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Preoperative biliary drainage in malignant jaundice causes a shift of the biliary microbiome and aggravates antibiotic resistance
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Electronic Poster Abstracts
FP24-04 PREOPERATIVE BILIARY DRAINAGE IN MALIGNANT JAUNDICE CAUSES A SHIFT OF THE BILIARY MICROBIOME AND AGGRAVATES ANTIBIOTIC RESISTANCE F. Scheufele1, L. Aichinger1, C. Jäger1, M. Erkan2, J. Kleeff3, H. Friess3 and G. Ceyhan3 1 Klinikum rechts der Isar, Technische Universität München, Germany, 2Surgery, Koc University School of Medicine, Turkey, and 3Surgery, Klinikum rechts der Isar, Technische Universität München, Germany Introduction: Patients with malignant obstructive jaundice often receive preoperative biliary drainage (PBD). Recently, increased postoperative complications were linked to contamination of the bile facilitated by PBD. However, the effect of biliary stenting on the microbiome of the biliary tree and its effect on postoperative outcome is still a neglected important clinical issue. Methods: Thus a retrospective database analysis of patients with malignant obstructive jaundice 07/2007-07/2014 was performed. Intraoperative microbiological bile samples were obtained after transection of the CBD. Postoperative complications were graded according the Clavien-Dindo classification and pancreatic fistula with the ISGPF classification. Results: Database search yielded 164 (60.3%) stented and 108 (39.7%) non-stented patients. Contamination of bile fluid was increased in stented patents (97.6% vs. 20.4%;p < 0.001). PBD resulted in a switch of the biliary microbiome from E. coli in non-stented patients (45.5% vs. 20%;p < 0.05) to E.faecalis (9.0% vs. 38.1%;p < 0.01) and E.cloacae (0% vs. 18.8%;p < 0.05) in biliary drained patients, resulting in enhanced incidence of bacterial resistance against Ampicillin/Sulbactam (61.9% vs. 18.2%; p < 0.001), Piperacillin/Tazbactam (27.5% vs. 0%;p < 0.01), Ciprofloxacin (28.5% vs. 5.3%;p < 0.05) and Imipenem (25.8% vs. 0%;p < 0.01). Wound infections were significantly augmented after PBD (5.8% vs. 21.2%;p < 0.001) and contamination of the bile with E.faecalis (p = 0.011), E.faecium (p < 0.01), Klebsiella (p = 0.014) or Citrobacter (p = 0.001) resulted in more frequent wound infections. Conclusion: This study emphasizes the crucial role of PBD in development of postoperative infectious complications by facilitating a shift of the biliary microbiome towards a more resistant and aggressive spectrum.
FP25 e Free Papers 25 (mini oral) e Liver: Metastases 3
FP25-01 OUTCOMES OF SIMULTANEOUS ALPPS AND COLORECTAL RESECTION FOR COLORECTAL LIVER METASTASES: RESULTS FROM THE INTERNATIONAL ALPPS REGISTRY K. N. Wanis1, S. Buac1, M. E. Tun-Abraham2, M. Linecker3, V. Ardiles4, E. de Santibañes4, P. -A. Clavien3 and R. Hernandez-Alejandro1,2 1 Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 2Multi-Organ
Transplant Program, London Health Sciences Centre, Canada, 3Swiss HPB and Transplant Center, University Hospital Zurich, Switzerland, and 4Liver Transplant Unit & General Surgery Service, Hospital Italiano de Buenos Aires, Argentina Introduction: Liver resection and colorectal surgery (CRS) are the only curative option in patients presenting with synchronous colorectal cancer and liver metastases (CRLM). While simultaneous resection has been shown to offer benefits in patients with low tumor load, in presence of extensive CRLM and a small predicted future liver remnant (FLR), with in-situ colorectal tumor, the use of simultaneous ALPPS and CRS is controversial with no published outcomes. Methods: All cases of simultaneous ALPPS and CRS prospectively entered into the ALPPS registry were examined. Cases with >14 days between stages were excluded to remain consistent with the ALPPS definition. Twenty-one cases were identified. Results: The mean age of the cohort was 54 9.3 years with a 2:1 male:female proportion and an average BMI of 25.5 kg/m2. CRS was performed during stage 1 in 86% (18/ 21) of cases. Fourteen percent of patients (3/21) had >10 liver lesions. Ninety-five percent of the cohort received preoperative chemotherapy, and all cases with available resection margin data achieved R0 margins (17/17). The mean sFLR prior to stage 1 was 0.23 0.09. The rate of severe (Clavien-Dindo IIIb) and minor (Clavien-Dindo < IIIb) complications was 9.5% and 23.8%, respectively, with one 90-day mortality. The one-year disease-free and overall survival was 30% and 83% respectively with a mean follow-up of 192 days (range:11e444). Conclusion: In young patients, with good performance status, simultaneous ALPPS and CRS for CRLM is associated with low morbidity and mortality with acceptable disease-free survival, and may be considered as an option.
FP25-02 LAPAROSCOPIC RESECTION RESULTS FOR TREATMENT OF COLORECTAL CANCER LIVER METASTASES: A CASE MATCH STUDY WITH PROPENSITY SCORE J. -M. Regimbeau1, F. Le Roux1 and I. Khaoudy2 1 Digestive and Oncoligic Surgery, University Hospital Amiens Picardie, and 2Amiens Hospital, France Introduction: The laparoscopic liver surgery for metastases is still uncommon. The aim of this study is to assess the laparoscopic approach for colorectal cancer liver metastases (CCRLM). Methods: This retrospective study with propensity score analysis compared postoperative course and long term outcome between laparoscopic and open liver surgery. Patients were included between 2008 and 2014 in a single center. The statistical analysis were realized in tow steps with an univariate analyses for preoperative data to discriminate the confounding factors (sex, ASA, number of tumors, location, preoperative chemotherapy, surgical technique) and a second multivariate analysis using the propensity score to evaluate the difference between laparoscopic and open surgery. HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts
FP24-04 PREOPERATIVE BILIARY DRAINAGE IN MALIGNANT JAUNDICE CAUSES A SHIFT OF THE BILIARY MICROBIOME AND AGGRAVATES ANTIBIOTIC RESISTANCE F. Scheufele1, L. Aichinger1, C. Jäger1, M. Erkan2, J. Kleeff3, H. Friess3 and G. Ceyhan3 1 Klinikum rechts der Isar, Technische Universität München, Germany, 2Surgery, Koc University School of Medicine, Turkey, and 3Surgery, Klinikum rechts der Isar, Technische Universität München, Germany Introduction: Patients with malignant obstructive jaundice often receive preoperative biliary drainage (PBD). Recently, increased postoperative complications were linked to contamination of the bile facilitated by PBD. However, the effect of biliary stenting on the microbiome of the biliary tree and its effect on postoperative outcome is still a neglected important clinical issue. Methods: Thus a retrospective database analysis of patients with malignant obstructive jaundice 07/2007-07/2014 was performed. Intraoperative microbiological bile samples were obtained after transection of the CBD. Postoperative complications were graded according the Clavien-Dindo classification and pancreatic fistula with the ISGPF classification. Results: Database search yielded 164 (60.3%) stented and 108 (39.7%) non-stented patients. Contamination of bile fluid was increased in stented patents (97.6% vs. 20.4%;p < 0.001). PBD resulted in a switch of the biliary microbiome from E. coli in non-stented patients (45.5% vs. 20%;p < 0.05) to E.faecalis (9.0% vs. 38.1%;p < 0.01) and E.cloacae (0% vs. 18.8%;p < 0.05) in biliary drained patients, resulting in enhanced incidence of bacterial resistance against Ampicillin/Sulbactam (61.9% vs. 18.2%; p < 0.001), Piperacillin/Tazbactam (27.5% vs. 0%;p < 0.01), Ciprofloxacin (28.5% vs. 5.3%;p < 0.05) and Imipenem (25.8% vs. 0%;p < 0.01). Wound infections were significantly augmented after PBD (5.8% vs. 21.2%;p < 0.001) and contamination of the bile with E.faecalis (p = 0.011), E.faecium (p < 0.01), Klebsiella (p = 0.014) or Citrobacter (p = 0.001) resulted in more frequent wound infections. Conclusion: This study emphasizes the crucial role of PBD in development of postoperative infectious complications by facilitating a shift of the biliary microbiome towards a more resistant and aggressive spectrum.
FP25 e Free Papers 25 (mini oral) e Liver: Metastases 3
FP25-01 OUTCOMES OF SIMULTANEOUS ALPPS AND COLORECTAL RESECTION FOR COLORECTAL LIVER METASTASES: RESULTS FROM THE INTERNATIONAL ALPPS REGISTRY K. N. Wanis1, S. Buac1, M. E. Tun-Abraham2, M. Linecker3, V. Ardiles4, E. de Santibañes4, P. -A. Clavien3 and R. Hernandez-Alejandro1,2 1 Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 2Multi-Organ
Transplant Program, London Health Sciences Centre, Canada, 3Swiss HPB and Transplant Center, University Hospital Zurich, Switzerland, and 4Liver Transplant Unit & General Surgery Service, Hospital Italiano de Buenos Aires, Argentina Introduction: Liver resection and colorectal surgery (CRS) are the only curative option in patients presenting with synchronous colorectal cancer and liver metastases (CRLM). While simultaneous resection has been shown to offer benefits in patients with low tumor load, in presence of extensive CRLM and a small predicted future liver remnant (FLR), with in-situ colorectal tumor, the use of simultaneous ALPPS and CRS is controversial with no published outcomes. Methods: All cases of simultaneous ALPPS and CRS prospectively entered into the ALPPS registry were examined. Cases with >14 days between stages were excluded to remain consistent with the ALPPS definition. Twenty-one cases were identified. Results: The mean age of the cohort was 54 9.3 years with a 2:1 male:female proportion and an average BMI of 25.5 kg/m2. CRS was performed during stage 1 in 86% (18/ 21) of cases. Fourteen percent of patients (3/21) had >10 liver lesions. Ninety-five percent of the cohort received preoperative chemotherapy, and all cases with available resection margin data achieved R0 margins (17/17). The mean sFLR prior to stage 1 was 0.23 0.09. The rate of severe (Clavien-Dindo IIIb) and minor (Clavien-Dindo < IIIb) complications was 9.5% and 23.8%, respectively, with one 90-day mortality. The one-year disease-free and overall survival was 30% and 83% respectively with a mean follow-up of 192 days (range:11e444). Conclusion: In young patients, with good performance status, simultaneous ALPPS and CRS for CRLM is associated with low morbidity and mortality with acceptable disease-free survival, and may be considered as an option.
FP25-02 LAPAROSCOPIC RESECTION RESULTS FOR TREATMENT OF COLORECTAL CANCER LIVER METASTASES: A CASE MATCH STUDY WITH PROPENSITY SCORE J. -M. Regimbeau1, F. Le Roux1 and I. Khaoudy2 1 Digestive and Oncoligic Surgery, University Hospital Amiens Picardie, and 2Amiens Hospital, France Introduction: The laparoscopic liver surgery for metastases is still uncommon. The aim of this study is to assess the laparoscopic approach for colorectal cancer liver metastases (CCRLM). Methods: This retrospective study with propensity score analysis compared postoperative course and long term outcome between laparoscopic and open liver surgery. Patients were included between 2008 and 2014 in a single center. The statistical analysis were realized in tow steps with an univariate analyses for preoperative data to discriminate the confounding factors (sex, ASA, number of tumors, location, preoperative chemotherapy, surgical technique) and a second multivariate analysis using the propensity score to evaluate the difference between laparoscopic and open surgery. HPB 2016, 18 (S1), e1ee384