Does amount of liver regeneration after liver resection for colorectal metastases correlate with recurrence rate? (a study of liver volumetric)

LIVER/BILIARY TRACT/PANCREAS Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy: A prospective study at a single institute Tomohiko Adachi, MD, PhD, Tamotsu Kuroki, MD, Amane Kitasato, MD, PhD, Masataka Hirabaru, MD, Hajime Matsushima, MD, Akihiko Soyama, MD, FACS, Mitsuhisa Takatsuki, MD, PhD, FACS, Susumu Eguchi, MD, FACS Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan INTRODUCTION: Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF. METHODS: A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n¼30) and the early-removal group in which the drain was removed on postoperative day1 (POD1) (n¼41). For the patients with a high drain amylase level ( 10,000 IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF. RESULTS: The incidence of PF was significantly lower in the early-removal group (0% vs the late removal 16%; p<0.001). In the early-removal group, TDT was administered to 12 patients (29%), and predictive factors for the introduction of TDT were high drain amylase level on POD1 (odds ratio [OR] 6.37, p¼0.04) and high serum CRP on POD3 (OR 13.35, p¼0.01), and none of the patients needed additional treatment after TDT. CONCLUSIONS: Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF. Pathological subtype and factors predicting survival in patients with ampullary adenocarcinoma Keiichi Okano, Minoru Oshima, Naoki Yamamoto, Ysuyuki Suzuki, MD, PhD Kagawa University, Kagawa, Japan INTRODUCTION: Carcinoma of the ampulla of Vater is uncommon. This study aimed to clarify predictors of survival for ampullary adenocarcinoma and to identify characteristics of its two major pathological subtypes. METHODS: Medical records were reviewed for 86 patients who underwent curative resection for ampullary adenocarcinoma between 2000 and 2012 at 12 principal hospitals in Kagawa, Japan.

ª 2014 by the American College of Surgeons Published by Elsevier Inc.

RESULTS: Resection was most common among 75e79-year-old patients. Actuarial 1-, 3-, and 5-year postoperative survival rates for ampullary adenocarcinoma were 90%, 72.3%, and 69.1%, respectively. Preoperative biliary drainage; serum CA19-9 and total bilirubin levels; pathological grade; perineural, vascular, pancreatic, and duodenal invasion; nodal metastasis; UICC-T stage; and pancreatobiliary subtype were predictors of poor survival. An elevated serum CA19-9 level; an elevated total bilirubin level; lymphatic, vascular, perineural, and pancreatic invasion; and advanced overall tumor stage were more common in patients with pancreatobiliarytype tumors than in patients with intestinal-type tumors. Additionally, pathologic subtype analysis showed that each subtype had distinct prognostic factors. CONCLUSIONS: Preoperative elevated serum CA19-9 and total bilirubin levels are prognostic factors for ampullary adenocarcinoma, and are both associated with pancreatobiliary-type tumors. Surgeons should be aware of these factors because pancreatobiliary-type adenocarcinoma is aggressively invasive and is associated with poor survival. Does amount of liver regeneration after liver resection for colorectal metastases correlate with recurrence rate? (a study of liver volumetric) Nouran Molla, MBBS, Mazen M Hassanain, MBBS, MD, PhD, FACS, FRCSC, Louis-Martin Boucher, MD, PhD, Zahir Fadel, MD, Ahmad Madkhali, Rahaf Altahan, MD, Eman Alrijraji, Eve Simoneau, MD, Peter Metrakos, MD, FACS, FRCSC McGill University, Montre´al, Que´bec, Canada INTRODUCTION: Hepatectomy is the only potential cure for colorectal cancer liver metastasis (CRCLM) patients. Overall fiveyear survival with liver resection is 25 - 44%. Recurrence rate is as high as 60%. The surge of growth factors and cytokines that promote liver regeneration postoperatively is linked to disease recurrence following hepatectomy in animal models. Our group has previously established the correlation of liver regeneration after portal vein embolization to tumor progression. Objectives: We studied the relationship between degree of liver regeneration after hepatectomy for CRCLM and disease recurrence. METHODS: Retrospective analysis of 120 patients who underwent a single staged hepatectomy using our CRCLM database. Total liver volume (TLV), future liver remnant volume (FLR), total tumor volume (TTV) and postoperative TLV were calculated from the preoperative and postoperative CT scans. Volume measurements were performed on axial view, porto-venous phase from 2.5 mm thick multiphasic CT images. Percentage of liver regeneration (%LR) was measured using this formula [(TLVpost op e FLR)/ FLR] x100. RESULTS: 70.8% of patients studied had major liver resection. Median estimated liver regeneration was 72.58% (-10.62 e 721.33%). Overall recurrence rate was 65.8%. Median diseasefree and overall survival was 10 and 32 months, respectively. There was no significant relation between %LR and disease-free or overall

e105

http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.664 ISSN 1072-7515/14

e106

Scientific Poster Presentations: 2014 Clinical Congress

survival rates (p¼0.641). Multivariate analysis revealed significant positive correlation of recurrence rate with FONG score (p ¼0.013), TTV (p ¼0.028), and margin status (p¼0.036). CONCLUSIONS: In our patient population, degree of liver regeneration post R0 CRCLM resection does not correlate with recurrence rate. Divergent effects of necroptosis blockade in acute liver injury Michael Deutsch, MD, Christopher Graffeo, Stephanie Greco, MD, Lena Tomkoetter, MD, Constantinos P Zambirinis, MD, MRes, Elliot Levie, Sarah Rokosh, George Miller, MD, FACS New York University Langone Medical Center, New York, NY INTRODUCTION: Necroptosis is a novel form of cell death that implies programmed necrosis. Necroptosis requires co-localization of RIP1 and RIP3. Acute liver injury (ALI) can result from diverse etiologies but has the common endpoint of hepatic failure. We postulated that necroptosis is the mechanism for hepatocyte death in ALI. METHODS: ALI was induced in WT or RIP3-/- mice using acetaminophen (APAP) or Concanavalin-A (ConA). Necrostatin-1 (Nec-1) was used to inhibit RIP1. Liver injury was quantified by assessing serum transaminases, histology, and survival. RESULTS: Both APAP and ConA-mediated injury resulted in hepatocyte death via necroptosis. However, blockade of necroptosis had divergent effects on outcome depending on the etiology of liver injury and the component of the necrosome inhibited. In ConAinduced injury, RIP3 deletion was protective whereas RIP1 inhibition markedly exacerbated disease. Our mechanistic work showed that in ConA hepatitis RIP1 inhibition diverted hepatocyte death from necroptosis toward apoptosis as excess RIP1 complexed with FADD and Caspase 8 forming the pro-apoptotic complex IIa, resulting in Caspase 3 activation. Conversely, RIP3 deletion was protective, effectively blocked necroptosis without upregulating apoptosis. Moreover, unlike ConA hepatitis, in APAP-mediated liver injury blockade of either RIP1 or RIP3 were protective by mitigating Nlrp3 inflammasome activation and limiting IL-1b and IL-18 production. CONCLUSIONS: Our work shows that diverse modes of ALI have distinct requirements for RIP1 and RIP3. Additionally within a single injury model, RIP1 and RIP3 blockade can have opposite effects on tissue injury suggesting that interference with specific components of the necrosome must be considered separately. Intraoperative diagnosis of hepatic tumors located in the liver surface and hepatic segmental visualization using indocyanine green-photodynamic eye imaging Atsushi Nanashima, MD Nagasaki University, Nagasaki, Japan

J Am Coll Surg

INTRODUCTION: To improve of diagnosis for occult tumor localization and define the accurate anatomical area for resection in the liver, we have applied the novel fluorescent diagnosis using the indocyanine green dye-photodynamic eye (ICG-PDE) system during hepatectomy in 125 patients with hepatic tumors accompanied with the enhanced ultrasonography between 2009 and 2013. METHODS: For tumor detection, 0.5mg/kg-weight of ICG was intravenously administrated 2-7 days prior to hepatectomy for the routine liver functional test. To define the accurate hepatic segmentation for anatomical hepatic resections, 0.075mg/10ml of ICG was administrated into the targeted portal vein of the estimated resected area. ICG was administrated into the bile duct to detect the biliary fistula at the transected planes. Fluorescence of ICG was detected by the photodynamic eye infrared-camera. RESULTS: Detectable liver lesions were 137 nodules during hepatectomy. Sensitivity of diagnosis for liver tumors was high as 96%. The newly detected liver lesions were observed in 25 lesions in hepatocellular carcinomas (HCC), in which 3 nodules were histologically diagnosed. In advanced HCC with portal vein thrombosis, extension of thrombi was remarkably detected via portal trunk by ICG-PDE system. In case of anatomical hepatectomy, marking of ICG-PDE was more significantly visible in comparison with the conventional dye injection method. ICG-PDE was also useful to detect the burden of the caudate lobe. Tiny biliary fistula was sensitively detected by ICG-PDE system in 5 cases. CONCLUSIONS: Novel fluoresence-navigation surgery using ICG-PDE system is a powerful diagnostic tool during hepatectomy to improve surgical results and curability of resections in patients with liver malignancies. Impact of race and socioeconomic status on survival following the surgical treatment of early stage hepatocellular carcinoma (HCC) e a retrospective analysis from the National Cancer Data Base Ramanathan Seshadri, MD, Ryan Z Swan, MD, John B Martinie, MD, FACS, Mark W Russo, MD, David A Iannitti, MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: HCC is the most common primary malignant liver tumor with over 30,000 new cases/year and 20,000 deaths/ year. Surgical treatment for early stage HCC includes resection or transplant. The aim of this study was to determine if there was a difference in survival after surgery based on race, type of health insurance, or income. METHODS: A retrospective analysis was performed from 1998 e 2011 using the National Cancer Data Base. 148,882 patients with liver cancer were identified of which 126,858 had HCC. 64,227 patients from 1998 e 2006 had 5-year survival data. Subgroup analyses were performed in patients with Stage I and II HCC (n¼3340) based on race (White, Black, Asian, Hispanic) and socioeconomic status. Kaplan Meier curves and Cox regression were used for statistical analysis.