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Tu1777 Clinical Outcomes of Percutaneous Cholecystostomy Tube Placement in Critically Ill Patients With Acute Cholecystitis
of 9.1+/- 2.4 and after surgery had distensibility of 10.8+/-1.2mm2/mmHg. When patients defined as "clinical failures" were compared to patients who had clinical improvement after surgery, we found patients with failure on Eckardt scores had significantly smaller diameters 8.7+/-0.2 versus 9.9+/-0.4mm (n=59, p=0.01). We also saw patients that failed on reflux severity index had a FLIP distensibility at the end of the procedure much less than patients that succeeded although not significant, 4.9+/-1.1 compared to 12.7+/-1.7 mm2/mmHg (n= 33, p=0.16). Conclusions: FLIP is a promising new device to supplement our diagnostic tools for evaluating lower esophageal sphincter pathology. The geometry of the sphincter measured by FLIP appears to correlate with gastroesophageal pathology and patient outcomes, however continued data collection and larger data sets are required to better understand these relationships. FLIP measurements for pathology
Tu1778 Choledochocystic Disease in a Western Center: A 30-Year Experience Maitham A. Moslim, Hideo Takahashi, R Matthew Walsh, Gareth Morris-Stiff BACKGROUND: Choledochocystic (CC) disease is a rare condition that has a varied presentation. The aim of this study was to report as single experience in the diagnosis and management of the condition at a Western center. METHODS: With institutional review board approval, the departmental database was interrogated to identify all patients who underwent surgical treatment of CC disease. The presentation, investigation, management, surgical pathology, post-operative course and follow-up were documented. All CC were classified as per the Todani system. RESULTS: 67 patients were identified including 15 children and 52 adults, with 76.1% being females. The mean age at diagnosis of CC was 3.7 years for children, and 44.6 years for adults. 48 patients (62.7%) were symptomatic, with the most common presentations including: (n=34); jaundice/deranged hepatic function (n=10); and acute pancreatitis (n=9). Two of 19 patients with incidental CC were diagnosed on prenatal ultrasound. Types of CC included: I (n=49, 73.1%); II (n=1, 1.5%), IV (n=9, 13.4%) and V (n=8, 12%). Malignancy was concomitant in 5 pathology specimens (gallbladder adenocarcinoma [n=2], cholangiocarcinoma [n= 3]), and atypia without cancer was reported in 3 patients. The median interval from diagnosis to operation was 95 days. 48 patients underwent excision of CC with Roux-en-Y hepatojejunostomy, and 8 resection with heptatoduodenostomy. 6 patients underwent liver resection with Roux-en-Y hepaticojejunostomy including right lobectomy (n=3), left lobectomy for (n=2) and gallbladder resection for CC associated with a gallbladder cancer (n=1). 5 patients underwent orthotopic liver transplantation (Type V [n=4], incidental type I cyst in native liver with primary biliary cirrhosis [n=1]). The surgical approach was open (n=57), laparoscopic (n=3), robotic (n= 6) and laparoscopic converted to open due to gallbladder cancer (n=1). Post-operative complications included intra-abdominal fluid collections (n=8), bile leak (n=6), anastomotic stenosis (n=6), malignancy (CCA [n=2], recurrence of gallbladder cancer [n=2], post-transplant lymphoproliferative disease [n=1]), cholangitis (n=4), pancreatitis (n=4), CBD stump lithiasis (n=4), ileus (n=3), liver failure (n=3), incisional hernia (n=3) and others (n=22). 5 patients (7.5%) expired due to recurrent CCA (n=3), pneumonia in the setting of recurrent gallbladder cancer (n=1) and hepatic failure (n=1). The median follow up interval from the diagnosis to the last surgical clinic visit was 25 months. CONCLUSIONS: The study has demonstrated the varied presentation and management of CC arising in a western population. Malignant change is not uncommon and often detected incidentally at resection of CC.
Tu1776 Lessons From a Quarter of Century Treating Esophageal Perforations: A Proposal of a Decision-Making Algorithm Marisa Aral, Hugo Santos-Sousa, José Costa-Maia Introduction: Esophageal perforation (EP) is a rare diagnosis, with a high morbidity and mortality, and its therapy is still challenging. The aim of this study was to assess the etiology, specific treatment and outcome of EP in order to generate an optimal therapeutic approach to improve patient's outcome. Methods: Analysis of a prospective database with cases of EP (n=71) treated in an Upper GI Surgery Unit, between January 1991 and October 2014. Results: The majority of EP were traumatic (60,6%) and thoracic (62%). The median timing of diagnosis was 24 [1-336] hours. The severity score median was 4 [0-14]. Non-operative treatment was done in 22,5%. Primary repair was the most common option (52,7%) in operative treatment. The median LOS was 26 [4-266] days. The morbidity and mortality rates were 40,8% and 15,5%. Morbidity was significantly associated to etiology (p=0,003), type of management (p=0,001) and severity score (p<0,001) [presence at presentation of tachycardia (p=0,001), pleural effusion (p<0,001), non-contained leak (p<0,001), respiratory compromise (p<0,001) and hypotension (p=0,012)]. Mortality was significantly associated to etiology (p=0,02), esophageal pathology (p=0,002), location (p=0,004) and severity score (p=0,009) [age (0,016), presence at presentation of tachycardia (p=0,002), hypotension (p= 0,006) and cancer (p=0,07)]. The timing of diagnosis didn't significantly influence morbidity or mortality. Conclusions: Based in the results of this study we propose a decision-making algorithm to best assist in the choice of EP treatment in each patient.
Tu1779 Acute Renal Failure Following Liver Resection for Hepatocellular Carcinoma: Prognostic Value of Acute Kidney Injury Network Consensus Criteria Alexsander Bressan, Elijah Dixon, Oliver F. Bathe, Francis R. Sutherland, Chad G. Ball
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Background: Postoperative renal failure is reported in approximately 15% of liver resections and is associated with increased morbidity and mortality. Patients with hepatocellular carcinoma (HCC) represent a high-risk population due to the increased prevalence of cirrhosis and potentially poor physiologic reserve. Applicability of Acute Kidney Injury Network (AKIN) criteria (48-hour increase in serum creatinine and urine output) remains poorly studied in this cohort of patients. Methods: All patients undergoing liver resection for HCC between January 2010 and October 2014 at a high-volume, quaternary care HPB referral center were included. Perioperative care remained constant over the study period, with routine intraoperative fluid restriction to maintain low central venous pressure (CVP) during resection, as well as reestablishment of normovolemia following specimen removal (i.e. continued in the post-anesthesia care unit). Retrospective data collection from electronic medical records utilized 8-hour shift periods to assess urine output from the point of surgery until the morning of postoperative day 2. Institutional laboratory databases were used to extract baseline and postoperative creatinine values. AKIN criteria were employed to diagnose AKI within 48 hours after surgery. Continuous variables were compared using t-test, and statistical analyses were conducted using SPSS, v.19, Chicago, IL. Results: A total of 71 liver resections was performed (median age: 62 years (IQR: 56-70); male=74.6%; median BMI=25.6 (IQR: 23.1-29.5)). Preoperative patient assessment identified 60.6% were ASA 2 and 28.2% were ASA 3. Underlying liver disease was identified in 58 patients (hepatitis B or C in 48 patients); 57 Child-Pugh A and 1 Child-Pugh B (score 7). Fifty-five surgeries (77.5%) were minor liver resections (2 segments or less), and 12 of these were laparoscopic. Estimated blood loss was 200 ml (IQR: 87 - 400) for minor and 650 ml (IQR: 375 - 800) for major liver resections. Inflow occlusion was used in 14 (19.7%) surgeries, for an average of 18 minutes. Fifty-nine (83.1%) patients had confirmed background cirrhosis in the liver specimen. Median hospital stay was 9 days (IQR: 7-12) and 30-day mortality was 4.2%. The incidence of AKI was 21.1% based on creatinine and 53.5% with urine output criteria. AKI was associated with prolonged hospital stay when defined by serum creatinine criteria (10.4 vs. 19.8 days, p<.01), but not by urine output criteria (10.3 vs. 14.1 days, p=.478). Conclusion: Urine output criteria results in an overestimation of AKI after liver resection for HCC, and therefore compromises the prognostic value of AKIN criteria in terms of hospital length of stay. Revision of the AKIN criteria to account for the physiologic postoperative reduction in urine output should be considered for patients with HCC undergoing lowCVP liver resection.
SSAT Abstracts
Clinical Outcomes of Percutaneous Cholecystostomy Tube Placement in Critically Ill Patients With Acute Cholecystitis Kenneth Sirinek, Ronald M. Stewart, Kent Van Sickle, Wayne Schwesinger BACKGROUND: The surgical treatment of acute cholecystitis in critically ill patients is associated with significant morbidity and mortality. Percutaneous placement of a cholecystostomy tube (PCT) is a widely available, less risky approach but is generally thought to mandate an interval cholecystectomy at some later date. In this study, we evaluated all acute cholecystitis patients treated initially with PCT to assess their subsequent courses and the overall outcomes. METHODS: Data from all patients undergoing PCT placement in the decade 2004-2013 were prospectively collected and retrospectively reviewed. Statistical analysis was performed using the Chi-Square test. RESULTS: One hundred fifty three critically ill patients (M/F = 99/54) with a mean age of 58 years (range = 22-95) underwent PCT at our tertiary care hospital over the ten year period of the study. Fever and symptoms (primarily pain and nausea) resolved within 48 hours in 143 patients (93.5%) while another 10 patients required urgent cholecystectomy within 1-4 days for unremitting signs and symptoms (6.5%). One hundred and one patients treated by PCT did not proceed to operation but had their tubes removed or replaced with no recurrent episodes of acute cholecystitis (66%). However, twelve of the patients in this group eventually died from their associated comorbidities (12%). Interval cholecystectomy was performed in another group of fifty-two patients at a mean of 68 days following PCT (range = 1-186 days) with no postoperative mortality. Five patients in this group also underwent intraoperative cholangiography with all studies negative for choledocholithiasis. Compared to all 7734 patients undergoing cholecystectomy at this hospital during the same decade, the 52 PCT patients undergoing cholecystectomy were 14 times more likely to have an initial open cholecystectomy (OC) (1.8% vs 25%) and they experienced an eight-fold higher conversion rate to open procedure when laparoscopic cholecystectomy (LC) was attempted (2.2% vs 18%). (Table) CONCLUSIONS: 1.PCT is both a safe and an effective initial treatment for acute cholecystitis in critically ill patients who are not candidates for urgent biliary surgery. 2. The majority of patients treated with PCT do not require interval cholecystectomy and often remain asymptomatic even after removal of the cholecystostomy tube. 3. When cholecystectomy is performed after PCT it is associated with an increased conversion rate but a satisfactory eventual outcome. Table
Tu1780 Identification of Prognostic Factors Following Resection of Colorectal Liver Metastases in the Modern Era of Treatment Cynthia Miller, Kshitij Arora, Shadi Razmdjou, Vikram Deshpande, Jing Zhao, David L. Berger, Kenneth Tanabe, Keith D. Lillemoe, Cristina R. Ferrone *P<.001 by Chi-Square analysis
SSAT Abstracts
Background: Advanced surgical techniques and new effective chemotherapeutic regimens have increased resection eligibility for colorectal liver metastases (CRLM), warranting reevaluation of prognostic factors. We sought to identify factors associated with overall (OS) and recurrence-free survival (RFS) in patients who underwent liver resection for CRLM in the modern era of treatment. Methods: We identified 270 patients who underwent 292 curative
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Tu1778 Choledochocystic Disease in a Western Center: A 30-Year Experience Maitham A. Moslim, Hideo Takahashi, R Matthew Walsh, Gareth Morris-Stiff BACKGROUND: Choledochocystic (CC) disease is a rare condition that has a varied presentation. The aim of this study was to report as single experience in the diagnosis and management of the condition at a Western center. METHODS: With institutional review board approval, the departmental database was interrogated to identify all patients who underwent surgical treatment of CC disease. The presentation, investigation, management, surgical pathology, post-operative course and follow-up were documented. All CC were classified as per the Todani system. RESULTS: 67 patients were identified including 15 children and 52 adults, with 76.1% being females. The mean age at diagnosis of CC was 3.7 years for children, and 44.6 years for adults. 48 patients (62.7%) were symptomatic, with the most common presentations including: (n=34); jaundice/deranged hepatic function (n=10); and acute pancreatitis (n=9). Two of 19 patients with incidental CC were diagnosed on prenatal ultrasound. Types of CC included: I (n=49, 73.1%); II (n=1, 1.5%), IV (n=9, 13.4%) and V (n=8, 12%). Malignancy was concomitant in 5 pathology specimens (gallbladder adenocarcinoma [n=2], cholangiocarcinoma [n= 3]), and atypia without cancer was reported in 3 patients. The median interval from diagnosis to operation was 95 days. 48 patients underwent excision of CC with Roux-en-Y hepatojejunostomy, and 8 resection with heptatoduodenostomy. 6 patients underwent liver resection with Roux-en-Y hepaticojejunostomy including right lobectomy (n=3), left lobectomy for (n=2) and gallbladder resection for CC associated with a gallbladder cancer (n=1). 5 patients underwent orthotopic liver transplantation (Type V [n=4], incidental type I cyst in native liver with primary biliary cirrhosis [n=1]). The surgical approach was open (n=57), laparoscopic (n=3), robotic (n= 6) and laparoscopic converted to open due to gallbladder cancer (n=1). Post-operative complications included intra-abdominal fluid collections (n=8), bile leak (n=6), anastomotic stenosis (n=6), malignancy (CCA [n=2], recurrence of gallbladder cancer [n=2], post-transplant lymphoproliferative disease [n=1]), cholangitis (n=4), pancreatitis (n=4), CBD stump lithiasis (n=4), ileus (n=3), liver failure (n=3), incisional hernia (n=3) and others (n=22). 5 patients (7.5%) expired due to recurrent CCA (n=3), pneumonia in the setting of recurrent gallbladder cancer (n=1) and hepatic failure (n=1). The median follow up interval from the diagnosis to the last surgical clinic visit was 25 months. CONCLUSIONS: The study has demonstrated the varied presentation and management of CC arising in a western population. Malignant change is not uncommon and often detected incidentally at resection of CC.
Tu1776 Lessons From a Quarter of Century Treating Esophageal Perforations: A Proposal of a Decision-Making Algorithm Marisa Aral, Hugo Santos-Sousa, José Costa-Maia Introduction: Esophageal perforation (EP) is a rare diagnosis, with a high morbidity and mortality, and its therapy is still challenging. The aim of this study was to assess the etiology, specific treatment and outcome of EP in order to generate an optimal therapeutic approach to improve patient's outcome. Methods: Analysis of a prospective database with cases of EP (n=71) treated in an Upper GI Surgery Unit, between January 1991 and October 2014. Results: The majority of EP were traumatic (60,6%) and thoracic (62%). The median timing of diagnosis was 24 [1-336] hours. The severity score median was 4 [0-14]. Non-operative treatment was done in 22,5%. Primary repair was the most common option (52,7%) in operative treatment. The median LOS was 26 [4-266] days. The morbidity and mortality rates were 40,8% and 15,5%. Morbidity was significantly associated to etiology (p=0,003), type of management (p=0,001) and severity score (p<0,001) [presence at presentation of tachycardia (p=0,001), pleural effusion (p<0,001), non-contained leak (p<0,001), respiratory compromise (p<0,001) and hypotension (p=0,012)]. Mortality was significantly associated to etiology (p=0,02), esophageal pathology (p=0,002), location (p=0,004) and severity score (p=0,009) [age (0,016), presence at presentation of tachycardia (p=0,002), hypotension (p= 0,006) and cancer (p=0,07)]. The timing of diagnosis didn't significantly influence morbidity or mortality. Conclusions: Based in the results of this study we propose a decision-making algorithm to best assist in the choice of EP treatment in each patient.
Tu1779 Acute Renal Failure Following Liver Resection for Hepatocellular Carcinoma: Prognostic Value of Acute Kidney Injury Network Consensus Criteria Alexsander Bressan, Elijah Dixon, Oliver F. Bathe, Francis R. Sutherland, Chad G. Ball
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Background: Postoperative renal failure is reported in approximately 15% of liver resections and is associated with increased morbidity and mortality. Patients with hepatocellular carcinoma (HCC) represent a high-risk population due to the increased prevalence of cirrhosis and potentially poor physiologic reserve. Applicability of Acute Kidney Injury Network (AKIN) criteria (48-hour increase in serum creatinine and urine output) remains poorly studied in this cohort of patients. Methods: All patients undergoing liver resection for HCC between January 2010 and October 2014 at a high-volume, quaternary care HPB referral center were included. Perioperative care remained constant over the study period, with routine intraoperative fluid restriction to maintain low central venous pressure (CVP) during resection, as well as reestablishment of normovolemia following specimen removal (i.e. continued in the post-anesthesia care unit). Retrospective data collection from electronic medical records utilized 8-hour shift periods to assess urine output from the point of surgery until the morning of postoperative day 2. Institutional laboratory databases were used to extract baseline and postoperative creatinine values. AKIN criteria were employed to diagnose AKI within 48 hours after surgery. Continuous variables were compared using t-test, and statistical analyses were conducted using SPSS, v.19, Chicago, IL. Results: A total of 71 liver resections was performed (median age: 62 years (IQR: 56-70); male=74.6%; median BMI=25.6 (IQR: 23.1-29.5)). Preoperative patient assessment identified 60.6% were ASA 2 and 28.2% were ASA 3. Underlying liver disease was identified in 58 patients (hepatitis B or C in 48 patients); 57 Child-Pugh A and 1 Child-Pugh B (score 7). Fifty-five surgeries (77.5%) were minor liver resections (2 segments or less), and 12 of these were laparoscopic. Estimated blood loss was 200 ml (IQR: 87 - 400) for minor and 650 ml (IQR: 375 - 800) for major liver resections. Inflow occlusion was used in 14 (19.7%) surgeries, for an average of 18 minutes. Fifty-nine (83.1%) patients had confirmed background cirrhosis in the liver specimen. Median hospital stay was 9 days (IQR: 7-12) and 30-day mortality was 4.2%. The incidence of AKI was 21.1% based on creatinine and 53.5% with urine output criteria. AKI was associated with prolonged hospital stay when defined by serum creatinine criteria (10.4 vs. 19.8 days, p<.01), but not by urine output criteria (10.3 vs. 14.1 days, p=.478). Conclusion: Urine output criteria results in an overestimation of AKI after liver resection for HCC, and therefore compromises the prognostic value of AKIN criteria in terms of hospital length of stay. Revision of the AKIN criteria to account for the physiologic postoperative reduction in urine output should be considered for patients with HCC undergoing lowCVP liver resection.
SSAT Abstracts
Clinical Outcomes of Percutaneous Cholecystostomy Tube Placement in Critically Ill Patients With Acute Cholecystitis Kenneth Sirinek, Ronald M. Stewart, Kent Van Sickle, Wayne Schwesinger BACKGROUND: The surgical treatment of acute cholecystitis in critically ill patients is associated with significant morbidity and mortality. Percutaneous placement of a cholecystostomy tube (PCT) is a widely available, less risky approach but is generally thought to mandate an interval cholecystectomy at some later date. In this study, we evaluated all acute cholecystitis patients treated initially with PCT to assess their subsequent courses and the overall outcomes. METHODS: Data from all patients undergoing PCT placement in the decade 2004-2013 were prospectively collected and retrospectively reviewed. Statistical analysis was performed using the Chi-Square test. RESULTS: One hundred fifty three critically ill patients (M/F = 99/54) with a mean age of 58 years (range = 22-95) underwent PCT at our tertiary care hospital over the ten year period of the study. Fever and symptoms (primarily pain and nausea) resolved within 48 hours in 143 patients (93.5%) while another 10 patients required urgent cholecystectomy within 1-4 days for unremitting signs and symptoms (6.5%). One hundred and one patients treated by PCT did not proceed to operation but had their tubes removed or replaced with no recurrent episodes of acute cholecystitis (66%). However, twelve of the patients in this group eventually died from their associated comorbidities (12%). Interval cholecystectomy was performed in another group of fifty-two patients at a mean of 68 days following PCT (range = 1-186 days) with no postoperative mortality. Five patients in this group also underwent intraoperative cholangiography with all studies negative for choledocholithiasis. Compared to all 7734 patients undergoing cholecystectomy at this hospital during the same decade, the 52 PCT patients undergoing cholecystectomy were 14 times more likely to have an initial open cholecystectomy (OC) (1.8% vs 25%) and they experienced an eight-fold higher conversion rate to open procedure when laparoscopic cholecystectomy (LC) was attempted (2.2% vs 18%). (Table) CONCLUSIONS: 1.PCT is both a safe and an effective initial treatment for acute cholecystitis in critically ill patients who are not candidates for urgent biliary surgery. 2. The majority of patients treated with PCT do not require interval cholecystectomy and often remain asymptomatic even after removal of the cholecystostomy tube. 3. When cholecystectomy is performed after PCT it is associated with an increased conversion rate but a satisfactory eventual outcome. Table
Tu1780 Identification of Prognostic Factors Following Resection of Colorectal Liver Metastases in the Modern Era of Treatment Cynthia Miller, Kshitij Arora, Shadi Razmdjou, Vikram Deshpande, Jing Zhao, David L. Berger, Kenneth Tanabe, Keith D. Lillemoe, Cristina R. Ferrone *P<.001 by Chi-Square analysis
SSAT Abstracts
Background: Advanced surgical techniques and new effective chemotherapeutic regimens have increased resection eligibility for colorectal liver metastases (CRLM), warranting reevaluation of prognostic factors. We sought to identify factors associated with overall (OS) and recurrence-free survival (RFS) in patients who underwent liver resection for CRLM in the modern era of treatment. Methods: We identified 270 patients who underwent 292 curative
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