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ALPPS – A tri-institutional scandinavian safety and feasibility study
E-HPBA: Poster Abstracts Conclusions: The implementation of ‘FABIB’ in addition to the Clavien-Dindo severity grading system could provide more information regarding the postoperative complication in comparing the results between different studies after liver resection.
LIVER 0740 SYNCHRONOUS SURGERY FOR COLORECTAL CANCER AND LIVER METASTASES: LAPAROSCOPIC COLORECTAL RESECTION REDUCES POSTOPERATIVE MORBIDITY INDEX. A CASE MATCHED ANALYSIS USING PROPENSITY SCORES F. Ratti, M. Catena, S. Di Palo, C. Staudacher and L. Aldrighetti IRCCS San Raffaele Hospital, Italy Aims: 30% of patients with colorectal cancer presents with liver metastases at diagnosis. Long-term survival is influenced by obtaining a complete removal of the primary tumor and liver metastases. Aim of this study was to assess short-term outcome of combined resection of left colon or rectum cancer and liver metastases, comparing the results of the primary tumor resection performed laparoscopically or by laparotomy. Methods: From January 2004 to December 2014, 141 patients underwent combined resection of colorectal cancer and synchronous liver metastases. All patients undergoing open colorectal resection (37 pts, LPS Group) were compared in a case-matched analysis with 74 patients undergoing laparoscopic colorectal resection (LPS Group). Right colonic resections were excluded from the analysis. Groups were matched with a 1:2 ratio using propensity scores based on covariates representing severity of primary and metastatic disease. The Modified Accordion Severity Grading System was used to quantify complications. Results: The groups resulted comparable in terms of patients and disease characteristics, extent of liver resection, lymphadenectomy and length of surgery. Patients in the LPS Group had a significantly lower blood loss and rate of overall transfusions compared to the LPT Group. LPS Group was associated with a lower postoperative morbidity, and a shorter postoperative median hospital stay. Colonic anastomosis leakage and abdominal abscess had the highest fractional burden of complications. Postoperative morbidity index in LPG Group was 0.093. Blood loss, morbidity and length of postoperative stay were not correlated to liver resection extent. Conclusions: Laparoscopic resection of colorectal cancer in with synchronous metastases is associated with a reduction of blood loss, morbidity and postoperative hospital stay, without affecting the oncologic radicality. In simultaneous resections of colorectal cancer and liver metastases, postoperative morbidity and hospital stay are mainly conditioned by the type of approach to intestinal surgery, rather than the extent of liver resection.
HPB 2016, 18 (S2), e685ee738
e729
LIVER 0744 REPEAT PROCEDURES FOR RECURRENT DISEASE AFTER SURGICAL TREATMENT OF COLORECTAL LIVER METASTASES. A PROMINENT ROLE FOR THERMOABLATION J. Hof, G. Sieders, P. M. J. G. Peeters, J. Widder and K. P. De Jong University of Groningen, Netherlands Aims: To analyse the impact of repeat procedures for recurrent disease after curative liver procedures for colorectal liver metastases (CRLM). Methods: Analysis of 426 patients undergoing 717 intentionally curative treatments (ICT) for metastatic colorectal cancer between 2000e2013. Survival times were calculated from the first liver procedure. Survival was compared in patients with 1 procedure versus patients with repeat procedures. Results: Of 717 ICTs, 314 were partial hepatectomies, 310 were thermoablation procedures with or without partial hepatectomy, 78 were lung-related procedures (stereotactic radiotherapy or VATS) and 16 were others. The median follow up time was 38.7 (34.1) months. 165 patients (39%) developed curatively treatable recurrences in different organs and 130 patients (31%) received palliative treatment. At the end of the follow up period, 209/426 patients had expired, 161/426 patients were alive and free of disease and 56/426 were alive with recurrent disease. After the first ICT in 426 patients, 308 patients developed recurrences of which 165 (54%) underwent a repeat ICT: 108 liverdirected, 48 lung-directed, 9 others. Of these 165 patients, 126 patients developed recurrent disease of which 71 (56%) underwent a third ICT. Of these 71 patients, 54 patients developed recurrences, of which 31 (57%) underwent subsequent ICTs. ICT of 198 recurrent liver metastases consisted in 55 cases (28%) of partial hepatectomy, in 124 cases (63%) of percutaneous thermoablation and in 19 cases (10%) of open thermoablation. Median overall survival and 5-year survival were 52.7 months and 47%, respectively, for patients with 1 ICT; 48.4 months and 40%, respectively, for patients with a second ICT, and 67.9 and 64%, respectively, for patients with 3 or more ICTs. Conclusions: Intentionally curative repeat treatments can be performed in about 55% of the patients with recurrences with an overall survival which is similar to patients with one ICT. Thermoablation plays a prominent role in treating liver recurrences.
LIVER 0748 ALPPS e A TRI-INSTITUTIONAL SCANDINAVIAN SAFETY AND FEASIBILITY STUDY B. Björnsson1, E. Sparrelid2, B. Røsok3, B. A. Bjørnbeth3, K. Hasselgren1, E. Pomianowska3, T. Gasslander1, B. Isaksson2 and P. Sandstrom1 1 Linköping University Hospital; 2Karolinska University Hospital; 3Oslo University Hospital, Sweden
e730
E-AHPBA: Poster Abstracts
Aims: Associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) is an alternative to conventional portal vein embolization or -ligation (PVE/PVL). In patients with technically resectable liver tumors but insufficient future liver remnant (FLR) some growth stimuli is needed. Initial experiences indicated that the complication rate and perioperative mortality following ALPPS exceeded that of PVE/PVL. The aim of this study was to assess the initial safety and feasibility of ALPPS at three Scandinavian HPB centers. Methods: Thirty-six patients (2:1 male:female), median age 67 (22e80) years were operated during a 26 month period at three Scandinavian institutions. Colorectal liver metastases was the most common diagnosis followed by cholangiocarcinoma and HCC. The number of lesions varied from 1e20. None of the patients had underlying liver disease. Results: All patients completed the 2-stage procedure at a median of 8 days (7e15) following stage 1. Majority of the patients had extended right hemi-hepatectomies, wheras the remaining few had conventional right hemi-hepatectomies and atypical ALPPS. Median hospital stay after the second procedure was 9.5 days (2e50). No perioperative mortality was observed. Although complications were observed in majority of the cases, the highest grade according to Clavien-Dindo grading was 3b, seen in 3 patients (8%). Conclusions: ALPPS is an alternative to PVE/PVL in some patients. An acceptable complication rate can be obtained in selected patient cohort and the feasibility and rate of severe complications found in this cohort compares favorably to previously published results with PVE and two-stage hepatectomy. Early recurrences have been found following ALPPS, and our short and intermediate oncological results will be presented. Randomized controlled trials to define what patients may benefit from ALPPS are lacking. A multicenter Scandinavian trial, LIGRO (www.clinicaltrials.gov NCT02215577) has therefore been initiated and has been enrolling patients since May 2014.
LIVER 0752 DIFFERENTIATION OF HEPATIC ADENOMA FROM FOCAL NODULAR HYPERPLASIA WITH PRIMOVIST MRI: VALIDATION OF DIAGNOSTIC CRITERIA M. Doyle1, J. S. Bagia2, J. Yeo1, A. Teixeira-Pinto2 and S. Tran1 1 St George Hospital; 2University of Sydney, Australia Aims: To evaluate performance of MRI with PrimovistÒ (Bayer Healthcare, germany) (pMRI) in discriminating Hepatic Adenoma (HA) from Focal Nodular Hyperplasia (FNH) by retrospectively applying assessment criteria described by Grazioli [1] to our series of pMRI images. Methods: Our hepatobiliary surgical database was retrospectively reviewed for patients with histologicallyconfirmed HA or FNH, who underwent pMRI prior to tissue sampling. 12 patients with a total of 13 lesions (7 FNH lesions, 6 HA lesions) were identified. Two independent readers performed qualitative and quantitative
analysis on all pMRI Including Signal Intensity (SI) characteristics during dynamic and delayed phases, and SI numerical quantification allowing contrast enhancement ratio (CER), liver-to-lesion contrast (LLC) and SI ratios to be calculated. Results: 12 patients with 13 lesions were included. Ther were 11 females. 5 patients had HA, 6 patients had FNH and 1 patient had 2 lesions, with one HA and one FNH. Mean size of HA lesions was 3.2cm and FNH 6.4cm. No HA demonstrated a central scar while 57e71% of FNH had SI characteristics in keeping with a central scar. All FNH lesions were iso- to hyperintense on portal venous and delayed dynamic phase imaging, while only 2 HA (33%) were iso-hyperintense during delayed dynamic phase imaging. 67e83% of HA were isointense during hepatobiliary phase imaging while only 14e29% of FNH were hypointense during similar image sequencing. The CER of HA in the arterial phase (mean 86.1% +/ 42%) was similar to FNH (mean 104% +/ 74.7%), while the LLC of HA during the hepatobiliary was more strongly negative (mean 0.70 +/ 0.69) than FNH (mean 0.08 +/ 0.85). Conclusions: pMRI continues to improve diagnostic accuracy between HA and FNH. This qualitative and quantitative assessment method is potentially reproducible, however some variability occurred as expected with small numbers and no prior experience with this type of imaging analysis.
LIVER 0760 SURGICAL OUTCOMES OF METABOLIC SYNDROME RELATED HCC: A COMPARATIVE STUDY WITH VIRAL AND ALCOHOLIC HCC A. Ruzzenente, M. De Angelis, S. Conci, F. Bagante, A. Valdegamberi, F. Bertuzzo, G. Mantovani, C. Iacono and A. Guglielmi University and Hospital Trust of Verona, Italy Aims: Up to 30% of HCC are not related to usual risk factors, the majority of these HCC are associated with nonalcoholic fatty liver disease (NAFLD), hepatic manifestations of metabolic syndrome (MS). The purposes of the study were to analyse the clinical features, short-term and long-term outcomes of metabolic syndrome HCC (MSHCC) compared to alcoholic and viral HCC. Methods: One hundred twenty-four consecutive patients with available etiology data underwent liver resection for HCC from January 2006 to December 2013 in a single HPB tertiary referral center. The clinical, pathological and surgical features, overall survival and disease-free survival data were analysed. Results: Among 124 patients with HCC, 26 patients (20.9%) had MS, 35 patients (28.2%) had alcohol consumption 60 g/die (alcohol-HCC) and 63 patients (50.9%) presented a HBV and/or HCV infection (viralHCC). Patients with MS-HCC resulted oldest compare with alcohol and viral HCC with a mean age of 74.83, 70.01 and 68.35 years, respectively, p = 0.029. MS-HCC showed lower rate of underlying cirrhosis (32% vs. 68.6% in alcohol-HCC and 68.3% in viral-HCC, respectively,
HPB 2016, 18 (S2), e685ee738
LIVER 0740 SYNCHRONOUS SURGERY FOR COLORECTAL CANCER AND LIVER METASTASES: LAPAROSCOPIC COLORECTAL RESECTION REDUCES POSTOPERATIVE MORBIDITY INDEX. A CASE MATCHED ANALYSIS USING PROPENSITY SCORES F. Ratti, M. Catena, S. Di Palo, C. Staudacher and L. Aldrighetti IRCCS San Raffaele Hospital, Italy Aims: 30% of patients with colorectal cancer presents with liver metastases at diagnosis. Long-term survival is influenced by obtaining a complete removal of the primary tumor and liver metastases. Aim of this study was to assess short-term outcome of combined resection of left colon or rectum cancer and liver metastases, comparing the results of the primary tumor resection performed laparoscopically or by laparotomy. Methods: From January 2004 to December 2014, 141 patients underwent combined resection of colorectal cancer and synchronous liver metastases. All patients undergoing open colorectal resection (37 pts, LPS Group) were compared in a case-matched analysis with 74 patients undergoing laparoscopic colorectal resection (LPS Group). Right colonic resections were excluded from the analysis. Groups were matched with a 1:2 ratio using propensity scores based on covariates representing severity of primary and metastatic disease. The Modified Accordion Severity Grading System was used to quantify complications. Results: The groups resulted comparable in terms of patients and disease characteristics, extent of liver resection, lymphadenectomy and length of surgery. Patients in the LPS Group had a significantly lower blood loss and rate of overall transfusions compared to the LPT Group. LPS Group was associated with a lower postoperative morbidity, and a shorter postoperative median hospital stay. Colonic anastomosis leakage and abdominal abscess had the highest fractional burden of complications. Postoperative morbidity index in LPG Group was 0.093. Blood loss, morbidity and length of postoperative stay were not correlated to liver resection extent. Conclusions: Laparoscopic resection of colorectal cancer in with synchronous metastases is associated with a reduction of blood loss, morbidity and postoperative hospital stay, without affecting the oncologic radicality. In simultaneous resections of colorectal cancer and liver metastases, postoperative morbidity and hospital stay are mainly conditioned by the type of approach to intestinal surgery, rather than the extent of liver resection.
HPB 2016, 18 (S2), e685ee738
e729
LIVER 0744 REPEAT PROCEDURES FOR RECURRENT DISEASE AFTER SURGICAL TREATMENT OF COLORECTAL LIVER METASTASES. A PROMINENT ROLE FOR THERMOABLATION J. Hof, G. Sieders, P. M. J. G. Peeters, J. Widder and K. P. De Jong University of Groningen, Netherlands Aims: To analyse the impact of repeat procedures for recurrent disease after curative liver procedures for colorectal liver metastases (CRLM). Methods: Analysis of 426 patients undergoing 717 intentionally curative treatments (ICT) for metastatic colorectal cancer between 2000e2013. Survival times were calculated from the first liver procedure. Survival was compared in patients with 1 procedure versus patients with repeat procedures. Results: Of 717 ICTs, 314 were partial hepatectomies, 310 were thermoablation procedures with or without partial hepatectomy, 78 were lung-related procedures (stereotactic radiotherapy or VATS) and 16 were others. The median follow up time was 38.7 (34.1) months. 165 patients (39%) developed curatively treatable recurrences in different organs and 130 patients (31%) received palliative treatment. At the end of the follow up period, 209/426 patients had expired, 161/426 patients were alive and free of disease and 56/426 were alive with recurrent disease. After the first ICT in 426 patients, 308 patients developed recurrences of which 165 (54%) underwent a repeat ICT: 108 liverdirected, 48 lung-directed, 9 others. Of these 165 patients, 126 patients developed recurrent disease of which 71 (56%) underwent a third ICT. Of these 71 patients, 54 patients developed recurrences, of which 31 (57%) underwent subsequent ICTs. ICT of 198 recurrent liver metastases consisted in 55 cases (28%) of partial hepatectomy, in 124 cases (63%) of percutaneous thermoablation and in 19 cases (10%) of open thermoablation. Median overall survival and 5-year survival were 52.7 months and 47%, respectively, for patients with 1 ICT; 48.4 months and 40%, respectively, for patients with a second ICT, and 67.9 and 64%, respectively, for patients with 3 or more ICTs. Conclusions: Intentionally curative repeat treatments can be performed in about 55% of the patients with recurrences with an overall survival which is similar to patients with one ICT. Thermoablation plays a prominent role in treating liver recurrences.
LIVER 0748 ALPPS e A TRI-INSTITUTIONAL SCANDINAVIAN SAFETY AND FEASIBILITY STUDY B. Björnsson1, E. Sparrelid2, B. Røsok3, B. A. Bjørnbeth3, K. Hasselgren1, E. Pomianowska3, T. Gasslander1, B. Isaksson2 and P. Sandstrom1 1 Linköping University Hospital; 2Karolinska University Hospital; 3Oslo University Hospital, Sweden
e730
E-AHPBA: Poster Abstracts
Aims: Associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) is an alternative to conventional portal vein embolization or -ligation (PVE/PVL). In patients with technically resectable liver tumors but insufficient future liver remnant (FLR) some growth stimuli is needed. Initial experiences indicated that the complication rate and perioperative mortality following ALPPS exceeded that of PVE/PVL. The aim of this study was to assess the initial safety and feasibility of ALPPS at three Scandinavian HPB centers. Methods: Thirty-six patients (2:1 male:female), median age 67 (22e80) years were operated during a 26 month period at three Scandinavian institutions. Colorectal liver metastases was the most common diagnosis followed by cholangiocarcinoma and HCC. The number of lesions varied from 1e20. None of the patients had underlying liver disease. Results: All patients completed the 2-stage procedure at a median of 8 days (7e15) following stage 1. Majority of the patients had extended right hemi-hepatectomies, wheras the remaining few had conventional right hemi-hepatectomies and atypical ALPPS. Median hospital stay after the second procedure was 9.5 days (2e50). No perioperative mortality was observed. Although complications were observed in majority of the cases, the highest grade according to Clavien-Dindo grading was 3b, seen in 3 patients (8%). Conclusions: ALPPS is an alternative to PVE/PVL in some patients. An acceptable complication rate can be obtained in selected patient cohort and the feasibility and rate of severe complications found in this cohort compares favorably to previously published results with PVE and two-stage hepatectomy. Early recurrences have been found following ALPPS, and our short and intermediate oncological results will be presented. Randomized controlled trials to define what patients may benefit from ALPPS are lacking. A multicenter Scandinavian trial, LIGRO (www.clinicaltrials.gov NCT02215577) has therefore been initiated and has been enrolling patients since May 2014.
LIVER 0752 DIFFERENTIATION OF HEPATIC ADENOMA FROM FOCAL NODULAR HYPERPLASIA WITH PRIMOVIST MRI: VALIDATION OF DIAGNOSTIC CRITERIA M. Doyle1, J. S. Bagia2, J. Yeo1, A. Teixeira-Pinto2 and S. Tran1 1 St George Hospital; 2University of Sydney, Australia Aims: To evaluate performance of MRI with PrimovistÒ (Bayer Healthcare, germany) (pMRI) in discriminating Hepatic Adenoma (HA) from Focal Nodular Hyperplasia (FNH) by retrospectively applying assessment criteria described by Grazioli [1] to our series of pMRI images. Methods: Our hepatobiliary surgical database was retrospectively reviewed for patients with histologicallyconfirmed HA or FNH, who underwent pMRI prior to tissue sampling. 12 patients with a total of 13 lesions (7 FNH lesions, 6 HA lesions) were identified. Two independent readers performed qualitative and quantitative
analysis on all pMRI Including Signal Intensity (SI) characteristics during dynamic and delayed phases, and SI numerical quantification allowing contrast enhancement ratio (CER), liver-to-lesion contrast (LLC) and SI ratios to be calculated. Results: 12 patients with 13 lesions were included. Ther were 11 females. 5 patients had HA, 6 patients had FNH and 1 patient had 2 lesions, with one HA and one FNH. Mean size of HA lesions was 3.2cm and FNH 6.4cm. No HA demonstrated a central scar while 57e71% of FNH had SI characteristics in keeping with a central scar. All FNH lesions were iso- to hyperintense on portal venous and delayed dynamic phase imaging, while only 2 HA (33%) were iso-hyperintense during delayed dynamic phase imaging. 67e83% of HA were isointense during hepatobiliary phase imaging while only 14e29% of FNH were hypointense during similar image sequencing. The CER of HA in the arterial phase (mean 86.1% +/ 42%) was similar to FNH (mean 104% +/ 74.7%), while the LLC of HA during the hepatobiliary was more strongly negative (mean 0.70 +/ 0.69) than FNH (mean 0.08 +/ 0.85). Conclusions: pMRI continues to improve diagnostic accuracy between HA and FNH. This qualitative and quantitative assessment method is potentially reproducible, however some variability occurred as expected with small numbers and no prior experience with this type of imaging analysis.
LIVER 0760 SURGICAL OUTCOMES OF METABOLIC SYNDROME RELATED HCC: A COMPARATIVE STUDY WITH VIRAL AND ALCOHOLIC HCC A. Ruzzenente, M. De Angelis, S. Conci, F. Bagante, A. Valdegamberi, F. Bertuzzo, G. Mantovani, C. Iacono and A. Guglielmi University and Hospital Trust of Verona, Italy Aims: Up to 30% of HCC are not related to usual risk factors, the majority of these HCC are associated with nonalcoholic fatty liver disease (NAFLD), hepatic manifestations of metabolic syndrome (MS). The purposes of the study were to analyse the clinical features, short-term and long-term outcomes of metabolic syndrome HCC (MSHCC) compared to alcoholic and viral HCC. Methods: One hundred twenty-four consecutive patients with available etiology data underwent liver resection for HCC from January 2006 to December 2013 in a single HPB tertiary referral center. The clinical, pathological and surgical features, overall survival and disease-free survival data were analysed. Results: Among 124 patients with HCC, 26 patients (20.9%) had MS, 35 patients (28.2%) had alcohol consumption 60 g/die (alcohol-HCC) and 63 patients (50.9%) presented a HBV and/or HCV infection (viralHCC). Patients with MS-HCC resulted oldest compare with alcohol and viral HCC with a mean age of 74.83, 70.01 and 68.35 years, respectively, p = 0.029. MS-HCC showed lower rate of underlying cirrhosis (32% vs. 68.6% in alcohol-HCC and 68.3% in viral-HCC, respectively,
HPB 2016, 18 (S2), e685ee738