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146
304
Journal of Gastrointestinal Surgery
Abstracts
analysis. Densitometry demonstrated an eight-fold induction of MIC-1 message at 6 hours. In situ hybridization of liver sections following bile duct ligation demonstrated a peri-portal expression pattern consistent with expression of MIC-1 in bile ducts and small peri-ductal hepatocytes. Examination of human livers with sclerosing cholangitis also demonstrated enhanced expression of MIC-1/GDF-15. Conclusion: MIC-1/GDF-15 is expressed following bile duct injury. Taken together with the documented anti-tumor and inflammatory effects our results suggest MIC-1/GDF-15 may play a role in control of bile duct growth and biliary tumor formation.
group there were 2 bile leaks and 2 retained stones (2.2%). 1 of these bile leaks required ERCP, while both cases of retained stones required ERCP. One of these required subsequent open common duct exploration. There were a total of 7 deaths, 4 (0.3%) in LC/CON and 3 (3.3%) in OP. The majority of deaths (3 in OP and 2 in LC/CON) were due to overwhelming sepsis, which was present prior to the cholecystectomy in these 5 cases. One LC patient died from unrelated C. difficile colitis. The other death was related to a failing lung transplant complicated by cholangitis. Conclusion: At our institution, the current incidence of biliary complications following LC is as low as the pre-laparoscopic era.
BILIARY Surgery 145
147
A Single-Center Experience on the Surgical Treatment of the Middle and Lower Bile Duct Carcinoma Yoshikazu Toyoki, Kenichi Hakamada, Shunji Narumi, Eishi Totsuka, Mutsuo Sasaki, Hirosaki University School of Medicine, Hirosaki, Japan Aim: To optimize surgical treatment of the middle and lower bile duct carcinoma, we analysed prognostic factors of these cancer patients based on a single center experience. [Methods] The records of 48 patients with the primary middle and lower bile duct cancer between January, 1989 and December, 2000 at our department were reviewed retrospectively. Data were collected by chart review including review of surgical records, pathological specimens and clinical information. Results: The overall 5year survival rate of was 34.2% and the 5-year survival rate of patients whom surgical Curability A was accomplished was 44.5%. No metastatic lymph node status and no vascular invasion were predictors of favorable outcome (p0.05). For the middle bile duct cancer, the prognosis of patients treated with pancreatoduodenectomy with/without pylorus preservation was better than that of patients performed bile duct resection under the condition of Curability A operation (p0.05). For the lower bile duct cancer, the 5-year survival rates of no invasion to the pancreas parenchyma, a little invasion to the pancreas and severe invasion to the pancreas were 60%, 55% and 25% respectively (p0.05). Conclusions: Pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy with extended lymphadenectomy should be performed for the patients with middle and lower bile duct cancer. Patients with metastatic lymph nodes, vascular invasion and/or invasion to the pancreas should receive systemic multimodal therapy (chemotherapy, radiation, etc.).
146 Biliary Complications a Decade After Introduction of Laparoscopic Cholecystectomy Matthew Lissauer, Randolph Reinhold, Hospital of St. Raphael, New Haven, CT Purpose: When laparoscopic cholecystectomy was first introduced a decade ago, multiple investigators reported an increasing incidence of bile duct injury. We studied the current incidence of direct biliary complications following cholecystectomies, ten years after the wide introduction of LC. Method: A retrospective chart review of 1465 consecutive primary cholecystectomies performed between 7/1/98 and 6/30/2001 was performed. Procedures were classified as laparoscopic (LC), open (OP), or laparoscopic converted to open (CON). Using intent to treat model, LC and CON groups were combined and compared to LC in terms of complications Results: 1465 consecutive cholecystectomies were performed: 1232 LC, 143 CON, and 90 OP. The overall biliary complication rate was 1.8%. The rate in the LC/CON group was 1.6% vs. 4.4% in the OP group. There was one major CBD injury in the LC/CON group (0.07%). The remainder of complications were minor. In the LC/CON group there were 10 bile leaks (0.7%) and 11 (0.8%) retained stones. 4 bile leaks required no intervention, 4 required ERCP, 1 required CT guided drainage, and 1 required operative drainage. All 11 retained stones required ERCP, and 1 required subsequent operative management. In the open
Open Laparoscopy: New Technique of Treatment of Choledocholithiasis Valery V Hodakov, Ural State Medical Academy, Yekaterinburg, Russia Background: An open laparoscopic operation with the use of the ring retractor is a new minimally invasive technique of surgical treatment of a pathology of biliary system. Purpose: To evaluate feasibility and outcomes of open lapa- roscopic operations with application of a minilaparotomy up to 4 cm in treatment of choledocholithiasis and ampullary stenosis. Patients: 586 patients were observed, an average age is 57.9 years (17-90). Cholecystitis accounted for over 90% of cases: 48% of the patients had acute form and 53% had chronic form of cholecystitis. 10 patients had history of previous biliary tract surgery. Stones of biliary tree and/or of ampullary stenosis were found in 78% of patients; 26% had obstructive jaundice. Other complications of cholelithiasis included purulent cholangitis (n65), pericystic infiltrate (n36), peritonitis (n20), bilio-digestive fistulas (n10), Mirizzi syndrome (n9), etc. Methods: A two-stage surgical approach was applied to 321 patients. On the first stage of treatment, open laparosco- pic cholecystectomy (OLCh n221), endoscopic papillotomy (EPST n88) or cholecystostomy (n12) were performed. 108 patients had a T-tube drainage of a common bile duct, 111 - drainage of a cystic duct by Halstedt technique. The transformation into open laparotomy was necessary in 2 cases. On the second stage of treatment EPST was performed on 216 patients (EPST failed in 2 of them), OLCh with choledocholititomy and T-tube drainage of common bile duct - on 51, OLCh alone - on 39. 4 patients had OLCh with choledocholititomy and choledochoduodenostomy (1 of them required transduodenal papillotomy) and 2 patients had a balloon dilatation of a Vater papilla. Transformation into open laparotomy was necessary in 3 patients. Patients with previous surgeries of bile ducts (n6) received minilaparotomy, choledocholititomy with a T-tube drainage of a common bile duct. A single-stage approach was used in 247 patients. OLCh with a T-tube drainage of a common bile duct is done at 38 patients, OLCh with a drainage of a cystic duct - at 123, OLCh with choledocholititomy and T-tube drainage of common bile duct - at 39 patients. 11 patients required papillotomy, 2 - choledochoduodenostomy, 1 - Rouxen-Y hepaticojejunostomy. In 33 patients OLCh was converted into open laparotomy. Results: Average hospital stay was 23.2 days, with 15.9 days in post-operative period. Intraoperative complications were encountered in eight cases. The complications in the postoperative period were observed in 7.75% patients with a mortality rate of 2.1%. Conclusion: open laparoscopy with the use of a ring retractor allows to perform minimally invasive operations for a wide spectrum of biliary tract pathology, including repeated restorative - reconstructive interventions. The frequency of conversion into open laparotomy in this series was 6.2%.
148 Patterns of Primary Recurrence after Resection for Gallbladder Cancer and Hilar Cholangiocarcinoma Leyo Ruo, Yuman Fong, Sarah A Little, Ronald P DeMatteo, Leslie H Blumgart, William R Jarnagin, Memorial Sloan-Kettering Cancer Center, New York, NY Objective: Gallbladder cancer and cholangiocarcinoma are often considered to be different manifestations of the same disease, but recent data suggest that they are distinct neoplasms with different invasive and meta-
Journal of Gastrointestinal Surgery
Abstracts
analysis. Densitometry demonstrated an eight-fold induction of MIC-1 message at 6 hours. In situ hybridization of liver sections following bile duct ligation demonstrated a peri-portal expression pattern consistent with expression of MIC-1 in bile ducts and small peri-ductal hepatocytes. Examination of human livers with sclerosing cholangitis also demonstrated enhanced expression of MIC-1/GDF-15. Conclusion: MIC-1/GDF-15 is expressed following bile duct injury. Taken together with the documented anti-tumor and inflammatory effects our results suggest MIC-1/GDF-15 may play a role in control of bile duct growth and biliary tumor formation.
group there were 2 bile leaks and 2 retained stones (2.2%). 1 of these bile leaks required ERCP, while both cases of retained stones required ERCP. One of these required subsequent open common duct exploration. There were a total of 7 deaths, 4 (0.3%) in LC/CON and 3 (3.3%) in OP. The majority of deaths (3 in OP and 2 in LC/CON) were due to overwhelming sepsis, which was present prior to the cholecystectomy in these 5 cases. One LC patient died from unrelated C. difficile colitis. The other death was related to a failing lung transplant complicated by cholangitis. Conclusion: At our institution, the current incidence of biliary complications following LC is as low as the pre-laparoscopic era.
BILIARY Surgery 145
147
A Single-Center Experience on the Surgical Treatment of the Middle and Lower Bile Duct Carcinoma Yoshikazu Toyoki, Kenichi Hakamada, Shunji Narumi, Eishi Totsuka, Mutsuo Sasaki, Hirosaki University School of Medicine, Hirosaki, Japan Aim: To optimize surgical treatment of the middle and lower bile duct carcinoma, we analysed prognostic factors of these cancer patients based on a single center experience. [Methods] The records of 48 patients with the primary middle and lower bile duct cancer between January, 1989 and December, 2000 at our department were reviewed retrospectively. Data were collected by chart review including review of surgical records, pathological specimens and clinical information. Results: The overall 5year survival rate of was 34.2% and the 5-year survival rate of patients whom surgical Curability A was accomplished was 44.5%. No metastatic lymph node status and no vascular invasion were predictors of favorable outcome (p0.05). For the middle bile duct cancer, the prognosis of patients treated with pancreatoduodenectomy with/without pylorus preservation was better than that of patients performed bile duct resection under the condition of Curability A operation (p0.05). For the lower bile duct cancer, the 5-year survival rates of no invasion to the pancreas parenchyma, a little invasion to the pancreas and severe invasion to the pancreas were 60%, 55% and 25% respectively (p0.05). Conclusions: Pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy with extended lymphadenectomy should be performed for the patients with middle and lower bile duct cancer. Patients with metastatic lymph nodes, vascular invasion and/or invasion to the pancreas should receive systemic multimodal therapy (chemotherapy, radiation, etc.).
146 Biliary Complications a Decade After Introduction of Laparoscopic Cholecystectomy Matthew Lissauer, Randolph Reinhold, Hospital of St. Raphael, New Haven, CT Purpose: When laparoscopic cholecystectomy was first introduced a decade ago, multiple investigators reported an increasing incidence of bile duct injury. We studied the current incidence of direct biliary complications following cholecystectomies, ten years after the wide introduction of LC. Method: A retrospective chart review of 1465 consecutive primary cholecystectomies performed between 7/1/98 and 6/30/2001 was performed. Procedures were classified as laparoscopic (LC), open (OP), or laparoscopic converted to open (CON). Using intent to treat model, LC and CON groups were combined and compared to LC in terms of complications Results: 1465 consecutive cholecystectomies were performed: 1232 LC, 143 CON, and 90 OP. The overall biliary complication rate was 1.8%. The rate in the LC/CON group was 1.6% vs. 4.4% in the OP group. There was one major CBD injury in the LC/CON group (0.07%). The remainder of complications were minor. In the LC/CON group there were 10 bile leaks (0.7%) and 11 (0.8%) retained stones. 4 bile leaks required no intervention, 4 required ERCP, 1 required CT guided drainage, and 1 required operative drainage. All 11 retained stones required ERCP, and 1 required subsequent operative management. In the open
Open Laparoscopy: New Technique of Treatment of Choledocholithiasis Valery V Hodakov, Ural State Medical Academy, Yekaterinburg, Russia Background: An open laparoscopic operation with the use of the ring retractor is a new minimally invasive technique of surgical treatment of a pathology of biliary system. Purpose: To evaluate feasibility and outcomes of open lapa- roscopic operations with application of a minilaparotomy up to 4 cm in treatment of choledocholithiasis and ampullary stenosis. Patients: 586 patients were observed, an average age is 57.9 years (17-90). Cholecystitis accounted for over 90% of cases: 48% of the patients had acute form and 53% had chronic form of cholecystitis. 10 patients had history of previous biliary tract surgery. Stones of biliary tree and/or of ampullary stenosis were found in 78% of patients; 26% had obstructive jaundice. Other complications of cholelithiasis included purulent cholangitis (n65), pericystic infiltrate (n36), peritonitis (n20), bilio-digestive fistulas (n10), Mirizzi syndrome (n9), etc. Methods: A two-stage surgical approach was applied to 321 patients. On the first stage of treatment, open laparosco- pic cholecystectomy (OLCh n221), endoscopic papillotomy (EPST n88) or cholecystostomy (n12) were performed. 108 patients had a T-tube drainage of a common bile duct, 111 - drainage of a cystic duct by Halstedt technique. The transformation into open laparotomy was necessary in 2 cases. On the second stage of treatment EPST was performed on 216 patients (EPST failed in 2 of them), OLCh with choledocholititomy and T-tube drainage of common bile duct - on 51, OLCh alone - on 39. 4 patients had OLCh with choledocholititomy and choledochoduodenostomy (1 of them required transduodenal papillotomy) and 2 patients had a balloon dilatation of a Vater papilla. Transformation into open laparotomy was necessary in 3 patients. Patients with previous surgeries of bile ducts (n6) received minilaparotomy, choledocholititomy with a T-tube drainage of a common bile duct. A single-stage approach was used in 247 patients. OLCh with a T-tube drainage of a common bile duct is done at 38 patients, OLCh with a drainage of a cystic duct - at 123, OLCh with choledocholititomy and T-tube drainage of common bile duct - at 39 patients. 11 patients required papillotomy, 2 - choledochoduodenostomy, 1 - Rouxen-Y hepaticojejunostomy. In 33 patients OLCh was converted into open laparotomy. Results: Average hospital stay was 23.2 days, with 15.9 days in post-operative period. Intraoperative complications were encountered in eight cases. The complications in the postoperative period were observed in 7.75% patients with a mortality rate of 2.1%. Conclusion: open laparoscopy with the use of a ring retractor allows to perform minimally invasive operations for a wide spectrum of biliary tract pathology, including repeated restorative - reconstructive interventions. The frequency of conversion into open laparotomy in this series was 6.2%.
148 Patterns of Primary Recurrence after Resection for Gallbladder Cancer and Hilar Cholangiocarcinoma Leyo Ruo, Yuman Fong, Sarah A Little, Ronald P DeMatteo, Leslie H Blumgart, William R Jarnagin, Memorial Sloan-Kettering Cancer Center, New York, NY Objective: Gallbladder cancer and cholangiocarcinoma are often considered to be different manifestations of the same disease, but recent data suggest that they are distinct neoplasms with different invasive and meta-