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Magnetic resonance imaging (MRI) as preoperative risc assessment for posthepatectomy liver failure (PHLF) and death after major liver resection
Electronic Poster Abstracts Method: We evaluated retrospectively from 2000 to 2015 short and long term results of 20 consecutive surgical resections of tumors with associated inferior vena cava resection at levels I and II selecting only HPB malignancies. Results: There were 4 male and 3 females with a mean age of 54.1. The series included 3 pancreatic cancers, 4 liver cancers (2 colorectal liver metastases and 2 hepatocarcinomas) Mean follow up was 38.5 months. There was 1 circular cava resections replaced by PTFE graft, and 6 primary repairs. Severe Clavien-Dindo complications occurred in 3 cases. Graft thrombosis occurred in one case at 14 months from operation. Pancreatic cancers and liver tumors overall survival were 41 and 36 months, respectively. Conclusions: Surgical resection with combined inferior vena cava resection can be performed in selected patients with acceptable morbidity and mortality with improved oncological results.
EP01E-047 PI3KCA-MUTATIONS ARE FREQUENT AND PERSIST WITH RECURRENCE OF LIVER METASTASES FROM BREAST CANCER A. Ruiz1,2, M. Sebagh3, R. Saffroy3, M. -A. Allard3, P. Bouvet de la Maisonneuve3, N. Bosselut3, D. Wicherts4, J. -F. Morère3, R. Adam3 and A. Lemoine3 1 AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, France, 2University Medical Center Utrecht, Netherlands, 3 AP-HP Hôpital Paul Brousse, France, and 4Academic Medical Center Amsterdam, Netherlands Introduction: Some genetic mutations in breast cancer have been associated with resistance to chemotherapy, anti-Her2/Neu or anti-estrogen therapies, and could be involved in tumor recurrence. We aimed to determine recurrent mutations in breast cancer liver metastases (BCLM). Methods: Nineteen women with BCLM underwent at least two liver resections with curative intent. Four of them had a third hepatectomy. Representative tumor samples of all nodules were collected and reviewed. Results: A total of 75 BCLM nodules were analyzed. Two major ‘hot spot’ mutations in the helical and catalytic domains of PI3KCA were isolated. Out of 19 patients, 5 (26%) had BCLM carrying PI3KCA-mutations. All 5 patients recurred and four of them had persistent PI3KCA-mutations. Two other patients with recurrent disease had de novo PI13KCA-mutations. Four patients underwent a third hepatectomy of which 2 had PI3KCA-mutations. At the first, second and third hepatectomy, 38 %, 32% and 50% of patients had PI3KCA mutations. When combining all hepatectomies, 42% of patients had this mutation at one point in their history. Three of seven (43%) patients without mutation had microscopic vascular invasion compared to four of five (80%) in those who had the PI3KCA-mutation at first hepatectomy. At second hepatectomy, 3 of 11 patients (27%) without the mutation had vascular invasion
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compared to 3 of 6 (50%) patients with the PI3KCAmutation. Conclusion: PI3KCA-mutations are frequently observed in BCLM and often persist in case of recurrent disease. A possible relation was seen regarding microscopic vascular invasion and the presence of the PI3KCA-mutation.
[Mutation]
EP01E-048 MAGNETIC RESONANCE IMAGING (MRI) AS PREOPERATIVE RISC ASSESSMENT FOR POSTHEPATECTOMY LIVER FAILURE (PHLF) AND DEATH AFTER MAJOR LIVER RESECTION S. A. Lang1, P. Wiggermann2, A. Proneth1, P. Hauer1, M. Haimerl2, C. Stroszczynski2 and H. J. Schlitt1 1 Surgery, and 2Radiology, University Hospital Regensburg, Germany Aim and background: MRI with liver-specific contrast agent has been associated with liver function. Therefore, we assessed whether preoperative MRI might also help to identify patients endangered for PHLF or even death after liver resection. Methods: Patients that received MRI with liver specific contrast agent (Gd-EOB-DTPA) and subsequently underwent extended liver resection (3 liver segments) between 2013 and 2015 at Regensburg University Hospital were included. Signal intensity before (native) and after (late phase) Gd-EOB-DTPA was assessed in MRI. Postoperative course was analysed regarding PHLF (“50-50 criteria”, “peak-bili 7”, “ISGLS”) and complications (DindoClavien). Results: 67 patients were included. Reasons for liver resection were colorectal liver metastases (n = 33), cholangiocarcinoma (n = 12), hepatocellular carcinoma (n = 12), gallbladder cancer (n = 2) and other hepatic processes (n = 8). Patients received right hepatectomy (RH, n = 12), left hepatectomy (LH, n = 9), extended RH (n = 18), extended LH (n = 4), RH with atypical resection/ ablation on the left side (n = 20), LH and atypical resection/ ablation on the right side (n = 2) and central resection (CR, n = 2). PHLF occurred in 4 (50-50 criteria; 6%), 9 (“peakbili 7”; 13.4%) and 15 patients (ISGLS; 22.4%), respectively. Complications according to Dindo-Clavien IIIb were observed in 16 patients (23.9%), including 5 postoperative deaths (7.5%). No association was observed between MRI and PHLF and complication (except V). However, patients that died during the postoperative
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hospital stay had significantly lower enhancement in the late phase of preoperative MRI scan (290 vs. 365; p < 0.05). Conclusion: Preoperative MRI with liver specific contrast might be a helpful tool to identify patients endangered for postoperative death after extended liver resection.
EP01E-049 A RETROSPECTIVE STUDY ON MANAGEMENT OF BENIGN CYSTIC LESION (BC) AND HEPATIC HAEMANGIOMA (HH): ALWAYS LISTEN TO PATIENTS A. Godin1, Y. Collin2, M. Plasse1, R. Letourneau1, S. Turcotte1, M. Dagenais1, A. Roy1, R. Lapointe1 and F. Vandenbroucke-Menu1 1 Hepato-Pancreato-Biliary and Transplant Surgery Service, University of Montreal, CRCHUM, Saint-Luc Hospital, and 2Hepato-Pancreato-Biliary Surgery Service, University of Sherbrooke, Fleurimont Hospital, Canada Introduction: We report our experience of management of BC and HH. Materials: From 1992 to 2014, 320 cases of BC and HH were followed and retrospectively analyzed. Results: A hundred-sixty-two cases of BC (110F: 52M; mean age: 48) and 158 cases of HH (128F: 30M; mean age: 61) were studied. Sixty-four (39,5%) of BC were polycystic disease. The median follow-up was 1 and 2 years for BC and HH respectively. Initially, 22 (14%) BC and 6 (4%) HH were operated. Of the observed ones, 22 (16%) BC and 13 (9%) HH were thereafter operated. Resected lesions were significantly more symptomatic (BC: 91% operated vs 3% observed; HH: 69% vs 9% (p < 0,05)). Indications for surgery were symptoms (BC: 84%; HH: 64%), inability to exclude other diagnostics (BC: 16%; HH: 9%) and size (HH: 27%). The desire to get pregnant was also considered in resected HH (27% operated vs 1% observed, (p < 0,05)). During the follow-up, 88 (85%) of CB were stable, 4 (4%) regressed, 4 (11%) progressed and 49 (50%) of HH were stable, 18 (19%) regressed, 30 (31%) progressed. Conclusion: While the presence of symptoms is a wellknown indication for surgery of BC and HH, diagnostic doubt and the desire to get pregnant were also factors that influenced, in our study, surgical decision. Progression in size of those benign lesions was observed so proper followup imaging could be needed.
EP01E-050 TRISULFATED DISACCHARIDE DECREASES INTRACELLULAR CALCIUM IN HEPATOCYTES UNDER CALCIUM OVERLOAD E. R. Vasques1, J. E. M. Cunha1, A. M. M. Coelho1, S. N. Sampietre1, R. A. Patzina1, H. B. Nader2, I. L. S. Tersariol2, M. A. Lima2, T. Rodrigues3, E. Chaib1 and L. A. C. D’Albuquerque1 1 Gastroenterology (LIM/37), University of Sao Paulo/ Medical School, 2Federal University of Sao Paulo, and 3 Federal University of ABC, Brazil
Background: Ischemia and reperfusion (I/R) with intracellular calcium overload are essential phenomena in tissue damage in liver surgery and transplantation. The sodium calcium exchanger (NCX) regulates calcium extrusion and TD affects the NCX in endothelial aortic cells in rabbits by decreasing intracellular calcium through the inhibition of the exchange inhibitory peptide (XIP), however, the mechanism involved in liver protection is not clear. Objective: To evaluate TD effect on hepatocytes under calcium overload. Material and methods: BRL3A culture cells from Rattus norvegicus liver were grown in Dulbecco’s modified Eagle’s medium for 24 h and loaded with the fluorescent Ca2+ indicator fura-2/AM (4 mM). After washing twice, 1.0 mL of specific medium were add to cells and the images acquired on a widefield microscope. Changes in cytosolic calcium levels were measured at 37 oC for 15 minutes. Thapsigargin 200 mM was used to promote a sustained raise in the cytosolic calcium level. To evaluate TD effect, 30 mM TD was added to the medium after and prior Thapsigargin. Results: TD added to the medium after Thapsigargin decreased transiently the intracellular calcium levels and this longed for about 250 seconds. A slight decrease in the intracellular calcium basal level was observed when TD was added prior to Thapsigargin. Conclusion: TD was able to decrease the intracellular calcium raise promoted by Thapsigargin and to prevent it when added prior to the inducer.
EP01E-051 LAPAROSCOPIC TREATMENT OF PATENT DUCTUS VENOSUS: CORRELATION WITH ICG RATE M. Perini1, G. Starkey1, G. Riddiough2, S. Goh3, R. Jones2 and C. Christophi3 1 University of Melbourne, 2Austin Health, Australia, and 3 Austin Health, University of Melbourne, Australia Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt communicating the umbelical vein and the inferior vena cava. This video presents the assessment and feasibility of treating PDV with laparoscopy. A 17-year-old male was referred with symptoms of hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. ICG measurement before the test occlusion were PDR 5.5 and R15 of 43.8. Immediate after shunt occlusion the rate went up to 11.9 and 16.8. Partial occlusion of the shunt was performed using a vessel loop. Post operative day 1, ICG measurement were PDR 14.2 and R15 11.9. And a Doppler scan of the portal vessels showed patency of the shunt and no signs of portal vein thrombus. Patient was discharged home POD2 and reviewed one week later. A new Doppler scan revealed that shunt was trombosed and there was normal portal vein flow to the liver. The present video shows the usefulness of laparoscopic approach and ICG measurement in assessing and treating PDV shunts.
HPB 2016, 18 (S1), e1ee384
EP01E-047 PI3KCA-MUTATIONS ARE FREQUENT AND PERSIST WITH RECURRENCE OF LIVER METASTASES FROM BREAST CANCER A. Ruiz1,2, M. Sebagh3, R. Saffroy3, M. -A. Allard3, P. Bouvet de la Maisonneuve3, N. Bosselut3, D. Wicherts4, J. -F. Morère3, R. Adam3 and A. Lemoine3 1 AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, France, 2University Medical Center Utrecht, Netherlands, 3 AP-HP Hôpital Paul Brousse, France, and 4Academic Medical Center Amsterdam, Netherlands Introduction: Some genetic mutations in breast cancer have been associated with resistance to chemotherapy, anti-Her2/Neu or anti-estrogen therapies, and could be involved in tumor recurrence. We aimed to determine recurrent mutations in breast cancer liver metastases (BCLM). Methods: Nineteen women with BCLM underwent at least two liver resections with curative intent. Four of them had a third hepatectomy. Representative tumor samples of all nodules were collected and reviewed. Results: A total of 75 BCLM nodules were analyzed. Two major ‘hot spot’ mutations in the helical and catalytic domains of PI3KCA were isolated. Out of 19 patients, 5 (26%) had BCLM carrying PI3KCA-mutations. All 5 patients recurred and four of them had persistent PI3KCA-mutations. Two other patients with recurrent disease had de novo PI13KCA-mutations. Four patients underwent a third hepatectomy of which 2 had PI3KCA-mutations. At the first, second and third hepatectomy, 38 %, 32% and 50% of patients had PI3KCA mutations. When combining all hepatectomies, 42% of patients had this mutation at one point in their history. Three of seven (43%) patients without mutation had microscopic vascular invasion compared to four of five (80%) in those who had the PI3KCA-mutation at first hepatectomy. At second hepatectomy, 3 of 11 patients (27%) without the mutation had vascular invasion
HPB 2016, 18 (S1), e1ee384
e301
compared to 3 of 6 (50%) patients with the PI3KCAmutation. Conclusion: PI3KCA-mutations are frequently observed in BCLM and often persist in case of recurrent disease. A possible relation was seen regarding microscopic vascular invasion and the presence of the PI3KCA-mutation.
[Mutation]
EP01E-048 MAGNETIC RESONANCE IMAGING (MRI) AS PREOPERATIVE RISC ASSESSMENT FOR POSTHEPATECTOMY LIVER FAILURE (PHLF) AND DEATH AFTER MAJOR LIVER RESECTION S. A. Lang1, P. Wiggermann2, A. Proneth1, P. Hauer1, M. Haimerl2, C. Stroszczynski2 and H. J. Schlitt1 1 Surgery, and 2Radiology, University Hospital Regensburg, Germany Aim and background: MRI with liver-specific contrast agent has been associated with liver function. Therefore, we assessed whether preoperative MRI might also help to identify patients endangered for PHLF or even death after liver resection. Methods: Patients that received MRI with liver specific contrast agent (Gd-EOB-DTPA) and subsequently underwent extended liver resection (3 liver segments) between 2013 and 2015 at Regensburg University Hospital were included. Signal intensity before (native) and after (late phase) Gd-EOB-DTPA was assessed in MRI. Postoperative course was analysed regarding PHLF (“50-50 criteria”, “peak-bili 7”, “ISGLS”) and complications (DindoClavien). Results: 67 patients were included. Reasons for liver resection were colorectal liver metastases (n = 33), cholangiocarcinoma (n = 12), hepatocellular carcinoma (n = 12), gallbladder cancer (n = 2) and other hepatic processes (n = 8). Patients received right hepatectomy (RH, n = 12), left hepatectomy (LH, n = 9), extended RH (n = 18), extended LH (n = 4), RH with atypical resection/ ablation on the left side (n = 20), LH and atypical resection/ ablation on the right side (n = 2) and central resection (CR, n = 2). PHLF occurred in 4 (50-50 criteria; 6%), 9 (“peakbili 7”; 13.4%) and 15 patients (ISGLS; 22.4%), respectively. Complications according to Dindo-Clavien IIIb were observed in 16 patients (23.9%), including 5 postoperative deaths (7.5%). No association was observed between MRI and PHLF and complication (except V). However, patients that died during the postoperative
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Electronic Poster Abstracts
hospital stay had significantly lower enhancement in the late phase of preoperative MRI scan (290 vs. 365; p < 0.05). Conclusion: Preoperative MRI with liver specific contrast might be a helpful tool to identify patients endangered for postoperative death after extended liver resection.
EP01E-049 A RETROSPECTIVE STUDY ON MANAGEMENT OF BENIGN CYSTIC LESION (BC) AND HEPATIC HAEMANGIOMA (HH): ALWAYS LISTEN TO PATIENTS A. Godin1, Y. Collin2, M. Plasse1, R. Letourneau1, S. Turcotte1, M. Dagenais1, A. Roy1, R. Lapointe1 and F. Vandenbroucke-Menu1 1 Hepato-Pancreato-Biliary and Transplant Surgery Service, University of Montreal, CRCHUM, Saint-Luc Hospital, and 2Hepato-Pancreato-Biliary Surgery Service, University of Sherbrooke, Fleurimont Hospital, Canada Introduction: We report our experience of management of BC and HH. Materials: From 1992 to 2014, 320 cases of BC and HH were followed and retrospectively analyzed. Results: A hundred-sixty-two cases of BC (110F: 52M; mean age: 48) and 158 cases of HH (128F: 30M; mean age: 61) were studied. Sixty-four (39,5%) of BC were polycystic disease. The median follow-up was 1 and 2 years for BC and HH respectively. Initially, 22 (14%) BC and 6 (4%) HH were operated. Of the observed ones, 22 (16%) BC and 13 (9%) HH were thereafter operated. Resected lesions were significantly more symptomatic (BC: 91% operated vs 3% observed; HH: 69% vs 9% (p < 0,05)). Indications for surgery were symptoms (BC: 84%; HH: 64%), inability to exclude other diagnostics (BC: 16%; HH: 9%) and size (HH: 27%). The desire to get pregnant was also considered in resected HH (27% operated vs 1% observed, (p < 0,05)). During the follow-up, 88 (85%) of CB were stable, 4 (4%) regressed, 4 (11%) progressed and 49 (50%) of HH were stable, 18 (19%) regressed, 30 (31%) progressed. Conclusion: While the presence of symptoms is a wellknown indication for surgery of BC and HH, diagnostic doubt and the desire to get pregnant were also factors that influenced, in our study, surgical decision. Progression in size of those benign lesions was observed so proper followup imaging could be needed.
EP01E-050 TRISULFATED DISACCHARIDE DECREASES INTRACELLULAR CALCIUM IN HEPATOCYTES UNDER CALCIUM OVERLOAD E. R. Vasques1, J. E. M. Cunha1, A. M. M. Coelho1, S. N. Sampietre1, R. A. Patzina1, H. B. Nader2, I. L. S. Tersariol2, M. A. Lima2, T. Rodrigues3, E. Chaib1 and L. A. C. D’Albuquerque1 1 Gastroenterology (LIM/37), University of Sao Paulo/ Medical School, 2Federal University of Sao Paulo, and 3 Federal University of ABC, Brazil
Background: Ischemia and reperfusion (I/R) with intracellular calcium overload are essential phenomena in tissue damage in liver surgery and transplantation. The sodium calcium exchanger (NCX) regulates calcium extrusion and TD affects the NCX in endothelial aortic cells in rabbits by decreasing intracellular calcium through the inhibition of the exchange inhibitory peptide (XIP), however, the mechanism involved in liver protection is not clear. Objective: To evaluate TD effect on hepatocytes under calcium overload. Material and methods: BRL3A culture cells from Rattus norvegicus liver were grown in Dulbecco’s modified Eagle’s medium for 24 h and loaded with the fluorescent Ca2+ indicator fura-2/AM (4 mM). After washing twice, 1.0 mL of specific medium were add to cells and the images acquired on a widefield microscope. Changes in cytosolic calcium levels were measured at 37 oC for 15 minutes. Thapsigargin 200 mM was used to promote a sustained raise in the cytosolic calcium level. To evaluate TD effect, 30 mM TD was added to the medium after and prior Thapsigargin. Results: TD added to the medium after Thapsigargin decreased transiently the intracellular calcium levels and this longed for about 250 seconds. A slight decrease in the intracellular calcium basal level was observed when TD was added prior to Thapsigargin. Conclusion: TD was able to decrease the intracellular calcium raise promoted by Thapsigargin and to prevent it when added prior to the inducer.
EP01E-051 LAPAROSCOPIC TREATMENT OF PATENT DUCTUS VENOSUS: CORRELATION WITH ICG RATE M. Perini1, G. Starkey1, G. Riddiough2, S. Goh3, R. Jones2 and C. Christophi3 1 University of Melbourne, 2Austin Health, Australia, and 3 Austin Health, University of Melbourne, Australia Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt communicating the umbelical vein and the inferior vena cava. This video presents the assessment and feasibility of treating PDV with laparoscopy. A 17-year-old male was referred with symptoms of hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. ICG measurement before the test occlusion were PDR 5.5 and R15 of 43.8. Immediate after shunt occlusion the rate went up to 11.9 and 16.8. Partial occlusion of the shunt was performed using a vessel loop. Post operative day 1, ICG measurement were PDR 14.2 and R15 11.9. And a Doppler scan of the portal vessels showed patency of the shunt and no signs of portal vein thrombus. Patient was discharged home POD2 and reviewed one week later. A new Doppler scan revealed that shunt was trombosed and there was normal portal vein flow to the liver. The present video shows the usefulness of laparoscopic approach and ICG measurement in assessing and treating PDV shunts.
HPB 2016, 18 (S1), e1ee384