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HPB : The Official Journal of the International Hepato Pancreato Biliary Association logoLink to HPB : The Official Journal of the International Hepato Pancreato Biliary Association
. 2014 Feb 16;16(Suppl 1):1–3. doi: 10.1111/hpb.12223

FRIDAY, FEBRUARY 21, 2014, 8:00AM–9:00AM PRESIDENT'S PLENARY

PMCID: PMC4098622  PMID: 24528487
HPB (Oxford). 2014 Feb 16;16(Suppl 1):1.

PP.01 THE NEAR INFRARED TECHNIQUE FOR CHOLANGIOGRAPHY: 10 REASONS THAT SUPPORT THE SYSTEMATIC UTILIZATION OF THE METHOD

F Dip 1, M Roy 1, C Simpfendorfer 1, E Lo-Menzo 1, S Szomstein 1, R Rosenthal 1

Introduction

We looked at the reasons why fluorescent cholangiography (FC) should be used routinely in laparoscopic cholecystectomy (LC).

Method

A single dose of 0.05 mg/kg of Indocyanin Green (ICG) was administered intravenously one hour prior to the surgery to perform fluorescent cholangiograhy.

Results

FC could be performed in all 45 (100%) patients whereas intra-operative cholangiography (IOC) could be performed in 42 out of 45 (93%) patients (p < 0.078). Individual median cost of performing FC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 US dollars per patient, p = 0.0001). The mean operative time was 64.95 ± 17.43 minutes. FC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p < 0.0001). The cystic duct was identified by FC in 44 out of 45 patients (97.77 %). The residents were able to identify the extrahepatic structures in all 45 cases (100%) with FC. No complications were detected related to surgery and the use of FC. Learning curve was not necessary to identify structures using FC. X-ray leads were only used for IOC. FC could be performed by all residents at different level of training in 100% of the cases. Smooth dissection, transection and resection could be safely performed in 45 cases (100%).

Conclusion

Fluorescent cholangiography seems to be feasible, cheap, expeditious, useful, an effective teaching tool, safe, no learning curve is necessary, does not require x-ray and easy to perform. It can be used for real time surgery to delineate the extrahepatic biliary structures.

HPB (Oxford). 2014 Feb 16;16(Suppl 1):1.

PP.02 IN SEARCH OF THE BEST RECONSTRUCTIVE TECHNIQUE IN THE WHIPPLE OPERATION PANCREATICOJEJUNOSTOMY VERSUS PANCREATICOGASTROSTOMY. A RANDOMIZED CLINICAL TRIAL

J Grendar 1, JF Ouellet 2, F Sutherland 1, O Bathe 1, C Ball 1, E Dixon 1

Background

Objective of this study is to compare rates of pancreatic fistulas and complications following the Whipple operation between pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG).

Methods

98 patients undergoing Whipple resection were randomized to either PG (48) or PJ (50) reconstruction. T-test and Chi-square tests were used for intention to treat data analysis. Logistic regression was used to measure the influence of surgical technique, preoperative ASA score and soft pancreatic gland on overall complications, severe post operative complications and overall fistula rates.

Results

The rate of pancreatic fistula formation was 18% (Grade A = 6%, B = 10%, C = 2%) in the PJ arm and 25% (Grade A = 8%, B = 13%, C = 4%) in the PG arm, p = 0.399. The rate of postoperative complications was 48% (Clavien 1 = 14%, 2 = 36%, 3 = 10%, 4 = 0%, 5 = 2%) in the PJ and 58% (Clavien 1 = 21%, 2 = 38%, 3 = 25%, 4 = 6%, 5 = 4%) in the PG arm, p = 0.306. There was a significant difference in severe complications (Clavien 3–5) with 12% in the PJ and 31% in the PG arm, p = 0.02. In the multivariate analysis randomization (together with ASA) was only predictive of severe complications (OR 0.10, p < 0.005 for randomization to PJ reconstruction; OR 11.58, p < 0.05 for ASA 2 and OR 30.89, p < 0.05 for ASA 3 compared to ASA 1).

Conclusion

Results of the study suggest that while there are no overall differences in rates of pancreatic leak/fistula and overall complications between PG and PJ arms, pancreaticogastrostomy is associated with a higher rate of severe post operative complications following the Whipple operation. This was also confirmed in the multivariate analysis.

HPB (Oxford). 2014 Feb 16;16(Suppl 1):1–2.

PP.03 PROGNOSTIC ROLE OF PLASMA VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) IN PATIENTS WITH HEPATOCELLULAR CARCINOMA UNDERGOING LIVER TRANSPLANTATION: EXPERIENCE OF A SINGLE WESTERN CENTER

W Zhang 1, C Quintini 1, K Hashimoto 1, M Fujiki 1, T Diago 1, D Kelly 1, B Eghtesad 1, C Miller 1, J Fung 1, F Aucejo 1

Background

Vascular endothelial growth factor (VEGF) has an important role in hepatocellular carcinoma (HCC) development by fostering tumor cell proliferation and new tumor vessel formation. Recent studies demonstrated the prognostic value of serum/plasma VEGF levels in patients undergoing liver resection or locoregional therapies for HCC. Most studies have been generated in Asian countries, and limited data correlating serum/plasma VEGF in the setting of liver transplantation (LT) for HCC is available. This study investigated the prognostic significance of pre-LT plasma VEGF levels in patients with HCC undergoing LT in a large western transplant center.

Methods

From January 2007 to December 2011, pre-LT plasma VEGF levels were measured by an enzyme-linked immunoassay in 113 patients with HCC. Median VEGF level of the entire cohort was used as the cutoff value to determine high and low plasma VEGF levels. Plasma VEGF levels were correlated with clinicopathological characteristics and overall and recurrence-free post-LT survival.

Results

Median pre-LT plasma VEGF levels were significantly associated with total tumor diameter &gt5 cm (p = 0.005), tumor vascular invasion (p = 0.000), pre-LT locoregional therapy (LRT) (p = 0.001) and beyond Milan criteria (p = 0.016) on univariate analysis. Median pre-LT plasma VEGF level >35 pg/ml was independently associated with vascular invasion (p = 0.006), worse overall (hazard ratio 2.693; p = 0.036) and recurrence-free patient survival (hazard ratio 2.590; p = 0.049) in comparison with median pre-LT plasma VEGF level <35 pg/ml on multivariate analysis.

Conclusion

In patients with chronic end stage liver disease undergoing LT with HCC, median pre-LT plasma VEGF level >35 pg/ml appears to be an independent predictor of vascular invasion, overall and recurrence-free post-LT survival. Due to the current absence of accurate prognostic biomarkers regarding LT in the setting of HCC, further studies are warranted to confirm this observation.

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HPB (Oxford). 2014 Feb 16;16(Suppl 1):2–3.

PP.04 THE EFFECT OF PREOPERATIVE RENAL INSUFFICIENCY ON POSTOPERATIVE OUTCOMES FOLLOWING MAJOR HEPATECTOMY: A MULTI-INSTITUTIONAL ANALYSIS OF 1170 PATIENTS

MH Squires 1, NL Lad 1, SB Fisher 1, DA Kooby 1, SM Weber 2, AS Brinkman 2, CR Scoggins 3, ME Egger 3, K Cardona 1, CS Cho 2, RC Martin 3, MC Russell 1, ER Winslow 2, CA Staley 1, SK Maithel 1

Background

Renal insufficiency is known to adversely affect outcomes after cardiac and vascular surgery. The effect of preoperative renal insufficiency on postoperative outcomes following major hepatectomy is unknown.

Methods

All patients who underwent major hepatectomy, defined as resection of ≥3 hepatic segments, at three academic institutions from 2000–2012 were identified. Resections were performed utilizing low CVP technique unless contraindicated. Renal function was analyzed by preoperative serum creatinine (sCr) level. Primary outcomes were major complications (Clavien Grade III-V), respiratory failure, acute renal failure (ARF) requiring new-onset hemodialysis, and 90-day mortality. Multivariate models for each endpoint were constructed using all variables with a p-value < 0.05 on univariate analysis.

Results

1170 patients with preoperative sCr levels available for analysis were identified. Renal function was analyzed using sCr dichotomized at 1.8 mg/dL, one standard deviation above the mean value (0.97 +/− 0.79 mg/dL) for the cohort. Twenty-three patients had sCr ≥ 1.8 mg/dL. Major complications occurred in 279 patients (23.8%), respiratory failure in 62 (5.3%), and ARF in 31 (2.6%). Ninety-day mortality rate was 5.4%. On univariate analysis, sCr ≥ 1.8 was significantly associated with each endpoint. On multivariate analysis, patients with sCr ≥ 1.8 remained at significantly increased risk for major complications (HR 3.94;95%CI:1.48–10.49; p = 0.006), respiratory failure (HR 4.43;95%CI:1.33–14.80; p = 0.015), and ARF (HR 4.63;95%CI:1.16–18.48; p = 0.030). Serum Cr ≥ 1.8 was not independently associated with 90-day mortality on multivariate analysis (p = 0.27).

Conclusion

Preoperative serum creatinine ≥1.8 mg/dL identifies patients at significantly increased risk of postoperative major complications, respiratory failure, and acute renal failure requiring dialysis. Patients are well-selected for major hepatectomy, and few patients with significant renal insufficiency are deemed operative candidates.

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Articles from HPB : The Official Journal of the International Hepato Pancreato Biliary Association are provided here courtesy of Elsevier

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