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Impact of preoperative ERCP on laparoscopic cholecystectomy
e498
Electronic Poster Abstracts
was routinely performed in all the cases prior to the repair. Bismuth type 3 was the commonest (14) type of injury/ stricture followed by type 2 (3) and type 1 (2). There was 1 mortality following surgery due to bile leak followed by severe sepsis. Remaining 18 patients had excellent postoperative outcome without significant morbid.
EP03D-020 IATROGENIC BILE DUCT INJURY: EXPERIENCE OF A MULTIDISCIPLINARY TEAM IN A FEDERAL UNIVERSITY IN BRAZIL C. Quireze Jr.1, E. Raymond Le Campion1, L. Kenny Morais1, M. Castrillon Rassi1, B. Baioni Sandre2, A. Karolyne Candida da Silva2, A. Bubna Hirayama2, B. Maia Amorim2 and R. Ramos Marangoni2 1 Surgery, and 2Federal University of Goias, Brazil Background: Iatrogenic bile duct injury (BDI) is the most feared complication associated with cholecystectomy. Despite laparoscopic improvments, inflammation of the gallbladder, anatomical variations, poor technique employed and bleeding are some of the risk factors associated with this injury. In this study, we aim the results of surgical treatment of BDI, with emphasis on clinical preoperative conditions, results and complications. Methods: Data from thirty three patients who had suffered a BDI were reviewed. The following variables were analyzed: gender, age, conditions of cholecystectomy, type of surgery, symptoms, classification of injury (Bismuth classification), treatment and complications. Results: Twenty two patients were female and eleven were male, with a mean age of 46.1 years. Twenty four patients (72.7%) had an open cholecystectomy and 9 (27.3%) had a laparoscopy approach. Only 1 patient underwent intraoperative cholangiography. Nine injuries (27.3%) were diagnosed intraoperatively. Twenty six patients (78.8%) had cholestasis, 6 (18.2%) had biliary fistula and 9 (27.3%) showed biliary peritonitis. Three patients (9.1%) had a type I injury, 14 (42.4%) type II, 10 (30.3%) type III, 5 (15.1%) type IV, and 1 (3.1%) type V. Hepaticojejunostomy was the most frequently performed surgery as definitive treatment for BDI (84.8%). Nine patients (27.3%) developed late complications, and 2 patients (6.1%) died. Conclusion: Most injuries occurred during open cholecystectomy and intraoperative cholangiography was rarely used. Therefore, few injuries were diagnosed intraoperatively. For most injuries, hepaticojejunostomy was performed as definitive surgical treatment due to the complexity of injuries.
EP03D-021 ABANDONMENT AND REFERRAL OF THE DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY: A GOOD ALTERNATIVE MANAGEMENT STRATEGY Z. Jawad, A. Draz, T. Pencavel and L. Jiao Department of Hepatobiliary Surgery, Hammersmith Hospital, Imperial College London, United Kingdom
Introduction: While laparoscopic cholecystectomy is usually a low risk procedure complications including bile duct injury and bile leak are more commonly associated with the ‘difficult’ gallbladder with such cases being hard to predict pre-operatively. Additionally, there is controversy over whether laparoscopic cholecystectomy should be performed by upper GI and HPB surgeons or whether this surgery can be performed equally by general surgeons. Alternative strategies to overcome the difficult gallbladder once it is encountered include using the ’critical window’ and subtotal cholecystectomy. Abandonment and referral to a hepatobiliary unit is undertaken in our centre and the outcomes of this alternative approach are reviewed in this paper. Methods: A retrospective review of all patients referred to our tertiary hepatobiliary unit with ’difficult’ cholecystectomies between March 2012 and August 2015. Outcomes include conversion to open, length of stay and complication rate. Results: 19 Patients were referred with difficult cholecystectomies. The indications for cholecystectomy were acute cholecystitis (58%), gallstone pancreatitis (32%) and biliary colic (10%). 4 Underwent abandoned laparoscopic cholecystectomies prior to referral with extensive adhesions being the most common reason given by the referring surgeon. Median length of stay was 3 days. 2 Patients were converted to open (10.5%) and 1 patient (5%) had a postoperative bile leak. Conclusion: Abandonment or referral of the difficult cholecystectomy reduces the risk to that of conventional cholecystectomy and should be considered as a feasible alternative management strategy.
EP03D-022 IMPACT OF PREOPERATIVE ERCP ON LAPAROSCOPIC CHOLECYSTECTOMY S. Vaccari, E. Picariello, A. Romano, F. Monari, A. Leone, A. Caira, B. Dalla Via, V. Tonini, M. Cervellera and U.O. Chirurgia in Urgenza e Dott. M.Cervellera Policlinico Sant’Orsola-Malpighi-Università degli Studi di Bologna, Italy Introduction: The aim of this study was to evaluate effects of ERCP on laparoscopic cholecystectomy (LC) in patients with gallstone disease. Method: From September 2011 to June 2015, among 599 patients who underwent LC for benign gallbladder disease, 255 had not shown acute cholecystitis or cholangitis preoperatively. These patients were divided into 2 groups; patients with preoperative ERCP prior to LC (EG, n = 32) and patients who underwent LC without preoperative ERCP (NEG, n = 223). Patients’ demographics, clinical parameters, intra and perioperative results were analyzed. SPSS was used for statistics; significance was defined as p < 0.05. Results: EG included 17 males (53,1%), aged 53.9 18.6 years [16e80]; NEG included 83 males (37,2%), aged 54.2 14.1 years [20e87] (p = ns). No significant differences were recorded for operative time (p = 0,7641), instead the rates of open conversion were more numerous in EG (12,5%) than in NEG (8,1%), respectively (p = 0,0020). Postoperative hospital stay was 4.2 5.7 days [1e33] in EG and 2.5 1.5 days [1e10], respectively (p = 0,7062). Postoperative complications were 12.5% in EG and 8.1% in NEG (p = 0,4956). No mortality was recorded among two groups. On multivariate analysis no
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts factors were significant for morbidity or mortality; instead preoperative ERCP was an independent risk factor for open conversion (p = 0,0040; OR6,605 IC 1,834e23,783). Conclusions: In our experience there were no differences in the number of complications and postoperative mortality among two groups. However, laparoscopic cholecystectomy after preoperative ERCP seemed to have a more numerous rate of conversion, within limits of the values reported in literature.
EP03D-023 MANAGEMENT OF SECTORAL BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY e EXPERIENCE FROM A TERTIARY CENTRE B. Othman and N. Houli Western Health, Australia Introduction: Sectoral bile duct injury is a rare complication of laparoscopic cholecystectomy but contributes to significant morbidity to the patient with multiple subsequent interventions and procedures. Our aim was to identify the prevalence of sectoral bile duct injury as a complication of laparoscopic cholecystectomy at our tertiary centre. Additionally, we wanted to identify the risk factors, methods of diagnosis and preventative strategies in management of this rare yet challenging problem. Methods: A retrospective analysis of patient records was performed between 2008 and 2015, which revealed 4 cases of sectoral bile duct injury during laparoscopic cholecystectomy. Case notes, imaging, post operative management and follow up data was retrieved. Imaging included intraoperative cholangiogram (IOC), computed tomography intravenous cholangiography (CT IVC), and magnetic resonance cholangiopancreatography (MRCP). Results: 3 patients were suspected to have biliary injury secondary to acute post operative bile leak, while 1 patient represented with fevers and abdominal pain. Post operative diagnosis was achieved through CT IVC and endoscopic retrograde cholangiopancreatography (ERCP). 3 Patients proceeded to biliary reconstruction, while 1 was treated with biliary stenting (required multiple ERCP procedures). Conclusion: Anomalous biliary tree anatomy and misidentification of the anatomy by the operating surgeons are the main risk factors for sectoral duct injury. Strategies to prevent sectoral bile duct injury include careful dissection of the hepatocystic triangle, awareness of variable biliary anatomy, and thorough evaluation of biliary tract imaging. One should maintain high suspicion of sectoral duct injury in a patient with post operative bile leak and an intact common bile duct.
EP03D-025 THE ALPPS PROCEDURE: A SURGICAL OPTION FOR HILAR CHOLANGIOCARCINOMA Y. Kawamoto, Y. Ome, K. Hashida, M. Yokota, Y. Nagahisa, K. Yamaguchi, M. Okabe, S. Okamoto, K. Kawamoto, T. Park and T. Ito General Surgery, Kurashiki Central Hospital, Japan
HPB 2016, 18 (S1), e385ee601
e499
Introduction: To induce a rapid and significant increase in future liver remnant (FLR) volume, an innovative approach called associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed, permitting an extended hepatectomy. This procedure was commonly performed for hepatocellular carcinoma, liver metastasis or intrahepatic cholangiocarcinoma, while only a few cases have been reported for perihilar cholangiocarcinoma requiring extrahepatic resection. Method: We describe a case of ALPPS in a 78-year-old male with perihilar cholangiocarcinoma. Results: The patient presented with jaundice and was diagnosed with Bismuth type 4 perihilar cholangiocarcinoma. Computed tomography (CT) volumetry revealed a very small FLR (247 ml, 22% of the total liver volume (TLV). His indocyanine green retention rate at 15 minutes was 12.9%. Due to the risk of liver failure, we performed percutaneous transhepatic portal embolization, but his FLR didn’t sufficiently increase (297 ml, 26% of the TLV). Therefore, we chose ALPPS. During the first stage, right lobe mobilization, liver partition, right portal vein ligation, left hepatic duct resection and cholangiojejunostomy were undertaken, and the right hepatic artery, duct, vein and common bile duct were secured with vessel loops. CT on postoperative day 5 (POD5) showed a sufficient FLR increase (from 297 ml to 456 ml, 26 e 35% of TLV). Second stage ALPPS was undertaken on POD7, completing resection of the right lobe. The patient experienced bile leakage but was able to discharge 73 days after the second step. Conclusion: ALPPS procedure resulted in a rapid increase of FLR despite the patient requiring simultaneous cholangiojejunostomy.
EP03D-026 REFORMED GALLBLADDER AFTER SUBTOTAL CHOLECYSTECTOMY: TWO CASE REPORTS AND LITERATURE REVIEW R. Capelli1, E. Barrocas1, L. Marques2, M. Enne2 and E. Viana3 1 General Surgery, Hospital Federal de Ipanema, 2Hospital Federal de Ipanema, and 3Cirurgia Geral, Hospital Federal de Ipanema, Brazil Introduction: Subtotal cholecystectomy is a procedure reserved for severe cholecystitis where the patient conditions are unstable and it is not possible to identify the structures of the Calot triangle. It is considered a safe procedure, however occasional reoperation may be necessary. Objective: The goal of the study is report two cases of reoperation for reformed gallbladder after subtotal cholecystectomy in a single center and to conduct a literature review on reformed gallbladders after incomplete gallbladder removal. Method: A literature search of PubMed and EMBASE (1985 e February 2015) was conducted. Search criteria included “reformed gallbladder” “subtotal cholecystectomy” “partial cholecystectomy” “reoperation” “remnant gallbladder” “retained gallbladder” using the Boolean operators “AND” “OR”, limited to title or abstract with publication in the English. The bibliographies of the recovered articles were examined to find supplementary references of data.
Electronic Poster Abstracts
was routinely performed in all the cases prior to the repair. Bismuth type 3 was the commonest (14) type of injury/ stricture followed by type 2 (3) and type 1 (2). There was 1 mortality following surgery due to bile leak followed by severe sepsis. Remaining 18 patients had excellent postoperative outcome without significant morbid.
EP03D-020 IATROGENIC BILE DUCT INJURY: EXPERIENCE OF A MULTIDISCIPLINARY TEAM IN A FEDERAL UNIVERSITY IN BRAZIL C. Quireze Jr.1, E. Raymond Le Campion1, L. Kenny Morais1, M. Castrillon Rassi1, B. Baioni Sandre2, A. Karolyne Candida da Silva2, A. Bubna Hirayama2, B. Maia Amorim2 and R. Ramos Marangoni2 1 Surgery, and 2Federal University of Goias, Brazil Background: Iatrogenic bile duct injury (BDI) is the most feared complication associated with cholecystectomy. Despite laparoscopic improvments, inflammation of the gallbladder, anatomical variations, poor technique employed and bleeding are some of the risk factors associated with this injury. In this study, we aim the results of surgical treatment of BDI, with emphasis on clinical preoperative conditions, results and complications. Methods: Data from thirty three patients who had suffered a BDI were reviewed. The following variables were analyzed: gender, age, conditions of cholecystectomy, type of surgery, symptoms, classification of injury (Bismuth classification), treatment and complications. Results: Twenty two patients were female and eleven were male, with a mean age of 46.1 years. Twenty four patients (72.7%) had an open cholecystectomy and 9 (27.3%) had a laparoscopy approach. Only 1 patient underwent intraoperative cholangiography. Nine injuries (27.3%) were diagnosed intraoperatively. Twenty six patients (78.8%) had cholestasis, 6 (18.2%) had biliary fistula and 9 (27.3%) showed biliary peritonitis. Three patients (9.1%) had a type I injury, 14 (42.4%) type II, 10 (30.3%) type III, 5 (15.1%) type IV, and 1 (3.1%) type V. Hepaticojejunostomy was the most frequently performed surgery as definitive treatment for BDI (84.8%). Nine patients (27.3%) developed late complications, and 2 patients (6.1%) died. Conclusion: Most injuries occurred during open cholecystectomy and intraoperative cholangiography was rarely used. Therefore, few injuries were diagnosed intraoperatively. For most injuries, hepaticojejunostomy was performed as definitive surgical treatment due to the complexity of injuries.
EP03D-021 ABANDONMENT AND REFERRAL OF THE DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY: A GOOD ALTERNATIVE MANAGEMENT STRATEGY Z. Jawad, A. Draz, T. Pencavel and L. Jiao Department of Hepatobiliary Surgery, Hammersmith Hospital, Imperial College London, United Kingdom
Introduction: While laparoscopic cholecystectomy is usually a low risk procedure complications including bile duct injury and bile leak are more commonly associated with the ‘difficult’ gallbladder with such cases being hard to predict pre-operatively. Additionally, there is controversy over whether laparoscopic cholecystectomy should be performed by upper GI and HPB surgeons or whether this surgery can be performed equally by general surgeons. Alternative strategies to overcome the difficult gallbladder once it is encountered include using the ’critical window’ and subtotal cholecystectomy. Abandonment and referral to a hepatobiliary unit is undertaken in our centre and the outcomes of this alternative approach are reviewed in this paper. Methods: A retrospective review of all patients referred to our tertiary hepatobiliary unit with ’difficult’ cholecystectomies between March 2012 and August 2015. Outcomes include conversion to open, length of stay and complication rate. Results: 19 Patients were referred with difficult cholecystectomies. The indications for cholecystectomy were acute cholecystitis (58%), gallstone pancreatitis (32%) and biliary colic (10%). 4 Underwent abandoned laparoscopic cholecystectomies prior to referral with extensive adhesions being the most common reason given by the referring surgeon. Median length of stay was 3 days. 2 Patients were converted to open (10.5%) and 1 patient (5%) had a postoperative bile leak. Conclusion: Abandonment or referral of the difficult cholecystectomy reduces the risk to that of conventional cholecystectomy and should be considered as a feasible alternative management strategy.
EP03D-022 IMPACT OF PREOPERATIVE ERCP ON LAPAROSCOPIC CHOLECYSTECTOMY S. Vaccari, E. Picariello, A. Romano, F. Monari, A. Leone, A. Caira, B. Dalla Via, V. Tonini, M. Cervellera and U.O. Chirurgia in Urgenza e Dott. M.Cervellera Policlinico Sant’Orsola-Malpighi-Università degli Studi di Bologna, Italy Introduction: The aim of this study was to evaluate effects of ERCP on laparoscopic cholecystectomy (LC) in patients with gallstone disease. Method: From September 2011 to June 2015, among 599 patients who underwent LC for benign gallbladder disease, 255 had not shown acute cholecystitis or cholangitis preoperatively. These patients were divided into 2 groups; patients with preoperative ERCP prior to LC (EG, n = 32) and patients who underwent LC without preoperative ERCP (NEG, n = 223). Patients’ demographics, clinical parameters, intra and perioperative results were analyzed. SPSS was used for statistics; significance was defined as p < 0.05. Results: EG included 17 males (53,1%), aged 53.9 18.6 years [16e80]; NEG included 83 males (37,2%), aged 54.2 14.1 years [20e87] (p = ns). No significant differences were recorded for operative time (p = 0,7641), instead the rates of open conversion were more numerous in EG (12,5%) than in NEG (8,1%), respectively (p = 0,0020). Postoperative hospital stay was 4.2 5.7 days [1e33] in EG and 2.5 1.5 days [1e10], respectively (p = 0,7062). Postoperative complications were 12.5% in EG and 8.1% in NEG (p = 0,4956). No mortality was recorded among two groups. On multivariate analysis no
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts factors were significant for morbidity or mortality; instead preoperative ERCP was an independent risk factor for open conversion (p = 0,0040; OR6,605 IC 1,834e23,783). Conclusions: In our experience there were no differences in the number of complications and postoperative mortality among two groups. However, laparoscopic cholecystectomy after preoperative ERCP seemed to have a more numerous rate of conversion, within limits of the values reported in literature.
EP03D-023 MANAGEMENT OF SECTORAL BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY e EXPERIENCE FROM A TERTIARY CENTRE B. Othman and N. Houli Western Health, Australia Introduction: Sectoral bile duct injury is a rare complication of laparoscopic cholecystectomy but contributes to significant morbidity to the patient with multiple subsequent interventions and procedures. Our aim was to identify the prevalence of sectoral bile duct injury as a complication of laparoscopic cholecystectomy at our tertiary centre. Additionally, we wanted to identify the risk factors, methods of diagnosis and preventative strategies in management of this rare yet challenging problem. Methods: A retrospective analysis of patient records was performed between 2008 and 2015, which revealed 4 cases of sectoral bile duct injury during laparoscopic cholecystectomy. Case notes, imaging, post operative management and follow up data was retrieved. Imaging included intraoperative cholangiogram (IOC), computed tomography intravenous cholangiography (CT IVC), and magnetic resonance cholangiopancreatography (MRCP). Results: 3 patients were suspected to have biliary injury secondary to acute post operative bile leak, while 1 patient represented with fevers and abdominal pain. Post operative diagnosis was achieved through CT IVC and endoscopic retrograde cholangiopancreatography (ERCP). 3 Patients proceeded to biliary reconstruction, while 1 was treated with biliary stenting (required multiple ERCP procedures). Conclusion: Anomalous biliary tree anatomy and misidentification of the anatomy by the operating surgeons are the main risk factors for sectoral duct injury. Strategies to prevent sectoral bile duct injury include careful dissection of the hepatocystic triangle, awareness of variable biliary anatomy, and thorough evaluation of biliary tract imaging. One should maintain high suspicion of sectoral duct injury in a patient with post operative bile leak and an intact common bile duct.
EP03D-025 THE ALPPS PROCEDURE: A SURGICAL OPTION FOR HILAR CHOLANGIOCARCINOMA Y. Kawamoto, Y. Ome, K. Hashida, M. Yokota, Y. Nagahisa, K. Yamaguchi, M. Okabe, S. Okamoto, K. Kawamoto, T. Park and T. Ito General Surgery, Kurashiki Central Hospital, Japan
HPB 2016, 18 (S1), e385ee601
e499
Introduction: To induce a rapid and significant increase in future liver remnant (FLR) volume, an innovative approach called associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed, permitting an extended hepatectomy. This procedure was commonly performed for hepatocellular carcinoma, liver metastasis or intrahepatic cholangiocarcinoma, while only a few cases have been reported for perihilar cholangiocarcinoma requiring extrahepatic resection. Method: We describe a case of ALPPS in a 78-year-old male with perihilar cholangiocarcinoma. Results: The patient presented with jaundice and was diagnosed with Bismuth type 4 perihilar cholangiocarcinoma. Computed tomography (CT) volumetry revealed a very small FLR (247 ml, 22% of the total liver volume (TLV). His indocyanine green retention rate at 15 minutes was 12.9%. Due to the risk of liver failure, we performed percutaneous transhepatic portal embolization, but his FLR didn’t sufficiently increase (297 ml, 26% of the TLV). Therefore, we chose ALPPS. During the first stage, right lobe mobilization, liver partition, right portal vein ligation, left hepatic duct resection and cholangiojejunostomy were undertaken, and the right hepatic artery, duct, vein and common bile duct were secured with vessel loops. CT on postoperative day 5 (POD5) showed a sufficient FLR increase (from 297 ml to 456 ml, 26 e 35% of TLV). Second stage ALPPS was undertaken on POD7, completing resection of the right lobe. The patient experienced bile leakage but was able to discharge 73 days after the second step. Conclusion: ALPPS procedure resulted in a rapid increase of FLR despite the patient requiring simultaneous cholangiojejunostomy.
EP03D-026 REFORMED GALLBLADDER AFTER SUBTOTAL CHOLECYSTECTOMY: TWO CASE REPORTS AND LITERATURE REVIEW R. Capelli1, E. Barrocas1, L. Marques2, M. Enne2 and E. Viana3 1 General Surgery, Hospital Federal de Ipanema, 2Hospital Federal de Ipanema, and 3Cirurgia Geral, Hospital Federal de Ipanema, Brazil Introduction: Subtotal cholecystectomy is a procedure reserved for severe cholecystitis where the patient conditions are unstable and it is not possible to identify the structures of the Calot triangle. It is considered a safe procedure, however occasional reoperation may be necessary. Objective: The goal of the study is report two cases of reoperation for reformed gallbladder after subtotal cholecystectomy in a single center and to conduct a literature review on reformed gallbladders after incomplete gallbladder removal. Method: A literature search of PubMed and EMBASE (1985 e February 2015) was conducted. Search criteria included “reformed gallbladder” “subtotal cholecystectomy” “partial cholecystectomy” “reoperation” “remnant gallbladder” “retained gallbladder” using the Boolean operators “AND” “OR”, limited to title or abstract with publication in the English. The bibliographies of the recovered articles were examined to find supplementary references of data.