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Extracorporeal shockwave lithotripsy (ESWL) for the treatment of gallbladder stones: long-term results after more than 20 years
E-HPBA: Free Prize Papers Aims: Acute cholecystitis generally mandates cholecystectomy. The use of extended postoperative antibiotic treatment is disputable. To determine the effect of extended antibiotics on postoperative infection rate in patients undergoing cholecystectomy, we conducted a multicentre randomized non-inferiority trial. We hypothesized that extended postoperative antibiotic treatment would not decrease the infectious complication rate. Based on a noninferiority margin of 5% and power of 80%, 78 patients were required in each groups. Methods: Patients with acute calculous cholecystitis undergoing cholecystectomy were eligible, provided that the APACHE-II score was 6 or less. Study participants were randomly assigned to a single pre-operative prophylactic dose of cefazoline (2000 mgs) 15e30 min prior to incision (group A), or postoperative antibiotic treatment (cefuroxime 750 mgs 3 dd and metronidazole 500 mgs 3 dd intravenously during three days) in addition to a single prophylactic dose (group B). Primary endpoint was the occurrence of postoperative infections (wound infection, intra-abdominal abscess, pneumonia, urinary tract infection). Secondary endpoints were other postoperative complications, hospital stay and total costs. Analysis was by intention-to-treat. Results: Between 2012 and 2014 a total of 156 patients were randomized in 6 teaching hospitals: 76 patients in group A and 80 patients in group B. Male/female ratio, age and APACHE-II score (average 3.5) were comparable between groups. Primary endpoint occurred in 3 patients (4%) in group A and in 3 patients (3.8%) in group B (RR 1.04, 95% CI 0.22e4.99; p=0.99). Other postoperative complications occurred in 4 and 5 patients respectively (NS). Conclusions: In patients with mild calculous cholecystitis, extended postoperative antibiotic treatment did not lead to a decrease of infectious complications.
BILIARY 0710 INCIDENTAL GALLBLADDER CANCER AFTER CHOLECYSTECTOMY IN THE SWEDISH VALIDATED POPULATION BASED REGISTRY GALLRIKS e GALLBLADDER CANCERS ARE MISSED L. Lundgren1, P. Sandström1, A. Ros2, G. Persson3, B. Andersson4 and K. Thorarinsson4 1 Surgical department Linköping; 2Ryhov Hospital; 3Växjö Hospital; 4Surgical Department Lund, Sweden Aims: Gallbladder cancer (GBC) is most often found after elective cholecystectomy for a benign indication. Not all gallbladders are sent for histology and the indications for doing so are not standardized. This study was conducted to evaluate if the frequency of histology analysis varies and if this has an impact on the frequency of diagnosed incidental gallbladder cancer (IGBC). Methods: This study is based on data from nationwide Swedish Registry of Gallstone Surgery and ERCP (GallRiks). All cholecystectomies registered between January 2007 and September 2014 was included. The database is a validated national quality registry for gallstone surgery and ERCP and has a coverage of 85% of all cholecystectomies in Sweden. Results: Altogether 95,045 cholecystectomies were registered and 38,008 specimens were histologically
HPB 2016, 18 (S2), e854ee856
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analysed (40.0%). The frequency of GBC varied from median, range 0.23 (0e1.11). A total of 295 incidentally gallbladder cancers were discovered during the time period. The hospitals sent median, range 32 (0e100)% of gallbladder specimens for histology, most often (31 out of 72) hospitals, submitted 20e40% of the cholecystectomies. 5 larger hospitals >500 operations, sent more than 85% of the gallbladders with a GBC frequency of 0.43. If this frequency is correct for the whole country 408 GBC would have been found, missing 113 in this material. Conclusions: Currently it is not standard practice to submit all gallbladder specimens for routine histology in Sweden, nor is the indications for sending standardized. If 85% or more of the gallbladders are sent and the frequency of IGBC is equal in the country, at least 113 cancers are missed during this time period. A deeper analysis is needed to give recommendations for what gallbladders should be sent.
BENIGN HPB 0788 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) FOR THE TREATMENT OF GALLBLADDER STONES: LONG-TERM RESULTS AFTER MORE THAN 20 YEARS T. Schöffmann, F. Primavesi, S. Stättner and J. Hutter Paracelsus Medical University, Austria Aims: We aimed to evaluate the long-term results of extracorporeal shockwave lithotripsy (ESWL) as a conservative treatment for symptomatic gallbladder stones. This therapy was used as a non-invasive alternative to surgery in many European countries in the 1980’s and 1990’s, but experience after some years showed poor stone-free rates with frequent relapse of symptoms. Introduction of minimal-invasive, laparoscopic cholecystectomy has replaced this treatment worldwide. This is the first study examining the results more than 20 years after ESWL. Methods: Retrospective study on all patients treated with ESWL for uncomplicated, symptomatic gallbladder stones at our institution between 1989 and 1990. The endpoints were stone-free recurrence rates, symptomatic or complicated gallbladder disease and subsequent need for surgical intervention as well as disease-related mortality. Results: From March 1989 to November 1990 some 160 patients were treated with a total of 217 ESWL sessions. After exclusion of 34 patients (loss of follow-up), the cohort comprised of 126 patients with a mean follow-up of 23.4 years. Only 22 (18%) patients remained free of symptoms and gallstones after the initial treatment during the study period. Symptoms recurred at a mean of 3.8 years, in 13 (10%) further interventional treatment (ESWL, ERCP, etc.) was necessary. Subsequent cholecystectomy was performed in 91 (72%) patients at a mean of 5.1 years after last ESWL. Three deaths (2.3% mortality) related to gallstone-relapse occurred (1 gallbladder carcinoma, 1 cholangio carcinoma, 1 acute purulent cholecystitis). Conclusions: Long-term results of ESWL are unsatisfactory. On the basis of our results, ESWL cannot be recommended for the treatment of symptomatic
e856
E-AHPBA: Free Prize Papers
cholecystolithiasis, especially in young patients. Indication for ESWL in older patients (>70 years) has to be well balanced with the risk of developing gallbladder cancer or
other stone related complications. This study serves as a critical reminder of unforeseeable long-term issues that may arise with a newly introduced technique.
HPB 2016, 18 (S2), e854ee856
BILIARY 0710 INCIDENTAL GALLBLADDER CANCER AFTER CHOLECYSTECTOMY IN THE SWEDISH VALIDATED POPULATION BASED REGISTRY GALLRIKS e GALLBLADDER CANCERS ARE MISSED L. Lundgren1, P. Sandström1, A. Ros2, G. Persson3, B. Andersson4 and K. Thorarinsson4 1 Surgical department Linköping; 2Ryhov Hospital; 3Växjö Hospital; 4Surgical Department Lund, Sweden Aims: Gallbladder cancer (GBC) is most often found after elective cholecystectomy for a benign indication. Not all gallbladders are sent for histology and the indications for doing so are not standardized. This study was conducted to evaluate if the frequency of histology analysis varies and if this has an impact on the frequency of diagnosed incidental gallbladder cancer (IGBC). Methods: This study is based on data from nationwide Swedish Registry of Gallstone Surgery and ERCP (GallRiks). All cholecystectomies registered between January 2007 and September 2014 was included. The database is a validated national quality registry for gallstone surgery and ERCP and has a coverage of 85% of all cholecystectomies in Sweden. Results: Altogether 95,045 cholecystectomies were registered and 38,008 specimens were histologically
HPB 2016, 18 (S2), e854ee856
e855
analysed (40.0%). The frequency of GBC varied from median, range 0.23 (0e1.11). A total of 295 incidentally gallbladder cancers were discovered during the time period. The hospitals sent median, range 32 (0e100)% of gallbladder specimens for histology, most often (31 out of 72) hospitals, submitted 20e40% of the cholecystectomies. 5 larger hospitals >500 operations, sent more than 85% of the gallbladders with a GBC frequency of 0.43. If this frequency is correct for the whole country 408 GBC would have been found, missing 113 in this material. Conclusions: Currently it is not standard practice to submit all gallbladder specimens for routine histology in Sweden, nor is the indications for sending standardized. If 85% or more of the gallbladders are sent and the frequency of IGBC is equal in the country, at least 113 cancers are missed during this time period. A deeper analysis is needed to give recommendations for what gallbladders should be sent.
BENIGN HPB 0788 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) FOR THE TREATMENT OF GALLBLADDER STONES: LONG-TERM RESULTS AFTER MORE THAN 20 YEARS T. Schöffmann, F. Primavesi, S. Stättner and J. Hutter Paracelsus Medical University, Austria Aims: We aimed to evaluate the long-term results of extracorporeal shockwave lithotripsy (ESWL) as a conservative treatment for symptomatic gallbladder stones. This therapy was used as a non-invasive alternative to surgery in many European countries in the 1980’s and 1990’s, but experience after some years showed poor stone-free rates with frequent relapse of symptoms. Introduction of minimal-invasive, laparoscopic cholecystectomy has replaced this treatment worldwide. This is the first study examining the results more than 20 years after ESWL. Methods: Retrospective study on all patients treated with ESWL for uncomplicated, symptomatic gallbladder stones at our institution between 1989 and 1990. The endpoints were stone-free recurrence rates, symptomatic or complicated gallbladder disease and subsequent need for surgical intervention as well as disease-related mortality. Results: From March 1989 to November 1990 some 160 patients were treated with a total of 217 ESWL sessions. After exclusion of 34 patients (loss of follow-up), the cohort comprised of 126 patients with a mean follow-up of 23.4 years. Only 22 (18%) patients remained free of symptoms and gallstones after the initial treatment during the study period. Symptoms recurred at a mean of 3.8 years, in 13 (10%) further interventional treatment (ESWL, ERCP, etc.) was necessary. Subsequent cholecystectomy was performed in 91 (72%) patients at a mean of 5.1 years after last ESWL. Three deaths (2.3% mortality) related to gallstone-relapse occurred (1 gallbladder carcinoma, 1 cholangio carcinoma, 1 acute purulent cholecystitis). Conclusions: Long-term results of ESWL are unsatisfactory. On the basis of our results, ESWL cannot be recommended for the treatment of symptomatic
e856
E-AHPBA: Free Prize Papers
cholecystolithiasis, especially in young patients. Indication for ESWL in older patients (>70 years) has to be well balanced with the risk of developing gallbladder cancer or
other stone related complications. This study serves as a critical reminder of unforeseeable long-term issues that may arise with a newly introduced technique.
HPB 2016, 18 (S2), e854ee856