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Major iatrogenic biliary injuries: epidemiological analysis in a French region
e486
Electronic Poster Abstracts
fashion, data on complications, laboratory indices, comorbidities, and imaging findings, and outcome were collected from the electronic medical record system. The Charlston Co-morbidity Index (CCI) was calculated for all patients. Continuous variables were described by quartiles and categorical variables were described by counts and percentages. Continuous variables were compared between patients undergoing cholecystectomy or not using the Wilcoxon rank-sum test, and categorical variables were compared using the Pearson chi-squared test. Results: 183 patients (88 women, 95 men), with a mean age of 67.7years (SD 14.3) underwent a PercChole. Calculous cholycystitis was present in 96 patients (52%), acalculous cholycystitis 73 patients (40%), and other causes for tube placement accounted for 14 patients (8%). The mean age adjusted CCI at the time of placement was 5.4 (SD 2.2). Cholecystectomy was performed in 68 patients at a mean of 118 (SD 110) days, with 19 (27%) early (<4 weeks) and 49 (72%) late (>4 weeks) after PercChole. Patients undergoing surgery were significantly younger (p < 0.0001) and had a lower CCI (p < 0.0001). There was no statistically significantly difference in patient characteristics in patients undergoing surgery compared to those who did not.
The fundamental deficiencies of laparoscopy increase the difficulty in locating the common bile duct. There is a need for easily accessible visual cues to help the surgeon orientate with respect to the bile duct. The aim of this investigation was to determine whether the shape of the quadrate lobe (segment IV) correlates with the location of the common bile duct during laparoscopic cholecystectomy. Method: Patients undergoing laparoscopic cholecystectomy at North Shore Hospital (New Zealand) from February to November 2014 were prospectively audited. Intraoperative cholangiograms and photographs of the quadrate lobe were reviewed noting the angle between the cystic duct and common bile duct and its relationship to quadrate shape. Result: 56 patients were included. 62.5% were rectangular, 23.2% were triangular and 14.3% square. The median cystic/bile duct angle was 43, 37 and 26 degrees for square, rectangular and triangular quadrate shapes respectively. The angle for triangular lobes was statistically smaller than for rectangular or square lobes (p < 0.05). Regression analysis showed an inverse relationship between the shape ratio and the cystic/bile duct angle (p = 0.015).
EP03C-017 - Table
N
No surgery N [ 115
Surgery N68
Tes statistic
Age at time of tube placement
177
62.0 73.0 80.0
53.8 62.5 76.0
F1,175 = 11.17, P = 0.0011
Gender : Male
183
50% (57)
56% (38)
c21 = 0.68, P = 0.4092
WBC
183
8.2 13.9 22.2
8.2 12.3 17.1
F1,181 = 2.76, P = 0.0981
Alkaline phosphatase
182
94.0 162.0 278.0
83.5 124.0 249.0
F1,180 = 2.84, P = 0.0941
Total bilirubin
182
0.6 1.9 4.7
0.8 1.2 2.1
F1,180 = 3.55, P = 0.0611
Age adjusted CCI
183
4-6- 8
3- 4- 6
F1,181 = 15.51, P < 0.0011
Indication for perc cole : Acalculous Cholycystitis
183
c2 = 0.17, P = 0.9212
41% (47)
38% (26)
Calculous Cholycystitis
51% (59)
54% (37)
Other
8 % (9)
7% ( 5)
[Crude comparisons between patients with surgery]
Conclusion: This study demonstrates a trend towards younger and healthier patients undergoing surgery following symptom resolution. Patients undergoing early surgery represent patient in which there was PercChole failure.
EP03C-018 THE QUADRATE LOBE: A RELIABLE LANDMARK IN LAPAROSCOPIC CHOLECYSTECTOMY? K. Rajkomar1, M. Bowman2, M. Rodgers3 and J. Koea4 1 UGI/HPB, Nepean Hospital, Australia, 2General Surgery, 3UGI/HPB, and 4HPB, North Shore Hospital, New Zealand Background: The rate of bile duct injury in the laparoscopic era is still twice that of the open era.
Conclusion: This investigation confirms the relationship between the shape of the quadrate lobe and the cystic/bile duct angle. When used in conjunction with the Rouviere’s sulcus it helps better define the location of the bile duct and helps give a safer starting point for the dissection of the critical view of safety.
EP03C-019 MAJOR IATROGENIC BILIARY INJURIES: EPIDEMIOLOGICAL ANALYSIS IN A FRENCH REGION V. Scholer1, T. Piardi1, R. Rhaiem2, M. Lhuaire2, G. Thiefin3, R. Kianmanesh1 and D. Sommacale1 1 General and Visceral Surgery, Robert Debre HospitalUniversity of Reims, 2Robert Debre Hospital-University of Reims, and 3Hepato-Gastro-Enterology, Robert Debre Hospital-University of Reims, France
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts Introduction: Major iatrogenic bile duct injuries (BDI) are serious complication of laparoscopic cholecystectomy (LC). Patients managed in a referral hepatobiliary center have better outcomes. The aim of this study was to evaluate the management of major BDI after LC in French region. Method: From 2012 to 2014, 14,321 LC were performed in Champagne-Ardennes-France. 16 major BDI (0.10%) were managed in our department. Strasberg classification, symptoms, surgical repair procedures, morbidity and mortality rates were evaluated. Results: Characteristics of the patients are reported in Tab1. Endoscopic treatment was successful in one patient. Surgery was needed in 15 patients, including 3 after endoscopic failure (21.4%). Major hepatic resection was performed in 2 (14.3%), Roux-en-y hepaticojejunostomy in 10 (71.4%) and repair on T-tube in 3 (14.3%) patients. No mortality was reported. Two patients had grade III or IV DindoeClavien complications after surgical repair (13.3%). Age (mean)
54
Gender female n. (%)
10 (62.5)
IOC n. (%)
4 (25)
Strasberg Strasberg B n. (%)
1 (6.2)
Strasberg D n. (%)
5 (31.3)
Strasberg E n. (%)
10 (62.5)
Recognition of injury Early (per-operative) n (%)
5 (31.3)
Late
11 (68.7)
[Characteristics of the patients]
Conclusions: Management of major iatrogenic BDI in a referral hepatobiliary center allows positive outcomes with a low complication rate.
EP03C-020 FACTORS OF MORTALITY IN SEPTIC ACUTE CHOLANGITIS P. Valsangiacomo, M. Perdomo, E. Moreira and L. Ruso Medicina, Uruguay Introduction: Biliary sepsis is 1% of receipts in CTI and 10% of sepsis. Mortality in septic acute cholangitis (SAC) has dropped significantly in the past 30 years, from 80% to 35%. The aim of our study is to analyze the factors that determine mortality. Methods: Registration retrospective SAC patients admitted to the ICU of the Hospital Maciel. Period: January 2002e August 2015. Variables analyzed: age, sex, history, origin, evolution time, bilirubin, etiology, while unclogging, shock, culture, SAPS II, treatment. Results: 81 patients were analyzed. Average age: 64 years. Female: 58%. Hometown: 40% derived from other centers. The mean duration of 7 days. Total bilirubin income: 11 mg/dl. SAPS II average score: 46. 33% of patients on admission were in shock. Etiology: 92% was
HPB 2016, 18 (S1), e385ee601
e487
for stones. Positive blood cultures: 26%, Klebsiella was the predominant germ. ESBL Klebsiella development by 50%. Ampicillin/sulbactam was the empirical antibiotic used in 59% and multiple antibiotics plans in 48%. Average time to biliary unblocking: 4 days. Mortality was 37%. Statistically significant factors for mortality were: age over 65, initial shock, male and biliary unblocking time. Conclusions: The presence of initial shock, in elderly patients and gall were tardy unblocking the determinants of mortality; whose decline is linked to the inicial, early and minimally invasive management of obstruction.
EP03C-021 GALLSTONE DISEASE; A DIFFERENT DISEASE IN SRI LANKA. A STUDY TO DETERMINE THE PREVALENCE OF DIFFERENT TYPES OF GALLSTONES IN SRI LANKA S. De Silva1, S. Kollure2, S. Amarasinghe3 and H. Hemachandra4 1 Department of Surgery, University Surgical Unit, Colombo South Teaching Hospital, 2Department of Surgey, National Hospital of Sri Lanka, 3Department of Chemical pathology, National Hospital of Sri Lanka, and 4 Department of Anaesthesia, University of Peradeniya, Sri Lanka, Sri Lanka Introduction: This study was carried out to determine the prevalence of different types of gallstones in Sri Lanka and to identify the association of known risk factors to the formation of a particular type of stone. Methods: Gallstones were harvested from a continuous sample of 60 patients who underwent cholecystectomy for symptomatic gallstone disease in Colombo, Sri Lanka over a period of one year. Gallstones were analyzed physically and then chemically, using the wet chemistry method and categorized according to the revised Japanese classification system. Results: 55.3% (n = 32) had pigment stones, 38.3% (n = 23) had mixed stones and only 8.3% (n = 5) had cholesterol stones. Advancing age is associated with the occurrence of pigment stones (p = 0.003). Majority of the study population were overweight (36.7%) or obese (56.7%), but no correlation between the BMI and the stone type was observed. Serum total cholesterol was significantly higher in patients with mixed cholesterol stones (p = 0.000). No positive correlations were observed between the type of stone and known co-morbidities which increases the risk of gallstone formation. Conclusion: Pigment stones are the commonest stone type found in the study population and the prevalence of it is associated with advancing age. Mixed stones were associated with high serum total cholesterol levels. Pure cholesterol stones are very rare in Sri Lanka.
Electronic Poster Abstracts
fashion, data on complications, laboratory indices, comorbidities, and imaging findings, and outcome were collected from the electronic medical record system. The Charlston Co-morbidity Index (CCI) was calculated for all patients. Continuous variables were described by quartiles and categorical variables were described by counts and percentages. Continuous variables were compared between patients undergoing cholecystectomy or not using the Wilcoxon rank-sum test, and categorical variables were compared using the Pearson chi-squared test. Results: 183 patients (88 women, 95 men), with a mean age of 67.7years (SD 14.3) underwent a PercChole. Calculous cholycystitis was present in 96 patients (52%), acalculous cholycystitis 73 patients (40%), and other causes for tube placement accounted for 14 patients (8%). The mean age adjusted CCI at the time of placement was 5.4 (SD 2.2). Cholecystectomy was performed in 68 patients at a mean of 118 (SD 110) days, with 19 (27%) early (<4 weeks) and 49 (72%) late (>4 weeks) after PercChole. Patients undergoing surgery were significantly younger (p < 0.0001) and had a lower CCI (p < 0.0001). There was no statistically significantly difference in patient characteristics in patients undergoing surgery compared to those who did not.
The fundamental deficiencies of laparoscopy increase the difficulty in locating the common bile duct. There is a need for easily accessible visual cues to help the surgeon orientate with respect to the bile duct. The aim of this investigation was to determine whether the shape of the quadrate lobe (segment IV) correlates with the location of the common bile duct during laparoscopic cholecystectomy. Method: Patients undergoing laparoscopic cholecystectomy at North Shore Hospital (New Zealand) from February to November 2014 were prospectively audited. Intraoperative cholangiograms and photographs of the quadrate lobe were reviewed noting the angle between the cystic duct and common bile duct and its relationship to quadrate shape. Result: 56 patients were included. 62.5% were rectangular, 23.2% were triangular and 14.3% square. The median cystic/bile duct angle was 43, 37 and 26 degrees for square, rectangular and triangular quadrate shapes respectively. The angle for triangular lobes was statistically smaller than for rectangular or square lobes (p < 0.05). Regression analysis showed an inverse relationship between the shape ratio and the cystic/bile duct angle (p = 0.015).
EP03C-017 - Table
N
No surgery N [ 115
Surgery N68
Tes statistic
Age at time of tube placement
177
62.0 73.0 80.0
53.8 62.5 76.0
F1,175 = 11.17, P = 0.0011
Gender : Male
183
50% (57)
56% (38)
c21 = 0.68, P = 0.4092
WBC
183
8.2 13.9 22.2
8.2 12.3 17.1
F1,181 = 2.76, P = 0.0981
Alkaline phosphatase
182
94.0 162.0 278.0
83.5 124.0 249.0
F1,180 = 2.84, P = 0.0941
Total bilirubin
182
0.6 1.9 4.7
0.8 1.2 2.1
F1,180 = 3.55, P = 0.0611
Age adjusted CCI
183
4-6- 8
3- 4- 6
F1,181 = 15.51, P < 0.0011
Indication for perc cole : Acalculous Cholycystitis
183
c2 = 0.17, P = 0.9212
41% (47)
38% (26)
Calculous Cholycystitis
51% (59)
54% (37)
Other
8 % (9)
7% ( 5)
[Crude comparisons between patients with surgery]
Conclusion: This study demonstrates a trend towards younger and healthier patients undergoing surgery following symptom resolution. Patients undergoing early surgery represent patient in which there was PercChole failure.
EP03C-018 THE QUADRATE LOBE: A RELIABLE LANDMARK IN LAPAROSCOPIC CHOLECYSTECTOMY? K. Rajkomar1, M. Bowman2, M. Rodgers3 and J. Koea4 1 UGI/HPB, Nepean Hospital, Australia, 2General Surgery, 3UGI/HPB, and 4HPB, North Shore Hospital, New Zealand Background: The rate of bile duct injury in the laparoscopic era is still twice that of the open era.
Conclusion: This investigation confirms the relationship between the shape of the quadrate lobe and the cystic/bile duct angle. When used in conjunction with the Rouviere’s sulcus it helps better define the location of the bile duct and helps give a safer starting point for the dissection of the critical view of safety.
EP03C-019 MAJOR IATROGENIC BILIARY INJURIES: EPIDEMIOLOGICAL ANALYSIS IN A FRENCH REGION V. Scholer1, T. Piardi1, R. Rhaiem2, M. Lhuaire2, G. Thiefin3, R. Kianmanesh1 and D. Sommacale1 1 General and Visceral Surgery, Robert Debre HospitalUniversity of Reims, 2Robert Debre Hospital-University of Reims, and 3Hepato-Gastro-Enterology, Robert Debre Hospital-University of Reims, France
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts Introduction: Major iatrogenic bile duct injuries (BDI) are serious complication of laparoscopic cholecystectomy (LC). Patients managed in a referral hepatobiliary center have better outcomes. The aim of this study was to evaluate the management of major BDI after LC in French region. Method: From 2012 to 2014, 14,321 LC were performed in Champagne-Ardennes-France. 16 major BDI (0.10%) were managed in our department. Strasberg classification, symptoms, surgical repair procedures, morbidity and mortality rates were evaluated. Results: Characteristics of the patients are reported in Tab1. Endoscopic treatment was successful in one patient. Surgery was needed in 15 patients, including 3 after endoscopic failure (21.4%). Major hepatic resection was performed in 2 (14.3%), Roux-en-y hepaticojejunostomy in 10 (71.4%) and repair on T-tube in 3 (14.3%) patients. No mortality was reported. Two patients had grade III or IV DindoeClavien complications after surgical repair (13.3%). Age (mean)
54
Gender female n. (%)
10 (62.5)
IOC n. (%)
4 (25)
Strasberg Strasberg B n. (%)
1 (6.2)
Strasberg D n. (%)
5 (31.3)
Strasberg E n. (%)
10 (62.5)
Recognition of injury Early (per-operative) n (%)
5 (31.3)
Late
11 (68.7)
[Characteristics of the patients]
Conclusions: Management of major iatrogenic BDI in a referral hepatobiliary center allows positive outcomes with a low complication rate.
EP03C-020 FACTORS OF MORTALITY IN SEPTIC ACUTE CHOLANGITIS P. Valsangiacomo, M. Perdomo, E. Moreira and L. Ruso Medicina, Uruguay Introduction: Biliary sepsis is 1% of receipts in CTI and 10% of sepsis. Mortality in septic acute cholangitis (SAC) has dropped significantly in the past 30 years, from 80% to 35%. The aim of our study is to analyze the factors that determine mortality. Methods: Registration retrospective SAC patients admitted to the ICU of the Hospital Maciel. Period: January 2002e August 2015. Variables analyzed: age, sex, history, origin, evolution time, bilirubin, etiology, while unclogging, shock, culture, SAPS II, treatment. Results: 81 patients were analyzed. Average age: 64 years. Female: 58%. Hometown: 40% derived from other centers. The mean duration of 7 days. Total bilirubin income: 11 mg/dl. SAPS II average score: 46. 33% of patients on admission were in shock. Etiology: 92% was
HPB 2016, 18 (S1), e385ee601
e487
for stones. Positive blood cultures: 26%, Klebsiella was the predominant germ. ESBL Klebsiella development by 50%. Ampicillin/sulbactam was the empirical antibiotic used in 59% and multiple antibiotics plans in 48%. Average time to biliary unblocking: 4 days. Mortality was 37%. Statistically significant factors for mortality were: age over 65, initial shock, male and biliary unblocking time. Conclusions: The presence of initial shock, in elderly patients and gall were tardy unblocking the determinants of mortality; whose decline is linked to the inicial, early and minimally invasive management of obstruction.
EP03C-021 GALLSTONE DISEASE; A DIFFERENT DISEASE IN SRI LANKA. A STUDY TO DETERMINE THE PREVALENCE OF DIFFERENT TYPES OF GALLSTONES IN SRI LANKA S. De Silva1, S. Kollure2, S. Amarasinghe3 and H. Hemachandra4 1 Department of Surgery, University Surgical Unit, Colombo South Teaching Hospital, 2Department of Surgey, National Hospital of Sri Lanka, 3Department of Chemical pathology, National Hospital of Sri Lanka, and 4 Department of Anaesthesia, University of Peradeniya, Sri Lanka, Sri Lanka Introduction: This study was carried out to determine the prevalence of different types of gallstones in Sri Lanka and to identify the association of known risk factors to the formation of a particular type of stone. Methods: Gallstones were harvested from a continuous sample of 60 patients who underwent cholecystectomy for symptomatic gallstone disease in Colombo, Sri Lanka over a period of one year. Gallstones were analyzed physically and then chemically, using the wet chemistry method and categorized according to the revised Japanese classification system. Results: 55.3% (n = 32) had pigment stones, 38.3% (n = 23) had mixed stones and only 8.3% (n = 5) had cholesterol stones. Advancing age is associated with the occurrence of pigment stones (p = 0.003). Majority of the study population were overweight (36.7%) or obese (56.7%), but no correlation between the BMI and the stone type was observed. Serum total cholesterol was significantly higher in patients with mixed cholesterol stones (p = 0.000). No positive correlations were observed between the type of stone and known co-morbidities which increases the risk of gallstone formation. Conclusion: Pigment stones are the commonest stone type found in the study population and the prevalence of it is associated with advancing age. Mixed stones were associated with high serum total cholesterol levels. Pure cholesterol stones are very rare in Sri Lanka.