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Laparoscopic resection of right posterior lobe: experience of 20 cases
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Electronic Poster Abstracts
epigastric area. Abdominal computed tomography and magnetic resonance imaging demonstrated 3 cm sized tumor at bifurcation of common hepatic duct with marked intrahepatic bile duct dilatation. Based on laboratory test and imaging, preoperative diagnosis was hilar cholangiocarcinoma with left intrahepatic bile duct invasion. Results: Extended left hepatectomy, caudate lobectomy, CBD resection was performed under the diagnosis of Klatskin’s tumor. At laparotomy, there was 1.5 cm sized polypoid mass at hilar portion and left intrahepatic bile duct and there was no vascular invasion. Pathologic examination showed tubulopapillary adenoma and there was no atypia and no dysplasia. The patient tolerated the procedure well and was discharge 3 weeks following surgery without any problems. Conclusions: Bile duct adenoma is a rare benign tumor, especially arising at hepatic hilar portion. Although it is very hard to differentiate the bile duct adenoma developed in hepatic hilar portion with Klatskin’s tumor, it should be considered to differentiate and it is important to make an effective plan for treatment.
EP03F-049 DILATION OF BILIODIGESTIVE ANASTOMOSIS BY TRANSJEJUNAL ACCESS J. C. Cavalcante Jr.1, M. F. C. Medeiros1, A. J. A. Fontan1, D. R. Costa1, J. Batista Neto1 and M. L. R. Moreira2 1 Oncologic Surgery, University Hospital of Alagoas, and 2 Oncologic Surgery, Hospital Memorial Arthur Ramos/ Oncos, Brazil Introduction: The treatment of iatrogenic bile duct injury comes as a challenge as well as the follow-up techniques and surgical complications which the patient are affected. Case report: Female, 28 years old, with iatrogenic injury history of conventional cholecystectomy complicated with stenosis biliary main and need for biliary-enteric bypass with hepatic-jejunal anastomosis, keeping afferent excluded jejunal loop fixed to the anterior abdominal wall. After hospitalization due to cholangitis frame, it was observed in cholangiography, biliodigestive anastomotic stenosis. It underwent attempted percutaneous transhepatic dilation unsuccessfully, external biliary drainage in progress. Accessed hepatic-jejunal anastomosis by surgical exposure excluded jejunal loop attached to the abdominal wall. Using a 12 60 mm balloon dilation of the anastomosis by access transjejunal, with restoration of hepatic-jejunal transit. It was held exceeding the biliodigestive anastomosis by existing Transhepatic access for placement of internal-external drain. The tube was removed after 30 days and the patient remains asymptomatic. Conclusion: The stenosis biliodigestive anastomosis is a major complication of shunts performed to repair damage after cholecystectomy bile, affecting about 10% of patients. The surgical approach to this complication is technically
difficult and can greatly increase morbidity. In addition, it is associated with a restenosis rate of up to 45%. In this context, the percutaneous transhepatic approach provides good results, with technical success rate of 60% and no recurrence of symptoms in 70 e 90% of cases.
EP03F-050 DILATACIÓN PERCUTÁNEA DE ESTENOSIS BILIAR BENIGNA S. T. Gauto Almada, G. Parquet and R. Sanchez Hospital Central Instituto de Prevision Social, Paraguay Introducción: En la estenosis de las anastomosis biliodigestivas, los procedimientos percutáneos son de primera elección como tratamiento, y se deja reservada la cirugía para los casos de mala evolución o las estenosis con graves defectos técnicos. Método: Se analizaron en forma retrospectiva los expedientes de 15 pacientes con estenosis biliar benigna cuyo tratamiento fue dilatación percutánea con balón en el Servicio de Mínima Invasión del Hospital Central de Instituto de Previsión Social desde el año 2009 hasta el 2015, con seguimiento de 6 meses. Antes del procedimiento se solicito pruebas de laboratorio que incluya perfil de coagulación dentro de los parámetros normales. Los paciente portaban drenaje biliar externo interno realizado previamente en el servicio, bajo anestesia local y sedación, se localiza la estenosis por vía radioscópica a través del drenaje previo, se introduce un balón (ATB AdvanceÒ) de dilatación por el mismo, se dilata en zona de la estenosis por 3 minutos, en tres oportunidades en nueve sesiones, el seguimiento se realizo con métodos de imágenes y estudios laboratoriales. Resultados: Durante en periodo de 6 años se realizaron dicho procedimiento 9 mujeres y 6 hombres con edad promedio de 42. Lesión de vía biliar post colecistectomía laparoscópica 6 pacientes, colecistetomía convencional 2; post operados de cáncer de cabeza de páncreas 3, lesión biliar post trauma 1, post operado de quiste de colédoco 1. Conclusión: En las estenosis biliares benignas la dilatación percutánea con balón es un método válido a tener presente en pacientes seleccionados.
General HPB EP04A - Electronic Poster: 4A e HPB Endoscopy
EP04A-001 LAPAROSCOPIC RESECTION OF RIGHT POSTERIOR LOBE: EXPERIENCE OF 20 CASES X. Cai1 and Y. Wang2 1 Department of HPB Surgery, and 2HPB Surgery, Sir Run Run Shaw Hospital, Zhejiang University, China Background: Laparoscopic resection of right posterior lobe is rarely performed because of the difficulty of
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts exposing the lesion in laparoscope, risk of massive bleeding and the difficulty of managing intra-operative emergencies. This procedure was performed routinely in our institute. The aim of this study was to report outcomes of laparoscopic resection of right posterior lobe. Methods: 20 Consecutive patients who underwent laparoscopic resection of right posterior lobe in Sir Run Run Shaw Hospital. The patients’ characteristics, surgical features, postoperative course, and so on were reviewed. All procedures were performed under general anesthesia with the patients in the left side position. Liver parenchyma was transected with the special instrument of laparoscopic peng’s multifunctional operative dissector. Results: No peri-operative death. 5 patients were converted to open hepatectomy. 3 Complications occurred. The mean operating time was 217.3 ml. The mean volume of intraoperative blood loss was 698.3 ml and 6 patients had intraoperative blood transfusion. The length of post-operative hospital stay was 8.4 days. Conclusion: laparoscopic resection of right posterior lobe was supposed to be a safe and effective procedure according to current results in our institute.
EP04A-002 THE EFFECT OF PORTAL HYPERTENSION ON ELEVATED GASTRIC ANTRUM EROSIONS F. C. d. A. Conejo1, E. M. d. C. Aranzana2, M. A. Ribeiro2, L. A. Szutan2 and F. Ferreira2 1 Endoscopy, and 2Surgery, Santa Casa de Sao Paulo School of Medical Sciences, Brazil Background: Portal hypertension (PH) is a syndrome characterized by a chronic increase in the pressure gradient between the portal vein and inferior vena cava. Some studies suggest an increased frequency of antral elevated erosive gastritis in patients with PH, but there is no histological evidence of this hypothesis to date. Objective: Evaluate the histological features found in elevated antral erosions in patients with and without PH. Method: Sixty-nine patients were included, 28 with and 41 without PH. All patients underwent endoscopy and areas with elevated antral erosion were biopsied. Results: In the PH group, 24 patients had inflammatory infiltration with or without edema and vascular congestion, and 4 patients had no inflammation. In the group without PH, all patients showed inflammatory infiltration of variable intensity. There was no statistical significance between groups when analyzing protective and aggressive factors, such as the presence of H. pylori, non-hormonal anti-inflammatory drugs use, smoking or protonpump inhibitors use. When PH patients without inflammation were excluded, there was histological similarity between the groups. However, there was significant more evidence of edema and vascular congestion in the PH group. Conclusion: The biopsies of elevated antral erosions revealed that edema and vascular congestion are more evident in patients with PH, instead of inflammatory infiltrate.
HPB 2016, 18 (S1), e385ee601
e529
EP04A-003 EXPERIENCE OF LAPAROSCOPIC ORGAN-PRESERVING OPERATIONS IN PATIENTS WITH BENIGN SPLENIC LESIONS D. Ionkin1, V. A. Koubyshkin1, D. A. Ionkin1, A. G. Kriger1, S. V. Birelavichus1 and Y. Stepanova2 1 Vishnevsky Institute of Surgery, and 2Radiology, A.V. Vishnevsky Institute of Surgery, Russian Federation Aim: To define proper surgical tactics in patients with focal splenic lesions. Materials and methods: More than 390 patients with focal splenic lesions were treated in the clinic from 1976. Concerning surgeries the preference was given to organpreserving operations, otherwise heterotopic autotransplantation of splenic tissue was performed. In addition to traditional access spleen resection and laparoscopic procedures were performed. Successful laparoscopic operations were performed in 67 cases. The following surgeries were performed: fenestration-41 (robotic-assisted-6), resection-23 (anatomical-6, peritumoral14, robotic-assisted-3), echinococcectomy-2, splenectomy due to echinococcosis-1, intervention due to complicated true cysts of accessory spleen-1. The morphological structure of the spleen diseases: non-parasitic cysts-46 (true-34), benign tumors-16, hydatid disease-2. In 3 cases laparoscopic procedures required conversion because of the pronounced bleeding. Results: Taking into account the post-operative results we began to complement the commonly used argon and/or coagulation de-epithelization of the remaining part of the cyst wall with the cyst alcoholization. The worst results were found in patients after organ removal. Conclusion: When benign origin of the splenic lesion is confirmed and at least a small part of the unaffected parenchyma remains the preference should be given to organpreserving operation with the use of modern means of hemostasis and appropriate related techniques.
EP04A-004 ENDOSCOPIC CONTRAST ENHANCED ULTRASOUND IN THE STUDY OF PORTAL HYPERTENSIVE GASTROPATHY G. F. S. d. Macedo1, E. M. d. C. Aranzana2, M. A. Ribeiro2, L. A. Szutan2 and F. G. Ferreira2 1 Endoscopy, and 2Surgery, Santa Casa de Sao Paulo School of Medical Sciences, Brazil Background: Portal Hypertensive Gastropathy (PHG) is a microvascular gastric mucosal e submucosal alteration associated to mucosal patterns, identified during upper endoscopy, responsible for acute and chronic gastrointestinal bleeding in patients with portal hypertension of any etiology. Objective: To establish patterns of mucosal and submucosal blood flow in patients with portal hypertension for chronic viral hepatitis with and without endoscopic PHG, using Contrast Enhanced Ultrasound (CEUS). Method: 20 Patients with portal hypertension for chronic viral hepatitis, presenting esophageal varices, without
Electronic Poster Abstracts
epigastric area. Abdominal computed tomography and magnetic resonance imaging demonstrated 3 cm sized tumor at bifurcation of common hepatic duct with marked intrahepatic bile duct dilatation. Based on laboratory test and imaging, preoperative diagnosis was hilar cholangiocarcinoma with left intrahepatic bile duct invasion. Results: Extended left hepatectomy, caudate lobectomy, CBD resection was performed under the diagnosis of Klatskin’s tumor. At laparotomy, there was 1.5 cm sized polypoid mass at hilar portion and left intrahepatic bile duct and there was no vascular invasion. Pathologic examination showed tubulopapillary adenoma and there was no atypia and no dysplasia. The patient tolerated the procedure well and was discharge 3 weeks following surgery without any problems. Conclusions: Bile duct adenoma is a rare benign tumor, especially arising at hepatic hilar portion. Although it is very hard to differentiate the bile duct adenoma developed in hepatic hilar portion with Klatskin’s tumor, it should be considered to differentiate and it is important to make an effective plan for treatment.
EP03F-049 DILATION OF BILIODIGESTIVE ANASTOMOSIS BY TRANSJEJUNAL ACCESS J. C. Cavalcante Jr.1, M. F. C. Medeiros1, A. J. A. Fontan1, D. R. Costa1, J. Batista Neto1 and M. L. R. Moreira2 1 Oncologic Surgery, University Hospital of Alagoas, and 2 Oncologic Surgery, Hospital Memorial Arthur Ramos/ Oncos, Brazil Introduction: The treatment of iatrogenic bile duct injury comes as a challenge as well as the follow-up techniques and surgical complications which the patient are affected. Case report: Female, 28 years old, with iatrogenic injury history of conventional cholecystectomy complicated with stenosis biliary main and need for biliary-enteric bypass with hepatic-jejunal anastomosis, keeping afferent excluded jejunal loop fixed to the anterior abdominal wall. After hospitalization due to cholangitis frame, it was observed in cholangiography, biliodigestive anastomotic stenosis. It underwent attempted percutaneous transhepatic dilation unsuccessfully, external biliary drainage in progress. Accessed hepatic-jejunal anastomosis by surgical exposure excluded jejunal loop attached to the abdominal wall. Using a 12 60 mm balloon dilation of the anastomosis by access transjejunal, with restoration of hepatic-jejunal transit. It was held exceeding the biliodigestive anastomosis by existing Transhepatic access for placement of internal-external drain. The tube was removed after 30 days and the patient remains asymptomatic. Conclusion: The stenosis biliodigestive anastomosis is a major complication of shunts performed to repair damage after cholecystectomy bile, affecting about 10% of patients. The surgical approach to this complication is technically
difficult and can greatly increase morbidity. In addition, it is associated with a restenosis rate of up to 45%. In this context, the percutaneous transhepatic approach provides good results, with technical success rate of 60% and no recurrence of symptoms in 70 e 90% of cases.
EP03F-050 DILATACIÓN PERCUTÁNEA DE ESTENOSIS BILIAR BENIGNA S. T. Gauto Almada, G. Parquet and R. Sanchez Hospital Central Instituto de Prevision Social, Paraguay Introducción: En la estenosis de las anastomosis biliodigestivas, los procedimientos percutáneos son de primera elección como tratamiento, y se deja reservada la cirugía para los casos de mala evolución o las estenosis con graves defectos técnicos. Método: Se analizaron en forma retrospectiva los expedientes de 15 pacientes con estenosis biliar benigna cuyo tratamiento fue dilatación percutánea con balón en el Servicio de Mínima Invasión del Hospital Central de Instituto de Previsión Social desde el año 2009 hasta el 2015, con seguimiento de 6 meses. Antes del procedimiento se solicito pruebas de laboratorio que incluya perfil de coagulación dentro de los parámetros normales. Los paciente portaban drenaje biliar externo interno realizado previamente en el servicio, bajo anestesia local y sedación, se localiza la estenosis por vía radioscópica a través del drenaje previo, se introduce un balón (ATB AdvanceÒ) de dilatación por el mismo, se dilata en zona de la estenosis por 3 minutos, en tres oportunidades en nueve sesiones, el seguimiento se realizo con métodos de imágenes y estudios laboratoriales. Resultados: Durante en periodo de 6 años se realizaron dicho procedimiento 9 mujeres y 6 hombres con edad promedio de 42. Lesión de vía biliar post colecistectomía laparoscópica 6 pacientes, colecistetomía convencional 2; post operados de cáncer de cabeza de páncreas 3, lesión biliar post trauma 1, post operado de quiste de colédoco 1. Conclusión: En las estenosis biliares benignas la dilatación percutánea con balón es un método válido a tener presente en pacientes seleccionados.
General HPB EP04A - Electronic Poster: 4A e HPB Endoscopy
EP04A-001 LAPAROSCOPIC RESECTION OF RIGHT POSTERIOR LOBE: EXPERIENCE OF 20 CASES X. Cai1 and Y. Wang2 1 Department of HPB Surgery, and 2HPB Surgery, Sir Run Run Shaw Hospital, Zhejiang University, China Background: Laparoscopic resection of right posterior lobe is rarely performed because of the difficulty of
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts exposing the lesion in laparoscope, risk of massive bleeding and the difficulty of managing intra-operative emergencies. This procedure was performed routinely in our institute. The aim of this study was to report outcomes of laparoscopic resection of right posterior lobe. Methods: 20 Consecutive patients who underwent laparoscopic resection of right posterior lobe in Sir Run Run Shaw Hospital. The patients’ characteristics, surgical features, postoperative course, and so on were reviewed. All procedures were performed under general anesthesia with the patients in the left side position. Liver parenchyma was transected with the special instrument of laparoscopic peng’s multifunctional operative dissector. Results: No peri-operative death. 5 patients were converted to open hepatectomy. 3 Complications occurred. The mean operating time was 217.3 ml. The mean volume of intraoperative blood loss was 698.3 ml and 6 patients had intraoperative blood transfusion. The length of post-operative hospital stay was 8.4 days. Conclusion: laparoscopic resection of right posterior lobe was supposed to be a safe and effective procedure according to current results in our institute.
EP04A-002 THE EFFECT OF PORTAL HYPERTENSION ON ELEVATED GASTRIC ANTRUM EROSIONS F. C. d. A. Conejo1, E. M. d. C. Aranzana2, M. A. Ribeiro2, L. A. Szutan2 and F. Ferreira2 1 Endoscopy, and 2Surgery, Santa Casa de Sao Paulo School of Medical Sciences, Brazil Background: Portal hypertension (PH) is a syndrome characterized by a chronic increase in the pressure gradient between the portal vein and inferior vena cava. Some studies suggest an increased frequency of antral elevated erosive gastritis in patients with PH, but there is no histological evidence of this hypothesis to date. Objective: Evaluate the histological features found in elevated antral erosions in patients with and without PH. Method: Sixty-nine patients were included, 28 with and 41 without PH. All patients underwent endoscopy and areas with elevated antral erosion were biopsied. Results: In the PH group, 24 patients had inflammatory infiltration with or without edema and vascular congestion, and 4 patients had no inflammation. In the group without PH, all patients showed inflammatory infiltration of variable intensity. There was no statistical significance between groups when analyzing protective and aggressive factors, such as the presence of H. pylori, non-hormonal anti-inflammatory drugs use, smoking or protonpump inhibitors use. When PH patients without inflammation were excluded, there was histological similarity between the groups. However, there was significant more evidence of edema and vascular congestion in the PH group. Conclusion: The biopsies of elevated antral erosions revealed that edema and vascular congestion are more evident in patients with PH, instead of inflammatory infiltrate.
HPB 2016, 18 (S1), e385ee601
e529
EP04A-003 EXPERIENCE OF LAPAROSCOPIC ORGAN-PRESERVING OPERATIONS IN PATIENTS WITH BENIGN SPLENIC LESIONS D. Ionkin1, V. A. Koubyshkin1, D. A. Ionkin1, A. G. Kriger1, S. V. Birelavichus1 and Y. Stepanova2 1 Vishnevsky Institute of Surgery, and 2Radiology, A.V. Vishnevsky Institute of Surgery, Russian Federation Aim: To define proper surgical tactics in patients with focal splenic lesions. Materials and methods: More than 390 patients with focal splenic lesions were treated in the clinic from 1976. Concerning surgeries the preference was given to organpreserving operations, otherwise heterotopic autotransplantation of splenic tissue was performed. In addition to traditional access spleen resection and laparoscopic procedures were performed. Successful laparoscopic operations were performed in 67 cases. The following surgeries were performed: fenestration-41 (robotic-assisted-6), resection-23 (anatomical-6, peritumoral14, robotic-assisted-3), echinococcectomy-2, splenectomy due to echinococcosis-1, intervention due to complicated true cysts of accessory spleen-1. The morphological structure of the spleen diseases: non-parasitic cysts-46 (true-34), benign tumors-16, hydatid disease-2. In 3 cases laparoscopic procedures required conversion because of the pronounced bleeding. Results: Taking into account the post-operative results we began to complement the commonly used argon and/or coagulation de-epithelization of the remaining part of the cyst wall with the cyst alcoholization. The worst results were found in patients after organ removal. Conclusion: When benign origin of the splenic lesion is confirmed and at least a small part of the unaffected parenchyma remains the preference should be given to organpreserving operation with the use of modern means of hemostasis and appropriate related techniques.
EP04A-004 ENDOSCOPIC CONTRAST ENHANCED ULTRASOUND IN THE STUDY OF PORTAL HYPERTENSIVE GASTROPATHY G. F. S. d. Macedo1, E. M. d. C. Aranzana2, M. A. Ribeiro2, L. A. Szutan2 and F. G. Ferreira2 1 Endoscopy, and 2Surgery, Santa Casa de Sao Paulo School of Medical Sciences, Brazil Background: Portal Hypertensive Gastropathy (PHG) is a microvascular gastric mucosal e submucosal alteration associated to mucosal patterns, identified during upper endoscopy, responsible for acute and chronic gastrointestinal bleeding in patients with portal hypertension of any etiology. Objective: To establish patterns of mucosal and submucosal blood flow in patients with portal hypertension for chronic viral hepatitis with and without endoscopic PHG, using Contrast Enhanced Ultrasound (CEUS). Method: 20 Patients with portal hypertension for chronic viral hepatitis, presenting esophageal varices, without