Mo1692 Extended Hepatectomy With Portal and Hepatic Artery Resection for Advanced Perihilar Cholangiocarcinoma Minoru Esaki, Kazuaki Shimada, Shutaro Hori, Yoji Kishi, Satoshi Nara, Tomoo Kosuge Objectives: The aim of this study was to clarify short- and long-term outcome of extended hepatectomy with portal vein resection (PVR) or hepatic artery resection (HAR) for perihilar cholangiocarcinoma. Methods: Patients with perihilar cholangiocarcinoma who underwent resection between January 2000 and December 2011 for perihilar cholangiocarcinoma were analyzed retrospectively. Operative variables, mortality, morbidity, and survival were compared among standard resection with no PVR and no HAR (S group), with PVR without HAR (PV group) and with HAR (HA group). Results: A total 230 patients underwent surgical resection for perihilar cholangiocarcinoma, 172 (75%) in S group, 37 (16%) in PV group, and 21 (9.1%) in HA group were enrolled. Operative time and blood loss were 633minutes and 1415ml in S group, 665 and 2028 in PV group, 775 and 2076ml in HA group, respectively. Those with PV and HA group were significantly more than in those with S group (both P = 0.04). Mortality and more than grade IIIa complications occurred in 4 (2.3%) and 17 (9.9%) patients with S group, in 0 and 5 (14%) with PV group and 0 and 3 (14%) with HA group. The rates of more than Grade IIIa complications were comparable among 3 groups. Overall 5-year survival rate and median survival time were 49% and 47.5 months in S group, 22 and 25.0 in PV group, 21 and 21.4 in HA group. There was significant difference in survival in patients between S and PV, S and HA group, respectively. Especially, patients in HA group with R1 (surgical margin positive) or with severe perineural infiltration were associated with unsatisfactory prognosis, which were not survived for more than 3 years. Conclusions: PVR and HAR for advanced perihilar cholangiocarcinoma were feasible. It can provide a favorable prognosis in selected patients of advanced perihilar cholangiocarcinoma
* 8 Patients died due to complications of acute BDI and are excluded Mo1690 Hepatolithiasis: Transhepatic Team Management Janak A. Parikh, Henry A. Pitt, Joal D. Beane, Matthew S. Johnson Background: Intrahepatic stones are very uncommon in Western societies. In comparison, hepatolithiasis occurs more frequently in Southeast Asia because of the high prevalence of congenital biliary cysts and hepatobiliary parasites. Many Asian patients present with advanced disease which is usually managed with left hepatectomy. In North America both the underlying biliary pathology and the timing of presentation differ, but management has not been standardized, in part, because of the rarity of the disease. This analysis documents the etiology, presentation and outcomes of a transhepatic team approach for management of hepatolithiasis at a Western referral center. Methods: The records of patients with hepatolithiasis managed by interventional radiologists (IR) and surgeons from 2002 through 2012 were reviewed. Surgery was undertaken when required to repair the biliary pathology and/ or when the stone burden was extensive. All but one patient were managed with 20F transhepatic stent(s) placed either percutaneously or during surgery. Choledochoscopy was performed in almost all patients either percutaneously or intraoperatively to assist with stone removal. Laser lithotripsy and balloon dilation were undertaken for difficult stones and strictures. Transhepatic stents were removed when patients were stone and stricture free. A successful outcome was defined as stent removal without symptoms requiring more procedures. Results: Seventy-four patients were managed by IR alone (66%) or by IR and surgery (34%). The mean age was 55.6 years, and 51.4% were women. The majority of patients were Caucasian (80%), and only five (7%) were Asian. Underlying biliary pathology included benign strictures (55%), choledocholithiasis (22%), sclerosing cholangitis (12%), choledochal cysts (10%), and biliary parasites (1%). Twenty patients (27%) had biliary cirrhosis, and 17 of these patients developed hepatolithiasis after undergoing orthotopic liver transplantation. Fifteen additional patients (20%) had a prior biliary-enteric anastomosis. Upper abdominal pain (65%), cholangitis (47%) and jaundice (34%) were the most common presenting symptoms. The median number of IR procedures was 11, and choledochoscopy (88%) laser lithotripsy (68%) and balloon dilation (47%) were performed frequently. Surgical management included cholangio- or hepatico-jejunostomy in 22 patients (88%) and hepatectomy in one (4%). Recurrent stone and stricture rates were both 26% and were managed with further biliary stenting. None of the patients have developed a cholangiocarcinoma with a median follow-up of 29 months. Conclusions: A combined interventional radiologic and surgical approach employing large bore transhepatic stents is a safe, but labor intensive, method for managing hepatolithiasis. This approach preserves hepatic parenchyma and prevents malignant degeneration.
Mo1693
According to Tokyo Guidelines 2007 for the magagemant of acute cholecystitis, early cholecystectomy has been recommended as first option. However percutaneous transhepatic gallbladder drainage (PTGBD) is available for patients with moderate or severe acute cholecystitis. After PTGBD, while most patients undergo cholecystectomy, some patients are treated by drainage alone, especially in very elder or high-risk patients. The indication of cholecystectomy after PTGBD remains unclear. Materials and Methods: Medical records of 340 patients who were admitted to our hospital with acute cholecystitis between November 2006 and October 2011 were reviewed. Results: Sixty-six patients underwent PTGBD under ultrasonographic guidance. Thirty-two patients underwent cholecystectomy after PTGBD (Group A), and 34 patients were treated by drainage alone (Group B). Because all the patients of Group B suffered from severe medical problems such as cardiovascular disease, neurologic disease, and dementia, they were not considered as indications for surgery under general anesthesia. All patients were categorized as moderate or severe cholecystitis. Average age of Group A and Group B were 74 and 83. One patient of each group died (3.1% and 2.9%) without discharge from the hospital. Rate of acalculous cholecystitis was 25% and 38%, respectively. Cholecystitis recurred in four patients of Group B (12%) and all of them were calculous. No significant difference was noted in the prognosis of the two groups. Conclusion: Though the recurrence rate of Group B was not negligible, total prognosis of each group was not significant. Therefore, PTGBD without cholecystectomy is likely to be acceptable for highrisk patients with acute cholecystitis, and cholecystectomy should be reserved for a salvage procedure after recurrence.
Mo1691 En Bloc Resection of Hepatoduodenal Ligament for Advanced Biliary Malignancy Yuji Kaneoka, Atsuyuki Maeda, Masatoshi Isogai From 1996, en bloc resection of the hepatoduodenal ligament (HDL) concomitant with the neighboring organs had been adapted for advanced biliary malignancy to achieve R0 (histological curative) resection. Preoperative indication for this drastic surgery is a locally advanced disease involving the portal trunk and bilateral hepatic arteries without the distant metastases. The portal vein was reconstructed by the autologous vein graft and the hepatic artery was reconstructed by the gastroduodenal or middle colic artery because the long segmental resections of the vessels were mandatory. Patients: This study comprised of 12 patients with 5 gallbladder carcinomas (GBC) and 7 cholangiocarcinomas (CCC). Mean age of the patients was 62 years (range, 43 to 71); 7 females and 5 males. HLPD (hepatoligamento-pancreatoduodenectomy) was applied for 5 GBC and 2 CCC, and HL (hepatoligamentectomy) for 5 CCC. PD was added when massive HDL invasion was apparent. About the extent of hepatic resection, 1 right trisectionectomy, 4 right hepatectomies, and 2 left hepatectomies in HLPD; 1 right hepatectomy and 4 left hepatectomies in HL, and total caudate lobectomy was routinely performed. Surgical technique and outcome of the patients were investigated retrospectively. Timing of vascular reconstruction: The portal vein resection and reconstruction was performed before the extirpation of the specimen, namely, just after the division of the hepatic ducts, and then the residual hepatic transection was followed. The right external iliac vein was always used for the graft. Contrary, the hepatic artery reconstruction was followed after the extirpation of the specimen. Results: R0 resection was achieved in 9 out of 12 patients (75%). Positive margin was found in the hepatic duct in 2 patients and the common hepatic artery in 1, and perineural invasion was mostly recognized. The median operation time and blood loss were 554 min. (range, 438 to 1025) and 1392 ml (610 to 2900), respectively. Median graft length and reconstruction time were 3 cm (2 to 4) and 24 min. (19 to 30), respectively, and the hepatic artery reconstruction spent 28 min. (14 to 60). Morbidity occurred in 50% and 2 patients (1 HLPD and 1HL) died in hospital for liver abscess and MRSA septemia. Median and 5-year survivals of all patients were 24 months and 33.3% (2 patients survived over 5 years). Conclusion: Despite the small number of the subjects, en bloc resection of HDL actually brought the favorable results for intractable diseases. This strategy can be justified for the rigorously selected patients.
Mo1694 Major Bile Duct Injury Requiring Operative Reconstruction After Laparoscopic Cholecystectomy: A National Perspective, 2001-2009 Taranjeet Kaur, Brian S. Diggs, Brett C. Sheppard, John G. Hunter, James P. Dolan Objective: Major bile duct injury (BDI) after laparoscopic cholecystectomy (LC) remains a serious concern. This study was done to determine the national incidence and mortality for major BDI requiring operative reconstruction after LC in the United States during the years 2001-2009. Our results were compared to previously publish major BDI rates after LC reported between 1991 and 2000. Design: Using the Nationwide Inpatient Sample of more than 4 million patients who underwent cholecystectomy for the years 2001-2009, we used procedure-specific codes to measure national estimates for LC. We then calculated biliary reconstruction procedures that occurred after LC. Biliary reconstruction performed as part of another primary procedure was excluded. Finally, we analyzed incidence and mortality rates associated with biliary reconstruction. Results: The percentage of cholecystectomies performed laparoscopically has increased over time from 71% in 2001 to 78% in 2009. The associated mortality rate for LC was 0.56% in 2001 and 0.42% in 2009 (p = 0.002). The incidence of BDI requiring reconstruction after LC was 0.11% compared to 0.15% during 1991-2000 (p , 0.001). The average mortality rate for patients undergoing biliary reconstruction was 4.3% vs. 4.5% (p = 0.576) as reported previously. Conclusions: The incidence of major BDI requiring reconstruction after LC has decreased slightly compared to that seen between 1991 and 2000. In addition, associated mortality rates are similar. This suggests that BDI requiring reconstruction after LC has attained a consistently low rate between 2001 and 2009.
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SSAT Abstracts
SSAT Abstracts
Percutaneous Transhepatic Gallbladder Drainage Without Cholecystectomy Is Optimum Procedure in High-Risk Patients Masanori Akada, Michinaga Takahashi, Tatsuya Ueno, Shun Sato, Shinji Goto, Kyohei Ariake, Shinpei Maeda, HIroo Naito