the time of transplantation was 1.5 years (range 0.66–6). The mean Child-Turcotte-Pugh score was 9 (S.D. ±1.89), and the mean PELD score was 15.6 (S.D. ±7.60). All patients presented with hyperbilirubinemia and/or complications from end-stage liver disease. 5 patients had undergone prior exploratory laparotomy to investigate the cause of neonatal jaundice. Hepatitis B and C were negative in all patients. Nine patients received left lateral segment grafts and one patient received an extended left lateral segment graft. The mean graft-to-recipient weight ratio was 2.92 (S.D. ±0.86). One patient with a primary duct-duct anastomosis developed biliary stricture that required conversion to a Roux-en-Y hepaticojejunostomy. Another patient developed intestinal B cell lymphoma with bone marrow metastasis which required small bowel resection and chemotherapy. There was one perioperative mortality from liver graft infarction secondary to portal vein occlusion. Another patient died at 15 months post transplantation from sepsis secondary to pneumonia. The mean follow-up was 59.89 months (S.D. ±22.34 months). Only 1 patient had an episode of acute cellular rejection. Liver function was normal in all surviving patients. The 6-month, 1-year and 5-year recipient survival rates were 90%, 80% and 80% respectively.

Conclusion. LDLT is a viable option for pediatric patients with end-stage liver disease secondary to neonatal hepatitis. Long-term follow up after liver transplantation shows excellent graft and patient survival.

PP 54.04

APPLICATION OF CRYOPRESERVED VEIN GRAFTS TO RECONSTRUCT PORTAL FLOW IN ADULT LIVING LIVER TRANSPLANTATION

Wu, Tsung-Han; Chou, Hong-Shiue; Wu, Ting-Jun; Lee, Wei-Chen; Jan, Yi-Yin; Chen, Miin-Fu

Chang-Gung Memorial Hospital, Department of General Surgery, Taipei, Taiwan

Introduction. Adult-to-adult living donor liver transplantation is not only an alternative but also the only way to solve shortage of liver donation for adult patients in Asia countries. When transplant candidates have portal vein thrombosis/fibrosis, living donor liver transplantation is relatively contraindicated because portal veins in the grafts are short and vein grafts may not be available to reconstruct portal vein. MATERIAL&Methods. From June 2003 and May 2007, 82 adult living donor liver transplantations were performed at Chang-Gung Memorial Hospital, and three of them having portal veins thrombosis/fibrosis were accepted to have living donor liver transplantation. Cryopreserved vein grafts were applied to reconstruct portal flow from engorged coronary vein to graft portal.

Results. Following Doppler ultrasound and computed tomography showed vein grafts are patent in 12, 12 and 3 months, respectively, after transplantation. All three patients are well and have normal liver function at present.

Conclusion. Portal vein thrombosis/ fibrosis increases surgical complexity of liver transplantation. When cryopreserved vein grafts are available, adult living donor liver transplantation can be successfully performed for the patients with portal vein thrombosis/fibrosis. A shortcut from engorged coronary veins to graft portal vein is preferred for portal vein reconstruction, which is short and may decrease re-thrombosis incidence of venous conduits.

PP 54.06

A COMPARATIVE STUDY ON THE PREDICTABILITY OF CT VOLUMETRY IN LIVING DONOR LIVER TRANSPLANTATION

Ko, Kyoung Hoon¹; Jung, Dong Hwan¹; Lee, Sung-Gyu¹; Hwang, Shin¹; Ahn, Chul-Soo²; Kim, Ki-Hun²; Moon, Deok-Bog²; Ha, Tae-Yong²; Song, Gi-Won²; Ryu, Je-Ho²; Park, Jeong-Ik²

¹Asan Medical Center, University of Ulsan College of Medicine, Department of Surgery, Seoul, Korea, Republic of; ²

Backgrounds. Accurate prediction of the functional mass of both graft and remnant livers is essential for proper donor selection and optimal recipient outcome in adult living donor liver transplantation (LDLT). The objectives of this study is to evaluate accuracy for determining lobar liver volumes using a multi-detector CT scanner in potential donors undergoing LDLT and to compare predictability of CT volumetry between right and left lobe.

Methods. During the period from January 2005 to December 2006, 472 donors who underwent hepatectomy for LDLT in our center were included this study. 359 patients underwent right lobectomy and 113 patients underwent extended left lobectomy. Multi-detector CT was preoperatively performed all patients. The estimated volume of the grafts in two-demensional image was compared with actual graft weight.

Results. In right lobectomy group, preoperatively measured right lobe volume was 779?133 mL and actual graft weight was 692?107 g. There was significant agreement between preoperatively measured right lobe volume and actual graft weight at surgery in right lobectomy group (r = 0.838). In extended left lobectomy group, preoperatively measured left lobe volume was 372?92 mL and actual graft weight was 384?82 g. There was significant agreement between preoperatively measured left lobe volume and actual graft weight at surgery in extended left lobectomy group (r = 0.841). Error ratio <=(estimated liver volume?actual graft weight)/actual graft weight * 100> was 12.9?10.3% and?2.7?11.6% for right lobe graft and extended left lobe graft, respectively.

Conclusions. The relationship between the estimated CT volume and actual graft weight was linear. The preoperatively measured volume of right lobe is substantially larger than the intraoperative actual graft weight. The preoperatively measured volume of left lobe is smaller than the intraoperative actual graft weight.

PP 54.07

INDICATIONS AND MANAGEMENT OF m-TOR AFTER LIVER TRANSPLANTATION

Bilbao, Itxarone¹; Sapisochin, Gonzalo²; Dopazo, Cristina²; Pou, Leonor³; Lazaro, Jose Luis¹; Castells, Luis⁴; Escartin, Alfredo¹; Lopez, Iñigo¹; Balsells, Joaquin¹

¹Hospital Vall d′Hebron, Surgery Department, Barcelona, Spain; ²; ³Hospital Vall d′Hebron, Biochemistry Department, Barcelona, Swaziland; ⁴Hospital Vall d′Hebron, Hepatology Department, Barcelona, Sweden

Aim. To asses our experience with the use and management of m-TOR after liver transplantation (LT).

Material: From 1988 to 2007, 783 LT has been performed in 725 patients. Fifty one patients (7%) received immunosuppression with m-TOR: Rapamicine 36 and everolimus 15. Mean age was 54.8 y (r:24–70). Indication of use, time between LT and introduction of m-TOR, eficacy, side effects and survival were analysed.

Results. Indications were: refractory rejection in the context of renal insufficiency 20 (39%), renal insufficiency 5 (10%), other side effects of CNI 6 (12%), extended HCC in the explanted live 7 (14%), HCC recurrence in the follow-up 7 (14%) and the novo tumour 3 (6%). Mean time between LT and m-TOR were 18±29 months; median 3 months (r:10 days-122months). Mean follow-up after conversion was 12 months (r: 1–65), with a median of 7. Half of the patients converted for refractory rejection, resolved the event; 4 required re-LT; 3 progressed to chronic rejection and 3 died due to non resolved rejection, overimmunosuppression and sepsis. Of 19 patients with renal insufficiency at time of conversion, 10 (52%) resolved. Three out of 7 patients with extended HCC, died and 4 out of 7 patients with recurrent HCC, died. The 3 the novo tumour were operated and are perfectly healthy. Half of the patients presented side effects related to m-TOR: diarrhea in 4 (8%), hematologic complications in 5 (10%), dyslipemia in 22 (43%), and infection in 8 (16%). Ten patients (20%) developed acute rejection after conversion. Nineteen patients (33%) discontinued drug: 9 due to ineficacy, 4 due to resolution of the cause, 3 due to intercurrent surgery and 3 due to advers event. Actuarial survival postconversion is 55% and 15% at 1y and 3y.

Conclusion. m-TOR are indicated in critical and sometimes irreversible situations where other immunosuppressants have failed. In the early period for refractory rejection or as prophylaxis for recurrence of extended tumors. In the late period for patients with serious CNI side effects

PP 54.08

BASILIXIMAB INDUCTION IN ORTHOTOPIC LIVER TRANSPLANT RECIPIENTS FOR DELAYED TA CROLIMUS INITIATION AND RENAL PROTECTION

McHugh, Patrick P¹; Clifford, Timothy M²; Thompson, Lisa A²; Johnston, Thomas D³; Jeon, Hoonbae³; Gedaly, Roberto³; Ranjan, Dinesh³

¹Transplant Center, University of Kentucky, Surgery, Lexington, Kentucky, United States; ²Transplant Center, University of Kentucky, Pharmacy, Lexington, Kentucky, United States; ³Transplant Center, University of Kentucky, Surgery, Lexington, KY, United States

Background. Tacrolimus, a calcinuerin inhibitor (CNI), is a mainstay of current immunosuppression, although its use is complicated by nephrotoxicity. CNI-sparing regimens, often with basiliximab induction, are sometimes used in renal transplant patients, but there is scant data in orthotopic liver transplant (OLT) patients. We hypothesized that using basiliximab for induction after OLT in patients with renal dysfunction provides adequate immunosuppression and allows delay of CNI initiation. OBJECTIVES: To evaluate if: 1. basiliximab induction coupled with delayed CNI initiation will favorably affect renal function (up to 3 months); 2. delaying CNI will result in increased incidence of acute rejection episodes.

Methods. We reviewed charts of all patients who underwent OLT since April 2005 who had elevated creatinine and/or oliguria postoperatively and received basiliximab induction with subsequent delay in CNI initiation. Patients were divided by serum creatinine: >1.5mg/dL (group A) and ¡Ü1.5mg/dL (group B).

Results. There were 12 patients in group A, and 11 in group B. Mean creatinine in group A at 1 day, 1 week, 1 and 3 months postoperatively was 2.2, 1.8, 1.6, and 1.4 mg/dL, and 1.3, 1.0, 1.2, and 1.3 mg/dL in group B, respectively. One patient (in group A) underwent treatment for acute rejection, which in retrospect was recurrent hepatitis C. Timing of the first basiliximab dose varied slightly but was postoperative day 1 on average (range 0–3). Mean times to CNI initiation were 4.5 days in group A and 4.1 in group B.

Conclusion. While improvement in postoperative renal function may be multifactorial and not only related to delayed CNI therapy, our data show no detrimental effect of basiliximab induction and delay of CNI initiation after OLT, particularly in patients with greater renal impairment (serum creatinine >1.5mg/dL). The degree of mild renal insufficiency at which optimal benefit is obtained with this regimen remains uncertain.

PP 54.09

DETERIORATION OF MITOCHONDRIAL FUNCTION IS THE KEY MECHANISM RESPONSIBLE FOR HEPATIC INJURY IN NON-HEART-BEATING DONOR LIVERS.

Roy, Debabrata¹; Morten, Karl²; Ashley, Neil²; Southerland, Andrew¹; Elker, Doruk³; Guerriero, Dino¹; Morovat, Reza⁴; Friend, Peter J¹

¹John Radcliffe Hospital, Nuffield Department of Surgery, Oxford, United Kingdom; ²John Radcliffe Hospital, Nuffield Department of Obstetric and Gynaecology, Oxford, United Kingdom; ³The Churchill Hospital, Oxford Transplant Center, Oxford, United Kingdom; ⁴John Radcliffe Hospital, Nuffield Department of Biochemistry, Oxford, United Kingdom

Introduction. Non-heart-beating-donor (NHBD) livers are extremely susceptible to ischaemia-reperfusion injury. Mitochondria play a central role in hepatic ischaemia reperfusion injury due to its role in reactive oxygen species (ROS) formation and apoptotic cell death. We have investigated the mitochondrial functional changes during ischaemia-reperfusion and its relationship with hepatocellular injury in NHBD livers.

Methods. Porcine livers (Group IR, n = 5) were subjected to 60 minutes of ischaemia and then connected to an extracorporeal perfusion circuit for 24 hours for assessment of viability. Group C (Control, n = 5) did not receive ischaemic injury. Both groups were subjected to transient cooling during the bench work prior to reperfusion. Sequential liver biopsies were analysed for ATP content and mitochondrial function (respiratory control ratio (RCR), cytochrome c release and caspase activation). The perfusate was analysed for serum transaminase, bile production and base deficit.

Results. 60 minutes of warm ischaemia did not alter mitochondrial function significantly (p = 0.128). However, subsequent cold preservation produced significant decline in mitochondrial function (RCR 3.97±0.43 vs. 2.45±0.21 p < 0.001). Mitochondrial function did not recover during reperfusion with oxygenated blood. ATP energetics mirrored the changes in mitochondrial function. Mitochondrial damage was associated with cytochrome c release and caspase activation and increased hepatocellular damage as evidenced by raised transaminase release (p < 0.05) in the perfusate. By comparison, Control livers (without warm ischaemia) maintained normal mitochondrial function during cold preservation and subsequent reperfusion with minimal hepatocellular damage.

Conclusions. Our data suggest that alteration of mitochondrial function is a critical event leading to cellular energetic failure and cell death in NHBD livers. This may have important implications in developing novel therapeutic strategies for resuscitation of NHBD livers.

PP 55.01

SURGICAL TREATMENT OF HYDATID LIVER DISEASE

Karamarkovic, Aleksandar¹; Ivancevic, Nenad²; Blazic, Ivan²; Doklestic, Krstina²; Mihailovic, Vojin²; Radenkovic, Dejan²

¹University Center for Emergency Surgery, School of Medicine Belgrade, Surgical Dpt. III, Belgrade, Serbia and Montenegro; ²University Center for Emergency Surgery, School of Medicine Belgrade, Surgical Dpt. III, Belgrade

Background. Surgery remains the main treatment modality of hydatid liver disease. There still debate about the best approach, conservative surgery (marsupialization, drainage, partial cystectomy) has opposed to radical surgery in which the cyst is totally removed including the pericyst by total pericystectomy or partial hepatectomy.

Aim. This study aims to show that radical surgery resection of the hepatic hydatid cysts is a safe and effective technique.

Patients andMethods. A series of 49 consecutive patients operated on for liver hydatid disease between January 2003 and December 2006 was analyzed. The most common compliant were pain (62%), hepatomegaly and abdominal mass ( 39%). Diagnostic assessment was obtained with serology (ELISA) and radiology (US and CT scan). Surgery comprised conservative methods like partial cystopericystectomy with intracavitary placed drainage and omentoplasty of residual cavity (21 pt.), and radical surgical methods like total cystopericystectomy (5 pts.) and liver resection (segmentectomy, lobectomy, hemihepatectomy) (23 pts.).

Results. In the entire series, morbidity was 19% of which 28% was seen with conservative surgery and 11% with radical methods (p < 0.05). Biliary fistula was more frequent complication in both groups: 15.9% vs. 4.2% (p < 0.01) in patients that underwent conservative methods and radical methods, respectively. There was no operative and postoperative mortality in our studied group. Long-term follow-up showed that hydatid disease relapsed frequently in patients who underwent conservative treatment than in those who underwent radical surgical approach: 4 pts. Vs. 0 pts.

Conclusion. According to our results, radical surgery of the hydatid liver disease represents the method of choice over others such as partial pericystectomy.

PP 55.02

INFECTIVE AND BILIARY COMPLICATIONS IN COMPLEX HEPATIC INJURIES – A TEN YEAR PERSPECTIVE

Srinivasan, Thiagarajan¹; Wig, Jai D¹; Gupta, Rajesh¹; Yadav, Thakur D¹; Doley, Rudra P¹; Kudari, Ashwinikumar¹; Kochhar, Rakesh²

¹PGIMER, Chandigarh, India, General Surgery, chandigarh, India; ²PGIMER, Chandigarh, India, Gastroenterology, chandigarh, India

Background. Nonoperative management is being increasingly employed in the management of bile leaks and infective complications in patients with blunt hepatic injury. AIM AND Methods. Patients with complex hepatic injuries with biliary and infective complications over a period of 10 years (1996 – 2006) were analyzed.

Results. 208 patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The mortality and morbidity in this series was 10.7% and 56.4% respectively. 26.2% patients had biliary complications and seventeen patients had intra-abdominal collections. The grade of the injury was proportional to the increased incidence of biliary and infective complications. The infective complications were significantly higher in the surgical group (37.5%) than the conservative group (10%). 4.8% patients had liver abscesses, eleven patients had bilomas, two had external biliary fistulas and two had bilioplueral fistulas. Endoscopic management for bile leaks was performed in five with nasobiliary drains initially and replaced with stents in 3 patients. Image guided pig-tail drainage was done for liver abscesses in 3 patients and bilomas in 8 patients. 43% (7/16) of patients with biliary and infective complications required surgery. Five patients underwent T-tube drainage for bile duct injuries and two patients underwent delayed surgery for evacuation of liver abscess. One patient underwent hepaticojejunostomy for delayed left hepatic duct stricture.

Conclusions. Biliary leaks and infective complications in complex liver injuries are the major causes of increased morbidity which can be managed successfully with multimodality treatment. Surgery is reserved for selected indications.

PP 55.03

SURGICAL TREATMENT OF HEPATIC INJURIES

Karamarkovic, Aleksandar¹; Ivancevic, Nenad²; Blazic, Ivan²; Radenkovic, Dejan²; Mihailovic, Vojin²

¹University Center for Emergency Surgery, School of Medicine Belgrade, Surgical Dpt. III, Belgrade, Serbia and Montenegro; ²University Center for Emergency Surgery, School of Medicine Belgrade, Surgical Dpt. III, Belgrade

Background/Aims. Aim of study was to analyse the results of the surgical treatment of 238 cases of hepatic injuries during the last six years (2001–2006).

Patients and Methods. 214 patients underwent surgical intervention, while 24 patients ith blunt liver trauma were treated conservatively.

Results. 89 patients (41.6%) had one or more associate abdominal injuries and more than 20% sustained extraabdominal lesions. The mean ISS was 35.9 According to the OIS, surgicaly treated patients presented lesions of grade I, II, III, IV and V in 11%, 25%, 41%, 19%, 4% of patients, respectively. The most common surgical procedure was hepatorrhapy without or with viable omental packing. Anatomical resection (segmentectomy, hepatectomy) was done in 17 pts (7.9%), while atypical resection performed in 5.1% cases. In 5.6% was necessary to perform a perihepatic packing and Staged Injury Repair (STIR), with multiple re-explorations and delayed definitive repair, utilizing a glider (ETIZIP) for temporary abdominal closure. Operative treatment also included Pringle manoeuvre or total vascular exclusion (TVE), cholecystectomy, vascular sutures of the inflow hepatic circulation, hepatic veins and VCI, and also bile duct reconstruction. The observed mortality in our series was 16% (34 patients). In the group of the most severe hepatic injuries (grade III, IV and V) the overall mortality rates were 10, 49 and 67%. The main causes of death were sepsis syndrome associated with DIC, ARDS and MODS. The most common specific complications in patients, after surgical treatment, were intraabdominal abscess (6.5%), late haemorrhage (4.2%), biliary fistula and peritonitis (8.8%).

Conclusions. There is the significant correlation between injury grade and mortality rate. Careful clinical assessment and close radiological monitoring of the patients with minor hepatic injuries, may prevent from unnecessary laparotomies. From that point of view, diagnostic laparoscopy play an important role.

PP 55.04

HEPATICODUODENOSTOMY AFTER EXCISION OF CHOLEDOCHAL CYST-A STUDY IN 43 PATIENTS

Dastidar, Arindam; Sen, Sudipta; Chacko, Jacob; Karl, Sampath; Kumar, Jyotish

Christian Medical College and Hospital, Department of Paediatric Surgery, Vellore, India

Background. Hepaticoduodenostomy is a controversial option in the management of Choledochal cyst.

Aim. The aim of this study is to analyze the outcome of Hepaticoduodenostomy (HD) in patient with Choledochal Cyst.

Materials and Methods. 72 patients with Choledochal cyst were operated over past 7 years. Among them 43 underwent HD after cyst excision. Most common complaint in these patients at presentation was abdominal pain with one or more episodes of jaundice. One patient was antenatally detected to have Choledochal cyst. 26 among these 43 patients were girls; average age of presentation was 6.8 years (Range 1year – 15 years). Average duration of admission was for 7 days with nasogastric drainage for 4 days and nil per oral for 5 days. All HD was done below the hilum to first part of duodenum. Duodenum was kocherised to form a tension free anastomosis. Suture line was further reinforced with an omental wrap.

Results. No major complications namely cholangitis, calculi encountered in any of our patient during follow up. Duration of follow up ranged from 6 months – 24 months (mean 15 months). Follow up was done in OPD with Liver Function Test, Ultrasound and HIDA scan.

Conclusion. Hepaticoduodenostomy is a physiological technique of reconstruction after cyst excision. It offers many advantages over other techniques, by limiting the operative field to the supra colic compartment and a single anastmoses. Apart from this it allows access to the biliary tree via an endoscope in the event of calculi or anastomotic stricture. Despite the controversy regarding this procedure in literature, we find HD a safe option in the treatment of Choledochal cyst

PP 55.05

A COMPARATIVE EXPERIMENT OF NEW HIGH-SPEED RADIOFREQUENCY SYSTEM WITH CONVENTIONAL MONOPOLAR RADIOFREQUENCY DEVICE

Yao, Peng; Akhter, Javed; Daniel, Steve; Morris, David

University of New South Wales, Department of Surgery, Sydney, Australia

Background. Radiofrequency (RF) is a safe and effective minimally invasive procedure in the treatment of liver and other organs neoplastic lesions. We have developed a new high speed radiofrequency system (HSRFS).

Aim. We sought to compare the efficacy of HSRFS with conventional monoporlar RF device on ex vivo perfused bovine liver.

Methods. Bovine livers were obtained from the local abattoir, then were preserved by HTK solution in accordance with the protocol for liver transplantation and brought back to our lab. Portal vein was cannulated and connected to a MasterFlex pump (Barnant Co, Barrrington, IL, USA). RFA was conducted with the RITA 1500 generator (RITA Medical systems, Mountain View, CA, USA). HSRFS and RITA StarBurst were tested in this study.

Results. We applied two different power setting: 100 watts×5 min and 150 watts×10 min. In the no perfusion setting, there was no significant difference between two devices. However there was significant difference in the perfusion model (both 500 ml/min and 1000 ml/min).

Conclusion. New HSRFS could create larger lesions than that of monopolar RFA device under perfusion.

PP 55.06

CONFLUENT HEPATIC FIBROSIS MIMICKING MASS LESION IN A PATIENT WITH BACKGROUND HEPATITIS B ON SCREENING ULTRASONOGRAPHY

Lai, Bo San Paul¹; Wong, John²; Ng, Wilson W C²; Lee, K F²

¹Prince of Wales Hospital, Chinese University of Hong Kong, Surgery, Hong Kong, Hong Kong; ²Prince of Wales Hospital, Surgery, Hong Kong

Introduction. Confluent hepatic fibrosis is an uncommon condition, even in patients with advanced cirrhosis. CASE REPORT: A 78-year-old gentleman was referred to our Joint Hepatoma Clinic for a mass lesion detected on screening USG done as part of a community health check program. He was also found to be a carrier of hepatitis B surface antigen and his liver function was normal. Clinically, he is Child¡∣s A. USG found a 14cm nodule occupying almost the whole right lobe of the liver with background cirrhosis. CT scan was then arranged for the patient which confirmed that he did not have liver cancer. Instead, CT reconstruction disgnosed that the liver was badly distorted and there was no mass lesion within the liver parenchyma. DISCUSSION: Confluent hepatic fibrosis (CHF) causes severe changes in the liver architecture as a result of regneration nodules formation together with capsular retraction during the process of cirrhosis. The shape of the liver can change so much that it does not look like a liver at all on imagings. It is also rare to have normal liver function in patients having CHF. Because of the distortion in the shape of hepatic lobes, the pseudolesions may mimic malignant lesions in the background of cirrhosis. In our patients, the radiologist doing the USG misread the dominant nodule on the right lobe as a mass lesion and CT scan together with 3D-reconstruction was required to reveal the correct diagnosis.

PP 55.07

HEPATECTOMY FOR RECURRENT PYOGENIC CHOLANGITIS

Wong, John; Lee, Kit Fai; Ng, Wilson Wing Chi; Ling, Eva; Fok, Ka Lung; Ng, Nancy; Lo, Xina; Mak, Oi Sze; Lai, Paul Bo San

The Chinese University of Hong Kong, Department of Surgery, Hong Kong, China

Background. Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia and is prevalent in Hong Kong. It is characterized by repeated attacks of cholangitis due to intrahepatic ductal stones. Management of RPC is multidisciplinary, aiming at retrieval of biliary stones, drainage of the biliary system and resection of the non-functioning liver segments.

Methods. A retrospective review of RPC patients requiring formal hepatectomy in a single centre between 2002 and 2007 was performed. Nature of operation, requirement of concomitant procedures, morbidity and mortality rates, specimen pathology and residual symptoms were analyzed.

Results. During the study period, 24 patients (9 males, 15 females) received hepatectomy, with a median age of 62.5 years (range 35–74 years). Median follow-up period was 12.4 months (range 1.2¡V55.7 months). Ex tent of hepatic resection included left lateral sectionectomy (segments II & III) (n = 19), left hepatectomy (n = 2) and right hepatectomy (n = 3). Choledochoscopy was performed at the same time for stone clearance in 19 patients. Four patients required a hepatico-jejunostomy for biliary drainage. Three patients (12.5%) had incidental finding of malignancy confirmed in specimen pathology: cholangiocarcinoma (n = 1), hepatocellular carcinoma (n = 1) and papillary adenocarcinoma (n = 1). There was no operative mortality. Surgical related morbidities included wound infection (n = 8), abdominal collection (n = 1), bile leak (n = 1) and left lung collapse (n = 1). No patient developed recurrent biliary tree stone or cholangitis subsequently. Survival at 1 and 2 years were both 87%. DISCUSSION: Hepatectomy is a safe and definitive treatment for RPC. Left lateral sectionectomy is performed in 79% of cases. Stone clearance can be ascertained by choledochoscopy. The most commonly encountered complication is wound sepsis. The malignant potential of this disease should not be overlooked.

PP 55.08

A TEN-YEAR STUDY OF EARLY OUTCOMES FOLLOWING HEPATIC RESECTION IN A HIGH-VOLUME TERTIARY REFERRAL UNIT

Lordan, Jeffrey T; Karanjia, Nariman D; Fawcett, William J.; Worthington, Tim R.; Quiney, Nail; Remington, Jacky

Royal Surrey County Hospital, Guildford, United Kingdom

Background. Centres with high volumes of high-risk surgery have significantly better outcomes than low-volume centres for pancreatic resection, oesophagectomy and pelvic exenteration. However, this has not to date been conclusively demonstrated for hepatic resection.

Patients and Methods. Data regarding 381 consecutive liver resections were prospectively recorded and retrospectively analysed in a high-volume tertiary referral unit over a 10 year period. Patients’ demographics, operative mortality and morbidity were analysed.

Results. Operative mortality was 1.6% and the morbidity rate was 24.1%. Bile leak was the most common complication followed by severe sepsis. Median intra-operative blood loss was 250ml and 13 patients received intra-operative blood transfusions.

Conclusion. This article conclusively demonstrates that high-volume centres are the safest environment for hepatic resection.

PP 55.09

OPERATIVE MANAGEMENT OF EXTENSIVE LIVER TRAUMA V. DJUKIC D.

Stepic, Z Loncar, S. Mijatovic, P Savic V. Bumbasirevic, A. Karamarkovic KCS Belgrade-Serbia Djukic, Vladimir.

KCS Belgrade, HPB and Emergency Surgery, Belgrade, Serbia and Montenegro

Background. Surgical, operative management of extensive blunt or penetrating injuries to the liver remains a significant challenge with a certainly high morbidity of 50% and mortality up to 80%Historicaly concept of surgical management has been tremedously shift towards non operative approach since CT implementation in 1981 Extensive liver trauma grade III an IV and V are still surgical and multidisciplinary task and hypotremia, acidosis and coagulopathy as fatal triade has to be solved in order to achieve better results THE AIME of the study is to eveluate the role of preconditioning and Pringle manuever in liver resection in patients with severe haemodynamic schock I

Methods and Results. The results of 20 patients who underwent different life saving procedures in Emergency Centre Belgrade Serbia 01012002 –30.05.2007 were analyzed 3 TVE total vascular exclusion, 1 atriocaval shunt, 1 IVC repair with graf repair,6 infrahepatic IVC repair,4 formal right hepatectomies,4 bisegmentectomies S 6,7, 2 segmentectomies S5with cholecystectomy, and 3 left sectorectomies S 2,3 Blood loss was 2340–7800ml, bile leak 35% Mortality rate was extremely high 60%.

Discussion. The authors report such a unsatifactory results because all of our patients had multiple organ injuries with dominant abdominal and bad AAST, TRISS ISS and Glasgow Comma Scale.

Conclussion. Vascular inflow control with preconditioning still has no alternative in allready hypoperfused and exsanguinated patients Surgeons has to be encourraged to apply Damage Control procedure widely in order to reduse high mortality rate

PP 55.10

INTRAARTERIAL CHEMOTHERAPHY OF LIVER METASTASES

Djukic, Vladimir; Stepic, D; Loncar, Z; Mijatovic, S.; Bumbasirevic, V.; Djurovic, M.; Culafic Dj, Radenkovic; Karamarkovic, A.

KCS Belgrade, HPB and Emergency Surgery, Belgrade, Serbia and Montenegro

Background. Regional hepatic arterial chemotherapy was proposed as a rational approach to intensify therapy based on pharmacological and anatomical approach.

The Aime. of the study was to evaluate retrospectively the effects of intraarterial chemotherapy for liver metastases of various origin.

The Resultsof 40 patients treated with implantable catheter HAI hepatic artery infusion for nonresectable metastic disease. Colorectal 24, pancreatic 6 breast 8 and gynecol 2. Liver replacement by tumor was >35% in our series measured by CT and NMR. Administered dose was 1 gr of 5 FU 6 cycles of 5 days per month. Assessment of response to treatment was based on CT and tumor markers C 19–9, CEA We had no single patient with complete response, partial response 50% of tumor volume CT control had 4 (10%) partial 25% of tumor size 10 (25%), 8 (20%) patients had very limited response. Unfortunately 18 (45%) patients had rapid tumor progression. Intraoperative mortality, was 0%. Total morbidity was 10%: port side infection in 2 (5%) 1(2,5%) perforation and thrombosis of the catheter in 1 (2,5%) three and five months after the implantation. The median survival was 12 months. The maximum of 34 months survived lady operated for colorectal adenocarcinoma with synchronous liver secondary tumor. After successful down stage period of six months we resected segments 6 and 7.

Discussion. Results of our study are disappointing comparing to Memorial Sloan –Kettering Cancer Center. Fong et al of Mayo Clinic with response rate following HAI of 48% or French multicentric 49%. with 2 year survival rate of 22% for HAI.

Concusion. Patients with hepatic replacement by tumor > 30% and concomitant extrahepatic metastatic disease are throught to be inappropriate candidates for hepatic artery chemotherapy

PP 55.11

POST CHOLECYSTECTOMY BILE DUCT STRICTURE WITH PORTAL HYPERTENSION: PRELIMINARY PORTOSYSTEMIC SHUNTING UNNECESSARY

Vyas, Frederick¹; Joseph, Philip²; Sanghi, Ravish²; Sitaram, Venkatramani²

¹Christian Medical College Hospital, Department of General Surgery, Ida Scudder Road, Vellore, India; ²Christian Medical College Hospital, Department of General Surgery, Vellore, India

Introduction. Portal hypertension develops in 15–20% of patients with benign bile duct stricture as a result of secondary hepatic fibrosis or direct damage to the portal vein. The outcome of patients with biliary stricture and portal hypertension is poor with an in hospital mortality rate of 25–40%.

Aim. To analyze our experience in managing these patients.

Methods. Case records of all patients with post cholecystectomy benign biliary stricture and portal hypertension between 1992 and 2007 were analyzed.

Results. Twenty three patients were available for review. All patients had developed biliary stricture after cholecystectomy and had evidence of portal hypertension on oesophago-gastroduodenoscopy. There were 10 males and 13 females with a mean age of 38 years. Median duration of symptoms before presentation was 42 months. Cholangitis was present in 16 patients and all 23 patients were jaundiced. Five patients had previous attempts at repair and three patients had multiple endoscopic interventions. There were 7 Bismuth type II, 13 type III and 3 type IV strictures. One patient had a preliminary interposition mesocaval shunt and one patient had an attempted shunt. All the other underwent hepaticojejunostomy without a preliminary shunt. There were 5 peri-operative deaths. The patient with mesocaval shunt died of progressive liver failure six months after surgery. One patient was lost to follow up. Follow up was available on 16 patients. Median duration of follow up was 38 months. Two patients needed dilatation of anastomosis; one for raised alkaline phosphatase levels and one for recurrent cholangitis. The other 14 patients are symptom free with an excellent outcome.

Conclusion. Satisfactory repair with acceptable morbidity and mortality is possible in patients with bile duct strictures and secondary portal hypertension. Portosystemic shunting is not necessary. Patients with complex injuries and borderline liver function should be considered for liver transplantation

PP 56.01

AVOIDING TOTAL PANCREATECTOMY IN A SUSPECTED MULTIFOCAL IPMT. A CASE REPORT

Guerra, Juan Francisco; Martínez, Jorge; Guzmán, Sergio; Jarufe, Nicolás

Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Chile

Introduction. Parenchyma-sparing resections have been described in order to reduce endocrine and exocrine postoperative insufficiency after pancreatic su rgery. A patient with a suspected mutifocal IPMT who underwent a pancreatoduodenectomy plus a distal resection of the pancreatic remnant is presented. Case Report. A 47 year-old male was admitted with a medical history of 12 episodes of acute pancreatitis, within the last 8 years. Abdominal US, CT Scan and MRI demonstrated a dilated main pancreatic duct, with a deformation in the pancreatic head, uncinate process and the tail of the gland, suggesting an Intraductal Papillary Mucinous Tumor (IPMT). The gallbladder and the bile duct were normal. ERCP showed a bulking papilla. Regarding radiologic findings, a Total Pancreatectomy was recomended, but the patient refused this kind of surgery, because the need of lifetime insuline use. A parenchyma-sparing resection, leaving a central segment of pancreatic parenchyma was planned. At surgery, a 4×4×3cm cystic appearence mass was adverted at the uncinate process and a smaller cystic mass was evident in the pancreatic tail. A Pancreatoduodenectomy, with pancreatojejunostomy reconstruction and a distal pancreatectomy and splenectomy was performed. A central portion of well irrigated pancreatic parenchyma was preserved. A well tolerated, low flow pancreatic fistula was the only surgical complication. Histology showed a main duct IPMT at the uncinate process. In the distal portion of the gland a sclerosing chronic pancreatitis was found, with no tumor evidence. After 24 months the patient has no exocrine insufficiency with normoglycemic status under oral antidiabetic therapy

PP 56.02

AMYLASE LEVEL IN ABDOMINAL DRAIN AFTER DUODENOPANCREATECTOMY: A SIGNIFICANT RISK FACTORS FOR PANCREATIC FISTULA

Matheus, Andre S.; Montagnini, Andre L.; Jukemura, Jose; Jureidini, Ricardo; Perini, Marcos V.; Haddad, Luciana B.P.; Abe, Emerson K.; Cecconello, Ivan; Cunha, Jose Eduardo M

University of Sao Paulo, Dept. of Gastroenterology, Sao Paulo, Brazil

Operative mortality rates after pancreaticoduodenectomy (PD) have decreased dramatically over the past 3 decades and recent series have reported very low mortality. Nevertheless pancreatic fistula (PF) remains the major cause of morbidity. A significant fraction of patients undergoing PD develop a postoperative pancreaticocutaneous leak.

Methods. Sixty five patients who underwent PD at our hospital were prospectively investigated. Standard PD was performed for 10 cases and pylorus-preserving PD for 55 cases. A duct-to-mucosa pancreaticojejunostomy was performed in all patients and a transanastomotic stent was placed in patients with soft pancreas and non-dilated duct. Octreotide was not used after surgery. Four preoperative, two intraoperative, and five postoperative risk factors with potential to affect the incidence of pancreatic fistula were analyzed. PF was defined and graded in accordance with the International Study Group on PF.

Results. Of the 65 patients, 11 (16.9%) were identified as having pancreatic leakage after operation. The hospital mortality in this series was 3.07%, and the mortality associated with pancreatic fistula was 0% (0/37). General risk factors including patient age, gender, history of jaundice, preoperative nutrition, and pathological diagnosis didn't have any relation with pancreatic fistula occurrence. Intraoperative risk factor, texture of the remnant pancreas, was not found to be significantly associated with pancreatic leakage. Blood loss, type of resection, and serum amylase level on postoperative day 1 did not have significantly relation with pancreatic fistula. The incidence of pancreatic leakage was 81.9% (9/11) in those patients with abdominal drain amylase level > 1000UI/dL on postoperative day 1, it was the only risk factor with significantly relation with pancreatic fistula (p < 0.05).

Conclusion. Amylase level > 1000UI/dL in the abdominal drain on postoperative day 1 is the only significant predictive factor of PF development.

PP 56.03

PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY: THE CHOICE OF CONSERVATIVE TREATMENT

Haddad, Luciana B P; Scatton, Olivier; Randone, Bruto; Andraus, Wellington; Massault, Pierre-Philippe; Dousset, Bertrand; Soubrane, Olivier

Cochin Hospital, Liver Department, Paris, France

Background. Pancreatic fistula (PF) is the most common complication after pancreaticoduodenectomy (PD), and its reported incidence varies from 2 to 28%. The aim of the present study is to analyze the treatment of complicated pancreatic fistula comparing the surgical approach to conservative techniques.

Methods. From January 2000 through August 2006, 121 patients were submitted to PD. There were 70 men and 47 women, with a median age of 60 years (SD ±12). The main indications for PD was pancreatic duct carcinoma in 52 patients (44.5%), ampullary carcinoma or adenoma in 18 (15.4%) and islet cell tumor in 11 (9.4%). Reconstruction by pancreatogastrostomy was performed in 65 patients (55.6%) and by pancreatojejunostomy in 52 patients (44%).

Results. Thirty five patients (30%) developed pancreatic fistula. Amongst these, 20 were managed conservatively and 14 were reoperated. These two groups of patients were compared with patients without PF for analysis. There was no significant difference in the mean age, the sex ratio, ASA classification, surgical time and blood replacement, number of associated procedure, vascular resection and type of reconstruction between the three groups. There were 5 postoperative deaths (4.2%), three patients (21.4%) in the surgical treatment group (p < 0.01). Mean total number of complications (p = 0.02) and mean length of hospital stay (p < 0.001) were greater in the surgical group. The medium delay between the pancreatic resection and the reoperation was 10 days (range, 3–32 days). Completion splenopancreatectomy was required in 5 patients while conservative treatment including debridement and drainage was applied in 9 patients.

Conclusion. Surgical approach of PF is associated with a higher mortality and morbidity. There is no advantage in performing completion pancreatectomy instead of extensive drainage due to the same mortality and morbidity rates and the risk of endocrine insufficiency. In cases of complicated PF, radiological or surgical conservative treatment is recommended.

PP 56.04

PIGMENTED EXTRA-ADRENAL PARAGANGLIOMA PRESENTING AS A MULTICYSTIC PANCREATIC TUMOR

Pace, Ronald F¹; Cummings, Brian²; Husien, Mohamed¹

¹Grand River Hospital, Surgery, Kitchener, Canada; ²Grand River Hospital, Pathology, Kitchener, Canada

Cystic pancreatic tumors frequently present as large pancreatic masses with few symptoms, and have a characteristic appearance on CT scanning. We present a case of a massive multicystic tumor apparrently arising in the tail of the pancreas which proved to be an extra-adrenal paraganglioma after histologic review. A 32 year old female of Vietnamese origin presented with occasional sharp pains in the left upper quadrant. An ultrasound and subsequent CT scan disclosed the presence of an 18.9×11.7×8 cm. solid mass with multiple cystic spaces which seemed to arise from the tail of the pancreas. She had no past medical illnesses, and had minimal left upper quadrant fullness as the only physical finding. She was taken to the operating room and an extensive evaluation showed no evidence of metastatic disease. The tumor seemed to arise from the tail of the pancreas, and infiltrated the mesentery of the splenic flexure of the colon. An enblock resection of the tumor was performed, including the tail of the pancreas, spleen, and splenic flexure of the colon. She had a smooth post-operative course. Histologic evaluation of the excised tumor proved it to be a Pigmented Extra-Adrenal Paraganglioma originating from the retroperitoneum and pressing on, but not invading the pancreatic tail. Although angioinvasion was identified histologically, there was no evidence of lymph node metastases. Urinary catecholamine levels are normal, and the patient has remained well clinically. Retroperitoneal tumors, such as Extra-Adrenal Paragangliomas may mimic pancreatic tumors on CT scanning, and should be considered when assessing patients for surgical intervention.

PP 56.05

MORPHOLOGICAL CLASSIFICATION OF SEROUS CYSTIC TUMOR (SCT) OF THE PANCREAS

Lee, Seung Eun; Lee, Seung Eun; Jang, Jin-Young; Kwon, Yujin; Kim, Young-Hoon; Hwang, Dae Wook; Hwang, Dae Wook; Lee, Kuhn Uk; Kim, Sun-Whe

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. Although honeycomb microcystic type is common and typical for serous cystic tumor (SCT), clinical and radiological features of SCT show diversely according to subtype. However, standard classification of subtype is not well established. The purpose of this study is to classify subtype of SCT and to clarify its clinicopathological characteristics.

Methods. From 1992 to 2006, clinical data from 52 patients with pathologically confirmed SCT were prospectively collected in standard data form. Radiologic finding and differential diagnosis were reviewed by one GI specific radiologist. According to cyst size and multiplicity on gross and radiologic feature, when every cyst was smaller than 2cm, SCT was classified as microcystic and if there were cysts larger than 2cm, SCT was classified as macrocystic. Then, microcystic tumors were subdivided into honeycomb and compact type, while macrocystic tumors were subdivided into unilocular and multilocular according to number of cyst. The cilicopathologic features of four subtypes were compared.

Results. Mean age was 50(25∼73) years. 22 cases were microcystic SCT which were subclassified into honeycomb (n = 21) and compact type (n = 1), while 30 cases were macrocystic SCT which were subclassified into multilocular (n = 16) and unilocular (n = 14). There were no differences between four subtypes in gender, tumor location, and size. Preoperative diagnostic accuracy of unilocular macrocystic SCT was only 35.7%, while that of honeycomb microcystic and multilocular macrocystic SCT were 81% and 87.5% respectively, and there was significant difference(P = 0.005).

Conclusion. Microcystic and multilocular macrocystic SCT can be accurately diagnosed at preoperative stage, so conservative treatment and observation is possible. However, unilocular macrocystic SCT is difficult to differentiate from other pancreatic cystic tumors with malignant potential, so resection must be considered cautiously. Our classification of SCT is linguistically clear and well reflect characteristic of subtypes of SCT.

PP 56.06

Diverse Clinical Feature and Outcome of Solid Pseudopapillary Neoplasm: Any Difference between Adult and Children?

Lee, Seung Eun; Jang, Jin-Young; Park, Kwi-Won; Lee, Seong-Cheol; Jung, Sung-Eun; Hwang, Dae Wook; Lee, Kuhn Uk; Kim, Sun-Whe

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background. The purpose of this study was to delineate clinical and pathological characteristics of solid pseudopapillary neoplasm (SPN) in adults and children, to determine predictive features suggesting malignant potential and to evaluate long-term outcome by examining a single institution¡^—s experience.

Methods. Between 1985 and 2006, 62 consecutive patients who underwent surgery for pathologically confirmed SPN were retrospectively reviewed. The patient demographic information and clinical presentation, radiological details, surgical data, pathology, postoperative course, and long-term survival were evaluated. The outcomes of clinical and pathological characteristics of adults and children were compared.

Results. Among 62 patients, 47 patients were adults (mean age, 36, range, 18–63 years) and 15 patients were children (mean age, 12, range, 8–13 years). A palpable mass was the most common presenting symptom (9/15, 60%) in children and an incidentally detected pancreatic mass (18/47, 38.3%) in adults(P = 0.001). The mean tumor size in children was significantly lager than in adults(8.0 vs. 6.0 cm, P < 0.028). In children, the tumor was located in head of pancreas (10/15, 66.7%), and in adults, in body or tail (38/47, 80.9%)(P = 0.001). Nine patients (14.5%) had malignant SPN. Deep pancreatic invasion or perineural invasion were the most common pathological findings. There was no significant clinical factor suggesting malignant potential. Follow-up ranged from 5 months to 20 years (mean 47.5 months). Two patients had a tumor recurrence. They were still alive after debulking surgery. There were no tumor-related deaths and all the patients are currently still alive.

Conclusion. SPN had different clinical features in adults and children. Further study is required to elucidate pathophysiology of these differences. Because long-term survival can be achieved, even with the synchronous or metachronous metastatic lesions, SPN should be treated aggressively, with complete resection, even if this requires metastatectomy.

PP 56.07

PANCREAS INVOLVEMENT IN VON HIPPEL-LINDAU DISEASE: TWO CASES

PARK, IL YOUNG; CHO, CHEONG EUN

Holy Family Hospital, Catholic University of Korea, Dept. of Surgery, Bucheon, Korea, Republic of

Von Hippel-Lindau(VHL) disease is an autosomal dominant multicancer syndrome caused by the germline mutation of a tumor suppressor gene. The affected patients developed cancers of central nervous system, renal cell carcinoma, pheochoromocytoma and cysts or benign tumors in pancreas. We report two cases of patients presenting with pancreatic cyst who had showed a mass in the cerebellum which was removed and hispathologically diagnosed as hemangioblastoma. The first patient was 47-year-old woman and the second case was 18-year-old daughter. Computed Tomography(CT) sacn showed multiple cysts in the pancreas. In VHL disease, pancreas involvement is frequent. Yearly follow up examinations were needed including abdominal CT scan, Magnetic Resonance Imaging in craniospinal axis, opthalmoscopy and plasma catecholamine and metanephrine determinations.

PP 56.08

DUODENOPANCREATECTOMY FOR CYSTIC DYSTROPHY IN HETEROTOPIC PANCREAS OF THE DUODENAL WALL.

ARNAUD, Jean-Pierre; BRIENNON, Xavier; ALABEIDI ALZAHRANI, Fahad; HAMY, Antoine; POUGET, Yael; LERMITE, Emilie

CHU, Chirurgie viscérale, Angers, France

Aim of the study. Cystic dystrophy in heterotopic pancreas (CDHP) is rare. The aim of this study was to evaluate the diagnosis, management, and follow-up of the CDHP.

Patients and Methods. Between August 1990 and March 2004, 12 patients with CDHP underwent a duodenopancreatectomy. The patients were retrospectively reviewed.

Results. There were 11 men and 1 woman with a mean age of 42.4 years (range: 34–54 years). Nine patients (75%) were alcoholic and 8 patients had chronic pancreatitis. The diagnosis of CDHP was performed in 8 patients (66.6%) after the preoperative workup. Seven patient had a medical treatment with octreotid and endoscopic cystic ponction (N = 3) or cystic fenestration (N = 1). Recurrence of pain was noted after a mean period of 5 months. Three patients had recurrent acute pancreatitis. Duodenopancreatectomy was performed in all cases. The mortality and morbidity rate were respectively 8.3% (N = 1) and 25% (N = 3). Mean follow-up was 64 months (ranges: 6–158 months). One patient was seen 70 months later with epigastric pain and features of acute pancreatitis of the pancreatic stump due to anastomotic stenosis. The other patients were asymptomatic.

Conclusions. Diagnosis of CDHP is difficult. After failure of medical treatment, duodenopancreatectomy can be proposed.

PP 56.09

TWO CASES OF METASTATIC PANCREAS TUMORS OF RENAL CELL CARCINOMA

Takamatsu, Susumu; Iseki, Hideaki; Kawai, Shigeo; Maruo, Hirotoshi; Kume, Shinichiro

Toshiba Hospital, Surgery, Tokyo, Japan

We experienced relatively rare two cases of metastases of renal cell carcinoma (RCC) to pancreas. Case 1: The patient was a 68 year-old-male and received left nephrectomy with lymphadenoctomy for the left RCC in 2002 at another hospital. The detail of the renal cell tumor was unknown. In follow up period, a hypervascular tumor of 2cm in diameter was detected in pancreas head and there were no abnormal findings in other organs on the enhanced abdominal computed tomography (CT). He had no symptoms and all laboratory data of endocrine function associated with pancreas was within normal limits. The hypervascular tumor was suspected a nonfunctional endocrine tumor of the pancreas preoperatively. We performed enuclation of the tumor in March 2007 and postoperative course was uneventful. In resected specimen, the tumor was diagnosed pancreatic metastasis of RCC in histologically. He has been still alive without recurrence. Case 2: The patient was a 47 year-old-female and received right nephrectomy with lymphadenoctomy for the right RCC in 2001 at another hospital. The RCC was diagnosed pT1b on TNM classification. In 2006, two hypoechoic mass were detected in pancreas body on abdominal ultrasonography and these tumors were hypervascular on enhanced CT. On magnetic resonance imaging, these tumors were shown low intensity on T1WI and high intensity on T2WI. We diagnosed as two metastatic tumors of RCC of the pancreas body and performed distal pancreatectomy in July 2007. The postoperative course was uneventful and pathological diagnosis of these tumors was metastatic tumor of RCC. She has been still alive with no recurrence. In conclusion, metastatic tumor of renal cell carcinoma of the pancreas is relatively rare and it is hypervascular. Therefore, the hypervascular tumor of the pancreas should be diagnosed carefully if the patient who had been resected renal cell carcinoma.

PP 56.10

THE INCIDENCE OF PANCREATIC LEAKS FOLLOWING PANCREATODUODENECTOMY FOR ‘NON-PANCREATIC CANCER’ PERIAMPULLARY LESIONS

Spalding, Duncan¹; Hutchins, Robert²

¹Hammersmith Hospital, HPB Surgery, Du Cane Road, London, United Kingdom; ²The Royal London Hospital, HPB Surgery, London, United Kingdom

Introduction. The literature reports 4–10% mortality, 30–60% morbidity and 9–29% anastomotic leak rates after a Whipples and its variant a pylorus preserving proximal pancreatoduodenectomy (PPPP) performed for periampullary tumours. These results often fail to distinguish between pancreatic cancers, which commonly have a dilated main pancreatic duct (MPD) and fibrosed pancreas, and ‘non-pancreatic cancer periampullary lesions whose MPDs are often small a nd pancreatic texture soft. The aim of this study was to assess the outcomes of Whipples and PPPP for ‘non-pancreatic’ cancer periampullary lesions based on the experience of two pancreatic units in affiliated university hospitals.

Methods. Between 2003–2006, 47 patients had a Whipples or PPPP for ‘non-pancreatic’ cancer periampullary lesions. The type of pancreatojejunostomy performed was determined by the pancreatic texture and MPD size (end-to-side duct-to-mucosa if a hard pancreas and dilated duct, end-to-end invaginating if a soft pancreas and normal duct). All patients received peri-operative octreotide. Their histology, operations and clinical outcome were reviewed retrospectively.

Results. There were 34 malignant neoplasms (ampullary adenocarcinoma 17, duodenal carcinoma 7, cholangiocarcinoma 6, stromal tumour 1, IPMT 1, lung and colorectal metastases 1 each), and 13 benign neoplasms (chronic pancreatitis 7, ampullary adenoma 3, duodenal polyposis 1, autoimmune pancreatitis 1, chronic duodenal sinus 1). Thirty seven patients had a PPPP and 10 had a Whipples. Post-operative mortality was 4.2% (PV thrombosis 1, non-occlusive small bowel necrosis 1). Overall morbidity was 53% (25 patients). The pancreatic leak rate was 10.6% (5 patients), all were successfully treated conservatively with drainage, octreotide and jejunal feeding.

Conclusions. The overall pancreatic leak rate in this series is low. Altering the type of pancreatojejunostomy performed at the time of operation depending on the pancreatic texture and MPD size may reduce the pancreatic leak rate.

PP 57.01

IS CYSTOPERICYSTECTOMY GOLD STANDARD IN THE MANAGEMENT OF HYDATID CYSTS OF LIVER?

Singh, Rana

Dr R M L Hospital, General Surgery, New Delhi, India

Background. Hydatid cyst of liver has been a global health problem because of its endemic nature. Multiplicity of treatment options available is a clear reflection of the fact that no available modality is close to the ideal.

Aims and Objectives. To evaluate the position of Cystopericystectomy in the era of multiple conservative methods available for managing hydatid disease of the liver.

Methods. We have got modest experience of managing nine consecutive cases of liver hydatid cysts by Cystopericystectomy. Eight patients had solitary cysts while one patient had three cysts in the liver and one in the right lung. In this patient one cyst replaced the whole of segment I and two other cysts appeared to be fused with the right and the middle hepatic veins on CECT of the abdomen. In at least three other patients hydatid cyst appeared fused with one of the hepatic veins in the CECT. It was always possible to dissect them off from these veins using CUSA. The CECT appearance was rather fallacious because they appeared fused with the veins due to compression rather than true adherence.

Results. There was no spillage of cystic fluid in any of the patients. Small amount of serobilious drainage in the immediate post operative period was almost universal but we did not encounter even a single case of biloma or wound infection. On a mean follow up of 2 years we are yet to see a recurrence. Diagnosis and planning of the surgery was done by CECT of the abdomen but in the follow up we used Ultrasound of the belly to demonstrate possible recurrence.

Conclusions. Following factors make Cystopericystectomy procedure of choice for liver hydatidosis i. No need to use intracystic scolicidal agent hence no fear of sclerosing cholangitis. ii. Lack of spillage of cystic fluid, brood capsules or daughter cysts in the abdomen. iii. Striking the cystobiliary communication away from pericyst provides practical immunity against major post operative bile leak or biloma formation. iv. It is always possible to separate hydatid cyst from major hepatic vessels.

PP 57.02

PORTAL VEIN ARTERIALISATION AS A SALAVAGE PROCEDURE DURING LEFT HEPATIC TRISECTIONECTOMY FOR HILAR CHOLANGIOCARCINOMA

Young, Alastair L; Abu-Hilal, Mohammed; Khan, Aamir Z; Malik, Hassan Z; Lodge, J Peter A

St James's University Hospital, Hepatobiliary and Transplant Surgery, Leeds, United Kingdom

Background. Surgical resection for Hilar Cholangiocarcinoma remains a technical challenge. Several authors have emphasised the need to combine standard bile duct resection with additional hepatic resection to obtain improved oncological clearance. More recently portal vein resection with reconstruction has become increasingly accepted as a way to further increase the number of patients who could be offered resection with long term survival. Hepatic artery resection remains controversial because of the difficulties of reconstruction.

Aims. We applied a technique of portal vein arterialisation in a case of very major liver resection where arterial reconstruction failed. This technique may increase the number of patients with Hilar Cholangiocarcinoma who can be offered surgical resection.

Methods. We present a case of Left Hepatic Trisectionectomy for Hilar Cholangiocarcinoma in a 54 year old man in January 2006 which utilised the technique of portal vein arterialisation. We also review the potential for this procedure as a possible way to expand the number of operable candidates

Results. A Left Hepatic Trisectionectomy was planned with curative intent. At operation a large hilar mass was removed en-bloc with only the right posterior sectional portal vein identified as clear of tumour. Following parenchymal transection arterial reconstruction was not possible and so after a failed venous conduit, the gastroduodenal artery was anastomosed to the right posterior portal vein. Technically this procedure was successful. A transient period of hyperbilirubinaemia persisted for several months following the operation but this settled. The patient has had no intra-abdominal recurrence although he has needed a thoracotomy to remove two lung nodules.

Conclusion. Our report shows that the successful use of portal vein arterialisation during major hepatic resections can safely further extend the boundaries of liver surgery thus increasing the number of patients who may benefit from a surgical resection

PP 57.03

COMPLICATIONS OF INTRAOPERATIVE RADIOFREQUENCY ABLATIONS OF LIVER METASTASES.

EVRARD, Serge¹; ISAMBERT, Milène¹; LALET, Caroline²; BROUSTE, Véronique²; MATHOULIN-PELISSIER, Simone²

¹Institut BERGONIE, Digestive Tumours Unit, BORDEAUX, France; ²Institut BERGONIE, Department of Biostatistics, BORDEAUX, France

Background. Intraoperative use of radiofrequency ablation (IRFA) is gaining more and more acceptance to achieve R0 treatment in complement of parenchymal resection. It is now well established than indications and efficiencies of IRFA and percutaneous applications (PRFA) are very different and may not be confused together. Complications of PRFA have been well documented.

Aim. The aim of this study was to analyse retrospectively our complications with IRFA.

Method. Until June 2007, 200 patients have been referred in our tertiary care centre to be treated for colorectal (70%) and noncolorectal (30%) liver metastases. Patients observations were prospectively entered in a computed database. Among them 172 patients could be analysed. They underwent 207 laparotomies, 102 for liver resections only (group 1), 60 for IRFA only (group 2) and 45 for IRFA plus resection (group 3). Respective indications of resection or IRFA were established on size, topography and number of the mets: small size, solitariness, closeness from biliary ducts, paravascular location were in favour of IRFA; large size, closed together and numerous, closed to biliary ducts were in favour of resection. Necessity to spare liver functions lead to use IRFA probably avoiding to use atropho-hypertrophy techniques by portal embolisation.

Results. Mortality was 2 patients by liver failure, 1 treated by IRFA alone and 1 by resection alone. Morbidity was 12.1%; 12.7% for group 1, 13.3% for group 2 and 8.9% for group 3. Complications were respectively for group 1, 2 and 3: 1) abscess: 3, 2, 0. 2) perihepatic collection: 7, 3, 1. 3) pleural effusion: 2, 1, 1. 4) haemorrhage: 1, 0, 1. 5) portal thrombosis: 0, 1, 0. No symptomatic biliary stenoses were observed. Reoperations were 6, 2 and 1.

Conclusion. IRFA indicated on lesion size, topography, number as well as hepatocytes reserve lead in our hands to very few complications. Pattern of complications seams also to be different from those published for PRFA.

PP 57.04

ARE THE TECHNOLOGICAL DEVICES USEFUL FOR PARENCHIMAL TRANSECTION DURING HEPATIC RESECTION?

Di Carlo, Isidoro¹; Sparatore, Francesca²; Primo, Stefano³; Pulvirenti, Elia³; Toro, Adriana³

¹Cannizzaro Hospital University of Catania, Dep of Surg Sciences OT AT, Catania, Italy; ²Cannizzaro Hospital University of Catania, Dep of Surgical Sciences OT AT, Catania, Italy; ³

Are The Technological Devices Useful For Parenchimal Transection During Hepatic Resection? I. Di Carlo, F. Sparatore, S. Primo, E. Pulvirenti, A. Toro Department of Surgical Science, Organs Trasplantation and Advanced Technologies University of Catania. Cannizzaro Hospital. Catania. Italy. Bleeding is the most important com plication in patients submitted to hepatic surgery, and many devices have recently been developed to avoid intraoperative blood loss. Moreover these devices became essential for laparoscopic hepatic resections. Aim of this study is to analyze retrospectively our results in hepatic resections using the Tissuelink® Monopolar Dissecting Sealer in order to estimate their usefulness. From 2003 to 2006, 55 patients, who underwent hepatic surgery, have been studied. Sex, age, type of disease and type of surgical procedure in association with the duration of the surgical procedure, type of parenchimal transection, blood loss, use of vascular camping of the liver, length of hospital stay, morbidity and mortality have been analyzed. Thirty-one males and 23 females, aged from 32 to 79 years, affected by hepatocarcinoma (15), liver metastasis (18) and miscellaneous (22) have been submitted to 4 major liver resections, 7 sectoriectomy, 20 segmentectomy, 17 limited resection and 7 total cistectomy, 37 using only Kellyclasia (group A) and 18 using technological devices (group B) for parenchimal transection. Average blood loss was 100–1000 ml for group A and 50–600 ml for group B. The operative time was longer for the group B. Pringle maneuver was used in 31 patients of group A. In group B one Pringle manouver and one total vascular exclusion have been used. Hospital stay was from 4 to15 days. Morbidity consisted of one ascites and one infected haematoma. Mortality in one patient (1,8%). Technological devices are safe instruments for hepatic resections and are useful for hepatic surgery, on the opposite they are mandatory for laparoscopic surgery.

PP 57.05

BILIOBRONCHIAL FISTULA ASYMPTOMATIC FOR 20 YEARS

Di Carlo, Isidoro¹; Sparatore, Francesca²; Primo, Stefano²; Pulvirenti, Elia²; Toro, Adriana²

¹Cannizzaro Hospital University of Catania, Dep of Surgical Sciences OT AT, Catania, Italy; ²

BILIOBRONCHIAL FISTULA ASYMPTOMATIC FOR 20 YEARS I. Di Carlo, F. Sparatore, S. Primo, E. Pulvirenti, A. Toro Department of Surgical Science, Organs Trasplantation and Advanced Technologies University of Catania. Cannizzaro Hospital. Catania. Italy. We report the case of a patient affected by biliobronchial fistula presented sudden bilioptisis, fever, and weight loss 20 years after surgery for hepatic hydatid disease. CT scan demonstrated a subphrenic cystic mass, engaging segments 6 and 7 and most of segments 5 and 8 of the right hepatic lobe, in the same location as a past hydatid cyst. In the thoracic cavity, there was a pleural empyema and atelectasis of the right inferior lobe. A fibrobroncoscopy performed preoperatively showed bile. Through thoracophrenolaparotomy, right inferior lobectomy of the lung, partial cistectomy of the hepatic cyst and partial resection of the diaphragm have been performed. As the preoperative examination had not revealed disease in the biliary tracts, air was injected through the cystic duct and the ensuing air bubbles identified the holes of leakages. These were sutured and thereafter the diaphragm was repaired by separated sutures. The surgical procedure resolved the symptoms because the patient is disease free eight months later. However, we do not have an explanation for the long asymptomatic period from the past surgical procedure to the actual disease.

PP 57.06

MANAGEMENT IN PATIENTS WITH LIVER CIRRHOSIS AND AN UMBILICAL HERNIA

Marsman, Hendrik A¹; Heisterkamp, Joos²; Halm, Jens A²; Tilanus, Hugo W²; Metselaar, Herold J²; Kazemier, Geert²

¹Academic Medical Center, Surgery, Amsterdam; ²Erasmus Medical Center, Surgery, Rotterdam, Netherlands

Background. Patients with liver cirrhosis and ascites are at high risk of developing an umbilical hernia. The expectance that surgical management in these patients is associated with high morbidity and mortality often leads to avoidance of operative treatment. However, conservative management can ultimately lead to serious complications as well.

Objective. To retrospectively compare the outcome in our series of operative versus conservative treatment of patients with an umbilical hernia in the presence of liver cirrhosis and ascites.

Methods. In the period between 1990 and 2004, 34 patients with an umbilical hernia combined with liver cirrhosis and ascites were identified from our hospital database. 21 patients underwent elective hernia repair, and 13 were initially managed conservatively.

Results. MELD (Model of End Stage Liver Disease) scores and mean age were not significantly different between the two groups. Elective hernia repair was successful in 16 out of 21 patients (76%). Complications occurred in 3 of these 21 patients (14%), consisting of wound related problems (infection, necrosis and haematoma) and hernia recurrence in 5 out 21 (24%). Success rate of the initial conservative management was only 23%; hospital admittance due to incarcerations occurred in 10 of 13 patients (77%) of which six patients required hernia repair in an emergency setting. Two patients of the initially conservative managed group died due to complications of the umbilical hernia. The complication rates between conservative management and elective surgical management (77% and 14% respectively) were significantly different, p = 0.0002.

Conclusions. Conservative management of umbilical hernias in patients with liver cirrhosis and ascites leads to a high rate of incarcerations with subsequent hernia repair in an emergency setting whereas elective repair can be performed with less morbidity and is therefore advocated.

PP 57.07

POST OPERATIVE COURSE AFTER LIVER RESECTION IS NOT INFLUENCED BY THE USE OF PORTAL INFLOW COMPRESSION (PRINGLE'S MANOEUVRE)

Patil, Vrishali; Riyad, Kallingal; Vadeyar, Hemant; Sherlock, David

North Manchester General Hospital, Surgery, Manchester, United Kingdom

Introduction. Portal inflow compression (PIC) is used to reduce blood loss at the time of parenchymal transection though hepatic ischaemia with reperfusion injury has been a theoretical possibility. Emerging evidence seems to indicate intermittent PIC may precondition the liver to tolerate ischaemia with some hepatoprotection. Our aim was to compare the post operative recovery and outcome of patients who had PIC at the time of major liver resection (>2 segments) with those who did not.

Methods. The biochemical and haematological data of patients were recovered from our prospectively maintained database for the period from January 2004 to June 2005. All patients who had undergone a major liver resection were included in our study. The change in haemoglobin concentration, the perioperative blood transfusion, liver function test and coagulation profile was all compared between the two groups along with length of hospital stay.

Results. A total of 102 (81 with no PIC vs. 21 with PIC) were included in the study. The two groups were similar in age and sex distribution and type of liver resection. The post operative course did not show any statistically significant difference in peak elevation of liver function tests, change in haemoglobin concentration, post operative morbidity and length of hospital stay. The blood product transfusion rates were similar in both group with no statistically significant difference.

Conclusion. PIC does not seem to influence the post operative recovery of patients undergoing liver resection and can be safely used without fear of post operative hepatic dysfunction. However there seems to be no difference in the perioperative blood usage in both groups.

PP 57.08

SURGICAL SITE INFECTION AFTER HEPATECTOMY: ITS CAUSE AND STRATEGY FOR PREVENTION

Abe, Tomoyuki¹; Shirabe, ken²; Kondo, Jyunnya¹; Tsujita, Eiji¹; Kajiyama, Kiyoshi¹; Nagaie, Takashi¹

¹Aso-Iizuka Hospital, Department of surgery, Iizuka city, Japan; ²Aso-Iizuka Hospital, Department of Hepatogastroenterology, Iizuka city, Japan

Background. S: Surgical site infection (SSI) remains a common complication after hepatectomy, and was reported to prolong the hospital stay and can be fatal.

Aim. To investigate the risk factors for surgical site infection (SSI) and to clarify the strategy for prevention SSI after hepatectomy, according to the outcome of 301 hepatectomized patients in a single center.

Patients and Methods. Between June 2002 and June 2007, three hundreds and one hepatectomized patients were enrolled into this study. For prevention of organ SSI, we started bile leakage test on August 2004. And to prevent the contamination during surgery, we start to wear double gloves and exchange every three hours on July 2006. These patients were divided into three groups, based on these procedures. Group I: (n = 101) No bile leakage test nor exchange of doubly weared gloves during surgery between June 2002 and July 2004, group II (n = 136) bile leakage test was performed, but no glove exchanges between August 2004 and June 2006, group III (n = 64) bile leakage test and glove exchange was performed between July 2006 and June 2007. The risk factors for superficial incisional SSI and organ SSI were investigated in group I. Incidence of superficial and organ SSI were compared among three groups.

Results. The incidence of superficial and organ SSI was 8.6% and 9.3% in all 301 patients. The most of bacteria isolated were skin bacteria in superficial SSI and those were gut bacteria in organ SSI. The significant risk factors for superficial SSI was operation time and those for organ SSI were bile leakage, blood loss, and blood transfusion in group I. The incidence of superficial SSI was 7%, 11%, and 3% in group I, II and III. The incidence of organ SSI was 14%, 8% and 5% in group I, II and III.

Conclusion. Doubly weared gloves and exchange every three hours reduced superficial SSI. This policy may prevent the contamination during surgery. Bile leakage was strongly related to organ SSI. Bile leakage test for prevention of bile leakage prevented the organ SSI.

PP 57.09

PORTAL TRIAD CLAMPING IN HEPATIC RESECTION-A SYSTEMATIC REVIEW AND META-ANALYSIS

Wente, Moritz N¹; Rahbari, Nuh N¹; Schemmer, Peter¹; Diener, Markus K¹; Hoffmann, Katrin¹; Motschall, Edith²; Schmidt, Jan¹; Weitz, Jürgen¹; Büchler, Markus W¹

¹University of Heidelberg, Heidelberg, Germany; ²University of Freiburg, Freiburg, Germany

Background. To determine the impact of portal triad clamping on perioperative outcome of patients undergoing hepatic resection.

Methods. A systematic literature search (Medline, Embase, The Cochrane Library database Clinical Trials, Science Citation Index) was conducted to detect randomized controlled trials assessing effectiveness and safety of portal trial clamping alone and with ischemic preconditioning of the liver. Studies on clamping of the inferior vena cava or hepatic veins were excluded. Meta-analyses were performed using a random-effects model.

Results. Nine randomized controlled trials comprising a total of 630 patients were eligible for final analysis. Study design of identified studies varied considerably. Analyses of postoperative morbidity, mortality, intraoperative blood loss, and blood transfusion revealed no difference between intermittent portal triad clamping and no portal triad clamping. Continuous but not intermittent portal triad clamping resulted in significantly increased postoperative alanine aminotransferase levels. Meta-analyses of studies on portal triad clamping with and without previous ischemic preconditioning showed no differences either; however postoperative transaminases were significantly lower in patients with ischemic preconditioning.

Conclusion. Based on current best available evidence, routine use of portal triad clamping does not offer any benefits in perioperative outcome to patients undergoing liver resection and can therefore not be recommended as a standard procedure.

PP 57.10

TOTAL CYSTO-PERICYSTECTOMY FOR HYDATID DISEASE OF LIVER – IS IT THE BEST CHOICE?

Joshi, Mukund¹; Joshi, Manohar J²; Pande, Eknath³; Jamkar, Arun³

¹B.J. Medical College & Sassoon General Hospital, Pune, India; ²India; ³

Introduction. This is a retrospective analysis of 16 cases, surgically treated over a period of five years. This study attempts to analyze the treatment of choice depending upon the size of the cyst, location & type of presentation.

Methods. There were 13 males & 4 females. Average age was 39 years. 15 cases were electively operated & 2 presented as infective complications. Decision of which procedure to be done was taken intra-operatively only. Various surgical treatments like marsupilzation with omental pack(OM)(2) hepatic resection(1), Total pericystectomy(8), Pericysto-jejunostomy(PJ)(5) & external drainage(ED)(1) were performed.

Results. There was no mortality. 2 patients developed transient biliary leaks & were managed conservatively. Blood loss was restricted to less than 250 cc in cases of ED, PJ &MO where as blood loss in total pericystectomy was 400 cc & hepatic resection was 850cc.

Discussion. Biliary leaks were observed in cases of hepatic resection, external drainage & marsupilization with omental pack. Least blood loss was noticed in Pericysto-jejunostomy & just external drainage was the quickest. All the different procedures had advantages & disadvantages. However we observed that total pericystectomy had two major advantages 1) complete excision was feasible without peritoneal contamination 2) less cumbersome than hepatic resection with lesser blood loss. External drainage appears to have a major possibility of biliary leak. Hepatic resection appeared over-treatment for the benign disease.

Conclusions. From the study it appeared that the total pericystectmy & pericysto-jejunostomy appeared to be the procedures of choice with less morbidity & minimal complication rate. We would advice total pericystectomy whenever possible, especially when the cysts are located at the periphery. For those placed centrally, pericysto-enterostomy or marsupilization with omental pack appeared better considering the difficulty in excision.

PP 58.01

CARCINOID OF THE GALLBLADDER; A CASE REPORT

Koizumi, Masaru; Sata, Naohiro; Kasahara, Naoya; Hyodo, Masanobu; Yasuda, Yoshikazu

Jichi Medical University, Surgery, Shimotsuke, Japan

We report a rare case of carcinoid of the gallbladder. The case was 45-year-old obese man. Annual abdominal ultrasonography (US) incidentally pointed out a polyp of the gallbladder. Endoscopic US detected an 18 mm protruding lesion in the neck of the gallbladder in Jichi Medical University Hospital. CT showed slight enhancement of the tumor. Tumor markers, such as CEA and CA19–9, were within normal limits. Laparoscopic cholecystectomy was performed under preoperative diagnosis of benign tumor (e.g. cholesterol polyp). However the lesion was histopathologically diagnosed as carcinoid of the gallbladder by the findings of funicular and tubular cells in lamia propria mucosa, homogeneous nuclei, basophilic cytoplasm, and positive staining of Chromogranin A, Synaptophysin, S-100 and CD56. The patient discharged on the fourth postoperative day uneventfully and showed no recurrence for six months after surgery. Generally, carcinoid of the gallbladder shows favorable postoperative outcomes. As far as we searched, there were 35 case reports in Japan and 42 case reports in Western countries. Many of these case reports confused the conception of carcinoid and were contaminated by neuroendocrine cell carcinomas of the gallbladder, which show distinctively different histological form and natural history. Carcinoid should be discussed separately from neuroendocrine cell carcinoma. Herein, we report a case and literature review.

PP 58.02

THE ROLE OF OPEN CHOLECYSTECTOMY IN THE ERA OF LAPAROSCOPIC SURGERY

Oniscu, Gabriel C; Coldham, Chris; Buckles, John AC; Mirza, Darius; Mayer, David; Bramhall, Simon R

The Queen Elizabeth Hospital, The Liver and Hepatobiliary Unit, Birmingham, United Kingdom

Background. Laparoscopic cholecystectomy is the standard treatment for gallstone disease. However, some patients require an open procedure AIM: To examine the indications and the role of open cholecystectomy in the laparoscopic era in a tertiary referral hepatobiliary unit.

Methods. 1012 patients who had a cholecystectomy between 1998 and 2007 in the unit were identified. Referral data, demographic, diagnostic and surgical details were obtained from a prospective database. Logistic regression was used to determine the factors associated with an indication for primary open cholecystectomy.

Results. 777 patients (77%) were referred directly to the unit, whilst 193 cases were referred from other surgical units. 679 cases (67.1%) were completed laparoscopically, 265 (26.2%) were primary open whilst 68 (6.7%) were converted open cholecystectomies. The differences in the indications for surgery between the groups are shown in the table. Open procedures (52.3%) were more common in the cohort referred from other units compared to primary referrals (19.3%, p < 0.001). Open cholecystectomy was carried out in older patients (median age 61 vs. 51 years, p < 0.001), more likely men and who had previous upper abdominal surgery. The morbidity and peri-operative mortality (30 days) were significantly higher following open procedures compared to laparoscopic ones as shown in the table. The indication for primary open cholecystectomy is associated with patient's gender, age at referral, the presence of previous abdominal surgery and the indication for bile duct exploration. Similarly, conversion is associated with previous surgery and male gender.

Conclusion. Open cholecystectomy accounts for a significant proportion of the cholecystectomies performed in a hepatobiliary unit. This may be due to a high number of secondary referrals due to suspicion of sinister or complex biliary pathology. These cases offer the training experience in open procedure that lacks in other general surgical units.

	Laparoscopic	Primary open	Converted open
Gallstone disease	65.4%	28.4%	45.6%
CBD stone	6.9%	21.2%	11.8%
Acute cholecystitis	12.1%	15.9%	19.1%
Gallbladder cancer	0.3%	5.3%	1.5%
Acute pancreatitis	9%	9.8%	11.8%
Perioperative mortality	0.7%	9.1%	1.5%

PP 58.03

AUDIT ON 3 PORT LAPAROSCOPIC CHOLECYSTECTOMY: PIONEER SRI LANKAN EXPERIANCCE

Ganesaratnam, M¹; Liyanage, Chandika²

¹National Hospital of Sri Lanka, Surgery, Colombo, Sri Lanka; ²Faculty of medicine, University of Kelaniya, Surgery, Ragama, Sri Lanka

Background. Laparoscopic choecystectomy is the commonest laparoscopic surgical operation performed in Sri Lanka. Many approach it with 4 port technique. We have found that 3 port technique is quicker, less cumbersome and reduced “sword fighting” during surgery. Other Sri Lankan surgeons are also catching up with this technique. Objectives: To analyze the the complications and the effectiveness of 3 port approach to cholecystectomy by a single team.

Methods. Retrospective anlysis of laparoscopic cholecystectomies done from October 2003 to March 2007. For this whole series the operating surgeon, the camera holding surgeon and the anaesthetist team were the same. The operative details, the complications and the outcome were recorded and analyzed.

Results. 374 laparoscopic cholecystectomies were performed during this period. All had Hassan technique of creation of pneumoperitoneum and had only 3 ports against the traditional 4 port technique. None of the patients had nasogastric suction or catheterization. 4 required (1.06%) conversion to open cholecystectomy. None required an insertion of an additional port. There were 2 (0.5%) common bile duct injuries and there was one (0.2%) mortality due to pulmonary embolism. The duration for surgery ranged from 20 minutes to 90 minutes. There were no significant wound infections or port site herniae. Average hospital stay was one day. Discussion: 3 port technique did not give rise to operative difficulties and maneuvering instruements appeared to be easier. The conversion rate was comparable and there was no procedure related mortality. The operating team required only the surgeon the camera surgeon and one scrub nurse. We conclude that 3 port approach is convienent, less cumbersome, safe and an efficient technique in laparoscopic cholecystectomy

PP 58.04

LAPAROSCOPIC APPROACH FOR TECHNICALLY DIFFICULT GALL BLADDER STONE DISEASE: THE ROLE OF LAPAROSCOPIC SUBTOTAL CHOLECYSTECTOMY

ELSEBAE, MAGDY; Nasr, Magid M.A; Ezzat, Hussin

Theodore Bilharz Medical Research Institute, General Surgery, Cairo, Egypt

A total of 531 consecutive patients were operated upon by laparoscopic cholecystectomy for symptomatic gallbladder stone disease in our institute over the last five years. Technical difficulty was encountered in 55 of them (10.36%). Parameters of difficulty at laparoscopic cholecystectomy in our study involved obscured anatomy of the Calot's triangle, absence of a dissection plane between the gallbladder and the liver bed or the occurrence of intraoperative complication. The operation was concluded by either standard laparoscopic technique, laparoscopic subtotal cholecystectomy or converted to open cholecystectomy. Technically Difficult laparoscopic cholecystectomy could be completed in 13 of the 55 patients (23.63%). In twenty-four of the patients conversion to open cholecystectomy was required (43.63%). Laparoscopic subtotal cholecystectomy was performed for 18 of patients (32.72%) who constituted 3.39% of the laparoscopic cholecystectomies performed at the same time period. There was no operative mortality. Two only of the eighteen patients operated upon by laparoscopic subtotal cholecystectomy have had postoperative local complications in the form of bile leak (11.1%). None of the patients who underwent laparoscopic subtotal cholecystectomy developed symptoms attributed to biliary disease or post-cholecystectomy syndrome at a mean follow-up period of 28 (range 6–40) months. Laparoscopic subtotal cholecystectomy LSC is a safe and definitive operation to treat diseases of the gallbladder, whenever there are major difficulties in dissection. It prevents bile duct injuries and allows removal of a difficult gallbladder without the need for conversion to open procedure. Key words: Subtotal cholecystectomy; Laparoscopic, Open.

PP 58.05

PHANTOM GALLBLADDER: THE FIRST CASE REPORT OF REACTIVE NODULAR FIBROUS PSEUDOTUMOR FOUND AT GALLBLADDER FOSSA AFTER CHOLECYSTECTOMY

Mak, Oi Sze¹; Lai, Chris K.C.²; Lee, K.F.¹; Wong, John¹; Ng, Wilson W.C¹; Ng, Nancy C.¹; Fok, K.L.¹; Lo, Xina¹; Lai, Paul B.S.¹

¹The Chinese University of Hong Kong, Surgery, Hong Kong, Hong Kong; ²The Chinese University of Hong Kong, Anatomical and Cellular Pathology, Hong Kong, Hong Kong

Introduction. Reactive Nodular Fibrous Pseudotumors (RNFP) are uncommon fibroinflammatory lesions that mimic primary bowel neoplasm or intraabdominal fibromatosis. Total 16 cases were reported since 2003 and most arose from serosa of intestine. We reported the first case of RNFP located in gallbladder fossa 12 years after cholecystectomy. CASE REPORT: A 54-year old lady underwent laparoscopic cholecystectomy 12 years ago for symptomatic gallstone. She presented to us with right upper quadrant pain. Ultrasonography and computed tomography showed a 3cm heterogeneous mass at porta hepatic area. Endoscopic ultrasonography revealed a globular mass containing sludge and small stones, which raised the suspicious of a gallbladder remnant. Surgical exploration was performed and a 4cm solid mass at the gallbladder fossa was found. The lesion was completely excised, and histological examination confirmed RNFP. DISCUSSION: All RNFP reported behave in benign manner. However, they often mimic neoplasms like gastrointestinal stromal tumor (GIST), which require more aggressive treatment. Differentiation by clinical, morphological and immunohistochemical features would facilitate the correct diagnosis. More than half of the reported cases of RNFP have a preceding history of surgery, trauma, or underlying pathology. Histologically, RNFP are usually hypocellular, with bland spindled and stellate cells arranged in short or haphazardly fascicles. They showed minimal nuclear atypia with low to absent mitotic activity. Immunohistochemicaly, most of the RNFP showed immunoreactivity towards SMA and/or MSA but conflicting result to c-kit & AE1/AE3 in reported literature.

PP 58.06

DOES CRITICAL VIEW AT LAPAROSCOPIC CHOLECYSTECTOMY REDUCE MAJOR DUCT INJURY: ANALYSIS OF 1010 CASES UNDERTAKEN BY A SINGLE FIRM?

Velchuru, Vamsi R; Atkins, Chris; Lameris, Madeleine; Walker, Cathryn; Kamat, Sachin; Studley, John G N

James Paget University Hospital, Upper GI surgery, Great Yarmouth, United Kingdom

Background. Duct injury at laparoscopic cholecystectomy is a devastating injury to the patient and also a medico-legal nightmare to the surgeon. Various methods have been used to identify ductal anatomy, including intra-operative cholangiography, infundibular technique, and critical view technique.

Aim. The purpose of the study was to evaluate whether critical view dissection during laparoscopic cholecystectomy reduces major duct injury. A secondary outcome measure was to identify its impact on conversion rates.

Methods. Data was collected from elective laparoscopic cholecystectomies performed by a single firm over a period of 14 years. All operations were performed by the critical view technique either by the main author or trained registrars on the firm under supervision. If the anatomy could not be displayed satisfactorily, open surgery was undertaken. Data was collected on indications for surgery, conversion rates, reasons for conversion and complications.

Results. Sample population (1992–2006) was 1010 after exclusions. On initial analysis of 289 cases there was no major duct injury and none had their procedures converted to an open procedure. Gallstones were the commonest indication (98%) and the rest were for gall bladder polyps. Two patients had port site bleeding and one patient had bile leak. Final analysis (1010 patients) will be presented in the meeting.

Conclusions. Critical view dissection during laparoscopic cholecystectomy resulted in no bile duct injury in this series.

PP 58.07

MEDICOLEGAL IMPLICATIONS OF BILE DUCT INJURIES FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

Roy, Pankaj¹; Soonawalla, Zahir²; Grant, Hugh³

¹John Radcliffe Hospital, Surgery, Oxford, United Kingdom; ²John Radcliffe Hospital, Hepato-biliary Surgery, Oxford, United Kingdom; ³John Radcliffe Hospital, Pediatric Surgery, Oxford, United Kingdom

Background. When successfully performed, laparoscopic cholecystectomy (LC) significantly reduces post-operative pain, shortens hospital stay and hastens post-operative recovery when compared with open cholecystectomy (OC). However, LC results in higher incidence of biliary, bowel and vascular injuries than with OC, and is associated with increased litigation.

Methods. This is a retrospective review of the claims reported to the NHS Litigation Authority (NHSLA) for England from 2000–2005 relating to LC. The data was analysed with respect to the type of injury, delay in recognition of the injury, mortality, and litigation costs. This was compared to previously published data from the USA.

Results. A total of 166 claims following laparoscopic procedures in general surgery were reported in England, of which 111 (67%) were for complications relating to LC. Bile duct injuries accounted for the majority (72%) of the LC claims, others being due to bowel injury (9%), bleeding (4%), vascular damage (3%), and miscellaneous problems (11%). Only 17 out of 80 (21%) bile duct injuries were recognized during surgery, while the majority were not noticed at the time of surgery resulting in late diagnosis, necessitating an additional intervention. The mortality rate amongst the claimants was 8.7% following biliary injuries. The LC claims resulted in payments of £6m (average of £54,054 per claim), of which £4.3m was paid out for bile duct injuries. The average cost was higher in patients who suffered a delay in diagnosis.

Conclusion. Litigation is more common after LC than OC. Bile duct, bowel and vascular injuries following LC remain a serious hazard for patients, despite improvements in training and instrumentation. Those resulting in litigation are a huge financial drain on the healthcare system. Delayed recognition appears to correlate with an increased risk of litigation. A low threshold for conversion to open surgery may decrease the risk of litigation.

PP 58.08

WORLDWIDE EPIDEMIOLOGY OF GALLBLADDER CANCER

Saied, Abdouslam; Hariharan, Deepak; Patel, Bijendra; Kocher, Hemant

Barts & the London School of Medicine & Dentistry, Institute of Cancer, London, United Kingdom

Background. Ethnic background and geographical location play an important role in the incidence of gallbladder carcinoma leading to variable mortality rate across the world.

Methods. Age-Standardized mortality rate [ASR (W)] were extracted separately for males and females from a data base maintained by International Agency for Research on Cancer for 50 countries across the world (Europe-32 countries, Americas-8 countries and Asia-10 countries) and compared for the period 1960– 2002. Further in-depth analysis over 10 years (1992–2002) was conducted by empirically dividing ASR (W) >/< 2 in 2002 and >/< 3.5 in 1992. RESULT: From 1960–2002, the ASR (W) in majority of countries the world over showed no change barring Netherlands, Germany, USA and Canada, which showed a decrease (range 4 to 0.6) while Italy and Japan, demonstrated an increase (range 0.9 to 8.5). Imposing the ASR (W) >/< 2 in 2002 and >/< 3.5 in 1992 for the 10 year period (1992–2002) most countries remained static; Germany, Sweden Slovenia, Czech, Hungary, Japan, USA and Canada showed a decline in mortality (range 7.8 to 0.6). In 2002 applying ASR (W) >/< 2, Korea showed an increase in mortality [male (6 to 7), female (3.2 to 4.5)] and in 1992 using ASR (W) >/< 3.5 as cut off Israel showed a downward trend [male (1.4 to 0.5), female (2.4 to 0.8)].

Conclusion. Overall there was a decline in ASR (W) for gall bladder cancer. Better diagnostic modalities resulting in appropriate staging of gall bladder/biliary cancers as well as changes in ICD classification and perhaps better hygiene/awareness have contributed to these trends

PP 58.09

AN EVALUATION OF NOVEL ELECTROSURGICAL DEVICES IN BILIARY TRACT SURGERY

Hope, William; Newcomb, William; Schmelzer, Thomas; Heath, Jessica; Lincourt, Amy; Heniford, B. Todd; Iannitti, David

Carolinas Medical Center, Department of Surgery, Charlotte, United States

Traditionally, metallic clips have been used for ligation of the cystic duct during laparoscopic cholecystectomy. The purpose of this study was to evaluate two novel electrosurgical devices in biliary tract surgery. Porcine common bile ducts were sealed with two electrosurgical devices, an electrothermal bipolar vessel sealing (EBVS) device and ultrasonic coagulation shears (HS). Metallic clips were used for control. Half the animals underwent bile duct ligation followed by immediate burst pressure testing and histologic evaluation. The remaining halves underwent bile duct ligation and were survived for one week or until signs of sepsis. Proximal bile duct pressures were documented. The study included 23 pigs that underwent bile duct ligation, 11 acute and 12 chronic. Seal failure rate for the acute study was 50% for both electrosurgical devices. There were no seal failures for the metallic clip. Acutely, the clip had significantly higher burst pressures than the EBVS (646±282 mmHg vs. 73±86mmHg, p = 0.002) and HS (646±282 mmHg vs. 72±89mmHg, p = 0.002). No difference in burst pressure was noted between the EBVS and HS (73±86mmHg vs. 72±89mmHg, p = NS) acutely. In the chronic study, obvious bile leaks were noted in 2 animals (50%) in the HS group and 1 animal (25%) in the EBVS group. There were no obvious bile leaks noted in the clip group. Burst pressures were unable to be obtained for the bile ducts ligated with HS and EBVS secondary to disruption of the seal with minimal dissection. Average chronic burst pressure for the clip was 1088±922. The average proximal bile duct pressure from seven animals was 16.1±4mmHg. The novel electrosurgical instruments studied cannot be recommended for routine use in sealing biliary structures secondary to the failure rate associated with the seals. The porcine common bile ducts sealed in this study may not be an ideal surrogate for the human cystic duct.

PP 58.10

GALLBLADDER PERFORATION DUE TO GALLSTONES FOLLOWING BLUNT INJURY ABDOMEN

Rajasekar, Arthanari

Sri Gokulam Hospital, Surgical Gastroenterology, 3/60 Meyyanur Road, Salem, India

Background. Gallbladder injuries secondary to abdominal trauma are extremely rare. We present a case of isolated gallbladder perforation due to gallstones following blunt injury abdomen Case Presentation: Sixty-two years old patient presented after having been involved in a motorcycle accident. He gave a history of blunt injury of the abdomen due to the motorcycle handle bar. On presentation he was haemodynamically stable and had features of peritonitis. He did not have any other injury. Ultrasonography of the abdomen showed free fluid in the abdomen. With the clinical and ultrasongraphy diagnosis of probably bowel perforation, laparotomy was done. Laparotomy revealed bile peritonitis with multiple gallstones lying freely in the peritoneal cavity around the gall bladder with perforation of the gallbladder in the neck. Cholecystectomy was done and patient recovered without any complication. Discussion: A review of the English literature shows a total of 104 patients with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The diagnosis of gallbladder in most of the cases was made during surgical intervention. Other gallbadder injuries reported following blunt injury abdomen are gallbladder contusions and avulsions. Cholecystectomy is the preferred surgical treatment and Cholecystostomy should be reserved for patients in moribund conditions due to other associated injuries.

PP 59.01

CLINICAL FACTORS AND PRE OPERATIVE QUALITY OF LIFE AS PREDICTORS OF SURVIVAL IN PATIENTS WITH COLORECTAL LIVER METASTASES UNDERGOING LIVER RESECTION

Dasgupta, Dowmitra¹; Needham, Paul²; Bedford, Matthew³; Prasad, K Rajendra¹; Toogood, Giles J³; Lodge, J Peter A³

¹St James's University Hospital, HPPB and Transplant Surgery, Leeds, United Kingdom; ²St James's University Hospital, HPB and Transplant Surgery, Leeds, United Kingdom; ³

Aim: Pre operative quality of life (QOL) has been shown to have prognostic value for survival in certain malignancies. Clinical status has been shown to influence quality of life and survival. There is no data analysing the relationship between preoperative QOL, preoperative clinical data and survival in patients with colorectal liver metastases (CRM) undergoing liver resections.

Methods. All patients with CRM undergoing liver resection between July 2002 and July 2003 completed the QOL questionnaire EORTC QLQ C30 preoperatively. Pre-operative clinical, operative and pathological data were recorded. Follow up was complete until July 2006. Univariate and multivariate survival analysis was performed using Cox regression.

Results. 73 patients (mean age 62.2 years, 66% male) underwent hepatic resection. In univariate analysis platelet count under 220 (p = 0.007) and age over 70 (p = 0.018); but no QOL domains were significant survival predictors. In multivariate analysis of QOL domains higher cognitive functioning, reduced diarrhoea and increased fatigue were predictive of improved survival (p < 0.05). When clinical factors and QOL domains were all entered into a Cox proportional hazards model the clinical factors remained robust survival predictors, but QOL domains were not predictive of survival. Pain (p = 0.008) and nausea (p = 0.038) were significantly higher in females, age was inversely correlated with financial difficulties (r = − 0.387, p = 0.001), and albumin was positively correlated with global QOL (r = 0.270, p = 0.021).

Conclusions. There are significant associations between certain pre-operative QOL domains and clinical data, but pre-operative QOL is not a prognostic factor for survival in patie nts undergoing liver resection for CRM.

PP 59.02

RELATIONSHIP BETWEEN QUALITY OF LIFE AND IMMUNE FUNCTION IN PATIENTS UNDERGOING RESECTION OF COLORECTAL LIVER METASTASES

Morris-Stiff, Gareth¹; Dasgupta, Dowmitra²; Gomez, Dhanwant¹; Needham, Paul¹; Bedford, Matthew¹; Toogood, Giles J¹; Prasad, K Rajendra¹; Lodge, J Peter A¹

¹St James's University Hospital, HPB and Transplant Surgery, Leeds, United Kingdom; ²

Background. There is increasing evidence as to the intricate relationship that exists between the immune system and behaviour characteristics of malignant tumours. The influence of quality of life (QOL) on immune-function has been well investigated in many disease states but there is little data in hepatobiliary disease, and in particular patients with colorectal cancer metastases. Aims: To evaluate the relationship between baseline quality of life in patients undergoing resection for colorectal liver metastases (CRLM) and immune function as determined by the neutrophile/lymphocyte ratio (NLR).Patients and Methods. The EORTC QLQ C30 cancer specific QOL questionnaire was prospectively administered to 74 consecutive patients with CRLM undergoing liver resection. The NLR was calculated on the basis of immediate pre-operative blood counts. Peri- and post-operative data was collected prospectively.

Results. The cohort consisted of 51 males and 74 females. The NLR was elevated > 5 in 8/74 (10.8%). There was no relationship between mean scores for any of the functional domains or the global QOL domain and immune function as assessed by NLR. Neither was the NLR related to any of the symptom domainsof the EORTC QLQ C30 questionnaire test.

Conclusions. In this small cohort, the immune function did not appear to be related to any of the QOL parameters measured. Further evaluation using larger numbers using a hepatobiliary-specific QOL questionnaire is planned.

PP 59.03

SIGNIFICANCE OF INDETERMINATE LUNG NODULES IN HEPATO-PANCREATICO-BILIARY MALIGNANCY

Pamecha, Viniyendra¹; Elaffandy, Ahemed²; Waleed, Al-Obaydi²; Yu, Dominic³; Davidson, Brian²; Sharma, Dinesh²

¹Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION, Pond Street, Hampstead, LONDON, United Kingdom; ²Royal Free Hospital, University College Medical School, HPB AND LIVER TRANSPLANTATION, LONDON, United Kingdom; ³Royal Free Hospital, University College Medical School, Department of Radiology, LONDON, United Kingdom

Background. Chest CT (Computed Tomography) is routinely used as a part of staging protocol for Hepao-Pancreatico-Biliary malignancy. About 20% of patients are found to have lung nodules on routine CT chest. If there are no definite benign or malignant morphological features, the pulmonary nodules are classified as indeterminate. A number of pulmonary nodules are difficult to characterize and 25%–39% of nodules are inaccurately classified after radiological assessment of size, margins, contour, and internal characteristics.

Objective. To know the incidence of indeterminate lung nodules and there evolution over time with follow up scans.

Methods. Prospectively collected data on patients undergoing CT chest as part of staging for HPB malignancy over 2 years. Evolution of indeterminate nodules with at least one three monthly scan was assessed. Demographic, clinical and details of nature of primary malignancy and treatment were noted.

Results. Of two hundred patients over a period of 2 years, 71 patients were found to have pulmonary nodules (35%). Thirteen patients had benign, 16 had malignant and 42(21%) had indeterminate pulmonary nodules. On follow up scan, out of 42 patients with indeterminate nodules 5(11%) patients had increase in the size of nodules and were characterized as malignant on subsequent scans.

Conclusion. Indeterminate lung nodules are common on routine chest scan for HPB malignancy. Most indeterminate nodules are benign but a proportion of them can be malignant and a high degree of suspicion is needed in order not to miss malignant nodules.

PP 59.04

COLONIC LESIONS IN PATIENTS WITH AMEBIC LIVER ABSCESS

Sinha, S K¹; Kochhar, R¹; Lal, A²; Sehagal, R³; Dutta, U¹; Rana, S S¹; Bhasin, D K¹; Singh, K¹

¹Post Graduate Institute Of Medical Education & Research, Department of Gastroenterology, Chandigarh, India; ²Post Graduate Institute Of Medical Education & Research, Department of Radiodiagnosis, Chandigarh, India; ³Post Graduate Institute Of Medical Education & Research, Department of Parasitology, Chandigarh, India

Introduction. Amebic liver abscesses (ALA) occur secondary to amebic colitis but history of diarrhea is uncommon in these patients. Prevalence of active amebic ulcers in colon among patients with ALA is not clearly defined.

Objective. To study the frequency of active amebic colitis in patients presenting with ALA.

Methods. This prospective study was conducted from November 2003 to July 2006 and included patients presenting with ALA. ALA was diagnosed on the basis of history, imaging findings, serology, microscopy and culture of aspirated pus. Each patient underwent full length colonoscopy within five days of presentation to our hospital. Bowel was prepared with polyethylene glycol lavage solution. Following patients were not subjected to colonoscopy: those unwilling to undergo colonoscopy, history of anti-amebic therapy for >5days prior to presenting in our hospital, hemodynamically unstable and ruptured liver abscess.

Results. A total of 47 patients (45males, 2 females, age 37.8 + 11.68 years) with amebic liver abscess were seen during the study period. Ten patients were not subjected to colonoscopy because they fulfilled the exclusion criteria. Out of 37 patients who underwent colonoscopy (36 males, 1 female, mean age 38.8 + 11.0 years), 27 had ulcers in colon. Distribution of ulcers was as follows: cecum and ascending colon in 25, transverse colon in 1and rectosigmoid in 1 patient. Biopsy from these lesions showed acute inflammation in all, ameba could be demonstrated in only two patients. History of recent episode of diarrhea was present in 9 out of 47 patients with ALA and 8 out of 37 patients who underwent colonoscopy. When the group with colonic ulcers was compared with the group without ulcers, there was no significant difference with respect to age, duration of fever, duration of pain, frequency of diarrhea, serum albumin level, number and size of liver abscesses.

Conclusion. Active amebic colitis is common in patients presenting with ALA. These ulcers are most commonly present in cecum and ascending colon.

PP 59.05

RECURRENT CHOLANGITIS AFTER ERCP IN PRIMARY SCLEROSING CHOLANGITIS

Andraus, Wellington¹; Haddad, Luciana B P¹; Moura, Fabio²; Bachella, Telésforo¹

¹University of São Paulo School of Medicine, Department of Gastroenterology, São Paulo, Brazil; ²

Introduction. Diagnosis of primary sclerosing cholangitis (PSC) is a challenge. Confirmation with an imaging exam is often necessary. ERCP is considered the gold standard; however it is an invasive method with its inherent risks. Magnetic Resonance (MR) appeared as a good option in such cases. OBJECTIVES: Report the risk of ERCP in PSC patients and compare two diagnostic methods (ERCP and MR) for this disease.

Methods. We report two cases of patients with PSC who developed recurrent cholangitis after ERCP. A review of literature was performed in a mesh database on MEDLINE in the last 15 years.

Results. The first case was 39 years old female, presenting high levels of canaliculare liver enzymes, underwent a ERCP for investigation. She had never experienced cholangitis before, and after ERCP procedure she started presenting recurrent biliary infections. The diagnosis of PSC was confirmed, however, for that reason, antibiotic profilaxy is permanently required. The second one, a 51 years old male, had the diagnosis of intestinal inflammatory disease. During a investigation of upper abdominal pain and hepatic enzymes alteration, he underwent a MR that showed irregularities in intrahepatic biliary tree. The diagnosis of PSC was already made, even though a ERCP was performed for complete investigation. The patient presented multiple hepatic abscesses after the procedure, with long period of hospitalization and antibiotic therapy. In the outcome he presented recurrent cholangitis. The literature reports cholangitis as a possible procedure complication. PSC is a rare disease and there is no data of recurrent cholangitis after ERCP. We report two cases of recurrent cholangitis after papilotomy, and they are in the waiting list of liver transplantation. Moreover, many authors showed the equivalency of MR and ERCP in diagnosis of PSC.

Conclusions. We recommend MR for diagnostic confirmation in PSC, and avoiding ERCP in such cases because of the recurrent cholangitis risk with this exam.

PP 59.06

MANAGEMENT OF HE PATIC TRAUMA IN ADULTS- A SINGLE-CENTRE EXPERIENCE

Akolekar, Deepika¹; Dhiya, Luay²; Hidalgo, Ernest²; Powell, James²; Ravindran, Ravi²; Wigmore, Steve J²; Garden, O James²; Parks, Rowan W²

¹Royal Infirmary of Edinburgh, Department of Clinical and Surgical Sciences, 51, Little France Crescent, Edinburgh, United Kingdom; ²Royal Infirmary of Edinburgh, Department of Clinical and Surgical Sciences, Edinburgh, United Kingdom

Background. Liver trauma is associated with significant mortality and morbidity. AIMS The aim of this study was to assess the management of patients with liver trauma and to assess factors that influence outcome in a specialist hepatobiliary centre.

Methods. All patients treated for liver trauma from 1995 to 2006 were identified from the prospectively collected Lothian Surgical Audit database and details regarding demographics, operative management and outcome were analysed.

Results. A total of 92 patients (73 males, 19 females) with a median age of 29 years were treated for liver trauma over this period. Thirty three patients (36%) were transferred to this unit from other hospitals. Blunt trauma especially road traffic accidents accounted for 41% of the injuries. Liver trauma with associated injures of other organs was noted in 64 (70%) patients. Fifty nine liver injuries (64%) were of low severity (grades I and II), while 33 (36%) were of high severity (grade III, IV and V). Thirty eight patients (41.3%) were haemodynamically unstable (systolic BP ≤ 90 mmHg) at presentation. 52.5% of the patients with low grade injuries were managed conservatively. Three of the 38 patients with liver trauma initially considered for conservative management required surgery due to bile leak or haemorrhage. Operative management was undertaken in 57 patients (62%). The overall mortality was 12%.The mortality rate was higher patients with haemodynamically instability (p = 0.009) and increasing severity of liver injury (p = 0.007).

Conclusion. Low grade liver injuries can be managed nonoperatively with excellent results. Associated injuries are common. Grade of injury and haemodynamic instability are associated with higher mortality.

PP 59.07

WHAT IS A MAJOR HEPATIC RESECTION IN 2007?

Morris-Stiff, Gareth; Gomez, Dhanwant; Toogood, Giles J.; Lodge, J. Peter A.; Prasad, Rajendra

Leeds Teaching Hospital NHS Trust, Hepatobiliary and Transplantation Unit, Leeds, United Kingdom

Background. A major hepatic resection is currently defined as the resection of 3 or more Couinaud segments. With advances in perioperative techniques, the safety of liver resection has improved in terms of both morbidity and 30-day mortality allowing removal of larger volumes of hepatic parenchyma without significant impairment of synthetic function thus raising the question as to whether the classification of liver resections should now be modified. Aims: To determine the preoperative morbidity and mortality of hepatic resection in relation to removal of 1–2, 3–4 or 5–6 hepatic segments.

Patients and Methods. All patients undergoing resection of colorectal liver metastases from 2000–2005 were identified from a prospectively maintained database. Data collected included: morbidity rate; number of patients experiencing morbidity; prevalence of hepatic failure; and 30-day mortality.

Results. During the period of the study 386 patients (246 Male and 140 females) with a mean age of 65.9 years, 268 of which were aged > 60 years, underwent resection. There were significant differences in both the number of patients experiencing morbidity and the overall morbidity rates for all 3 groups and significant differences in both the hepatic failure and mortality rates between the 1–2/3–4 and the 5–6 segment groups. When the 1–2 and 3–4 groups were combined there were clear differences between the combined group and those undergoing extended resections of 5–6 segments in all parameters examined.

Conclusions. The results show that there are clear differences in relation to the number of segments excised and morbidity allowing division into: Minor (1–2); Moderate (3–4); and Major (5–6) segments. Alternatively, as the major concerns are hepatic failure and death, the resections could be classified as 2 groups: Minor (1–4) and Major 5–6) Couinaud segments. Further work is required to confirm these results and to sub-analyse in relation to chemotherapy-associated hepatic parenchymal damage as this may lead to ‘group migration’.

PP 59.08

A CASE OF HEPATOCELLULAR CARCINOMA ACCOMPANIED WITH DUBIN-JOHNSON SYNDROME

Katagiri, Satoshi; Kotera, Yoshihito; Ariizumi, Shun-ichi; Takahashi, Yutaka; Okano, Shunsuke; Yamamoto, Masakazu

Institute of Gastroenterology, Tokyo Women‘s Medical University, Dept. Surgery, Tokyo, Japan

A 77-year-old man was admitted to our hospital because of liver tumor by screening ultrasonography at medical checkups. He had been pointed out slightly jaundice thirty years ago. Abdominal computed tomography showed a strong enhanced tumor of 3cm in diameter identified at the segment 7 and the tumor had a corona. The preoperative total bilirubin was 2.7 mg/dl and direct bilirubin was 2.0 mg/dl, but other hepatic functional reserves were kept in normal limits. Virus markers were not detected. He was diagnosed as having Hepatocellular Carcinoma (HCC) accompanied with Dubin-Johnson syndrome (DJS) without chronic hepatitis. On June 2007, Segment 7 resection of the liver was performed. Intraoperative findings showed a black liver without liver fibrosis. Histopathologically, the hepatic tumor was a moderately differentiated HCC without intrahepatic metastasis and portal invasion. The liver parenchyma was a rough brown granule. The total bilirubin level rose up to 9.4 mg/dl after operation but it gradually decreased. So, HCC accompanied with DJS in which hepatic resection was performed were rare report.

PP 59.09

FDG-PET IN THE STAGING AND SURVEILLANCE FOR PATIENTS WITH CHOLANGIOCARCINOMA

Rath, Siddhartha; Byrnes, Kerry; Shokouh-Amiri, Hosein; Lilian, David; Johnson, Lester; Johnson, Lester; Turnage, Richard; Zibari, Gazi

Louisiana State University Health Sciences Center, Surgery, Shreveport, United States

Purpose. FDG PET is a valuable tool in both staging and surveillance of multiple malignancies. Cholangiocarcinoma is rare and frequently presents late. Computed tomography has become the gold standard in staging cholangiocarcinoma, however it has its weaknesses. The purpose of this study is to assess the value of conventional FDG-PET in both the staging and surveillance of patients with cholangiocarcinoma.

Methods. All patients with a diagnosis of cholangiocarcinoma from 1999–2004 were identified and reviewed retrospectively. Patients who underwent PET scanning as part of their staging preoperative workup and surveillance were selected. Concomitant computed tomography scans were reviewed when available. Pathology reports and operative findings were reviewed in detail. The sensitivity of both PET imaging and computed tomography was determined.

Results. Thirteen patients with cholangiocarcinoma who underwent FDG-PET scanning were identified. A total of 19 PET scans were obtained of which eight were performed as part of pre-operative staging; the remaining eleven underwent PET for surveillance. All patients who had pre-operative PET scans underwent surgery, (7 laparotomies, 1 laparoscopy), and in all cholangiocarcinoma was confirmed by histology. The sensitivity of PET in detecting primary disease was 100%. In two patients distant disease existed and PET scan accurately identified one of these. Eleven surveillance (post-operative) PET and CT scans were performed in seven patients. The sensitivity of PET in detecting recurrence was 100%. In comparison, computed tomography detected recurrence with a sensitivity of 33%.

Conclusion. PET scan is a valuable tool for pre-operative staging of cholangiocarcinoma and compares favorably to conventional computed tomography as a surveillance tool.

PP 59.10

THE CLINICAL VALUE OF REPEAT FOLLOW-UP IMAGING STUDIES IN PATIENTS WITH BLUNT HEPATIC TRAUMA.

Lee, Minjae¹; Evans, Peter¹; Usatoff, Val¹; Atkin, Chris²

¹The Alfred Hospital, Commercial Road, Department of Surgery, Monash University, Melbourne, Australia; ²The Alfred Hospital, Commercial Road, Department of Trauma Surgery, Melbourne, Australia

Background. There has recently been much controversy surrounding follow-up management of patients with blunt hepatic trauma, in particular whether repeat imaging is routinely required in asymptomatic patients after livery injury. Currently there are conflicting recommendations in the literature. AIMS: To test the hypothesis that blunt hepatic trauma patients who receive follow-up imaging studies have the same outcomes as patients who do not receive follow-up imaging studies.

Methods. A 6 year retrospective review was conducted on consecutive cases of blunt hepatic trauma at a level 1 trauma centre. Repeated Computed Tomography and Ultrasound scans during the follow-up period were reviewed together with detailed analysis of patients' medical records. With each of the repeated imaging studies, chronological correlations were made with the medical records to observe for changes in clinical management as a consequence of these imaging studies.

Results. Over the period from 2001 to 2007, 386 patients were admitted with blunt hepatic trauma at a level 1 trauma centre. Mean age at time of trauma was 38 years of age. There were 262 (68%) grade I and II, 59 (15%) grade III, 47 (12%) grade IV, 16 (4%) grade V and 2 (1%) grade VI hepatic injuries. Repeated Computed Tomography or Ultrasound scans during the follow-up period were shown to have minimal impact in clinical management of patients after blunt hepatic trauma.

Conclusion. Routine use of Computed Tomography scans in follow-up management of patients is not warranted in most cases of blunt hepatic trauma, with limited impact on subsequent clinical management of these patients. Use of Ultrasound as a follow-up imaging modality is an alternative to Computed Tomography for patients who may be at high risk of developing complications from blunt hepatic trauma.

PP 59.11

CONGENITAL ABNORMALITIES OF THE INTRA AND EXTRAHEPATIC BILIARY TREE IN ADULTS.

Bracco, Ricardo¹; Grondona, Jorge²; Moreno, Adrián³; Lo Veci, Juan⁴

¹Clinica Pueyrredón, HPB unit, Mar del Plata, Argentina; ²Centro médico martín y Omar, HPB unit, San isidro, Argentina; ³Clinica Pueyrredón, HPB fellow, Mar del Plata, Argentina; ⁴Centro médico Martín y Omar, HPB fellow, San Isidro, Argentina

Background. congenital abnormalities of the intra and extrahepatic biliary tree are characterized by cystic and/or diffuse dilatations and usually present pancreatobiliary maljunction with potential risk of malignant transformation.

Aim. to describe a 16 year period experience in the treatment of congenital biliary tree dilatations in adults.

Methods. out of 20 patients with congenital biliary tree dilatations, 18 females(90%) and 2 males(10%) were observed. Most frequent lesions treated were Type I and IV A of Todani-Watanabe classification. In 7 patients(35%) a pancreatobiliary maljunction was detected. Out of 20, in 8 cases the whole extrahepatic biliary tract, including the convergence of both left and right hepatic ducts were resected. In addition, 8 liver resections were performed: 4 sectionectomies and 4 hepatectomies.

Results. no postoperative mortality was observed. A neumopathy, a bile leak, a subphrenic abscess and a biliary peritonitis were the complications registered. The last two were treated succesfully by laparoscopic and laparotomic approach respectively. Thorough follow up was achieved in 19 patients(95%).

Conclusions. congenital abnormalities of the intra and extrahepatic biliary tree in adults can be diagnosed by modern imaging techniques for hepatopancreatobiliary diseases. Surgical approach consist of removing pathological extrahepatic cystic areas. Liver resections should be carried out according to the presence of stenosis, biliary stasis and/or intrahepatic stones. The surgical technique must be accurate in extension and meticulous when performed.

PP 60.01

THE ROLE OF MRCP IN THE PREOPERATIVE ASSESSMENT OF CHOLEDOCHAL CYSTS IN CHILDREN.

Hegab, Bassem; Korayem, Enas; El Araby, Hanaa

National Liver Institute, University of Menoufiya, Menoufiya, Egypt

Aims. To assess the preoperative diagnostic value of MRCP versus intraoperative cholangiography and surgery in children with choledochal cysts.

Patients andMethods. Twelve children who were initially diagnosed with choledochal cyst by ultrasonography were included in this study. All the patients performed preoperative MRCP and intraoperative cholangiography before cyst excision. The type of choledochal cyst, anomalous pancreaticobiliary ductal union (APBDU), and associated pathology were characterized on the basis of MRCP findings and were compared with those findings of intraoperative cholangiography and surgery. All patients underwent cyst excision and hepaticojejunostomy Roux-en-Y anastomosis except five patients with associated biliary atresia who underwent Kasai's portoenterostomy operation.

Results. There were 12 patients, with median age of 3.19 (2months-13 years) years, of whom 9 were girls and 3 were boys. The commonest presenting symptom was jaundice in 9 (75%) patients, followed by abdominal pain in 7 (58.3%) patients, abdominal mass in 4 patients (33.3%), cholangitis in 2 (16.7%) patients and acute pancreatitis in 2 (16.7%) patients. Only 2 (16.7%) patients presented with the classical triad of abdominal mass, pain, and jaundice. MRCP depicted a diagnosis of choledochal cyst in all patients, characterized the type of cyst (2 Type Ia, 2 Type Ib, 5 Type Ic, 1 Type II, and 2 Type IVa). MRCP findings were confirmed by surgery and intraoperative cholangiography in all patients. APBDU was detected by MRCP and intraoperative cholangiography in 5 (41.6%) and 3 (25%) of 12 patients, respectively, all of them were of type B anomaly. Biliary stones were found in three patients (25%). Associated pathology with choledochal cyst included 5 (41.7%) patients with biliary atresia.

Conclusion. MRCP appears to be a reliable, non invasive and safe method in the diagnosis, specifying type and determining the extent of the choledochal cyst as well as diagnosis of associated pathology and duct anomalies.

PP 60.02

BILE DUCT INJURIES: CAUSES AND MANAGEMENT

Kantharia, Chetan¹; Prabhu, Ramkrishna²; Dalvi, Abhay²; Bapat, Ravindra²; Supe, Avinash²

¹Kemh & Seth Gs Medical College, Surgical Gastroenterology, Parel, Mumbai, India; ²Kem Hospital & Seth Gs Medical College, Clinical Pharmacology, Mumbai, India

Background. Cholecystectomy is associated with bile duct injury (BDI). We review our experience of BDI with attention to the cause and treatment.

Material and Methods. From 2003 to 2006, 27 patients of BDI were referred. 21 (14 females; age range 25–68 years) were following elective Laparoscopic cholecystectomy (LC) and six (4 females; age range 24–72 years), were following elective open cholecystectomy (OC). BDI classified as per Strasberg classification BDI following LC: Type A (n = 1), type B, C (n = 1), type D (n = 3), type E1 (n = 5), type E2 (n = 3), type E3 (n = 6), type E4 (n = 1) and type E5 (n = 1). BDI following OC: Type E2 (n = 3), E3 (n = 1) and type E4 (n = 2). Reasons leading to the BDI were assessed.

Results. The reasons for BDI in LC group was Difficult anatomy (11pts), Bleeding with excessive clip applications 94 pts), sub-optimal facilities and assistance (11 patients) and visual perception defect (2 pts). In OC group, it was difficult anatomy (2 patients) and sub-optimal facilities and assistance (2 patients). All the 21 LC were operated by experienced laparoscopic surgeons. BDI was identified at the time of occurrence in 9 patients. 7 patients underwent further surgery\procedures before referral. None of the BDI following OC were detected on table. The post referral treatment was: In OC group – Hepaticodocho Jejunostomy in all six patients, In LC group: Hepaticojejunostomy (11) T-tube drainage (3), operative drainage of biloma (1), ERCP/stent (4), percutaneous transhepatic stenting (2). There was no mortality in the open group but 5 in the LC group (3 patients were referred late with multi-organ failure, and 2 patients had severe cholangitis). The median F/U was 45 months (range 1–104).

Conclusions. The common causes of causes of BDI in both groups were difficult anatomy and sub-optimal facilities and assistance. 2) The learning curve excuse does not hold true in the present study. 3) The recent trend towards the referral to specialist HPB unit, of what ultimately turn out to be minor injuries is encouraging.

PP 60.03

UNUSUAL CAUSES OF OBSTRUCTIVE JAUNDICE

Gawade, Sandesh; Prabhu, Ramkrishna; Kantharia, Chetan; Supe, Avinash; Bapat, Ravindra

Kem Hospital & Seth Gs Medical College, Surgiacl Gastroenterology, Mumbai=, India

We present four rare presentations of OJ with review of literature. 38 year old lady presenting with cholangitis, underwent stenting, followed by Open cholecystectomy with CBD exploration. Intra operatively diagnosed to have a CBD mass and subjected to cholecystectomy with T- tube insertion. Biopsy revealed endocrine tumor of pancreas. CT scan showed mass at confluence. She had two subsequent stent changes. On presentation she was subjected to MRCP showed CBD mass and was followed by PTCD. Complete excision of tumour with high hepaticodocho–jejunostomy done. HP confirmed Extra-Hepatic Carinoid tumour. Case 2: 54 year patient with h/o recurrent cholangitis since last 11/2 years and OJ since 1 month. H/O undergone open cholecystectomy with CBD exploration 2years back for cholecystitis with choledocholithiasis. She was non-diabetic and HbSAg and HIV negative.USG and CT-Scan done revealed dilated IHBR and dilated CBD. Subjected to PTBD to alleviate her rising bilirubin. It revealed characteristic pattern suggestive of mucormycosis. Bile culture was positive for Mucormycosis. She was started on antifungal, but she succumbed.Case3: 54 year man who had undergone choledochojejunostomy after choledochal cyst excision, developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop. Case 4: 24-year lady presented with bilious expectoration and H/O OJ, following open cholecystectomy. Pleurocentesis, followed by intercostals drainage done, which drained about 300 ml bilious fluid per day for a month. Her symptoms were relieved. A pleuro-biliary fistula was demonstrated by percutaneous transhepatic cholangiogram, HIDA scan and ERCP, showed complete cut-off at the lower end. The patient underwent bilio-enteric bypass with gastric access loop, with complete healing of the pleuro-biliary fistula.

PP 60.04

CHOLEDOCHAL CYST IN ADULTS: A SINGLE CENTER EXPERIENCE

Penteado, Sonia¹; Perini, Marcus Vinicius²; Cunha, Jose Eduardo²; Jureidini, Ricardo³; Jukemura, Jose⁴

¹University of S.Paulo, Department of Gastroentrology, S.Paulo, Brazil; ²Department of Gastroenterology, S.Paulo, Brazil; ³University of S.Paulo, Department of Gastroenterology, Brazil; ⁴Department of Gastroenterology

Background. The low incidence of choledochal cysts in Western adults has resulted in little information about results of surgical treatment of these patients.

AIM. to analyze long term results of surgical excision of choledochal cysts diagnosed after childhood.

Methods. retrospective review of patients presenting with extrahepatic choledocal cysts from 1987 on, excluding Caroli's disease. Data included demographics, symptoms, surgical procedure, surgical pathology results, morbidity, mortality and follow-up. Cysts were grouped according to Todani's classification by imaging techniques, surgical findings and intra-operative cholangiogram.

Results. Thirty patients, 20 women and 10 men, ages from 14 to 77 years (mean 33.6), were treated since 1987. Symptoms were pain in 96% and jaundice 56%, prior cholangitis 56% and acute pancreatitis 13%, none had palpable mass. Prior treatments were endoscopic papillotomy in seven (23%), biliary stenting in one, 14 patients underwent previous laparotomy (27,5%), including cholecystectomy 24,1% (8/29), cystenterostomy 10,3% (3/29), pancreatic pseudocyst drainage (1/29), splenectomy (1/29), laparotomy (1/29). The cysts were resected distally as far as the biliopancreatic junction, however a dome like segment of about 0.5 was left in the biliary confluence to avoid anastomotic stricture.Twenty seven patients underwent excision, one had only a biopsy because of carcinomatosis, and two (type II and III) refused operation. Type I cists were more frequent, 70%, type IV 23%, type II 3.3% as type III,3.3%. No postoperative deaths were observed. Mean follow up was 51 months; one had recurrence of cholangitis and was submitted to left hepatectomy. None had biliary strictures and so far none presented with cholangiocarcinoma.

Conclusion. The technique for excision prevented strictures, but the fate of the small remnant mucosa is a major concern.

PP 60.05

NON TRAUMATIC INFLAMMATORY STRICTURES OF THE BILE DUCT

Vyas, Frederick¹; Joseph, Philip²; Sanghi, Ravish²; Eapen, Anu³; Sitaram, Venkatramani²

¹Christian Medical College Hospital, Department of General Surgery, Ida Scudder Road, Vellore, India; ²Christian Medical College Hospital, Department of General Surgery, Vellore, India; ³Christian Medical College Hospital, Department of Radiodiagnosis, Vellore 632004, India

Background. Non traumatic inflammatory strictures of bile duct are uncommon. Strictures occurring within common hepatic duct and common bile duct without a history of prior surgery in that region or stone disease are usually thought to be due to cholangiocarcinoma unless proved otherwise. It is often impossible to distinguish between benign and malignant strictures before laparotomy.

Aim. To examine the clinical and pathological features of benign idiopathic strictures of the bile duct.

Methods. From February 2002 to January 2007, 76 patients with benign bile duct strictures were operated upon. Ten patients had a final diagnosis of non traumatic benign stricture. We reviewed these patients retrospectively and they are the focus of this study.

Results. There were 10 patients (7 male, 3 female) with a mean age of 36 years (range 14–65). Presenting symptoms included jaundice (8), abdominal pain (6), fever (5) and weight loss (4). Their mean bilirubin and alkaline phosphatase levels were 6.21 mg/dl and 430u/dl respectively. Pre-operative imaging was consistent with cholangiocarcinoma in all patients (9 MRCP, 1 ERCP). None of them had evidence of stone disease on pre-operative imaging. CA 19.9 levels were normal in all patients except 2. There were 7 proximal and 3 mid bile duct strictures. Nine patients underwent cholecystectomy with biliary enteric bypass and 1 patient underwent double bypass for suspicion of advanced malignancy. Based on operative and histopathological reports, the causes were congenital (1), tuberculosis (3) and non specific fibrosis/inflammation (7). Major morbidity occurred in 2 patients but none died.

Conclusion. Differentiating benign from malignant biliary strictures is often difficult. Surgical resection is the treatment of choice. However, benign etiology should be considered when younger patients present with bile duct strictures

PP 60.06

POST CHOLECYSTECTOMY BILIARY COMPLICATIONS: PRESENTATION AND MANAGEMENT.

Virk, Satpal¹; Babra, Ravinder Pal Singh²; Ahuja, Ashish¹

¹Dayanand Medical College & Hospital, Dept of Surgery, Ludhiana Punjab, India; ²Dayanand Medical College & Hospital, Dept Of Surgery, Ludhiana Punjab, India

Background.Cholecystectomy is associated with bile duct injury, incidence of which has doubled since the introduction of laparoscopic cholecystectomy. This study reviews the presentation and management of bile duct injury in a tertiary care centre.

Methods. From 2003 to 2007, 37 patients (28 females) of median age 42 years (range 25–70)were referred to this centre with bile duct injury following open and laparoscopic cholecystectomy.

Results. Patients were referred after a median of 30 (range 0–3650) days after cholecystectomy. Patients with laparoscopic cholecystectomy (40.54%) had median of 7(0–425) days while patients with open cholecystectomy (59.45%) had median of 46 (1–3650) days. Management before surgical referral included definitive reconstruction [hepaticojejunostomy (1) and T tube drainage (1)], drainage of abcess (6), ERCP (3). Management after referral included definitive surgical reconstruction (29) laparotomy/laparoscopic drainage (4) ERCP with stent insertion (3) and stump closure (2). Definitive surgical reconstruction comprised of Roux-en-Y hepaticojejunostomy (Hepp-Couinard technique) for Bismuth type of striture which included TypeI(7) TypeII(15) TypeIII (3) TypeIV(2) TypeV(2). Two patients died, who had undergone laparotomy and drainage for biliary peritonitis at our centre. They had median inpatient stay following referral of 6 days.

Conclusion.: Bile duct injury following cholecystectomy is a complex management problem and results in significant postoperative morbidity. Most patients reffered required reconstructive surgery and patients with complex high injuries had a risk of long term morbidity.

PP 60.07

CHOLEDOCHAL CYSTS – A RETROSPECTIVE ANALYSIS

Khandelwal, Manish¹; Kumar, Bindey²; Khandelwal, Chiranjiva²

¹Aberdeen Royal Infirmary, Aberdeen, United Kingdom; ²Indira Gandhi Institute of Medical Sciences, Patna, India

Background. Choledochal cysts are congenital anomalies of the bile ducts. They consist of cystic dilatations of the extra-hepatic biliary tree, intrahepatic biliary radicals, or both. It poses a considerable challenge in terms of diagnosis & management.

Objective. We analysed the sixty four cases that presented to us over the last 17 years in terms of age of presentation, clinical features, type of cyst & perioperative complications.

Methods. Retrospective analysis of 64 cases over the last 17 years.

Results. Sixty Four patients with Choledochal cyst were treated over a period of 17 years. Thirty three (52%) patients were under 12 year's age. Forty two (66%) of patients were females. Upper abdominal pain was the most common presenting symptom (66%) followed by jaundice & fever (28%). Investigations included Ultrasonography in all cases, Endoscopic Retrograde Cholangio Pancreatogram (ERCP) in most (60%), Percutaneous Transhepatic Cholangiogram (PTC) & Intra-operative Cholangiogram in two cases each. Commonest type was Todani Type I (77%). Complete excision was possible in 55(86%) cases (Type I & II) & excision of extra hepatic cyst with wide drainage of intra hepatic cyst in 6(9%) cases (Type IVA). Submucosal excision of cyst (Lilly's technique) was done in 2 cases & internal bypass in one. Overall we had only one (2%) periope rative mortality. 48% of our patients were adults but cholangitis and hepatitis was more common in children (24%).No patient had cholangiocarcinoma.

Discussion. Choledochal cyst, though are congenital anomalies may not present until adulthood. If presented in childhood, patients tend to have serious Hepato-biliary complications (cholangitis, hepatitis & cirrhosis) more commonly as compared to their adult counterparts.Choledochal cysts should be treated by early surgical intervention. With experience most Choledochal cysts can be excised safely.

PP 60.08

PORTAL BILIOPATHY- A STUDY OF 39 SURGICALLY TREATED PATIENTS

Sharma, D¹; Girish, S.P.¹; Singh, Shivendra¹; Agarwal, S.¹; Chaudhary, A.¹; Sakhuja, Puja²; Agarwal, Anil¹

¹G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ²G. B. Pant Hospital and Maulana Azad Medical College, Pathology, New Delhi, India

Background. Portal biliopathy denotes intrahepatic and extra hepatic biliary ductal abnormalities in portal hypertension. It is usually associated with extra hepatic portal vein obstruction (EHPVO).

Methods. Retrospective analysis of prospectively collected data of surgically managed portal biliopathy patients between 1996 to 2007 was performed for presentation, clinical features, imaging and the results of surgery. All patients were taken up with plan of decompressive shunt surgery in the first stage and biliary drainage procedure in second stage 6–8 weeks later if required.

Results. 39 patients (27 males, mean age 29.57 years) of symptomatic portal biliopathy were surgically managed. Jaundice was the commonest symptom followed by right upper quadrant pain and recurrent cholangitis. The first stage surgery included proximal splenorenal shunt (37), esophago-gastric devascularization with simultaneous hepaticojejunostomy (1 patient with peroperatively found nodular liver), and hepaticojejunosotmy alone (1 patient found to have splenic vein thrombosis in preoperative workup). During follow up, clinical and biochemical improvement was monitored. Those with persistent symptoms underwent Doppler and MRCP examination. Thirteen patients underwent second stage surgery-12 required biliary drainage procedures (Hepaticojejunostomy-11, Choledochoduodenostomy-1). These patients had dominant strictures and choledocholithiasis. One patient had successful endoscopic clearance of CBD stones after first stage and required only cholecystectomy in second stage for gall stones. Average blood transfusion requirement at second surgery was 0.92 unit, post-op complications were minimal with no mortality. Over a follow up of 5–48 months the patients are asymptomatic and well.

Conclusion. Symptomatic portal biliopathy needs intervention. Surgical decompressive shunt followed by biliary drainage is the best possible treatment. While for most of the early biliary changes shunt alone is effective, patients with dominant stricture will need a second stage biliary drainage procedure.

PP 60.09

THE ROLE OF STAGING LAPAROSCOPY IN EXTRA HEPATIC PROXIMAL BILIARY TRACT MALIGNANCIES

Basu, A K; Singh, R P; Mandal, Sanjoy; Singh, Shivendra; Agarwal, Anil

G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India

The staging laparoscopy of Extra hepatic proximal biliary tract malignancies has a potential to identify intra-abdominal metastasis and thereby avoid laparotomy in unresectable cases. This prospective study evaluates the role of staging laparoscopy in Extra hepatic proximal biliary tract malignancies in a tertiary referral centre.

Methods. a total of 130 cases of Extra hepatic proximal biliary tract malignancies that were deemed resectable by preoperative imaging were included in this study. There were 115 cases of Gallbladder Cancer (GBC) 44 with biliary obstruction (SOJ) (n = 44); and 71 cases without. 15 cases were of cholangiocarcinoma (Cholangio Ca). All patients were subjected to staging laparoscopy prior to laparotomy.

Results. laparoscopy spared laparotomy for metastatic disease in 43 cases of GBC and 6 cases of cholangioCa. Laparoscopy failure rate was in 14 cases of GBC SOJ (11.27%) and 3 cases of cholangioCa. Overall, staging laparoscopy spared 44.61% of patient from unnecessary laparotomy. Patients with unresectable disease that were not detected by laparoscopy most often had locally advanced tumors. The average hospital stay was shorter in the only staging laporoscopy group.

Conclusion. Laparoscopy avoided laparotomy in 43 of 115 cases and 6 of 15 cases of cholangiocarcinoma., Laparoscopy thus significantly reduces the morbidity, and cost of hospitalization by avoiding unnecessary laparotomy.

PP 60.10

BILIARY TRACT INJURIES AFTER CHOLECISTECTOMIES: FIVE CASES REPORT

Ribeiro, Marcelo; Condi, GA; Jurado, MM; Albuquerque, JR MS; Saad, WA

Medical Sciences College, Pontifical Catholic University, Department of Hepatic Surgery, Sao Paulo, Brazil

Introduction. Due to the continuous increasing of the diagnostic methods for gallblader disease colelithiasis, an increasing of the number of cholecistectomies has been also achieved, including open or laparoscopic approachings. Biliary tract stenosis ranges from 0,16% to 2,35% (Duca et al., 2003, Ahrendt et al., 2005). Consequently, the biliary tract injury incidence should not be underestimated, once it affects patients morbidity and mortality rates.

Objective. Report of five uncommon cases of biliary tract injuries during conventional or laparoscopic cholecistectomies and the appropriate treatment for each patient, by using clinical history and subsidiary exams.

Report. Case 1: KCVM, 28 years, female, submitted to conventional procedure, presented ascitis one week later. At the second surgery, there were found common bile duct perforation and section of right hepatic artery. Case 2: RBS, 34 years, female, presented bile leak during laparoscopic surgery. After that, intra-operative colangiography was not performed. Three months later, a cholangio MR demonstrated hepatic ducts junction stenosis (Bismuth IV). Case 3: MAVF, 40 years, female, presented jaundice and chronic colangitis after laparoscopic cholecistectomy. Case 4: EFR, 35 years, male, presented recurrent jaundice after the same procedure, with Bismuth II/III injury. Case 5:SAS, 30 years, female, presented at laparoscopic surgery complete biliary tract section. Discussion: When Y-Roux hepaticojejunostomy is used for such lesions, the results success rate in the literature are between 80% and 90% (Csendes et al., 1992, Bergmann et al., 1996). In the first four cases, complete section of the biliary tract was identified and according to that the patients underwent Y-Roux technique. In one case, the lesion was found intra-operatively, and the proposed treatment at that moment was end-to-end anastomosis of the bile duct. All patients presented satisfactory post-operative clinical recover, which was possible because of the appropriate Y-Roux hepaticojejunostomy anastomosis.

Conclusions. The biliary tract is a common site for complications when it is not handle with great care and high index of suspicious. Nevertheless, the early recognition of the injuries constitutes an important factor for reducing patients morbidity.

PP 60.11

CHOLEDOCHAL CYST, EMERGING PATTERNS OF PRESENTATION

Joseph, Philip; Vyas, Frederick; Raju, Ravish Sanghi; Sitaram, Venkatramani

CMC Hospital, Hepatobiliary Unit (Surgery Unit 4), Vellore, India

Background. Choledochal cyst is an uncommon anomaly which is more common in the Asian population. It usually presents in childhood and there is a female preponderance. Excellent results have been achieved with timely management. However in a developing country like India, this disease may present in adults. Complications including malignancy seen in the adult population continue to remain a challenge.

Methods. The hospital records of all adult patients who underwent surgical treatment for choledochal cyst in a single centre during 2001– 07 were analysed.

Results. There were a total of 56 adult patients. Abdominal pain was the commonest presenting symptom, the next being cholangitis. Type 1 choledochal cyst (69%) was the commonest type. Malignancy was seen in 3 patients (1 male, 2 females). Nineteen patients had undergone a previous operative procedure (cholecystectomy, cyst enteric bypass, t-tube drainage, partial excision and Roux en y bypass) before they presented to us. Major morbidity included bile leak, bleeding, intra-abdominal collection, wound infection and was seen in 14 patients. There was no increase in the morbidity or mortality from the definitive operation, in patients who had undergone previous biliary enteric bypass or other operative procedure. Three patients died (intra-operative bleeding 1, post-operative bleeding 1, post-operative sepsis 1).

Conclusion. The female preponderance is different from quoted literature in adults. Abdominal pain and cholangitis are common presenting symptoms in adults. When diagnosed in adults complete excision must be offered as they have an increased risk of developing malignancy.

PP 61.01

CXCL16, CXCR6 AND A DINSINTEGRIN AND MATRIX METALLOPROTEINASE (ADAM10) – AN INTERPLAY LEADING TO PROGRES SION OF PANCREATIC CANCER?

Gaida, Matthias M¹; Haag, Natascha¹; Mayer, Christine¹; Giese, Thomas¹; Felix, Klaus¹; Bergmann, Frank¹; Giese, Nathalia A¹; Friess, Helmut²; Büchler, Markus W¹; Wente, Moritz N¹

¹University of Heidelberg, Heidelberg, Germany; ²Technical University of Munich, Munich, Germany

Background. Regulated shedding of transmembrane chemokines by disintegrin and metalloproteinases (ADAMs) facilitates detachment of adherent leukocytes. Tumor cells are known to appropriate chemokine pathways to promote own dissemination. The chemokine CXCL16 was implicated to play a role in pancreatic cancer (PaCa) through yet unknown mechanisms. In leukocytes, CXCL16 processing is regulated by ADAM10. We investigated whether ADAM10 is expressed in PaCa cells and influences balance between soluble and membrane-bound CXCL16 forms.

Methods. Expression of CXCL16, its receptor CXCR6 and ADAM10 was determined by quantitative RT-PCR (qPCR) and immunohistochemistry (IHC) in pancreata of PaCa patients and healthy donors and human PaCa cell lines. To evaluate the size of soluble CXCL16 detected in patient sera by ELISA, mass spectrometry (MS) analysis was performed using SELDI-TOF. Soluble CXCL16 was also measured in supernatants of ADAM10-siRNA transfected PaCa cell lines (BxPC-3, Colo-357).

Results. PaCa cell lines expressed ADAM10, CXCL16 and CXCR6, with ADAM10 being strikingly high. In cancerous compared to normal pancreata, qPCR showed 6.4, 6.8, and 1.4 fold increase of CXCL16, CXCR6 and ADAM10, respectively. IHC revealed a heterogeneous expression pattern of investigated targets: CXCL16 was strongly expressed in most precancerous lesions and CXCR6 was detected in tumor cells in all specimen. MS revealed significant peaks obtained from the profiled spectra, confirmed by ELISA, showing a 2.0 fold increase of CXCL16 in PaCa patient sera vs. controls. Silencing ADAM10 in PaCa cells caused a decrease of soluble CXCL16 proven by ELISA.

Conclusion. In PaCa cells, abundantly expressed ADAM10 may augment processing of overexpressed transmembrane CXCL16 to its soluble form, therefore intensifying detachment of tumor cells and promoting dissemination. Increased ectodomain shedding may create a gradient of soluble CXCL16 which will attract CXCR6-positive leukocytes and further aggravate cancer-associated inflammation in pancreatic cancer.

PP 61.02

CEACAM1 EXPRESSION IN INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS (IPMNS) OF THE PANCREAS: A FACTOR OF PROGNOSTIC SIGNIFICANCE IN INVASIVE IPM-CARCINOMAS

Vashist, Yogesh; Link, Bjoern; Reichelt, Uta; Bogoevski, Dean; Liebl, Lena; Gawad, Karim; Izbicki, Jakob; Yekebas, Emre

University Clinic Hamburg-Eppendorf, General, Visceral and Thoracic Surgery, Hamburg, Germany

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) is a member of the carcinoembryonic antigen (CEA) family and is involved in intercellular adhesion, signal transduction and tumor cell growth regulation. Aim of the study was to correlate CEACAM1 expression with outcome in intraductal papillary mucinous neoplasms (IPMNs). By immunohistochemistry CEACAM1 expression was evaluated in 32 IPMNs of the pancreas (4 IPM-Adenomas (A), 15 IPM-Borderlines (B), 2 non-invasive IPM-Carcinomas (C), 11 invasive IPM-C). There are several distinctive staining pattern: cytoplasmatic and apical negative (−), apical positive (+), moderate cytoplasmatic and apical positive (+ + ), strong cytoplasmatic and apical positive (+ + +). Kaplan-Meier analysis were performed with an up to 80 month follow-up to assess the prognostic relevance of CEACAM1 expression. 27 tumors (84%) were classified as CEACAM1 positive. In IPM-A and -IPMN-B a weak apical staining (+) was observed in 50% and 80% respectively. Median follow-up in IPM-A was 58 month, in IPM-B 49 month. No patient died of tumor-relapse. Non-invasive IPM-C showed both cytoplasmatic and apical positive staining (+ + ). One patient died of tumor recurrence 49 month after initial diagnosis, the other patient is still disease-free after 56 month. The strongest CEACAM1 expression was observed in invasive IPM-C of relapse-free survivors (1x + +, 3x + ++). The median follow-up for relapse-free survivors was 39 month. In patients with tumor related death (median tumor related follow-up 12 month) the CEACAM1 expression was significantly lower (4x+, 1x + +). Kaplan-Meier analysis revealed a highly significant association between CEACAM1 overexpression and long-term survival (p < 0,033) in invasive IPMN-C. Moderate to high cytoplasmatic and apical expression of CEACAM1 in invasive IPM-C of the pancreas is highly associated with a long-term survival (p < 0.033). This raises the possibility to stratify patients with invasive IPM-C into low-risk and high-risk groups.

PP 61.03

DETECTION OF K-RAS GENE MUTATIONS AT CODON 12 AND CODON 13 IN PANCREATIC CANCER AND CHRONIC PANCREATITIS PATIENTS IN NORTH INDIAN POPULATION

Polipalli, Sunil¹; Agarwal, Anil²; Gondal, Ranjana³; Husain, Syed Akhtar⁴; Medhi, S.¹; Kar, P.¹

¹Maulana Azad Medical College, University of Delhi, PCR- Hepatitis Laboratory, Dept. of Medicine, New Delhi, India; ²G. B. Pant Hospital and Maulana Azad Medical College, Department of GI Surgery, New Delhi, India; ³G. B. Pant Hospital and Maulana Azad Medical College, Pathology, New Delhi, India; ⁴Jamia Millia Islamia University, Department of Biosciences, New Delhi, India

Background & Aim. To clarify the sensitivity and the validity of K-ras point mutational analysis at codon 12 and codon 13 in North Indian patients with pancreatic malignancy & chronic pancreatitis, and the possible correlation between the presence of the mutation and the histopathological findings.

Methods. 45 patients with pancreatic ductal adenocarcinoma, and chronic pancreatitis were enrolled in this study. 15 female (33.3%) & 30 male patients (66.7%) with an average age of 48.09±12.11 years for carcinoma (22– 70 years), 27± 12.21 years for chronic pancreatitis (22–55 years). DNA extracted from 10 normal human pancreas was utilized as a control. Codon 12 K-ras mutations were examined using the two step polymerase chain reaction (PCR) combined with restriction enzyme digestion, followed by nonradioisotopic single-strand conformation polymorphism (SSCP) analysis and by means of automated DNA sequencing.

Results. The sensitivity of K-ras mutational analysis in surgically resected tissue samples of the pancreatic carcinoma was 80%( 24/30) while in the chronic pancreatitis, it was 33% (5/15) (P < 0.01). The mutation pattern of Kras codon 12 and codon 13 observed in pancreatic carcinoma was GGT? GGA and GGC ? GGG and this was identical in patients of chronic pancreatitis also. K-ras mutation rate was progressively increased from normal duct at the tumor free resection margin to pancreatic carcinoma.

Conclusion. The presence of similar mutation pattern of K ras in chronic pancreatitis in 33% of our study group may be an indicator of the malignat potential of chronic pancreatitis. The value of K-ras gene mutation for the detection of early pancreatic cancer and differentiation of pancreatic cancer from chronic pancreatitis remains uncertain in clinical practice. However, if this mutation is identified in large number of established chronic pancreatitis cases progressing to PC, it could be a useful as a molecular marker for early diagnosis of pancreatic cancer.

PP 61.04

DENSITY AND SIZE OF LYMPHATIC VESSELS ARE REDUCED IN CANCER OF THE PANCREATIC HEAD DESPITE EXPRESSION OF VEGF-C AND -D

Cartland, Sarah J¹; Menon, Krishna V²; Rahman, Sakhawat H³; Verbeke, Caroline S⁴

¹The Leeds Teaching Hospitals NHS Trust, Deparment of Histopathology, Leeds, United Kingdom; ²The Leeds Teaching Hospitals NHS Trust, Deparment of Surgery, Leeds, United Kingdom; ³The Leeds Teaching Hospitals NHS Trust, Department of Surgery, Leeds, United Kingdom; ⁴The Leeds Teaching Hospitals NHS Trust, Department of Histopathology, Leeds, United Kingdom

Background. Lymph node metastasis is common in pancreatic head cancer and adversely affects prognosis. AIMS: To determine if pancreatic head cancers are associated with lymphangiogenesis, and whether this correlates with VEGF-C/-D expression by the tumours.

Methods. Paraffin-embedded tissue from normal pancreas, ampulla, common bile duct (CBD) and each 15 cases of adenocarcinoma of the pancreas (PC), ampulla (AC) and distal common bile duct (CC) was immunostained with D2–40 (lymphatic endothelial marker), VEGF-C and -D antibodies. Lymphatic vessel size (vascular area), shape (largest/smallest diameter) and lymphatic vessel density (LVD) in the centre and at the periphery of each tumour were assessed on digitized images.

Results. LVD was higher (p≤.02) and vessel size smaller (p<.001) in normal ampulla and CBD compared to pancreas. LVD in the centre and periphery of PC did not differ from the low LVD found in normal tissue. In CC, central and peripheral LVD were similar to that in PC, and significantly lower than in normal CBD (p=.03). LVD in AC was higher than in PC and CC (p≤.03), but significantly reduced compared to that in normal ampulla (p<.001). In AC, central LVD was lower than peripheral LVD (p=.04), but no such difference was seen in PC or CC. LVD was inhomogeneous in individual tumours and highest where cancer infiltrated the ampulla and duodenum. In all cases, lymphatics were of similar size in normal tissue and tumour periphery, but significantly smaller in the tumor centre (p<.001). No difference in vessel shape existed between cancers and normal tissue. Immunolabeling for VEGF-C was stronger than for VEGF-D, and expression of both factors was higher in AC than PC or CC (p≤.05) but did not correlate with LVD.

Conclusions. Rather than inducing lymphangiogenesis, pancreatic head cancers seem to destroy and constrict lymphatic channels, despite expression of VEGF-C and -D. LVD varies within individual tumours, reflecting differences in LVD of the normal tissue compartments within the pancreatic head.

PP 61.05

CLINICAL IMPACT OF MIDKINE EXPRESSION IN PANCREATIC HEAD CANCER

Maeda, Shinichi¹; Shinchi, Hiroyuki¹; Maemura, Kousei¹; Noma, Hidetoshi¹; Mataki, Yuko¹; Kurahara, Hiroshi¹; Ueno, Shinichi¹; Sakoda, Masahiko¹; Kubo, Fumitake¹; Aikou, Takashi¹; Takao, Sonshin²

¹Kagoshima University, Surgical Oncology and Digestive Surgery, Kagoshima, Japan; ²Kagoshima University, Frontier Science Research Center, Kagoshima, Japan

Background. Midkine (MK) is a heparin-binding growth factor and a product of a retinoic acid-responsive gene. MK is overexpressed in many carcinomas and thought to play an important role in carcinogenesis. However, no studies have been focussed on the role of MK in pancreatic carcinoma. This study sought to evaluate the clinical significance of MK expression in pancreatic head carcinoma, including the relationship between immunohistochemical expression and clinicopathologic factors.

Methods. Immunohistochemical expression of MK and CD34 was evaluated in pancreatic head carcinoma specimens from 75 patients who underwent surgical resection.

Results. MK was expressed in 53.3% of patients. MK expression was significantly correlated with venous invasion, microvessel density, and liver metastasis (P = 0.0063, 0.0025 and 0.0153, respectively). The 5-year survival rate was significantly lower for patients positive for MK versus patients negative for MK (P = 0.0073). Multivariate analysis revealed that MK expression was an independent prognostic factor (P = 0.0033).

Conclusions. This is the first report of an association between MK expression and pancreatic head carcinoma. MK may play an important role in the progression of pancreatic head carcinoma, and evaluation of MK expression is useful for predicting malignant properties of pancreatic head carcinoma.

PP 61.06

SURGICAL PROCEDURES IN BENIGN PANCREATIC PATHOLOGIES: ANALYSIS OF RESULTS

Patil, Bhushan; Bhange, Snehal; Singh, Rajinder; Adhikari, Devbrata; Shetty, Tilakdas; Joshi, Rajeev

TNMC & BYL Nair Ch. Hospital, General Surgery, Mumbai, India

Background. Surgical procedures for various benign pancreatic pathologies have of late been ignored because of the emergence of sophisticated endoscopic and radiological alternatives. Although these surgeries are technically demanding they may yet be the most efficacious therapeutic option.

Objective. To analyse the outcome of surgical procedures for various benign pancreatic disorders with respect to alleviation of symptoms, morbidity and mortality.

Methods. 135 patients treated in a referral unit from February 1999 to July 2007, were analysed. Diagnosis was based on clinico-radiologico-pathological co-relation. The cases included 55 pseudocysts, 50 chronic pancreatitis, 12 solid cystic pancreatic neoplasms, 5 insulinomas, 3 carcinoids, 4 acute necrotising pancreatitis,4 pancreatic injuries and 2 pseudoaneurysms.

Results. Significant pain relief after surgery was seen in 78% of patients with chronic pancreatitis. In previously diabetic patients with chronic pancreatitis, the insulin requirements decreased in 70% patients whereas 15% patients were rendered non-diabetic after the surgery. Significant pancreatic leak was seen in 1 patient following necrosectomy who succumbed and in 1 patient following insulinoma enucleation who was successively managed conservatively. Trivial leaks were seen in 3 patients post distal pancreatectomies and in 1 patient following Puestow's procedure. These were managed conservatively. Overall 2 patients succumbed. The morbidity rate was 17.03% and the mortality rate was 1.48%.

Conclusion. Surgical intervention remains a relevant and important component in management of benign pancreatic pathologies, being a one off procedure as opposed to repetitive endoscopic or radiologic interventions. Relief of symptoms following surgery as seen in our series re emphasizes the role of surgery as an efficacious and viable option.

PP 61.07

GERMLINE GENETIC ALTERATION IN THE PATIENTS WITH INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM AND ASSOCIATED EXTRAPANCREATIC TUMORS.

Ahn, Young Joon

Seoul National University Boramae hospital, General surgery, Seoul, Korea, Republic of

Background/Aim. IPMN is frequently reported in combination with a variety of extrapancreatic tumors. The IPMN in these patients might represent the phenotype of genes associated with the multiple tumor syndrome. The purpose of this study was to confirm the presence of germline mutations in the p53, MLH2, MSH2, BRCA1/2, and CDH-1 genes known to be associated with gastrointestinal malignancies in hereditary tumor syndromes such as Li-Fraumani syndrome, HNPCC (Hereditary Nonpolyposis colon cancer), Hereditary Breast/Ovarian cancer, and Hereditary diffuse gastric cancer.

Methods. 14 patients with IPMN and extrapancreatic tumors who underwent resection between 1996 and 2003 were enrolled in this study. The extrapancreatic tumors included 6 gastric cancers (early 4, advanced 2), 5 colorectal malignancies, 1 gastric GIST, 2 hepatocellular carcinomas and 1 ampulla of Vater cancer. We performed conventional PCR and direct sequencing analysis for the following genes: p53, MLH1, MSH2 and CDH-1 in addition, multiplex PCR, fluorescent CSGE and direct sequencing was performed for BRCA1/2 genes.

Results. We identified 2 novel mutations in the p53 gene (exon 1, codon 31, GTC> CTC, Glu-- > Gln) and the CDH1 gene (exon 14, codon 2218, CCC> TCC, Pro-- > Ser). In addition, we identified 11 identical coding SNP (exon 11, codon 3232, AAG > AGG, Glu-- > Gly) among 13 patients with a high allele frequency (46.1%) compared with the allele frequency of 30.1% reported in Korean breast cancer patients. For BRCA2, we identified a coding SNP with an allele frequency of 2.6% (exon 11-2, codon 2578, AAG > AGG, Met-- > Val).

Conclusion. Germline alterations of the p53 and CDH-1 genes in IPMN patients with extrapancreatic cancer suggest that IPMN may be a manifestation of the multiple tumor syndrome. The large difference in allele frequency between BRCA1 gene findings in this study and the Korean breast cancer database, and the low allele frequency in the SNP of the BRCA2 gene suggest the possible existence of a disease-causing process.

PP 61.08

ALTERATION OF THE LANGERHANS ISLETS IN PANCREATIC CANCER

Iki, Katsumichi¹; Iki, Katsumichi¹; Urakami, Atsushi¹; Nagatsuyka, Ryousuke¹; Pour, PM²; Tsunoda, Tsukasa¹

¹Kawasaki Medical School, Gastroentelorogical Surgery, Kurashiki, Japan; ²University of Nebraska Medical Center, UNMC Eppley Cancer Center, Omaha, United States

Background and Aims. Previous studies have shown a significant alteration of pancreatic islets in disarrangement in endothelial cells and the expression of ductal and cancer cell markers. However, it could not be found whether these alterations are restricted to cancer areas or are global. To clarify this issue, we extended our studies by using tumor-free tissues adjacent to cancer and a series of antibodies.

Material and Methods. Five normal pancreatic tissue from donors and 21 surgical pancreatic cancer of different degree of differentiation and the adjacent tumor free areas were examined by immunohistochemistry. Antibodies to all four islet hormones were used. In each specimen the number of the reactive islet cells was counted.

Results. Compared to control specimens, alteration in immunoreactivity for all antibodies was found in 15 out of 21 specimens in both pancreatic cancer and in tumor-free tissues. The number of insulin cells was reduced but the number of glucagon, somatostatin and PP cells was increased significantly. In one case, a remarkable tumor-like proliferatin of somatostain cells was identified in the periductal area in one of the tumor-free specimens.

Conclusion. The result of the current and previous studies highlights alteration of islets in morphological and biological pattern in pancreatic cancer. The occurrence of these alteration in both cancer tissue and tumor-free area support our view that the observed changes of islet cells in pa ncreatic cancer is a primary effect and unrelated to the presence of cancer. These changes could well explain the altered glucose tolerance and diabetes in most pancreatic cancer patients.

PP 61.09

THE PROTEOME OF RODENT MESENTERIC LYMPH IN FASTED AND FED STATES

Mittal, Anubhav¹; Middleditch, Martin²; Ruggiero, Katya³; Buchanan, Christina M²; Jullig, Maria²; Loveday, Benjamin⁴; Cooper, Garth JS³; Windsor, John A⁴; Phillips, Anthony RJ³

¹University of Auckland, Surgery, Auckland, New Zealand; ²University of Auckland, Maurice Wilkins Centre for Molecular Biodiscovery; ³University of Auckland, School of Biological Sciences; ⁴University of Auckland, Surgery

Background. Mesenteric lymph contributes to the pathogenesis of multiple organ dysfunction syndrome. We have previously shown that ischaemia conditioned mesenteric lymph adversely affects acute pancreatitis. Despite this growing interest in mesenteric lymph, there is no description in the literature of the normal mesenteric lymph proteome.

Aims. The aim of this study was to define the proteome of normal rodent mesenteric lymph in the fasted and fed states.

Methods. Eight male Wistar rats fed a standard rodent diet were randomised to 2 groups. Group 1 ('fasted', n = 4) were fasted for 24 hours prior to anaesthetised collection of mesenteric lymph. Group 2 ('fed', n = 4) had no intervention prior to collection. Mesenteric lymph was subjected to proteomic analysis using iTRAQ™ with liquid chromatography–tandem mass spectrometry.

Results. 150 proteins, including 26 hypothetical proteins were identified in this study. All were identified in both the fasted and fed states, but differences were found in the relative abundance of some proteins between the two states. The relative abundance of proteins in the mesenteric lymph differed significantly from that reported for serum. The largest functional protein classes identified were protease inhibitors (16%) and proteins related to innate immunity (12%).

Conclusion. This is the first comprehensive description of the normal mesenteric lymph proteome in the fed and fasted states. Mesenteric lymph contains a wide spectrum of known protein classes. These differ from previously reported proteomic studies of plasma and between the fasted and fed states in their relative distribution. This approach can now be used to determine how different diseases, including acute pancreatitis and hypovolaemic shock, alters the ML proteome.

PP 61.10

INTRATUMORAL LYMPHANGIOGENESIS CORRELATES WITH LYMPHATIC INVASION, NODAL STATUS, AND VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF)-C IN PANCREATIC CANCER

Kurahara, Hiroshi¹; Takao, SonShin²; Shinchi, Hiroyuki¹; Aikou, Takashi¹

¹Kagoshima university graduate school, Surgical oncology and digestive surgery, Kagoshima city, Japan; ²Kagoshima university graduate school, Frontier science research center, Kagoshima city, Japan

Background. Lymph node metastasis is a major prognostic factor in pancreatic cancer. Identifying characteristics of the primary tumor that may predict nodal metastasis and understanding the mechanisms of lymphatic metastasis are, therefore, essential for the development and selection of better treatment strategies for pancreatic cancer. OBJECTIVES: The aim of this study was to elucidate the relationships between lymphangiogenesis and lymphatic metastasis and prognosis in pancreatic cancer.

Methods. Formalin-fixed, paraffin-embedded blocks were obtained from 75 patients with pancreatic cancer. All patients underwent a curative resection. To evaluate the lymphangiogenesis, we measured the density of lymph vessels as assessed with the marker D2-40 in non-cancerous pancreatic tissues resected with pancreatic cancer and cancerous pancreatic tissues. Expression of VEGF-C was evaluated by immunohistochemical staining. When over 25□“ of the tumor cells showed distinct staining, the tumor was judged as having high expression of VEGF-C.

Results. Lymphatic vessel density (LVD) in pancreatic cancer was significantly increased compared with the non-cancerous pancreatic tissues (P < 0.0001). In pancreatic cancer, node-positive group exhibited significantly higher LVD compared with the node-negative group (P = 0.0208). Furthermore, high expression of VEGF-C was clearly associated with increased LVD in pancreatic cancer (P = 0.0001). Interestingly, tumor cells invading lymphatic vessels expressed more VEGF-C than other tumor cells of the primary tumors (P = 0.0074). The 5-year survival rate of patients with high LVD was significantly lower than that of patients with low LVD (P = 0.0414).

Conclusion. Lymphangiogensis in pancreatic cancer was significantly associated with VEGF-C expression and lymphatic metastasis and poor prognosis.

PP 62.01

BROKEN DORMIA IN BILIARY SYSTEM: UNUSUAL CASE REPORT

Anand, Kaushal; Saxena, Rajan; Kapoor, V.K.; Kumar, A; Richa, L; Behari, A; Singh, R; Prakash, A

SGPGIMS, Surgical gastroenterology, lucknow, India

Introduction. This a 3rd case reported in the literature with history of broken dormia basket retained during ERCP clearance of large CBD stone. extended indications for endoscopist to clear large and impacted stones with dormia may invite such complication in the future, needs a serious measures. A case history: 73 yr, male with pain in right hypochondrium for the 1 month not associated with fever, jaundice or vomiting.examination unremarkable. ultrasound showed cholelithiasis with multiple large CBD stones. Biochemistry– s. bilirubin T: 0.1 mg%, SGOT/ SGPT: 14/13 U/L, SAP.103 IU/L, TLC: 6.5 cells/cmm. Patient underwent ERCP- EPT, cholangiogram -3 large stones impacted in lower part of CBD. One 12mm stone crushed with mechanical lithotripter and failed to extract the stone, plastic stent placed. Patient remained asymptomatic 1 year readmitted march 2007. ultrasonography showed no stones in the CBD with stent in situ and dilated CBD at the upper part. MRCP before the laparoscopic cholecystectomy – large artifact coming at the hilum- forced to withheld the study. Patient remained stable. Radiologist opinion s/o metal artifact within CBD. In view to previous failed attempt by dormia, digital X ray AP view of abdomen(Image 1) confirmed broken dormia basket at hilum. After consultation with medical gastroenterologist endoscopic attempt done. At cholangiogram, no stones were present within CBD and dormia visualized in the CHD. A new dormia basket inserted and broken dormia held within it and gently removed without injury to the duct wall. Completion cholangiogram showed cleared CBD. Post procedure patient remained stable and on next day he underwent laparoscopic cholecystectomy with uneventful post operative course.

Discussion. Endoscopic management remains a gold standard for the CBD stones in the present era. With the increased experience of medical gastroenterologist and extention of indications may invite such complications.

PP 62.02

ROLE OF ENDOSCOPIC ULTRASOUND IN OBSCURE LOWER BILIARY TRACT OBSTRUCTION: A PROSPECTIVE STUDY

Kumar, Pavan¹; Bhatia, Vikram²; Dash, Nihar Ranjan¹; Pal, Sujoy¹; Sahani, Peush¹; Chattopadhyay, T.K.¹; Garg, Pramod²

¹AIIMS, Gastrointestinal surgery, New Delhi, India; ²AIIMS, Dept. of Gastroenterology, New Delhi, India

Background. Confirmatory diagnosis of lower biliary tract obstruction (LBT) continues to elude diagnostic modalities like CECT, MRCP and side viewing endoscopy (SVE) in a few proportion of patients. Endosonography (EUS) has the potential to assess the LBT from a close range.

Objective. To assess (i) the diagnostic accuracy of EUS in obscure lower biliary obstruction (OLBO) and (ii) its impact on management.

Methods. Fifty-five patients with a dilated common bile duct (CBD > 8 mm); the cause of which could not be ascertained by CT, MRCP and SVE were included in the study. By using a radial echoendoscope, CBD was evaluated. The result was correlated with surgicopathological/ ERCP findings/ clinical behaviour on long term (>6 months) follow-up.

Results. Patients were studied in 2 groups, Gr I (suspected benign, n = 24) and Gr II (suspected malignant n = 31). The sensitivity, specificity and accuracy of EUS in detecting the cause of obstruction were 93.3%, 100%, and 95.8% respectively in Gr I and 92.3%, 100%, and 92.8% respectively (likelihood ratio 25 & 14.2) in Gr II. EUS correctly identified the cause of obstruction in 14 and 27 patients respectively in Gr I and II and ruled out obstruction in 9 and 2 patients. EUS helped avoid a diagnostic ERCP in 41.6% and 22.5% in Gr I and II. It also avoided surgery in 9 patients in Gr I. In Gr II, EUS avoided surgery in 8 patients, simplified in one and strengthened indication for surgery in 8. EUS helped patient counseling regarding the nature of further management in 95.8% and 93.5% in the respective groups.

Discussion andConclusion. EUS is a sensitive, specific and accurate method for evaluation of OLBO. It has an im pact on management by avoiding ERCP and unnecessary surgery. It is useful in counseling prior to therapeutic interventions, especially in the present scenario of medico-legal litigation. However in our study EUS missed a 0.9 mm sized ampullary tumor and malignancy associated with a case of chronic pancreatitis. Operator dependence is also a limitation to EUS.

PP 62.03

NOTES IN PEG ASSISTED TRANSGASTRIC CHOLECYSTECTOMY BY DOUBLE CHANNEL FLEXIBLE ENDOSCOPY

Sugimoto, Maki; Yasuda, Hideki; Koda, Keiji; Yamazaki, Masato; Tezuka, Tohru; Kosugi, Chhiro; Higuchi, Ryota; Yagawa, Yousuke; Suzuki, Masato

Teikyo University Chiba Medical Center, Department of surgery, 3426-3 Anesaki Ichihara Chiba, Japan

Background. Natural orifice transluminal endoscopic surgery (NOTES) is a novel concept that combines aspects of laparoscopic with flexible endoscopic surgery. This might offer advantages over open and laparoscopic surgery.

Objective. We develop novel advanced technologies specifically for NOTES to overcome the limitations of isolated transgastric surgery using percutaneous endoscopic gastrostomy (PEG) assisted double channel flexible endoscopy.

Methods. Transgastric cholecystectomy was performed in five survival porcine studies. A flexible double channel endoscope was inserted perorally and PEG was replaced under infusion of carbon dioxide. Endoscope-induced pneumoperitoneum through the abdominal and stomach wall was applied, the endoscope was advanced into the peritoneal cavity over the PEG. Via the endoscopic double channel, a grasping instrument and a knife with an isolated tip were inserted for gallbladder traction to facilitate exposure of the cystic duct and artery assisted with a percutaneous needle grasper. Both the cystic duct and artery were identified, clipped, and transected. The gallbladder itself was then dissected and retracted through the mouth, and the gastric wall incision was safely closed with endoscopic clips.

Results. The time for transgastric removal of the gallbladder was within 60 minutes. The PEG could allowed the safe performance of a controlled gastric perforation and shorten the procedure time. Percutaneous gallbladder grasping and manipulation by needle grasper through the PED insertion, proved to be particularly valuable to enhance gastroscope-guided counter-traction and dissection. These approaches increased safety of initial gastric puncture and gastric wall incision.

Conclusions. Blending the use of a flexible endoscope and PEG approach might potentially overcome multiple intraperitoneal limitations in NOTES, and simplifies peroral transgastric cholecystectomy, could be used to decrease invasiveness.

PP 62.04

BILE DUCT INJURY AFTER LAPAROSCOPIC CHOLECYSTECTOMY, THE VALUE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Cheung, Chin Cheung¹; Leung, Kam Fung²; Wong, Wai Man²

¹Tuen Mun Hospital, Department of Surgery, Tuen Mun, New Territories, Hong Kong; ²Tuen Mun Hospital, Department of Surgery, New Territories, Hong Kong

Introduction and Aims. This study describes the value of endoscopic retrograde cholangiopancreatography (ERCP) in patients with bile duct injury after laparoscopic cholecystectomy(LC).

Method. and Results. 24 consecutive patients were studied over 4 year period (2002–2006) with ERCP done after bile duct injury from LC. The median age is 55 year old (31 to 77) with no gender difference. ERCP was performed after median of 14 days post-operatively (3 to 90 days). They presented with fever (20/24), pain (15/24) and cholestasis (4/24). Most of them had ultrasonography done with fluid collection around the Morrison pouch. In all patients, the biliary tree was visualised with ERCP. Two of them had complete bile duct obstruction with proximal hepaticojejunostomy performed; another two had incomplete obstruction at cystic duct area; while the remaining patients with leakage was detected at variable sites: 10 out of 24 leak over cystic duct stump; 3 leak over common hepatic duct; 3 leak over common bile duct; 3 leak over right intrahepatic duct and 3 leak over gall baldder bed. They all treated by endoscopic sphincterotomy and subsequent stent placement. One patient died of uncontrolled sepsis after ERCP.

Conclusion. Two patients with complete obstruction presented with a relatively prolonged symptom free period before diagnosis (1 month and 3 months). When patients do not recover uneventfully after lap cholecystectomy, even without cholestasis or jaundice, early ERCP is recommended as a safe and valuable method to detect bile duct injury and to suggest treatment. Subsequently, most of such patients can be treated endoscopically. Extended follow up is needed to evaluate the long term results.

PP 62.05

LAPAROSCOPIC ULTRASONOGRAPHY DURING LAPAROSCOPIC SURGERY IN HEPATOBILIARY DISEASE

PARK, IL YOUNG; KIM, SEONG AH

Holy Family Hospital, Catholic University of Korea, Surgery, Bucheon, Korea, Republic of

Introduction. With the increasing minimal invasive surgery, laparoscopic ultrasonograpy(LUS) has become more important. In laparoscopic surgery, surgeon can not palpate intra-abdominal and retroperitoneal structures. But by using the LUS, the surgeon is able to overcome some of this limitation.

Methods. Between August 2005 and July 2007, we underwent 52 patients consisting of gallbladder and common bile duct stones (38), malignancy staging (2), hepatobiliary mass (9) pancreatic mass (2). We use 7.5 MHz flexible tip ultrasound probe. LUS probe is passed through the umbilical or epigastric port. This probe has the capability of Doppler ultrasound including color flow-imaging. LUS is used in many procedures, including the examination of the common bile duct during laparoscopic cholecystectomy, the examination of the liver for primary and metastatic tumors, and the staging of hepatobiliary and pancreatic carcinomas. After learning the LUS technique, surgeons are able to provide optimal care for their patients by using the LUS.

Conclusions. We conclude that the use of LUS is a minimal, less time consuming and highly accurate method during laparoscopic surgery

PP 62.06

REVIEW OF BILIARY STENTINGS

Nakamura, Takayuki¹; Tagaya, Ranko²; Nogawa, Hideyuki²; Kon, Yoichi²; Fukai, Yasuyuki¹; Haga, Norihiro¹; Kawano, Noriaki¹; Sawada, Toshio¹

¹Gunma Prefectural Cancer Center, Surgical oncology, Ota, Gunma, Japan; ²Gunma Prefectural Cancer Center, Gastroenterology, Ota, Gunma, Japan

Introduction. Obstructive jaundice is one of the major complications in biliary malignancy. It causes hepatic dysfunction and sometimes biliary infections. Patients suffered general fatigue, anorexia, and insomnia duo to itchiness. That does not only disturb anticancer treatment but also interfere with quality of life. Biliary stenting brings a chance to recanalize stenotic biliary tracts. Two different approaches are available to place the biliary stent these days. One is percutaneous transhepatic route and another is endoscopical.

Aims. Benefits and problems are analyzed for the biliary stenting.

Methods. We reviewed all cases with biliary metallic stents in Gunma Prefectural Cancer Center from April 2006 to August 2007.

Results. Forty three patients (24 males and 19 females) were placed biliary metallic stents for their biliary obstructions or stenoses. Mean age was 69.2 years old. All of those stenoses and obstructions in biliary tracts were made by malignancy. Twenty one cases were bile duct carcinoma that was the leading causes. Pancreas cancer was the second and made fifteen cases. We chose the endoscopical approach for twenty six patients and the percutaneous transhepatic route for seventeen patients. Three patients had cholecystitis, that was the top of the early complications after biliary stenting. Eleven cases had stent malfunction. We experienced one case of stent migration and an interesting complication of intussuscepted stent. Median duration of the patency after stenting was sixty five days. Five patients couldn□ft leave hospital until the end of their lives after stenting. One of them took cerebro-vascular accident and other four cases had uncontrolled advances of their cancers.

Conclusions. Biliary stenting is safe and could improve quality of patient□fs life. The stenting devices are expected to have much longer biliary patency for the near future.

PP 62.07

SELECTION AND PLACEMENT OF STENTS IN A MALIGNANT NARROWING OF THE BILE DUCT

OGATA, KENJI; MAESHIRO, KENSEI; YAMASHITA, YUICHI; IKEDA, SEIYO

Fukuoka University School of Medicine, Gastroenterological Surgery, Fukuoka, Japan

Background. In bile duct cancer, the placement of multiple stents may be required, so the selection, placement, and patency period become issues.

Objectives. By April 2006, stent treatment (EMS: 57; TS: 60; no stent: 4) was performed for 121 cases of non-resected bile duct cancer. Problems in stent treatment were compared according to placement pathway, stent type, and treatment method, and countermeasures were discussed.

Results. 1. Placement pathway: Papillary placement of multiple TS or EMS was possible but difficult in the procedures, and cholangitis frequently occurred as a complication, so treatment in cases of reocclusion after EMS placement was difficult. 2. Stent types: TS has advantages in that it is inexpensive and easily converted and replaced, but the bore diameter and number that can be used is limited. The 50% patency rate of stents was 12 months in EMS and 3.5 months in TS, and particularly in cases of occlusion in the hepatic hilum, EMS was significantly superior. 3. Effects and complications of localized treatment: Tumor morphology is closely involved with reocclusion of stents. In histological types with a strong tendency of hemorrhagic necrosis filling the lumen of the bile duct or with large mucus production, early occlusion and dysfunction of stents frequently occur. For these cases, localized treatment from the lumen of the bile duct was effective (no stents in four cases). In addition, localized treatment not only prolonged the patency period of the stent but also contributed to prolongation of survival time. In localized treatment cases, internal drainage from a single route was possible in all cases.

Conclusion. In stent treatment for non-resected bile duct cancer, it is necessary to determine the placement pathway and the type of stent while taking the indications and particulars of localized treatment carefully into account.

PP 62.08

LONG-TERM RESULTS OF HEPATICO-JEJUNOSTOMY FOLLOWING BILIARY INJURY DURING CHOLECYSTECTOMY

Goihman, Yaakov¹; Kori, Issac²; Nakache, Richard¹; Klausner, Joseph¹; Ben-Haim, Menahem¹

¹Tel-Aviv Sourasky Medical Center, Surgery B and Transplantation, Tel-Aviv, Israel; ²Tel-Aviv Sourasky Medical Center, Interventional Radiology, Tel-Aviv, Israel

Introduction. The long-term outcome of hepatico-jejunostomy (H-J) to repair biliary injury during cholecystectomy is inadequately defined.

Metods. Retrospective analysis of data. Reconstructions by H-J were performed “immediately”, if diagnosed so; “delayed”, if diagnosed within 24–72 hours or electively (6–8 weeks) if diagnosed later. In the “elective” group, the anatomy of injury was studied and biliary drainage was achieved by percutaneous trans-hepatic cholangiography (PTC). Outcome was defined as “good”, if there was no need for any further intervention; “Fair”, if strictures were managed successfully by interventional radiology (IR) or “poor” if there was a need for surgical revision following failure of IR procedures.

Results. 24 patients were referred (2003–7). Injuries were at laparoscopic cholecystectomy in 18 and at open in 6 and included complete transaction of CHD (16), RHD (3), RPHD (2) and of more than 1 major duct (3). Original repairs were “immediate” in 10, “delayed” in 6 or “elective” in 8. Strictures developed in 7/10 (70%), 6/6 (100%) and 1/8 (12.5%) of H-J's, respectively. When compared by timing of repair, end-results were “good” in 3/10, 0/6 and 7/8; “fair” in 2/10, 3/6 and 1/8 and “poor” 5/10, 3/6 and 0/8, respectively (p < 0.05). Original H-J repairs were done by a HPB surgeon in 18 or by a general surgeon in 6. End-results were “good” in 10/18 vs. 0/6, “fair” in 5/18 vs. 0/6 and “poor” in 3/18 vs. 6/6 when compared accordingly (p < 0.05). Interval to clinical presentation of a stricture was 2–24 months and 5 years in one case.

Conclusions. The incidence of H-J stricture following biliary injury is higher than reported and long term follow-up is mandatory. Timing of definitive repair and surgeon's expertise are significant risk factors.

PP 62.09

BILIOBRONCHIAL FISTULA AFTER LIVER SURGERY FOR GIANT HYDATID CYST

Loinaz, Carmelo¹; Hernández, Teresa²; Martín, Jaime³; Pacheco, Pedro³; Ochando, Federico³; Fernández, Beatriz³; Hernández, Pilar³; García, César³; Rueda, José A³; Ramos, María³; Jiménez, Pedro³; Vorwald, Peter³; Fernández, Jose María³; Quintáns, Antonio³

¹Fundación Hospital Alcorcón, Surgery, Alcorcón (Madrid), Spain; ²Fundación Hospital Alcorcón, Radiology, Alcorcón (Spain), Spain; ³Fundación Hospital Alcorcón, Surgery, Alcorcón (Spain), Spain

Background. Biliobronchial fistula (BBF) is a rare complication in the natural history of liver hydatid disease by E. granulosus. We present a case of BBF after resection of a giant liver hydatid cyst in a 72 years old woman.

Methods. A total cyst-pericystectomy was done, leaving only the left lateral section, that was fixed to the diaphragm at the end of the operation. She developed a postoperative biliary fistula and obstructive jaundice. An ERCP showed an “stop” at hte junction of the left biliary duct and the main biliary duct, and contrast leak. At reoperation the main duct showed a torsion at its longitudinal axis and the tissue seemed ischemic. A hepatotomy was done at the hilar plate and a biliary duct (1cm) was dissected to anastomose to a Roux en Y jejunal loop. She was discharge without complications.

Results. Five months later she developed a bout of cholangitis and was successfully treated with antibiotics. After repeated respiratory infections she was admitted four months later with fever, cough, right lower lobe pneumonia and bilioptisis. the doagnosis of BBF was confirmed with HIDA. At transhepatic cholangiography an important bile duct dilation was seen, with a bilio-thoracic leak. A stenosis of the bilio-jejunal anastomosis was dilated and an external-internal catheter was left in place. Repeated controls showed nor fistula neither stenosis and the catheter was retrieved 3 1/2 months later. One year later the patient is in very good condition.

Conclusion. An indirect treatment of the BBF by dilation of the biliary stenosis avoided a more invasive treatment

PP 62.10

ONLY PERCUTANEOUS DRAINAGE PROCEDURES WITHOUT ENDOSCOPIC INTERVENTION AS THE TREATMENT OF BILE LEAK AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Lee, Daesung; Kim, Hyuntae

Sunlin hospital, Pohang, Korea, Republic of

Background. Bile leak is a potential complication after laparoscopic cholecystectomy. Early diagnosis and treatment are very important to decrease the morbidity and mortality related to bile leak.

Objective. Endoscopic intervention is widely accepted as a choice of diagnosis and treatment in patients who are decided to be treated non-operatively today. But, we treated symptomatic bile leak only by drainage procedures without endoscopic modalities.

Methods. From July 2004 to May 2007, 207 patients underwent laparoscopic cholecystectomy at Sunlin hospital by a single surgeon. Patient records and radiologic findings were reviewed. A bile leak was identified in 4 patients. Three patients were mananged non-operatively and one was reoperated by primary suture on right hepatic duct for a severe bile peritonitis. We analysed 3 patients underwent a non-operative management.

Results. The male-to-female ratio was 2:1. All was dignosted gallbladder stone with cholecystitis in preoperative ultrasound. All were operated with infrahepatic drainage tube. We detected bile leaks through postsurgical drainage tubes in all patients. We performed a computer tomography and a hepatobiliary scintigraphy. One patient could be successfully managed without any other modalities. Two patients were managed with percutaneously drainage procedure without endoscopic intervention. External biliary drains were removed at postoperative 20 or 82 days, respectively. All patients were asymptomatic at a mean follow-up of 15 months.

Conclusion. A infrahepatic drain insertion may be usefully by a case-by-case basis for the early detection of bile leaks. Bile leaks can be successfully treated by Only percutaneous drainage procedures without endoscopic intervention.

PP 62.11

A CASE OF NEUROENDOCRINE CARCINOMA OF COMMON BILE DUCT

Cho, Chol Kyoon¹; Koh, Yang Seok¹; Kim, Hyun Jong¹; Kim, Jung Chul¹; Hur, Yong Hoi¹; Park, Chang Hwan²; Lee, Wan Sik²; Choi, Sung Kyu²; Rew, Jong Sun²; Jung, Yong Yeon³; Shin, Sang Soo³; Lee, Jae Hyuk⁴

¹Chonnam National University Medical School, Surgery, Gwangju, Korea, Republic of; ²Chonnam National University Medical School, Internal Medicine, Gwangju, Korea, Republic of; ³Chonnam National University Medical School, Radiology, Gwangju, Korea, Republic of; ⁴Chonnam National University Medical School, Pathology, Gwangju, Korea, Republic of

Background/Aim. Neoplasm derived from neuroendocrine(NE) system comprise a large and heterogenous spectrum with a range of benign NE tumor or carcinoid to NE carcinoma. The ability to differentiate between NE carcinoma and benign NE tumor is based on histologic, cytologic, and immunohistochemical differences. NE carcinoma of extrahepatic bile duct(EHBD) is extremely rare and accounts for 0.2–2% of all gastrointestinal NE t umor. The biological behavior of NE carcinoma of EHBD is aggressive and is associated with a significantly shorter survival time than carcinoma with exocrine differentiation. Herein we present a case of NE carcinoma of common bile duct(CBD) with evaluation of clinical course.

Methods. The patient was 57 year-old-female and abdominal CT and MRI showed 2.5X2.0 cm sized well-enhancing polypoid mass at distal CBD with dilatation of intra and extrahepatic bile duct. The laboratory findings including tumor markers were non-specific except the findings of obstructive jaundice. In operation, there was 3X3 cm sized hard mass at distal CBD and pylorus preserving pancreaticoduodenectomy with lymphnode dissection was performed.

Results. In gross finding, there was 2.6X2.2 cm sized well defined white mass at distal CBD obstructing the lumen. In microscopic examination, the tumor was mixed tumor of ductal adenocarcinoma and NE carcinoma. The results of immunohistochemical study were as follow; p53 (+), Ki–67 (+), Topoisomerase II (+), CK7 (+), CK 20(+, focal), E-cadherin (+), Vimentin(−), Chrmogranin (+), Synaptophysin (+), CD56 (+), Insulin (−), Glucagon (−), Pancreatic polypeptide (−). The TNM staging was T2N0M0. The postoperative course was unremarkable and adjuvant chemotherapy with Gemcitabine and 5-FU was administered. In the follow up evaluation, multiple hepatic metastasis were detected 3 months after operation and the patient received conservative treatment.

Conclusions. We report a case of NE carcinoma of CBD which is extremely rare and is very aggressive in clinical course.

PP 63.01

VASCULAR RESECTIONS DURING PANCREATODUODENECTOMY FOR PERI-AMPULAR TUMORS

Vigia Duarte, Emanuel; Pereira, Jorge; Coelho, João; Pereira, José António; Marques, Hugo; Mira, Paulo; Martins, Américo; Barroso, Eduardo

Hospital de Curry Cabral, Centro Hepatobiliopancreático e de Transplantação, Lisboa, Portugal

Background.Nowadays, vascular resection during pancreatoduodenectomy (PD) for peri-ampular tumors (PAT) is feaseble and can lead to a survival similar to the one found in patients without vascular invasion.

Aims. To prove that in 8 cases of vascular resection during PD for PAT of 97 patients, prognosis and survival were similar to those patients without vascular invasion.

Methods. 97 PD between 2003 and 2007; 8 patients (4 male and 4 female) with vascular invasion: Vena cava (1); Portal Vein (3); Superior mesenteric artery (1); Right hepatic artery (2); Superior mesenteric vein (1). Surgical procedures: 7 Whipple's PD and 1 Traverso-Longmire PD. One case: Gore-Tex prothesis due to superior mesenteric artery resection (intra-operatively arterial invasion finding).

Results. Mortality: 1 case of sepsis in the peri-operative period; Morbidity: ascitic fluid infection leadind to reoperation at day 5 (1 case); Post-operative fever (2 cases); Outcome: 2 patients died (7 months and 12 months); Median follow-up: 15 months (5–32 months) all without relapse.

Conclusions. Outcome of patients with PAT with vascular invasion (excluding superior mesenteric artery) is comparable to the one of patients without it, inespective of tumor stage, extent of wall invasion and extent of vascular resection. Surgical resection of a PAT with vascular invasion must always be considered as a valuable technique in these patients.

PP 63.02

IS STAGE AND LONG-TERM SURVIVAL OF PANCREATIC CANCER PATIENTS UNDERGOING A WHIPPLE'S PROCEDURE PREDICTED BY PREOPERATIVE BODY COMPOSITION?

Smith, Ross C¹; Aslani, Alireza²; Cooper, Bruce A³

¹Royal North Shore Hospital, Department of Surgery, Sydney, Australia; ²Royal North Shore Hospital, Department of Nuclear Medicine, Sydney, Australia; ³Royal North Shore Hospital, Department of Renal Medicine, Sydney, Australia

Background. The status of the resection margins for pancreatic cancer is a significant predictor of survival but it could also be important to determine the influence of nutritional status on this outcome.

Aims/Objectives. The aim of this study was to determine the difference in survival between patients undergoing Whipple's Procedure (WP) and receiving a Clear Margins (CM) and the patients receiving an Unclear Margins (UCM). In addition, the predictive value of different body composition (BC) measurement parameters were assessed and investigated.

Methods. WP was performed on 31 patients, 17 males and 14 females (age range: 42 to 81y; mean: 67y; median 69y), with pancreatic cancer. Detailed preoperative BC measurements included: Total Body Nitrogen (TBN) using In Vivo Neutron Capture Analysis (IVNCA), Nitrogen Index (NI), Total Body Water (TBW) by Bioelectrical Impedance Analysis (BIA), percentage body fat (%BFat) from skin-folds and BIA.

Results. Patients with involved margins at the time of resection were significantly more likely to be males (7/11 v 10/20), with a lower Body Mass Index (22.0 v 24.9 m/kg2), Body Fat (13.6 v 22.9 kg), and total body potassium to height ratio (0.58 v 0.63 g/m) (Binary Logistic Analysis). Cox's backwards stepwise regression analysis demonstrated survival to be predicted by margins and presentation values for age, fat mass, Lean body mass and Total Body Potassium (TBK).

Conclusions. When patients with resectable cancers of the head of the pancreas have involved surgical margins they are also likely to have preoperative nutritional deficits compared to those without resectable margins. Further more these nutritional deficits appear to have an impact on the patient's long term survival.

PP 63.03

CARCINOMA OF THE AMPULLA OF VATER: EARLY AND LATE RESULTS OF PATIENTS UNDERGOING RADICAL RESECTION

Haddad, Luciana B P¹; Almeida, José L J¹; Jukemura, José¹; Andraus, Wellington¹; Montagnini, André¹; Penteado, Sônia¹; Abdo, Emilio¹; Jureidini, Ricardo¹; Matheus, André S¹; Perini, Marcos²; Bachella, Telésforo¹; Machado, Marcel C C¹; Cecconello, Ivan¹; da Cunha, José E M¹

¹University of São Paulo School of Medicine, Department of Gastroenterology, São Paulo, Brazil; ²

Background. Ampullary tumors consist a rare clinical entity and have a better prognosis than others periampullary tumors. The aim of this study was to analyze presenting clinical features, surgical outcome and predictive survival factors in a single institution series.

Patients andMethods. From January 1985 through December 2006, 106 patients underwent pancreaticoduodenectomy for ampullary adenocarcinoma at Hospital das Clínicas of São Paulo University School of Medicine. The correlation between clinicopathologic variables and survival was tested by Kaplan-Meier method and log-rank test.

Results. There were 64 men (60.4%) and 42 women with a mean (s.d.) age of 59.3 (11) years. Jaundice (81.6%), weight loss (68.6%) and abdominal pain (60.7%) were the most common presenting symptoms. Sixty-one (57.6%) patients were submitted to pylorus-preserving pancreaticoduodenectomy and 45 (42.4%) to a Whipple resection. Median operative time was 581±126 minutes. The surgical morbidity rate was 56.6%. Delayed gastric emptying (27.4) and pancreatic fistula (21%) were the most frequent complications. Thirty-day mortality was 2.9% (3 of 106 patients). Median follow-up was 54 months (range 6–156 months). Median survival was 108 months. The overall 5-year survival was 54.7%, and 30,7% in node-positive patients. Survival was found to be significantly affected by pre operative jaundice (0.001), serum albumin levels lower than 3g/dL (p = 0.011), blood transfusion (p = 0.024), tumor grade (p = 0.011) and nodal status (p = 0,003). In multivariable analysis, jaundice, tumor grade and lymph node status were related with worse survival rates.

Conclusion. Pancreatoduodenectomy is the treatment of choice for ampullary carcinoma, but despite the low mortality, there is still a high morbidity associated with this procedure. Preoperative jaundice, tumor grade and lymph node status showed to be important survival factors.

PP 63.04

WHITE CELL COUNT AND ALBUMIN PREDICTS THE INCIDENCE OF POST-OPERATIVE COMPLICATIONS FOLLOWING PANCREATIC SURGERY.

Wijeyekoon, Sanjaya¹; Fusai, Giuseppe²; Ramamoorthy, Rajarajan²; Sra, Harminder³; Davidson, Brian R²

¹The Royal Free Hospital, Hepato-Pancreato-Biliary & Liver TransplantSurgery, Pond Street, London, United Kingdom; ²The Royal Free Hospital, Hepato-Pancreato-Biliary & Liver TransplantSurgery, London, United Kingdom; ³University College London, London, United Kingdom

Background. Pancreatic surgery has a high complication rate, early detection of which potentially reduces mortality. Inflammatory markers have traditionally been used to predict development of complications in a non-quantitative way. Several studies have identified a prognostic role for IL6, IL8 and IL10, procalcitonin, body mass index, obesity, patient age and extended res ections. We evaluated the utility of simple inflammatory markers such as white cell count (WCC), Platelet count (PLT), C-reactive protein (CRP) and albumin (ALB) to quantitatively predict the development of post-operative complications after pancreatic surgery.

Method. A retrospective cohort of 123 consecutive pancreatic resections performed between 2004–2007 was analysed. Serial inflammatory markers between day 0–15 were evaluated for their association with “In-hospital complications”, the out-come measure. Analyses were performed with logistic regression.

Results. 34.1% experienced a complication. Only WCC (p = 0.013) and ALB (p = 0.05) on the 5th post-operative day were significantly and independently associated with the outcome. The risk model based on WCC & ALB had an ROC = 0.65, sensitivity of 69.1%, specificity 54.3%, positive predictive value 43.9% and negative predictive value of 77.2%. Patients with a combination of ALB on day 5 <25 and WCC ≥11 had 7.6 (2.0 — 28.8) times the risk, along with a probability of 63% of developing a complication.

Conclusion. WCC and ALB on the fifth post-operative day only were significantly and independently related to the development of in-hospital complications. CRP and PLT showed no association with complications. A combination of WCC ≥11 and ALB <25 resulted in the highest risk. The nomogram we have developed could be used at the bedside to predict a given patient's probability of developing complications after the 5th post-operative day.

PP 63.05

TREATMENT OF PERIAMPULLARY AND PANCREAS TUMORS: A SINGLE CENTER EXPERIENCE

uguz, alper¹; gurcu, baris²; aydin, unal²; nart, deniz²; ersoz, galip²; ozutemiz, omer²; tekesin, oktay²; elmas, nevra²; goker, erdem²; ozkok, serdar²; yilmaz, funda²; zeytunlu, murat²; coker, ahmet²

¹ege university school of medicine hospital, HPB working group, izmir, Turkey; ²ege university school of medicine hospital, HBP working group, izmir, Turkey

Purpose. our purpose is to study mortality and morbidity and survival of the pancreatic and periampullary tumors which has diagnosed, treated in Ege University School of Medicine Department of General Surgery.

Methods. findings in new 143 cases between the dates of June 2003 and December 2006 were retrospectively analyzed according to diagnosis, tumor regions, surgical and adjuvant therapy, mortality and morbidity and survivals. We perform standart pancreaticoduodenctomy to periampullary tumors and distal standart pancreatectomy to pancreas body tumors as surgigal treatment. The patients received gemcitabine and combined gemcitabine-radiotherapy as adjuvant therapy. Kaplan-meier proportions used in survival analysis.

Results. forty cases had radiological vascular invasion and only 18 of them had vascular invasion. Diabetes and/or hipertension were the most common systemic diseases. Mean ASA(american society of anesthesiologists) scores was two and mean CA19–9 was 229. preop biliary stent insertion was performed to 45 cases. Twenty six cases were not operated. Fifteen cases had perioperative major complication. Surgical procedures performed on 77(%57) cases for periampullary tumors, 37(%27) cases for pancreatic body masses. Four (%3) of them was chronic pancreatitis. Seventyone of them were adenocancer, and 43 was the other types. Perioperative mortality was 3(%0,65), and major mobidity(leakage, GÝ bleeding) was 5(%1,38). Median survival rates of pancreas head and distal bile duct cancers were 19.62±1,42 months, pancreatic body tumors were 12,32±1,11 tumors of the papilla were 20,36±1,41 months.

Conclusion. this study demonstrates that surgery can be performed safely in an experienced department on HPB. The results are acceptable. The major aim must be to continue performing a standart surgery and giving a treatment chance to the patients with adjuvant therapies.

PP 63.06

SIMULTANEOUS HEPATIC RESECTION WITH PANCREATODUODENECTOMY AND PORTAL VEIN RESECTION FOR METASTATIC PANCREATIC CANCER: A CASE REPORT

Dulundu, Ender; Ozel, Yahya; Ozkan, Erkan; Kayahan, Munire; Topaloglu, Umit

Haydarpasa Numune Education and Research Hospital, 5th Department of Surgery, Istanbul, Turkey

Introduction. Pancreatic cancer is a common gastrointestinal cancer with one of the worst prognostic malignancy. Despite recent advances in the field of medical and radiation oncology, surgery remains the single most important modality for the treatment of pancreatic cancer. On the other hand most patients are diagnosed at an advanced and unresectable stage. Generally, metastatic liver tumors from pancreatic cancer are not indicated for surgical treatment in most of the center, and simultaneous liver and pancreatic resection was recently considered to be a safe operation.

Case Report. A case of simultaneous hepatic resection with pancreatoduodenectomy and portal vein resection for metastatic pancreatic cancer, in a 66 –year- old man who obtain relatively long survival, is presented. Patient presented to our clinic with jaundice and loss of appetite. A computed tomography examination showed a 20×25 mm mass lesion on the pancreatic head which was also invaded the portal vein. As the patient agreed to operation, he was admitted to the operation theatre. During the exploration of the abdominal cavity a 1.5 cm metastatic tumor was found in the right anterior segment of the liver. Pancreatoduodenectomy with portal vein resection and hepatectomy was performed. Patient is still alive after two years of the operation, without any metastases and recurrences.

Conclusion. Hepatectomy with pancreatoduodenectomy might offer a prolonged survival in highly selected patient with metastatic liver disease from a pancreatic cancer.

PP 63.07

EFFECT OF SURGICAL MARGINS ON LONG TERM BODY COMPOSITION CHANGES AFTER A WHIPPLES PROCEDURE

Smith, Ross¹; Aslani, Alireza²

¹Royal North Shore Hospital, Department of HPB and Upper GI Surgery, 5/5 North Shore Private Hospital, St.Leonards, Australia; ²Royal North SHore hospital, Body Composition, StLeonards, Australia

Recovery following a Whipple's Procedure may be determined by the patient's nutritional status. Recovery of protein and fat losses should improve patient's response to adjuvant therapy which is mandatory when margins are involved. It is important to study the effect of margin involvement on long term nutritional status through detailed body composition measurements.

Aim. The aim of this study was to describe the detailed body composition changes that occur during the first 6 months after a Whipples Procedure for pancreatic cancer and to determine the differences in patients with clear (CM) and Unclear margins (UCM).

Methods. 31 consecutive patients undergoing a Whipples Procedure (WP) for pancreatic cancer were invited to undergo detailed nutritional assessment at time points -1 and 2, 5, 14, and 26 weeks after surgery. Nutritional assessment included measures of body weight, protein using in vivo neutron capture (TBP), fat skin folds (TBF), water by bioimpedance (TBW) and potassium shielded chamber (TBK).

Results. 11 were reported by the pathologist to have UCM while 20 had CM. All patients were studied at -1, 2 and 5 week time points, while 3/11 UCM v 3/20 CM patients could not attend at 14 weeks and 8/11 UCM v 5/20 CM patients could not attended at 26 weeks because of progressive disease or chemotherapy. Although the UCM patients had lower fat stores prior to surgery these were maintained at 5 and 14 weeks after surgery similarly to those with CM. The patients with CM gained a mean of 0.83 kg protein by 14 weeks (P = 0.04) while those with UCM maintained discharge TBP values during this period. TBK and Fat free mass were maintained equally well in UCM and CM groups during the first 14 weeks after surgery.

Conclusions. It is concluded that patients maintain their discharge body composition for the first 14 weeks after surgery even when the pathological margins are involved but the rapid drop off rate in those with UCM implies that disease progression with many patients after that time point.

PP 63.08

RE-ADMISSIONS AFTER PANCREATICODUODENECTOMY: CAUSES AND OUTCOME.

Tank, Avinash Kumar; Tank, Avinash Kumar; Singh, Rajneesh Kumar; Behari, Anu; Kumar, Ashok; Saxena, Rajan; Kapoor, Vinay Kumar

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Surgical Gastroenterology, Lucknow, India

Introduction. Postoperative morbidity following pancreaticoduodenectomy (PD) has been highlighted in several reports, there are however very few published series of re-admissions after PD.

Method. Between 1989 and 2006, 338 patients underwent PD and 307 were available for follow-up (31 died in the post operative period). Sixty four patients (19%) required readmissions. Prospectively maintained database was analyzed with regards to presentation, treatment and outcome.

Results. There were 106 re-admissions of 64 patients; 64 (60%) re-admissions were related to complications of index surgery, 38 (36%) re-admissions were related to tumor recurrence and 4 (4%) re-admissions were related to post-radiotherapy complications. Forty-two re-admissions were within 1 year following index surgery and 64 were beyond 1 year. The major causes of re-admissions related to complications of index surgery were-small bowel obstruction (n = 9), stent or T-tube related re-admission (n = 8). Seventeen (16%) re-admissions required surgery, 23 (22%) were treated with percutaneous/ endoscopic interventions and 66 (63%) were managed conservatively. The overall outcome of re-admissions (n = 106) was complete recovery in 32 (30%), partial recovery in 39 (37%), problem persisted in 7 (6%) and 28 (27%) re-admissions showed gradual deterioration, including hospital death of 2 patients. There was no statistical difference in survival in the readmitted Vs not readmitted group (median survival 30 months Vs 20 months respectively). On comparison of two groups, postoperative intra-abdominal abscess (p = 0.021) was predictive of subsequent readmission.

Conclusion. Re-admission is frequently required after PD for reasons related to complications of index surgery, tumor recurrence and post-radiotherapy complications. Most patients with index surgery related re-admissions could be managed successfully while tumor recurrence related re-admission has a low success rate. Re-admissions did not adversely impact the overall survival of patients.

PP 63.09

CLINICAL AND PATHOLOGICAL PROGNOSTIC FACTORS AFTER RESECTION FOR PANCREATIC CANCER

Perini, Marcus Vinicius¹; Montagnini, Andre Luiz¹; Penteado, Sonia¹; Jukemura, Jose¹; Patzina, Roseli¹; Cunha, Jose Eduardo²; Cecconello, Ivan³

¹University of S.Paulo, Department of Gastroenterology, S.Paulo, Brazil; ²University of S.Paulo, Department of Gastroenterology, Brazil; ³Brazil

Background. -Pancreatic cancer one of the main causes of cancer related deaths, surgical resection is currently the only established therapeutic option with curative potential for this disease.

AIM. to correlate clinical and pathological parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma.

Methods. Surgical resection with curative intent was performed in sixty five patients with pancreatic cancer between 1990 and 2006. The results of surgical treatment were retrospectively analyzed and compared to the clinicopathological features of these patients.

Results. Pylorus preserving pancreatoduodenectomy was performed in 56.9%, Whipple resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. Postoperative complications occurred in 28 patients (43.1%) Mean survival and 5-year survival rate after surgical resection were 27.17 months and 7.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and resection margin involvement were the significant prognostic factors.

Conclusion. Pancreatic cancer patients, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.

PP 63.10

BINDING PANCREATO-JEJUNOSTOMY, A NEW TECHNIQUE FOR SAFER PANCREATODUODENECTOMY

Verma, G.R.

PGIMER, Surgery, Chandigarh, India

Background.Pancreato duodenectomy is a formidable procedure associated with sizable morbidity and mortality up to 5%. Major morbidity is due to disruption of pancreato enteric anstomosis. The anastomotic leakage related mortality accounts for 40–50%. A number of procedures and modifications have been described in the literature to curtail the incidence of PJ Leak following pancreato duodencetomy. However, the leak rate still hovers around 7–20%.

Methods.Pancreato duodenectomy was performed by a single surgeon in fifteen patients of periampullary or pancreatic tumors in the preceding three and half years (2003–07) at PGI Chandigarh, a tertiary referral hospital in northern India. Ten patients were male and five females. The age varied from 27–65 years (mean 48.6 years). In ten patients, a standard Whipple's while in five, pylorus preserving Pancreato duodenectomy was performed. Pancreto-jejunal anastomosis was done with a new technique called “Binding pancreato jejunostomy”. Technical detail shall be discussed.

Results. Drain fluid amount and amylase values were estimated up to ten days after surgery. Octreotide was not given to any patient. Mean post operative stay was 16.8 days (11–38 days). Morbidity was observed in 36.3% (6/14). However, none of the patients except one developed PJ leak, due to avoidable technical reason. One patient died from Post operative bleed due to uncontrolled hypertension. The remaining fourteen patients were followed up from 3–40 months (mean- 15.9 months). Twelve are alive and free of disease. Two died after twelve and fourteen months of surgery from disseminated disease.

Conclusion. It may be concluded that Binding Pancreato Jejunostomy is a safe and efficient technique to prevent PJ leak following pancreato duodenectomy.

PP 64.01

STEREOTACTIC RADIATION THERAPY WITH BODY FRAME (SBF) IN HEAPTICO-PANCREATICO-BILIARY (HPB) TUMORS

Mahantshetty, Umesh¹; Patil, Nikhilesh¹; Jamema, SV²; Engineer, Reena¹; Shrivastava, SK¹; Mohandas, KM³; Shukla, PJ⁴; Shrikande, SV⁴; Dinshaw, KA⁵

¹Tata Memorial Hospital, Radiation Oncology, Mumbai, India; ²Tata Memorial Hospital, Medical Physics, Mumbai, India; ³Tata Memorial Hospital, Digestive Diseases and Nutrition, Mumbai, India; ⁴Tata Memorial Hospital, GI Surgical Oncology, Mumbai, India; ⁵Tata Memorial Centre, Radiation Oncology, Mumbai, India

Background and Rationale. Unresectable HPB tumors have dismal outcome with a median survival of 6 months. Various treatment modalities like, bypass surgeries, palliative resections, stenting, embolisation, chemotherapy and radiation therapy have been tried. Recent reports have demonstrated that the stereotactic technique using a body frame is safe and with hypo-fractionated regimens could be efficacious for palliation. At Tata Memorial Hospital, Stereotactic irradiation of extracranial targets was initiated in 1998 adopting the method from Karolinska Hospital, Stockholm. With an aim to evaluate the feasibility, toxicities and treatment results of extracranial stereotactic radiotherapy (ESRT) for palliation in extra cranial targets mainly HPB lesions, we undertook this retrospective analysis.

Material andMethods. Patients with locally advanced/unresectable HPB tumors less then 3 in number and none more than 4cm were offered palliative radiation with stereotactic radiotherapy. All patients underwent stringent planning process which requires 5–7 days.

Results. With a mean age of 44 (30–65) years, thirty-one (HPB: 15; Hepatic mets: 4; Cholangiocarcinomas: 5) patients treated with stereotactic radiotherapy using body frame between 1998–2006. Out of 31, Partial response 10 (33%), stable disease15 (48%) and remaining 6 (19%) had progressive disease. Few patients also received palliative chemotherapy. With a median follow-up of 27 months (3–32 months), 21 patients achieved good palliation. One patient developed duodenal ulceration at 10 months post treatment, but improved with conservative treatment only.

Conclusions. Our initial experience with extracranial stereotactic radiotherapy in hepato-biliary cancers and non-colorectal hepatic metastasis is enterprising.

PP 64.02

OVERLAY NAVIGATION SYSTEM OF CARBON DIOXIDE MDCT CHOLANGIO-PANCREATOGRAPHY GENERATED BY OSIRIX PROVIDE ACCURATE 3D IMAGE GUIDED HEPATO-PANCREATO-BILI

Sugimoto, Maki¹; Yasuda, Hideki¹; Koda, Keij¹; Yamazaki, Masato¹; Tezuka, Tohru¹; Kosugi, Chihiro¹; Higuchi, Ryota¹; Yagawa, Yohsuke¹; Suzuki, Masato²

¹Teikyo University Chiba Medical Center, Surgery, 3426–3 Anesaki Ichihara Chiba, Japan; ²

Background/Aim. The application of virtual reality (VR) surgical assistance, in which medical images are processed to provide reference images for preoperative surgical planning or during surgery, is being evaluated. Overlay technique is a most recent VR navigation system. We describe a new overlay navigation system with carbon dioxide MDCT cholangio-pancreatography (CMCP) enables synchronous visualization of HPB anatomy overlaid on the real operative field provides real time image-guided 3D navigation for HPB surgery.

Methods. 16-slice MDCT was performed in 70 HPB patients under trans-papillary infusion of carbon dioxide and synchronously contrast material administered intravenously. Virtual CMCP angiography (CMCPA) was generated by DICOM viewer OsiriX. 3D reconstruction (volume rendering) were incorporated and overlaid on the patient body surface and operative field from the projector during surgery. Capability of the intra-operative virtual navigation was evaluated.

Results. Overlay of CMCPA, superimposed on the actual space in front of the surgical operator on the patient□fs operative field or the surface of the abdomen, provided accurate information for localizing the target lesions of HPB and GI anatomy with its relationship to the surrounding vessels. This could help acquiring better hand-eye coordination to decrease the intraoperative complications and avoide organ injuries by accurate augmentation.

Disscusions/Conclusions. When a surgeon consults an image displayed on a monitor, there is a distance arising from the actual view of the operative field, hence, a technology for dynamic 3D images that fuses together the actual space and the virtual space became necessary. Our overlaid image guided navigation system demonstrated its clinical usefulness in reproducing detailed planning simulation in complex HPB surgeries. It makes it possible to perform detailed HPB surgeries easily and accurately by providing accurate intraoperative real time 3D navigation.

PP 64.03

SHORT – TERM RESULTS OF ROBOTICALLY ASSISTED LAPAROSCOPIC TREATMENT OF HEPATIC CYSTS

Langer, Daniel; Ryska, Miroslav; Dolezel, Radek; Pudil, Jiri

Surgery Department, 2nd Faculty of Medicine, Charles University and Central Military Hospital Prague, Prague, Czech Republic

Background. Hepatic cysts do not fall into common disease group in the middle Europe. There are non-parasitic cystical lesions in nearly all of the cases. Only minor part of patients with cystical liver masses suffer from clinical disorders and vindicate surgery treatment. The authors intention is a short-period results presentation of robot-assisted liver cyst surgery.

Method. Group evaluation of 8 patients, who underwent minimally invasive operative treatment for symptomatic liver cyst disease in our surgery department since the 1.4.2006 till 31.5.2007.

Results. Group of our patient was composed of 7 women (88%) and one man (12%), average aged 61.1 years, in range of 42 to 72 years. All operative procedures were finished in laparoscopic way. Operation duration time averaged 105 minutes. There were only solitary cyst masses in our group, localized in the right hepatic lobe in one half of cases. Cholecystectomy was accomplished in one patient simultaneously. We did not record any early complications nor deaths in evaluated patients. Blood losses were negligible with no need of any blood transfusion product substitution. We revealed just one recurrence 12 months after operation in one of our patients. The average follow-up time was 5 months (in range of 2 to 12 months).

Conclusion. Our laparoscopic liver cyst (polycystosis excepted) surgery experience supports and advocates laparoscopic treatment to be useful modality with minimal morbidity and mortality in concordance with literature conclusions. Da Vinci robotic system has notably assisted in less accessible hepatic segments. Presented results of our group are comparable with other published conclusions. We rate our results as temporary considering short term trial.

PP 64.04

MUCINOUS CYSTIC NEOPLASM OF THE PANCREAS: CLINICOPATHOLOGIC MARKER THAT MIGHT SUGGEST MALlGNANT POTENTIAL

Yang, Sung Hoon

Seoul National University College of Medicine, Department of Surgery, Seoul, Korea, Republic of

Background & Aims. Mucinous cystic neoplasm (MCN) of the pancreas could have a malignant potential. But, we would be difficult to differentiate between benign and malignant lesion of MCN. Our aims were to investigate the clinicopathologic marker that might suggest malignant potential of MCN.

Methods. In this retrospective study, we enrolled 56 MCN patients who received the resection of the MCN at our center between 1991.8.1 and 2006.8.30. Medical records of the MCN patients were reviewed to obtain clinico-pathologic data.

Results. Patients with MCN were almost exclusively (n = 55, 98.2%) women; we identified 1 man with benign MCN. The mean (±SD) age at resection was 49±14 years (82.5% < 60 y). Abdominal pain was the most common presenting symptom; 32.1% (n = 18) were asymptomatic. Most MCN (n = 52, 92.9%) were in the pancreatic body/tail region. Their median size was 5 cm (range: 1.5–20 cm, 55.4% > or = 5 cm). Histologically, 32 (57.1%) were benign MCNs, 18 (32.1%) were borderline MCNs, 4 (7.1%) were non-invasive MCNs, and 2 (3.6%) had invasive cancer. Among the 40 MCN patients who the pathologic review could be performed, 36 (90%) had the ovarian stroma. All 4 MCNs without the ovarian stroma were benign or borderline. The 2 invasive MCNs had 5 and 11 cm-sized tumors, respectively. The 4 non-invasive MCNs had 1.5, 2.5, 3, 6.5 cm-sized tumors, respectively. The tumor sizes of benign and borderline MCNs were very various from 1.5 cm to 20 cm. The average ages of non-invasive or invasive MCN patients and benign or borderline MCN patients were 48.5 and 48.9 years, respectively. One female patient with a 4 cm-sized benign MCN of the pancreas had a metastatic MCN of the liver.

Conclusions. In this study, no clinicopathologic marker that might suggest malignant potential could not be found. Further study would be needed to determine the malignant marker in the MCN of the pancreas.

PP 64.05

PANCREATICO-DUODENECTOMY FOR BENIGN PANCREATIC LESIONS IN A UK SPECIALIST HPB CENTRE

Mukherjee, Samrat; Adansi-Pipim, Yaw; Smith, Marty; Bhattacharya, Satyajit; Hutchins, Robert R; Abraham, Ajit T; Kocher, Hemant M

Barts and the London HPB Centre, London, United Kingdom

Background. Over the last 25 years, pancreatico-duodenectomy (PD) has gained increasing acceptance as an effective and safe method for treating malignant neoplasm of the pancreas. Increasingly PD is done for benign diseases in the peri-ampullary region. AIMS: To evaluate clinical experience with patients undergoing a PD, with a benign histological diagnosis, in a UK specialist HPB centre.

Methods. Patients with pancreatic pathologies undergoing resection at our institution from 1999 to 2007 were identified and those with benign histology were extracted. We analysed the outcomes with respect to mortality, morbidity and length of stay.

Results. Of 166 patients undergoing a PD, 27 (16.2%) patients had a benign histology [Chronic pancreatitis (n = 11), endocrine tumours (n = 7), intra-papillary mucinous neoplasm (n = 3), duodenal adenoma (n = 3) and others (n = 3)]. Median age was 51 (range 31 to 82) years. There was no mortality and the overall morbidity was 12 (44.4%). The most frequent and severe complication was a pancreatic anastomotic leak (n = 4, 14.8%) of which 2 patients (7.4%) underwent a re-laparotomy. The median length of stay was 18 (range 9 – 316) days.

Conclusions. PD performed for benign pancreatic lesions have satisfactory outcomes in a specialist centres.

PP 64.06

MANAGEMENT OF PANCREATIC TRAUMA AT A TERTIARY CENTRE

Singh, A; Choubey, R P

Army Hospital (R&R), GI Surgery, New Delhi, India

Intoduction. Pancreatic trauma is relatively uncommon, but it has high morbidity and usually detected late and usually missed if urgent laparotomy is done for hamodynamically unstable patient.

Methods. A total of 9 cases of pancreatic injury were treated during a 2 year period at a tertiary center were reviewed retrospectively. Diagnosis and assessment of injury severity were based on imaging studies and peroperative findings as most of patient had laparotomy before referral to this centre.

Results. Of the 09 patients, 01 underwent distal pancreatectomy with splenectomy, 3 received a pancreatic duct stent, with the remaining 5 individuals underwent drainage alone. The 3 patients developed psudocyst and 2 patients had necrotizing pancreatitis.All the patients with stent developed complications.

Conclusion. All 9 cases were managed without any mortality and Magnetic resonance pancreatography was found to be unreliable early after injury. Treatment has to be tailored to the individual situation with prolonged in hospital treatment.

PP 64.07

LYMPHO EPITHELIAL CYST OF PANCREAS: A RARE CASE REPORT.

Sharma, Sandesh¹; Naik, Saleem¹; Sewkani, Ajit¹; Varshney, Subodh²; Maudar, K.K²

¹Bhopal Memorial Hospital Bhopal, Dept.Of Surgical gastroenterology and Clinical Nut, Bhopal, India; ²

Background. Lymph epithelial cysts are rare pancreatic lesions of undetermined pathogenesis. The literature on this entity is limited to case reports or small series. 0BJECTIVE-To present a rare case report of pancreatic Lympepitheleal cystand discuss its management.

Method. We describe a case of 66 year male, incidentally diagnosed as lymph epithelial cyst of pancreas. To our knowledge this is the first case report of lymph epithelial cyst of pancreas from India.

Result. Our patient had high CA 19.9 levels preoperatively and CT scan was suggestive of a large cystic mass arising from head of pancreas. We performed total Enucletion of the cyst from the head of pancreas. The biopsy of the cyst was consistent with the lymphoepitheal cyst of the pancreas without squamous metaplasia. One year postoperative patient is well with normalization of the CA-19.9 levels and no recurrence of the cyst on ultrasound imaging.

Discussion. An extensive Medline search was carried out for lymphoepithelial cyst of pancreas. Total of 81 cases were identified in available English literature. These 82 cases (including our case) were analyzed. Lymphoepithelial cyst of the pancreas is a rare and distinct lesion mostly found in adolescent male. Majority of patients present with non-specific symptoms making preoperative diagnosis difficult it is mostly seen in the tail region of pancreas with male preponderance. Because of the cystic appearance on imaging it should be considered in the differential diagnosis of the cystic neoplasm of the pancreas. It is not associated with the clinical syndromes that are seen with their analogues in the salivary glands. Eneucleation from the head or distal pancreatectomy is the recommended surgery for such lesions.

Conclusion. Lymph epithelial cyst of the pancreas is a rare benign lesion, which is difficult to diagnose preoperatively. High index of suspicion and preoperative fine needle aspiration cytology may help in making diagnosis and avoiding surgery in asymptomatic patients.

PP 64.08

DISTAL PANCREATECTOMY- INDICATIONS AND OUTCOME IN A TERTIARY CARE CENTER

Yalakanti, Raghavendra Babu¹; Singh, Rajneesh Kumar²; Behari, Anu²; Lal, Richa²; Kumar, Ashok²; Saxena, Rajan²; Kapoor, Vinay Kumar²

¹Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Gastro Surgery, LUCKNOW, India; ²Sanjay Gandhi Post Graduate Institute Of Medical Sciences, Gastrosurgery, Lucknow, India

Background. Distal pancreatectomy (DP) may have significant post-operative morbidity including pancreatic fistula and diabetes. We present our experience with DP at a tertiary care referral center.

Methods. Sixty three patients underwent DP at our institution between Jan 1989 Dec 2006. Retrospective analysis of indications, mortality, morbidity, factors affecting morbidity (e.g. firmness of pancreatic parenchyma, extent of resection, and method of stump/ duct management and outcome) was done.

Results. The indications of DP were pancreatic diseases in 34 (54%) patients (chronic pancreatitis in 21, pancreatic tumours in 8 and others in 5) and extra-pancreatic diseases in 29 (46%) patients (tumours involving pancreas). The overall operative mortality was 4 (6.3%), the morbidity was 29 patients (46%) and was similar in the two groups. The major post-operative complications in the two groups (pancreatic and extra-pancreatic diseases) were: new-onset diabetes (22% and 4%), pancreatic fistula (15% and 10%), and intra-abdominal abscess (12% and 28%) respectively. Re-operation was required in 6 patients (14.7% and 3.4% respectively). The overall incidence of post-operative pancreatic fistula was 8 (13%) patients. Upon statistical analysis it was found that the intra-operative pancreatic duct identification was the only significant factor predicting pancreatic fistula (p = 0.023). The overall incidence of new-onset diabetes was 6 (12%) patients. There was no difference in the incidence of diabetes if the resection line was at the neck (12 patients) or in the distal body (37 patients). Spleen was preserved in 9 patients and the results (morbidity, intra-operative blood loss, operative time, and length of stay) were similar to those in whom splenectomy was done.

Conclusion. We conclude that intra-operative pancreatic duct identification decreases the incidence of pancreatic fistula and the extent of pancreatic resection did not influence the incidence of new-onset diabetes. Spleen preserving DP is a safe and feasible procedure.

PP 64.09

HEPATIC RESECTION WITH PANCREATODUODENECTOMY: BE AWARE OF THE PANCREAS

Melloul, Emmanuel; Chirica, Mircea; Kianmanesh, Réza; Sauvanet, Alain; Belghiti, Jacques

Hospital Beaujon, HPB Surgery, Clichy, France

Background. Liver resections associated with pancreatoduodenectomy (PD) is a procedure which is indicated for some biliary cancers. However this intervention is rarely performed because of its high risk. We aimed to present in this study the first homogenous western series.

Patients andMethods. From year 2001 to 2006, 10 patients with a median age of 53 years (range 34–70) underwent liver resection with PD for stage IV gallbladder carcinoma (n = 7), neuroendocrine tumor of the pancreas (n = 1), GIST (n = 1), and main bile duct carcinoma (n = 1), respectively. All patients had a PD associated with major hepatectomy in 4, which was prepared by portal vein embolization (PVE) and biliary drainage in all cases and with minor hepatectomy consisted of bisegmentectomy IV-V in 6.

Results. Mean operative time was 480 minutes (range 345–720) and operative blood loss 850 mL (range 150–1700). The mortality rate was nil. Only one patient experienced major liver morbidity with episodes of angiocholitis due to biliary anastomosis stenosis. There was no postoperative liver failure. Pancreatic complications included fistulas in half of patients, requiring pancreatico-jejunal anastomosis refection in one. The pancreatic fistula rate was 75% after major hepatic resection. The mean ICU/hospital stay after PD with major and minor hepatectomy was 18/56 and 7/27 days, respectively.

Conclusions. Liver resection with PD is a procedure which can be performed safely, providing that major hepatectomy is prepared by both biliary drainage and PVE. Results of this study showed that pancreatic complications are underestimated with a high rate of fistulas.

PP 64.10

CHOLEDOCHOLITIASIS DURING PREGNANCY SUCCESSFULLY TREATED WITH ERCP.

Morales, Dieter¹; Mellado, MJ²; de La Peña, J²; Silvan, M²; Martin-Oviedo, J²; Yagüe, E²; Naranjo, A²; de Miguel, JR²

¹University Hospital “Marqués de Valdecilla”, Department of Surgery, Santander, Spain; ²

Introduction. Choledocholithiasis is an uncommon complication of gallstone disease during pregnancy. Therapeutic approach of choledocholithiasis during pregnancy has maternal and fetal riks and remain controversial. We present a case of choledocholithiasis during the third trimester successfully treated with ERCP and recorder laparoscopic cholecystectomy.

Case Report. A previously healthy 35-yr-old white female presented at 28-wk gestation was addressed to our hospital with sudden right upper quadrant pain radiate through to the back. Obstetric and abdominal exploration were normal. Four days after, the pain remains and the patient present jaundice. White cell count and serum amylase level were normal. Liver function test showed high levels of alkaline fosfatase and transaminases Ultrasonography showed normal liver, gallbladder with stones, CBD diameter increased and a single stone at the end of CBD. Pancreas was normal (figure 1). Therapeutic ERCP with sphincterotomy was performed with sedation and two seconds X-ray and the calculi was removed with Dormia basket without problems (Figure 2). Patient recovered unevenfull. and the birth was at 35-wk with Caesarean operation without complications. One month after the birth, laparoscopic cholecystectomy was performed and patient is asymtomatic.

Conclusions. 1.- ERCP at third trimester and recorder laparoscopic cholecystectomy after birth is a safe therapheutic option for mother and feto. 2.- Cholecystectomy, cholangiography and common bile duct exploration during third trimester carry a relatively low maternal morbidity and mortality but the evidence of fetal wastage may be quite high with open surgery, and laparoscopic approach remain controversial.

PP 65.01

HUMAN HEPATOCYTE ISOLATION FOR CELL TRANSPLANTATION: THE ST GEORGE EXPERIENCE

Yao, Peng¹; Akhter, Javed²; Johnson, Loreena²; Morris, David²

¹University Of New South Wales, Sydney, Australia; ²UNiversity of New South Wales, Department of Surgery, Sydney, Australia

Background. Isolated hepatocytes can be an attractive therapeutic alternative to the patients who are waiting for orthotopic liver transplantation. However, the availability of healthy human livers for cell isolation is limited. Currently the isolated human hepatocytes are mainly from livers unsuitable for transplantation, surgical waste materials for split-liver transplantation and resected tissues from partial hepatectomy.

Aim. Our group has sought to use liver resection materials from cancer patients.

Methods. Study was approved by local authority. Between Jul 2004 to Jan 2007, 54 patients who giving consent were eligible for the study. The tumour was dissected with at least 1 cm margin from the resected liver specimen, the liver was then cannulated and perfused by modified two step collagenase digestion technique. Isolated hepatocytes were functionally tested using attachment rate, albumin secretion, urea secretion and diazepam metabolism.

Results. Hepatocyte isolation was performed in the designed lab. The mean weight of specimen was 211 g, mean digestion rate was 40%, mean viability was 56%, mean viable cell per isolation was 1,080 millions. There was no correlation between warm ischaemic time and yield and viability of isolated hepatocytes, but there was correlation between cold ischaemic time and yield and viability. Age did impact the yield of hepatocytes.

Conclusion. Isolate d hepatocytes from liver resection materials maintain good functions, and can be a good source for hepatocyte transplantation.

PP 65.02

MITOCHONDRIAL FUNCTIONAL CHANGES IN NON-HEART-BEATING DONOR LIVERS: ADVERSE EFFECT OF COOLING

Roy, Debabrata¹; Ashley, Neil²; Southerland, Andrew³; Elker, Doruk³; Morovat, Reza⁴; Coussios, Constantin⁵; Friend, Peter J³

¹John Radcliffe Hospital, Nuffield Department of Surgery, oxford; ²John Radcliffe Hospital, Nuffield Department of Obstetric and Gynaecology, oxford, United Kingdom; ³John Radcliffe Hospital, Nuffield Department of Surgery, oxford, United Kingdom; ⁴John Radcliffe Hospital, Nuffield Department of Biochemistry, oxford, United Kingdom; ⁵University of Oxford, Department of Bioengeenering, oxford, United Kingdom

Introduction. The use of livers from non-heart-beating-donors (NHBD) has been restricted because the liver does not tolerate prolonged warm ischaemia followed by cold preservation. The purpose of this study is to investigate the kinetics of energy metabolism and mitochondrial function during ischaemia and its relationship with increased hepatocellular injury in non-heart-beating donor livers.

Methods. After 60 minutes of warm ischaemia, porcine livers (n = 5) were cold preserved for 60 minutes in University of Wisconsin solution and then connected to an extracorporeal perfusion circuit for 24 hours for functional assessment. Sequential liver biopsies were analysed for ATP content and mitochondrial functions (respiratory control ratio (RCR), cytochrome c release and caspase activation). The perfusate was analyzed for serum transaminases, bile production, and base deficit. Apoptotic and necrotic changes after reperfusion were examined by TUNEL and haematoxylin staining respectively.

Results. Although cellular ATP levels declined sharply during 60 minutes of warm ischaemia (p < 0.01), mitochondrial function was maintained. However, subsequent cold preservation produced significant decline in mitochondrial function (RCR 3.83±0.16 vs. 2.04±0.11, p < 0.01). Reperfusion with oxygenated blood led to further loss of mitochondrial function (p < 0.01), ATP energetics (p < 0.05), initiation of apoptosis through cytochrome c release and the caspase activation. This was associated with increased hepatocellular (p < 0.01) damage with apoptosis, necrosis and destruction of architecture on histology. These features not seen in livers subjected to warm ischaemia without cold preservation.

Conclusions. Combination of warm ischaemia and cold preservation produces significant hepatocellular injury due to its profound effects on cellular energetics and mitochondrial function. This may have important implications in developing novel therapeutic strategies for resuscitation of NHBD livers

PP 65.03

PROTECTIVE EFFECT OF ANTIOXIDANT N2-MERCAPTOPROPIONYLGLICYNE IN EXPERIMENTAL ISCHEMIA/REPERFUSION OF LIVERS

Abdo, Emilio; Jureidini, Ricardo; Ali Taha, Mohamed; Penteado, Sonia

University of S.Paulo, Department of Gastroenterology, S.Paulo, Brazil

N2-mercaptopropionylglycine (N2-MPG), a simple thiol, among other properties, is a powerful superoxide synthesis inhibitor and was tested as a preventive agent of metabolic and structural damage of several organs, in the ischemia/reperfusion process.

Aim. To evaluate the effect of the thiol N2-MPG on modulation of some biochemical and histological aspects of animal livers.

Methods. Twenty-two rats and twenty-two dogs were divided into four groups: Group I: rats that received I.V. saline 0.9%; Group II: rats that received I.V. 100mg/kg of N2-MPG; Group III: dogs that received saline I.V. 0.9% and Group IV: dogs that received IV 100mg/kg N2-MPG. Ten minutes after the saline or drug administration, each group was submitted to left lobe liver ischemia for 25 minutes followed by reperfusion.

Results. Biochemical studies 24 hours after reperfusion revealed a significant decrease of transaminases in animals of groups G-II (AST = 271±182; ALT = 261±161) and G-IV (AST = 101±45; ALT = 123±89) when compared to the controls G-I (AST = 2144±966; ALT = 1869±1040 00) and G-III (AST = 182±76.51; ALT = 277±219) respectively (p < 0,001). All the results are expressed in IU/dl. Histology study showed a significant minor aggression to animals of G-II and G-IV when compared to G-I and G-III respectively (p < 0,05).

Conclusion. These results suggest an actual and significant release of free radicals of oxygen in the isquemia/reperfusion process of the liver and that N2-MPG may have a significant protective effect on its parenchyma

PP 65.04

LIVER APOPTOSIS FOLLOWING NORMOTHERMIC ISCHEMIA-REPERFUSION: IN VIVO DETERMINATION OF CASPASE ACTIVITIES BY FLIVO ASSAY

Cursio, Raffaele¹; Colosetti, Pascal²; Auberger, Patrick²; Gugenheim, Jean¹

¹Univ. de Nice Sophia Antipolis, Laboratoire de Recherches Chirurgicales, Nice, France; ²Univ. de Nice Sophia Antipolis, INSERM U526, IFR50, C3M, Nice, France

Background/Aim. The mode of cell death after liver ischemia-reperfusion (I-R) is considered to be necrotic, but there is increasing evidence that apoptosis plays also a role. The aim of this study was to determine in vivo caspase activities during normothermic liver I-R-induced apoptosis.

Methods. In rats a segmental normothermic ischemia of the liver was induced for 120 minutes. After intravenous injection of green probe FLIVOTM, in vivo caspase -3 and -7 specific activity was determined, by fluorescence microscopy, in non-ischemic and ischemic liver lobes, 3 and 6 h after reperfusion. Liver apoptosis was assessed by the TUNEL assay.

Results. Fluorescence microscopy showed that liver apoptosis and in vivo caspase -3 and -7 specific activity were increased in ischemic lobes after 3 and 6 h of reperfusion, compared to non-ischemic liver lobes (p < 0.005). Quantitative analysis of apoptotic cells showed that more than 35 per cent of the cells were TUNEL-positive in ischemic lobes 3 and 6 h after reperfusion, compared with less than 1 per cent in non-ischemic liver lobes (p < 0.005).

Conclusions. Normothermic liver I-R resulted in increased in vivo caspase -3 and -7 specific activity and in liver apoptosis.

PP 65.05

CURCUMIN ENHANCES LIVER HYPOTHERMIC PRESERVATION AND DECREASES APOPTOSIS IN AN EX-VIVO PERFUSION MODEL

Chen, Changguo; Johnston, Thomas D; Jeon, Hoonbae; Gedaly, Roberto; Mchugh, Patrick; Wu, Guanghan; Ranjan, Dinesh

University of Kentucky, College of Medicine, Surgery, Lexington, Kentucky, United States

Background. Curcumin (Cur), a component of the spice turmeric, has antioxidant and anti-inflammatory properties and has been used as a wound healing agent.

Objective. To assess the effect of Cur on liver hypothermic preservation in an isolated perfusion model.

Methods. Sprague-Dawley rat livers were flushed with different preservation solutions of phosphate buffered saline (PBS), Euro-Collins solution (EC), University of Wisconsin solution (UW) with or without Cur (25–200 µM) and stored at 4°C for 24–48h. The livers were then perfused for 120 min via the portal vein with oxygenated Krebs-Henseleit bicarbonate buffer (pH 7.4, 37°C) at a pressure of 18 cm H₂O in a perfusion apparatus. The livers in the normal (NL) group were flushed with PBS, EC or UW, then immediately perfused (zero preservation time).

Results. We found that Cur at optimal concentration (100 µM) significantly (p < 0.05, n = 10) increased portal vein flow rate and bile production and significantly decreased the release of liver enzymes (alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase) to the perfusate in the EC + Cur and PBS + Cur preserved livers as compared to the EC or PBS preserved livers. Comparing UW +Cur vs. UW, there was no difference in these parameters after 24h preservation; however, after 36h and 48 h of preservation, the portal vein flow rate and bile production were significantly higher in the UW + Cur livers than in the UW livers. Histological analysis after perfusion indicated that the mean number of apoptotic bodies per field was 0.16±0.05 in NL group, 0.09±0.04 in EC + Cur group, 0.24±0.05 in EC group. The number of apoptotic bodies in the EC group was significantly higher than in the EC + Cur and NL groups (p < 0.05, n = 10).

Conclusions. Cur has inherent organ preservation property as it improves liver preservation which may be related to reduced apoptosis in the Cur preserved livers.

PP 65.06

PERITONEAL IMPLANTATION OF CRYOPRESERVED ENCAPSULATED PORCINE HEPATOCYTES IN RATS WITHOUT IMMUNOSUPPRESSION: VIABILITY AND FUNCTION

Cursio, Raffaele¹; Baldini, Edoardo¹; De S ousa, Georges²; Margara, Andrea¹; Honiger, Jiri³; Saint-Paul, Marie-Christine⁴; Bayer, Pascale¹; Raimondi, Vincent¹; Rahmani, Roger²; Mouiel, Jean¹; Gugenheim, Jean¹

¹Univ. de Nice Sophia Antipolis, Laboratoire de Recherches Chirurgicales, Nice, France; ²INRA, Lab. Pharma-Toxicologie Cellulaire, Antibes, France; ³Univ. de Paris V, INSERM U420, Paris, France; ⁴Univ. de Nice Sophia Antipolis, Service d'Anatomo-Pathologie, Nice, France

Background/Aim. Encapsulated hepatocyte transplantation is a promising approach to cell transplantation without immunosuppression as an alternative to whole organ liver transplantation. The aim of this study was to assess viability and function of cryopreserved encapsulated porcine hepatocytes implanted intraperitoneally in rats without immunosuppression.

Methods. Isolated porcine hepatocytes were cryopreserved at -196 degrees Celsius for 1 month. Thereafter they were thawed and encapsulated in hollow fibers (AN69 polymer). Four groups were created: Group 1 (n = 10), freshly encapsulated porcine hepatocytes cultured in albumin-free medium for 10 days; Group 2 (n = 10), freshly encapsulated porcine hepatocytes implanted in rat peritoneum without immunosuppression for 1 month, and cultured for 10 days after explantation; Group 3 (n = 10), cryopreserved encapsulated porcine hepatocytes cultured for 10 days; Group 4 (n = 10), cryopreserved encapsulated porcine hepatocytes implanted in rat peritoneum without immunosuppression for 1 month and cultured for 10 days after explantation. Hepatocyte viability, liver enzyme release, urea and albumin production were assessed.

Results. There was no significant difference in urea synthesis between the groups. Albumin synthesis was significantly decreased in group 4 compared to the other groups (p < 0.01). There was no significant difference in AST, ALT and LDH levels in culture medium (p > 0.05). Encapsulated cryopreserved porcine hepatocytes explanted from rat peritoneum after 1 month appeared morphologically viable and their ultrastructure was preserved.

Conclusions. Long-term cryopreservation of porcine hepatocytes resulted in retention of their biological activity and in significant viability when transplanted into rat peritoneum without immunosuppression.

PP 65.07

SUCCESSFUL LIVE DONOR LIVER TRANSPLANT FROM A DONOR WITH UNUSUAL BILIARY ANATOMY

Srivastava, Ajitabh¹; Vij, Vivek²

¹Indraprastha Apollo Hospital, Surgical Gastroenterology and Liver Transplant, New Delhi, India; ²Successful Live Donor Liver transplant from a donor with unusual biliary anatomy Ajitabh Srivastava, Vivek Vij, Neerav Goyal, Manav Wadhawan, Ashish Singhal, Subash Gupta Department of Surgical Gastroenterology and Liver Transplantation Indraprastha Apollo Hospital, Sarita Vihar, New Delhi

Background. Preoperative magnetic resonance cholangiography (MRC) is used to screen donors for LDLT. As living donors are scarce, donors should not be rejected unless there is a risk to donor or recipient. Complicated biliary anatomy must be correctly interpreted in order to ensure smooth donor and recipient recovery. We present a case of an unusual biliary anatomy on MRC which we operated successfully.

Patients and Materials. A 44 year old, healthy female was evaluated for right lobe donation to her brother. MRC during evaluation revealed a dilated right hepatic duct draining into the cystic duct, with multiple anomalous intrahepatic communications between left and right ductal system. Findings were confirmed on intraoperative cholangiogram, and hepatectomy in the ischemic plane yielded a single RHD for anastomosis. The anomalous connections were ligated and divided. Post transection cholangiogram showed complete drainage of the left lobe.

Results.The donor had an uneventful recovery except for minor bile leak which stopped after 7 days. The recipient post operative recovery was marked by high ascitic output for two weeks and later developed a small bile collection which required pigtail drainage which gradually settled.

Conclusion. Right hepatic duct insertion into the cystic duct is very uncommon. However if it is recognized on intraoperative cholangiogram successful liver transplantation is possible.

PP 65.08

DEVELOPMENT OF A NEW EXTRACORPOREAL PORCINE LIVER PERFUSION MODEL WITH A HOLLOW FIBRE FILTER

Bikhchandani, Jai¹; Metcalfe, Matthew¹; Illouz, Severine¹; Nicholson, Michael²; Dennison, Ashley R¹

¹University Hospitals of Leicester NHS Trust, Department of Hepatopancreatobiliary Surgery, Leicester, United Kingdom; ²University Hospitals of Leicester NHS Trust, Department of Transplant Surgery, Leicester, United Kingdom

Backgroundand Aims. Liver transplantation is the only effective treatment of acute liver failure, but a large proportion of patients die while on the waiting lists. Arguably, there is a need for a liver support device that can act as a bridge to transplantation. An isolated porcine liver perfused with patients’ blood has shown good results as a support system but with concerns about the possible transfection of porcine retroviruses. A separating membrane (or filter) between the patient and porcine liver could potentially block the transfer of these viruses. The current study was aimed to design a liver perfusion model with a hollow fibre filter and to test its efficacy in providing hepatic function.

Methods. Normothermic ECMO based perfusion of porcine liver was carried out using a circuit including a haemofilter unit Evaclio-EC4A, pore size 30 nm. A reservoir of blood with high ammonia levels was used as a “surrogate-patient” of acute liver failure. Viability of liver was assessed by bile outflow and 15 min retention of indocyanine green (ICGR15). Ammonia clearance and galactose elimination from the “surrogate” patient circuit were used as measures of hepatic function.

Results. Mean oxygen consumption of 56.1 + 28.6 ul/min/gram of hepatic tissue, bile production of 7 + 4.2 ml/hour and ICGR15 22.5 + 9.7% confirmed optimum hepatic perfusion (n = 10). More than 75% of ammonia (1000 mg) was cleared from the “surrogate-patient” blood in 15 minutes. Galactose-elimination rate (Vmax) of 128 ¬+ 51.9 mg/min/Kg liver was seen.

Conclusion. We have shown that in an experimental set up it is possible to provide reliable hepatic function across a hollow fibre filter using this liver perfusion system. The next step would be to test this system in a live animal model of acute liver failure.

PP 65.09

A PROSPECTIVE STUDY OF ABDOMINAL PAIN AND FUNCTIONAL SYMPTOMS IN LIVING LIVER DONORS AFTER PARTIAL LIVER DONATION AND GALLBLADDER REMOVAL

Søndenaa, Karl¹; Royaie, Sasan²; Emre, Sukru³; Goldman, Jody S³; Gondolesi, Gabriel³; Hausken, Trygve⁴; Schwartz, Myron E³

¹Haraldsplass Deaconal Hospital, Department of Surgery, University of Bergen, Bergen, Norway; ²; ³Recanati/Miller Transplantation Institute/Mount Sinai Hospital, Liver Transplantation& Hepatobiliary Surgery, New York, United States; ⁴University of Bergen, Institute of Medicine, Bergen, Norway

Introduction. Abdominal complaints occur fairly frequently after removal of the gallbladder in gallstone disease but the cause of this disorder has not been ascertained. We wanted to examine the nature of possible abdominal complaints after removal of the gallbladder and part of the liver in living donors.

Objective. Twelve patients referred for live donor operations were enrolled in the study during a three-year period and followed up a 6 and 12 months. There were nine men, aged 18–45 years, and three women, aged 32–46 years. Ethnicity was mixed with caucasian (n = 7), hispanic (n = 3), asian and afro-american origin. Patients filled out questionnaires including questions pertaining to typical gallstone symptoms and functional abdominal complaints (FAC) using a recognised questionnaire, Rome II.

Reuslts. Abdominal pain occurred in 8 patients at 6 months but was reduced to 5 patients at one year and FAC in 11 and 9, respectively. Pain was accompanied by FAC in all instances, with the exception that 2 patients had FAC but no abdominal pain at one year. A pain attack pattern only vaguely similar to typical gallstone pain was only found consistently in one patient at each follow-up. Irritable bowel syndrome (IBS) was found in the majority of patients but functional dyspepsia (FD) was also observed. Dyspepsia appeared de novo in all but one patient at the two follow-ups including those two patients thought to have symptoms reminiscent of a gallstone pain pattern.

Conclusion. Pain and FAC was fairly common after living liver donation but pain waned with time during a one-year follow-up. Pain and FAC seemed to indicate a general postoperative disorder, perhaps influenced by psychosomatic factors not evaluated further in this study, and not connected with removal of the gallbladder in particular.

PP 65.10

FORMULA FOR CALCULATING STANDARD LIVER VOLUME (SLV) IN INDIANS

Chandramohan, Anuradha¹; Venkatramani, Sitaram²

¹Christian Medical College and Hospital, Department of Radiology, Vellore, India; ²Christian Medical College, Department of Hepatobiliary and Pancreatic Surgery, Vellore, India

Aim. To assess the formula described by Johnson (2005) to calculate SLV in Indians, and to compare it with formulae derived from Indian, Korean and Chinese populations.

Materials and Methods. This is a retrospective study of 398 cadavers with normal liver at autopsy between 1999 and 2005. Patient's height, weight and liver weight were obtained from autopsy records. Density of formalin preserved liver was estimated using water displacement method. Volume of liver was calculated from liver weight and density. Body surface area (BSA) was calculated using Mosteller's formula. Liver volume obtained from autopsy record was compared with liver volume estimated from the formulae. The best formula to estimate SLV in Indians was obtained by applying Akaike information criteria, ICC and paired t-test to the formulae.

Results. There were 281 males and 117 females, median age 45 years (8–70). The mean BSA was 1.57 square meter (0.67–2.18); liver volume was 1204.67 cc (310.9– 2089). The density of the liver was found to be 1.158kg/l. There was good agreement between the total liver volume (TLV) and SLV estimated by formulae derived from the Indians (ICC = 0.39, p < 0.001), Koreans (ICC = 0.41, p < 0.001) and the Johnson model (0.41, p < 0.001). However the correlation was less good with the gender based formula derived from the Chinese population (ICC = 0.27, p < 0.001). Mean difference between the TLV and formula estimated SLV was least with the Johnson model (−27.7 cc, p = 0.003) and maximum with the Chinese formula (205.7 cc, p < 0.001). The difference obtained using Indian formula was (47.1 cc, p < 0.001). Akaike information criteria (AIC) supported the above. Gender had no significant effect on liver volume.

Conclusions. The Johnson model is the best available formula for estimating SLV in Indians. However the formula derived from Indian population (Anuradha model) can be used in view of its close AIC value and its simplicity.

PP 66.01

WRAPPING OF ANASTOMOTIC SITE OF PANCREATICOGASTROSTOMY USING THE FALCIFORM LIGAMENT AND THE GREATER OMENTUM IN PANCREATICODUODENECTOMY

Mimatsu, Kenji¹; Oida, Takatsugu¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kaskabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. A leakage of pancreatic juice at the anastomotic site of pancteaticojejunostomy or pancreaticogastrostomy (PG) is a major cause of morbidity in patients undergoing pancreaticoduodenectomy (PD). A pancreatic fistula may expose skeltonized vessels directly to pancreatic juice, causing delayed intra-abdominal bleeding. Also, it may cause to the intra-abdominal abscess due to melting tissue around surgical site by pancreatic juice. With the aim of protecting vessels and anastomotic site, we have adopted an operative technique by which these vessels and anastomotic site are wrapped using a pedicled falciform ligament and fixation of greater omentum.

Methods. After PD with lymph node dissection, Child or Cattell reconstruction with PG was performed. The pedicle falciform ligament and greater omentum is spread out widely on major vessels including portal vein, hepatic artery and stump of gastroduodenal artery, and protected anastomotic site of PG. Between April 2005 and July 2007, PD with PG was undergone 11 patients in periampullary caner. We reviewed the 11 patients who underwent PD with these procedures.

Results. The mobilization of the falciform ligament and the greater omentum and wrapping of the anastomotic site of PG was successfully performed without any operative complications. The amount of drain amylase had become below 10000 U/l until 3.7 days, and drain removed until 9.1 days after operation. Wound infection was occurred in 1 patient, although, major complication such as pancreatic fistula and delayed intra-abdominal bleeding was not occurred in any of the patients.

Conclusions. The wrapping of the falciform ligament and fixation of the greater omentum was convenient and safe technique, and may be reduce major complication including pancreatic fistula and delayed intra-abdominal bleeding.

PP 66.02

RECONSTRUCTION METHOD FOLLOWING PANCREATICODUODENECTOMY IN PERIAMPULLARY CANCER PATIENTS AFTER BILLROTH-I GASTRECTOMY

Mimatsu, Kenji¹; Oida, Takatsugu¹; Kawasaki, Atsushi¹; Aramaki, Osamu¹; Kuboi, Youichi¹; Kanou, Hisao¹; Miyake, Hiroshi²; Amano, Sadao³

¹Social Insurance Yokohama Central Hospital, Surgery, Yokohama, Japan; ²Kasukabe Municipal Hospital, Surgery, Kasukabe, Japan; ³Nihon University School of Medicine, Surgery, Tokyo, Japan

Background. With recent aging, we have often experienced pancreaticoduodenectomy (PD) for periampullary cancer patients after gastrectomy. Billroth-I is major reconstruction after gastrectomy for gactric ulcer and gastric cancer. There are many methods of reconstruction following PD, however, the reconstruction following PD after Billroth-I gasterctomy is unclear. We elucidated reconstruction following PD after Billroth-I gastrectomy, retrospectively.

Methods. Between 1997 and 2007, nine patients underwent PD after Billroth-I gastrectomy with the Billroth I type (Imanaga and Cattell method: n = 3) and Billroth II trype (Modified Child method: n = 6). We reviewed nine patients who underwent PD after Billroth-I gastrectomy, and compared with duration until removal of nasogastric tube, duration until oral taking and complications between the two groups.

Results. Although leakage of pancreaticojejunostomy was one case of Billroth-II type (Modified Child method), the incidences of other complications was not significant different between two groups. Duration until removal of naso-gastric tube and oral taking was significantly shorter Billroth-II than Billroth-I type. Postoperative roenterography showed stasis into the residual stomach in Billroth-I (Cattell method) type, however, it showed smooth passage to jejunum in Billroth-II (Modified Child method) type.

Conclusions. Billroth-II type reconstruction of modified Child method may prevent gastric stasis following PD in periampullary cancer patients after Billroth-I gastrectomy.

PP 66.03

IS ISOLATED ROUX LOOP PANCREATICOJEJUNOSTOMY SUPERIOR TO CONVENTIONAL PANCREATICOJEJUNOSTOMY?-A COMPARATIVE STUDY

Perwaiz, Azhar; Singhal, Dinesh; Chaudhary, Adarsh

Sir Ganga Ram Hospital, Surgical Gastroenterology, New Delhi, India

Introduction. Pancreatic fistula (PF) predicts mortality and morbidity in patients undergoing pancreaticoduodenectomy (PD). Though there is no comparative study, proponents of isolated Roux loop pancreaticojejunostomy (IPJ) believe in its superiority over conventional pancreaticojejunostomy (CPJ).

Objective. To assess whether isolated Roux loop reconstruction is superior to conventional PJ.

Methods. Between September 2003 to July 2007, we performed 108 pancreaticoduodenectomies. All patients underwent conventional PD with pancreaticojejunostomy (PJ). Patients were divided into two groups. Group I- IPJ and group II- CPJ. A retrospective analysis of prospectively collected data was performed. Primary end points were PF, duration of surgery, length of hospital stay, over all complications and operative mortality.

Results. There were 81 males and 27 females with median age of 54.3 years (18–80). There were 53 patients in group I and 55 in group II. Over all incidence of PF was 10.1% (n = 11). No statistically significant difference in the incidence of PF was noted in the two groups (5 in group I versus 6 in group II). Clinically significant PF was noted in 6 out of 11 patients (3 in each group). The outcome of patients with clinically significant PF was no different in the two groups (2 patient died in each group). Overall complications, mortality and length of hospital stay were similar in the two groups, however duration of surgery was higher in group I (442 minutes versus 370 minutes).

Conclusion. Isolated pancreaticojejunostomy is not superior to conventional PJ; instead it increases the duration of surgery.

PP 66.04

IMPACT OF CLINICAL PATHWAY FOR PANCREATICODUODENECTOMY(PD) AT A TERTIARY CARE CENTRE

Goja, Sanjay; Singhal, Dinesh; Chaudhary, Adarsh

Sir Ganga Ram Hospital, Surgical Gastroenterology, New Delhi, India

Introduction. Pancreaticoduodenectomy has evolved to be safe procedure in high volume centers. Comprehensive perioperative clinical pathway has improved outcomes and reduced length of hospital stay. Clinical pathway is sequence of treatment related events with daily goals to provide quality and efficient care.

Aim. To assess impact of application of clinical pathway in PD in improving outcomes at our institution.

Methods. Prospectively collected data of 108 consecutive pancreaticoduodenectomies, performed between September 2003 to July 2007 at our centre, was analyzed. Clinical pathway was applied in last 50 patients(GroupI).First 58 patients in whom no clinical pathway was used were put in Group II. Pathway execution started preoperatively with patient counseling about surgery, followed in immediate post operative period and continued in subsequent days. Protocol included early removal of nasogastric tube and ambulation on POD (postoperative day) 1, orally liquids, removal of urinary catheter and drain fluid amylase on POD2, drain removal on POD3, stopping I/V fluids and switching to oral medication on POD4, USG abdomen on POD5 and discharge on POD 5 or 6. Out comes analyzed were perioperative complications, mortality, length of postoperative hospital stay and readmission.

Results. Out of 108 patients 81 were male and 27 female with median age of 54.3 years (18–80). Mean hospital stay in group I was 6.7 days (5–22) compared to 11.01 days (5–27days) in group II Pancreatic fistula developed 10.3%( n = 6) in group II compared to 10%(n = 5) in group I. Overall mortality was 3.7% with 4% in group I compared to 3.4% in group II, not statistically significant. Overall 6 patients were readmitted, 4 in group II and 2 in group I. Commonest reason for readmission was delayed gastric emptying (about 50%)

Conclusion. Implementation of clinical pathway in pancreaticoduodenectomy results in earlier discharge of patients from hospital and thus better hospital resource utilization without any detrimental effect on patient care

PP 66.05

ADENOSQUAMOUS CARCINOMA OF THE PANCREAS

Hsu, Jun-Te; Yeh, Chun-Nan; Yeh, Ta-Sen; Hwang, Tsann-Long; Jan, Yi-Yin; Chen, Miin-Fu

Chang Gung Memorial Hospital, Chang Gung Univeristy, Department of General Surgery, Taipei, Taiwan

Introduction. Primary adenosquamous carcinoma of the pancreas (ASC) is a rare pancreatic malignancy subtype, which is identified to have two histological patterns of ductal adenocarcinoma and squamous carcinoma for the same tumor. This study investigated the clinicopathological features of 12 cases of ASC.

Method. From January 1993 to December 2006, 12 patients (5 men and 7 women; age range, 32 to 79 years; median, 71 years) diagnosed with ASC undergoing surgical treatment at Chang Gung Memorial Hospital were retrospectively reviewed. Survival rate was calculated using the Kaplan-Meier method.

Results. Symptoms of ASC were as follows: abdominal pain (91.7%), body weight loss (83.3%), anorexia (41.7%) and jaundice (25.0%). The tumors were located at the head of the pancreas in 5 (41.7%) patients, at the tail in 5 (41.7%), and at the body in 4 (33.3%). Anemia was identified in 9 patients (75.0%). Nine (75.0%) patients had elevated serum CEA and CA 19-9 levels, respectively. Surgical resections were performed on 7 patients including 5 curative resections, bypass surgery on 3, and exploratory laparotomy on 2. The median tumor size was 6.3 cm, ranging from 3.5 to 8 cm. Two patients underwent intraoperative radiotherapy and 7 received postoperative chemotherapy. No surgical mortality or morbidity occurred. Seven (58.3%) and 11 (91.7%) patients died within 6 and 12 months after surgery, respectively. Median survival of 12 patients was 4.92 months, ranging from 1.12 to 22.42 months. Five patients receiving curative resections had median survival of 4.08 months (range, 2.50 to 10.82 months).

Conclusions. Symptoms of patients with ASC are similar to those of adenocarcinoma of the pancreas reported in the literature. Distribution of ASC is even in the pancreas, and the tumor size is big at the time of diagnosis. In this limited cases study, patients with ASC seemingly show dismal outcomes despite aggressive surgery.

PP 66.06

TUMOUR LOCATION AND NUMBER OF POSITIVE LYMPH NODES ARE INDEPENDENT PROGNOSTIC FACTORS IN DISTAL BILE DUCT CANCER

Gomez, Dhanwant¹; Menon, Krishna V¹; Smith, Andrew M¹; Verbeke, Caroline S²

¹The Leeds Teaching Hospitals NHS Trust, Department of Surgery, Leeds, United Kingdom; ²The Leeds Teaching Hospitals NHS Trust, Department of Histopathology, Leeds, United Kingdom

Background. To date, clinicopathological data on distal bile duct (DBD) cancer are limited, and the factors that influence survival following curative resection remain inconclusive. AIMS: To identify prognostic factors in a series of DBD cancers that underwent fully standardized pathological examination, including exact mapping of the tumour extension.

Methods. Patients undergoing potentially curative resection (pancreaticoduodenectomy) for DBD adenocarcinoma between January 2000 and April 2007 were identified from the Pathology database. Demographics, histopathology and survival data were analysed.

Results. 50 patients were identified with a median age of 61 (range: 37 – 86) years. Over 75% of cases were stage pT3 and associated with multiple adverse factors, including nodal metastasis, lymphovascular and perineural invasion. Margin involvement was found in 70%, whereby the R1 rate differed significantly between tumours that involved the very distal part of the DBD and were entirely intrapancreatic (40%), and those located more proximally, towards the superior border of the pancreas, with or without encroachment on the extrapancreatic DBD stump (60%; p = 0.012). Overall, the 1, 3 and 5 year survival was 77%, 30% and 20%, respectively. Vascular invasion was an adverse prognostic factor (p = 0.018) on univariate analysis only. Independent predictors of poorer overall survival on multivariate analysis were involvement of the DBD at the superior border of the pancreas (p = 0.039), and > 3 positive lymph nodes (p = 0.033). Age, sex, lymphatic or perineural invasion, lymph node positivity rate, differentiation, tumour size and resection margin status did not have an impact on overall survival.

Conclusion. DBD cancer is a locoregionally advanced cancer with a high R1 rate. Tumour involvement of the proximal end of the DBD close to the superior pancreatic border, and more than 3 positive lymph nodes are independent prognostic factors of poorer overall survival after curative resection.

PP 66.07

EXTENDED EXTRAHEPATIC BILE DUCT RESECTION TO AVOID PERFORMING PANCREATODUDENECTOMY IN PATIENTS WITH MID BILE DUCT CANCER

Hwang, Shin; Lee, Sung-Gyu; Kim, Ki-Hun; Ahn, Chul-Soo; Moon, Deog-Bok; Ha, Tae-Yong

Asan Medical Center, University of Ulsan, Department of Surgery, Seoul, Korea, Republic of

Background. Since mid bile duct cancers often involve the proximal part of intrapancreatic bile duct (IPBD), resection of the extrahepatic bile duct (EHBD) results in a tumor-positive distal resection margin. We developed a surgical procedure to obtain a tumor-free distal resection margin during EHBD resection, in which R0 resection can be achieved without performing pancreatoduodenectomy.

Patients and Method. Based on preparatory pathologic analyses, the extent of IPBD excavation was designed to resemble a 2 cm-long funnel. The surgical procedure was a combination of usual EHBD resection and funnel-shaped excavation of the proximal IPBD. This unique procedure, which we named extended EHBD resection, was performed in 3 patients over 70 years old with mid bile duct cancer.

Results. Deep IPBD excavation per se required about 1 hour. Tumor-free IPBD resection margin was obtained in all 3 patients. Only minor complications occurred, and all patients have been doing well for 10–16 months without tumor recurrence.

Conclusion. Extended EHBD resection can benefit some mid bile duct cancer patients in whom pancreatoduodenectomy has a high operative risk, by achieving R0 resection.

PP 66.08

LAPAROSCOPY-ASSISTED PANCREATODUODENECTOMY

Nagao, Yoshiko¹; Cho, Akihiro²; Yamamoto, Hiroshi²; Nagata, Matsuo²; Kainuma, Osamu²; Takiguchi, Nobuhiro²; Soda, Hiroaki²; Gunji, Hisashi²; Miyazaki, Akinari²; Ikeda, Atsushi²; Matsumoto, Ikuko²; Arimitsu, Hidehito²; Ryu, Munemasa²

¹Chiba Cancer Center Hospital, Division of Gastroenterological Surgery, Chiba, Japan; ²

Minimally invasive surgery has been accepted widely as a superior alternative to conventional surgery in many gastrointestinal fields, and laparoscopic procedures of the pancreas have rapidly emerged as good alternatives to open surgery. However, major laparoscopic resections of the pancreas, including pancreatoduodenectomy (PD), are still highly specialized field because laparoscopic pancreatic surgery presents severe technical difficulties, and leakage from pancreaticoenteric anastomoses after PD remain associated with intra-abdominal hemorrhage and subsequent high mortality rates. The recent rapid development of technological innovation, improvements in surgical skills, and extensive experiences of surgeons ha ve proved the feasibility and safety of a laparoscopic approach for properly selected patients. We successfully performed laparoscopy-assisted PD (the resection was performed laparoscopically, with the reconstruction performed through a small midline incision) for patients with IPMN. Although our experience is limited and appropriate indications must await future studies, we believe that laparoscopy-assisted PD can be feasible and safe in highly selected patient. This report describes an operative procedure of laparoscopy-assisted PD.

PP 66.09

SURGICAL TREATMENT OF THE PANCREATIC CANCER

Bilanovic, Dragoljub¹; Randjelovic, Tomislav¹; Zdravkovic, Darko¹; Toskovic, Borislav¹; Dikic, Srdjan¹; Stanisavljevic, Natasa²

¹University Medical Center Bezanijska Kosa, Department of Surgery, Belgrade, Serbia and Montenegro; ²University Medical Center Bezanijska Kosa, Department of Hematology, Belgrade, Serbia and Montenegro

Background. Pancreatic cancer is a highly lethal disease and the most frequent histology is adenocarcinoma. The advances in therapy do not improve the prognosis significantly. The new methods of exploration have not improved its detection at an earlier stage of the disease

Method. The authors analyzed the resectability rate, treatment, morbidity, mortality and follow up of 196 pts (118 male and 78 female) with pancreatic cancer treated and prospectively monitored at the Medical Centre “Bezanijska kosa” from January 2000 to December 2005.

Results. Radical (potentially curative) procedure was performed in 63 cases (32.1%) and 133 palliative procedures (67.9%). In the group of patients that underwent potential curative resection there were 39 cephalic duodenopancreatectomies, 8 total duodenopancreatectomies, 13 distal, 2 central, 1 near total pancreatectomies. Portal vein (PV) resection was performed in 2 pts and lateral PV excision in 3 pts. The operative treatment of pancreatic head cancer in the group of patients that underwent palliative procedures in most cases (97 pts) involved biliary enteric bypassing (hepaticojejunostomy) and prophylactic or therapeutic GEA as a standard procedure. Operative mortality in radically treated was 5 pts (7.9%). In the group of patients that were subjected to palliative procedures mortality was 8 pts (6%). The average survival in the group that underwent palliative treatment was 13.5 months. In the group of radically treated pts 23 have died to date and their average survival time was 26 months.

Conclusion. Although surgical resection is not efficient in the long-term, it is currently the only procedure for extending the lifetime and provide with the hope of total cure. The quality of life can be significantly improved within the group of patients with non-resectable tumors with adequate palliative procedures (biliodigestive bypass and GEA).