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Outcomes of laparoscopic cholecystectomy for acute and chronic cholecystitis in elderly patients: Preliminary results
e260
Electronic Poster Abstracts
EP01C-106 LESS DISPUTE OVER ALPPS: IMPROVED OPERATIVE OUTCOMES THROUGH BETTER CASE SELECTION
Optimal surgical approach for LR-HCC, when limited to minor resection, was also evaluated as compared laparoscopic hepatectomy (LR-Lap) with open hepatectomy (LROp). Data variables were analyzed with Chi-Square test, ttests and log-rank test.
J. Kruger, V. Jeismann, G. Fonseca, R. Araujo, F. Coelho and P. Herman Liver Surgery Unit e Hospital das Clinicas, University of Sao Paulo, Brazil Introduction: In instances were a large amount of parenchyma is sacrificed (i.e. extended hepatectomies) the main concern is the risk of postoperative liver failure. Strategies employed to reduce the risk of postoperative liver failure are staged operations, portal vein ligation and portal vein embolization (PVE). A recent strategy, “Associating Liver Partition and Portal vein Ligation for Staged hepatectomy” e termed ALPPS e appeared as an interesting approach to induce massive hypertrophy in a short time period. This was a clear benefit over the previous techniques, but brings a costly result on morbidity and mortality, respectively up to 90% and 28.7% of patients. Methods: This case series aims to report a successful strategy of patient selection to reduce morbidity and mortality associated with the ALPPS procedure. Patients were selected for surgery as indicated: age under 60 years; no severe comorbidities (ASA 1 or 2); no cholestasis; no previous biliary instrumentation (i.e. ERCP); insufficient hypertrophy after PVE; no associated major abdominal operation. Results: Between November 2011 and January 2015 8 patients undergone ALPPS. There were 7 male patients with an average age of 52 years. Mean time between the two operative stages was 8 days. Mean hypertrophy of the future remnant was 67%, there were 2 complications (25%) and no deaths occurred. Conclusion: ALPPS is a debatable new strategy that offers the opportunity of complete resection of advanced tumors and reduces the risk of postoperative liver failure. In order to avoid operative complications, patient selection plays a key role in this procedure.
Results: In total, 101 patients were analyzed. Of these, 37 patients had LR-HCC, of which 14 underwent LR-Lap and 12 did LR-Op. LR-HCC tended to be invasive (p = 0.04) and develop extrahepatic metastasis (p = 0.033). Recurrence-free survival (RFS) and overall survival (OS) in patients with LR-HCC were worse; 3-year RFS and OS were 10.8% (p = 0.007) and 56.9% (p = 0.059), respectively. In surgery for LR-HCC, longer operative time was needed (p = 0.028) and estimated blood loss (EBL) increased (p = 0.02). In comparison to LR-Op, LR-Lap was significantly superior in EBL, and otherwise there were no significant differences for surgical outcomes. Conclusions: Because of its highly malignant potentials, LR-HCC should be resected with the most curative procedure, which may result in an advanced surgery. However, laparoscopic approach can be more feasible and safer even for patients with history of repeated HCC therapies and/or impaired liver functions.
EP01C-107 OPTIMAL MANAGEMENT FOR LOCALLY RECURRENT HEPATOCELLULAR CARCINOMA AFTER LOCAL THERAPY WITH HIGH VERSATILE LAPAROSCOPIC HEPATECTOMY T. Minagawa, O. Itano, M. Shinoda, M. Kitago, H. Yagi, Y. Abe, T. Hibi and Y. Kitagawa Surgery, Keio University School of Medicine, Japan Introduction: A subset of patients with locally recurrent hepatocellular carcinoma (HCC) after local therapy (LRHCC) may have worse prognosis, but little is known about the clinical course. We aim to clarify characteristics and optimal management for LR-HCC. Methods: All patients undergoing hepatectomy for recurrent HCC between 2004e2015 were enrolled. These HCC patients identified as local recurrence after local therapy (LR-HCC) and the other patterns of recurrence (OR-HCC) were analyzed as to difference of the clinical course.
EP01C-108 OUTCOMES OF LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE AND CHRONIC CHOLECYSTITIS IN ELDERLY PATIENTS: PRELIMINARY RESULTS E. R. R. Figueira1, T. Bachella1, J. A. Rocha Filho2, S. G. C. Grande3, M. D. S. Vilas-Boas3, I. S. L. Sacramento3, R. Jureidini1, G. N. Namur1, T. C. Ribeiro1, E. E. Abdo1 and I. Cecconello1 1 Division of Digestive Surgery, Department of Gastroenterology, 2Discipline of Anesthesiology, Hospital das Clínicas from University of Sao Paulo School of Medicine, and 3University of Sao Paulo School of Medicine, Brazil Introduction: Laparoscopic cholecystectomy (LC) is the standard therapy for cholecystolithiasis. LC is considered a very safe intervention with occasional complications. However in elderly patients the presence of comorbidities may increase the risk of complications especially in cases of acute cholecystitis. In this study we aimed to compare
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts LC outcome for acute (CCA) and chronic (CCC) cholecystitis in patients over 60 years. Methods: We retrospectively evaluated 138 patients over 60 years old that were submitted to LC for cholecystolithiasis. We analyzed age, sex, BMI, ASA, cardiac risk (CR), length of hospital stay, comorbidities and postoperative complications. Results: There were no differences in age, sex, BMI, ASA classification and cardiac risk between groups. The mean of comorbidities per patient was increased in CCA compared to CCC group (p = 0.028). The length of postoperative hospital stay was 4.72 4.18 days in CCA and 2.49 3.54 days in CCC group (p < 0.0001). The mean of complications for patient was higher in the CCA group (p = 0.0077), and 33% of patients with CCA presented complications compared to 12% with CCC (p < 0.0001). Near 6% of patients died in the CCA and less than 1% in the CCC group, without statistical significance. Conclusion: This study demonstrated that elective LC is a safe procedure in aged patients with chronic cholecystolithiasis. However patients with acute disease have increased incidence of postoperative complications with prolonged postoperative hospital stay that may be related to the increased incidence of comorbidities.
EP01C-109 SALVAGE HEPATECTOMY IN FAILED PORTAL VEIN EMBOLISATION S. Iype1, K. Dajani1, T. Ali2, T. See2, E. Huguet1, A. Jah1 and S. Harper1 1 HPB Surgery, and 2Dept of Radiology, Cambridge University Hospital, United Kingdom Background: The traditional approach to induce liver hypertrophy of future liver remnant (FLR) is portal vein embolization (PVE). We analyse the cases which failed to achieve sufficient hypertrophy following PVE and has been salvaged by two staged hepatectomy. Methods: Of 72 cases of PVE over 8 years, 4 cases didn’t achieve sufficient hypertrophy and subsequently underwent two stage hepatectomy. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results: All 4 patients had extended right hepatectomy. One patient had colorectal liver metastasis and the other three had hilar cholangiocarcinoma. Three patients with hilar cholangiocarcinoma or gall bladder carcinoma had resection of extrahepatic bile ducts and PV resection. The staged resections were carried out at an average of 11 (7e 20) days apart. Patient 1 had an FLR of 18%after PVE that increased to 28% after parenchymal transection (stage 1). Patient 2 had an FLR of 20% after PVE which increased to 29% after stage 1 resection. Patient 3 had FLR of 21% after PVE which increased to 34% after stage 1 resection. Patient 4 had FLR volume of 30% with background chronic liver fibrosis that increased to 38% after stage 1. A further 10% (8e13) increase in FLR was achieved following stage 1 resection. Two patients had postoperative bile leak. There was no operative mortality and all patients are alive with a median disease free survival of 20 months.
HPB 2016, 18 (S1), e1ee384
e261
Conclusion: Salvage resection of liver is an effective approach to patients who do not achieve sufficient FLR volume following PVE.
EP01C-110 OPERATING STRESS RESPONCE AFTER LAPAROSCOPIC VERSUS OPEN LIVER RESECTIONS D. Panchenkov1,2, Y. Ivanov1,2, G. Aleksanyan1,2, N. Akhmatova3, M. Efanov4, R. Alikhanov4, D. Astakhov1,2 and I. Kazakov4 1 A.I. Evdokimov Moscow State University of Medicine and Dentistry, 2Federal Research Clinical Center of Specialized Medical Care and Medical Technologies FMBA, 3I.I. Mechnikov Scientific Research Institute of Vaccines and Serums, and 4Moscow Clinical Scientific Center, Russian Federation Aim: To compare the immunological status in patients after laparoscopic and open liver resections. Material and methods: The study cohort consists of 40 rabbits (Chinchilla), of mixed sexes, weighing up to 3 kg. Each group have been divided into two subgroups: primary laparoscopic liver resection (extensive, “small” wedge resections), and the control group: open liver resection (extensive, “small” wedge resections). Blood samples collected before surgery, 4 hours after surgery, and 1, and 7 days after surgery. Total leukocyte count, proliferative, phagocytic activity and lytic activity peripheral blood mononuclear leukocytes have been measured at each time point. The laboratory animals (rabbits) of control group placed in supine position; an incision made across the right upper abdomen, below the ribcage. The liver resections of experimental group performed laparoscopically using three trocars. Laparoscopic liver resections performed using LigaSure 5mm. Clinical part of the study presented with the comparison of postoperative stress responce paramerters in patients according to the desighn, before used in the experiment. Results: The phagocyte activiny was practically the same before and after the procedure in main group and significantly decreased in postoperative period in control group (neutrofiles e 35%, monocytes e 50%). Cytotoxic activity of mononuclear leucocytes to NK-sensible line K562 eryrhroblast leucosis decreased in control group more then on 45%, in main group e on about 20%. This data indirectly demonstrates decreasing of antivirus and antitumor potential of NK-cells. First clinical results, based on the group of 22 patients show the similar results in both groups of patients.
EP01C-111 TOLERABILITY OF EVEROLIMUS AFTER LIVER TRANSPLANT B. Bandeira de Andrade1, M. Ferranti Smaniotto1, C. Novello Batzner1, C. Casmierchcki Picollo1, L. Bandeira de Andrade1, G. Sartori1 and M. A. Scheidemantel Nogara1,2 1 Medicina, Universidade Regional de Blumenau, and 2 Gastroenterologia e Hepatologia, Hospital Santa Isabel, Brazil
Electronic Poster Abstracts
EP01C-106 LESS DISPUTE OVER ALPPS: IMPROVED OPERATIVE OUTCOMES THROUGH BETTER CASE SELECTION
Optimal surgical approach for LR-HCC, when limited to minor resection, was also evaluated as compared laparoscopic hepatectomy (LR-Lap) with open hepatectomy (LROp). Data variables were analyzed with Chi-Square test, ttests and log-rank test.
J. Kruger, V. Jeismann, G. Fonseca, R. Araujo, F. Coelho and P. Herman Liver Surgery Unit e Hospital das Clinicas, University of Sao Paulo, Brazil Introduction: In instances were a large amount of parenchyma is sacrificed (i.e. extended hepatectomies) the main concern is the risk of postoperative liver failure. Strategies employed to reduce the risk of postoperative liver failure are staged operations, portal vein ligation and portal vein embolization (PVE). A recent strategy, “Associating Liver Partition and Portal vein Ligation for Staged hepatectomy” e termed ALPPS e appeared as an interesting approach to induce massive hypertrophy in a short time period. This was a clear benefit over the previous techniques, but brings a costly result on morbidity and mortality, respectively up to 90% and 28.7% of patients. Methods: This case series aims to report a successful strategy of patient selection to reduce morbidity and mortality associated with the ALPPS procedure. Patients were selected for surgery as indicated: age under 60 years; no severe comorbidities (ASA 1 or 2); no cholestasis; no previous biliary instrumentation (i.e. ERCP); insufficient hypertrophy after PVE; no associated major abdominal operation. Results: Between November 2011 and January 2015 8 patients undergone ALPPS. There were 7 male patients with an average age of 52 years. Mean time between the two operative stages was 8 days. Mean hypertrophy of the future remnant was 67%, there were 2 complications (25%) and no deaths occurred. Conclusion: ALPPS is a debatable new strategy that offers the opportunity of complete resection of advanced tumors and reduces the risk of postoperative liver failure. In order to avoid operative complications, patient selection plays a key role in this procedure.
Results: In total, 101 patients were analyzed. Of these, 37 patients had LR-HCC, of which 14 underwent LR-Lap and 12 did LR-Op. LR-HCC tended to be invasive (p = 0.04) and develop extrahepatic metastasis (p = 0.033). Recurrence-free survival (RFS) and overall survival (OS) in patients with LR-HCC were worse; 3-year RFS and OS were 10.8% (p = 0.007) and 56.9% (p = 0.059), respectively. In surgery for LR-HCC, longer operative time was needed (p = 0.028) and estimated blood loss (EBL) increased (p = 0.02). In comparison to LR-Op, LR-Lap was significantly superior in EBL, and otherwise there were no significant differences for surgical outcomes. Conclusions: Because of its highly malignant potentials, LR-HCC should be resected with the most curative procedure, which may result in an advanced surgery. However, laparoscopic approach can be more feasible and safer even for patients with history of repeated HCC therapies and/or impaired liver functions.
EP01C-107 OPTIMAL MANAGEMENT FOR LOCALLY RECURRENT HEPATOCELLULAR CARCINOMA AFTER LOCAL THERAPY WITH HIGH VERSATILE LAPAROSCOPIC HEPATECTOMY T. Minagawa, O. Itano, M. Shinoda, M. Kitago, H. Yagi, Y. Abe, T. Hibi and Y. Kitagawa Surgery, Keio University School of Medicine, Japan Introduction: A subset of patients with locally recurrent hepatocellular carcinoma (HCC) after local therapy (LRHCC) may have worse prognosis, but little is known about the clinical course. We aim to clarify characteristics and optimal management for LR-HCC. Methods: All patients undergoing hepatectomy for recurrent HCC between 2004e2015 were enrolled. These HCC patients identified as local recurrence after local therapy (LR-HCC) and the other patterns of recurrence (OR-HCC) were analyzed as to difference of the clinical course.
EP01C-108 OUTCOMES OF LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE AND CHRONIC CHOLECYSTITIS IN ELDERLY PATIENTS: PRELIMINARY RESULTS E. R. R. Figueira1, T. Bachella1, J. A. Rocha Filho2, S. G. C. Grande3, M. D. S. Vilas-Boas3, I. S. L. Sacramento3, R. Jureidini1, G. N. Namur1, T. C. Ribeiro1, E. E. Abdo1 and I. Cecconello1 1 Division of Digestive Surgery, Department of Gastroenterology, 2Discipline of Anesthesiology, Hospital das Clínicas from University of Sao Paulo School of Medicine, and 3University of Sao Paulo School of Medicine, Brazil Introduction: Laparoscopic cholecystectomy (LC) is the standard therapy for cholecystolithiasis. LC is considered a very safe intervention with occasional complications. However in elderly patients the presence of comorbidities may increase the risk of complications especially in cases of acute cholecystitis. In this study we aimed to compare
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts LC outcome for acute (CCA) and chronic (CCC) cholecystitis in patients over 60 years. Methods: We retrospectively evaluated 138 patients over 60 years old that were submitted to LC for cholecystolithiasis. We analyzed age, sex, BMI, ASA, cardiac risk (CR), length of hospital stay, comorbidities and postoperative complications. Results: There were no differences in age, sex, BMI, ASA classification and cardiac risk between groups. The mean of comorbidities per patient was increased in CCA compared to CCC group (p = 0.028). The length of postoperative hospital stay was 4.72 4.18 days in CCA and 2.49 3.54 days in CCC group (p < 0.0001). The mean of complications for patient was higher in the CCA group (p = 0.0077), and 33% of patients with CCA presented complications compared to 12% with CCC (p < 0.0001). Near 6% of patients died in the CCA and less than 1% in the CCC group, without statistical significance. Conclusion: This study demonstrated that elective LC is a safe procedure in aged patients with chronic cholecystolithiasis. However patients with acute disease have increased incidence of postoperative complications with prolonged postoperative hospital stay that may be related to the increased incidence of comorbidities.
EP01C-109 SALVAGE HEPATECTOMY IN FAILED PORTAL VEIN EMBOLISATION S. Iype1, K. Dajani1, T. Ali2, T. See2, E. Huguet1, A. Jah1 and S. Harper1 1 HPB Surgery, and 2Dept of Radiology, Cambridge University Hospital, United Kingdom Background: The traditional approach to induce liver hypertrophy of future liver remnant (FLR) is portal vein embolization (PVE). We analyse the cases which failed to achieve sufficient hypertrophy following PVE and has been salvaged by two staged hepatectomy. Methods: Of 72 cases of PVE over 8 years, 4 cases didn’t achieve sufficient hypertrophy and subsequently underwent two stage hepatectomy. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results: All 4 patients had extended right hepatectomy. One patient had colorectal liver metastasis and the other three had hilar cholangiocarcinoma. Three patients with hilar cholangiocarcinoma or gall bladder carcinoma had resection of extrahepatic bile ducts and PV resection. The staged resections were carried out at an average of 11 (7e 20) days apart. Patient 1 had an FLR of 18%after PVE that increased to 28% after parenchymal transection (stage 1). Patient 2 had an FLR of 20% after PVE which increased to 29% after stage 1 resection. Patient 3 had FLR of 21% after PVE which increased to 34% after stage 1 resection. Patient 4 had FLR volume of 30% with background chronic liver fibrosis that increased to 38% after stage 1. A further 10% (8e13) increase in FLR was achieved following stage 1 resection. Two patients had postoperative bile leak. There was no operative mortality and all patients are alive with a median disease free survival of 20 months.
HPB 2016, 18 (S1), e1ee384
e261
Conclusion: Salvage resection of liver is an effective approach to patients who do not achieve sufficient FLR volume following PVE.
EP01C-110 OPERATING STRESS RESPONCE AFTER LAPAROSCOPIC VERSUS OPEN LIVER RESECTIONS D. Panchenkov1,2, Y. Ivanov1,2, G. Aleksanyan1,2, N. Akhmatova3, M. Efanov4, R. Alikhanov4, D. Astakhov1,2 and I. Kazakov4 1 A.I. Evdokimov Moscow State University of Medicine and Dentistry, 2Federal Research Clinical Center of Specialized Medical Care and Medical Technologies FMBA, 3I.I. Mechnikov Scientific Research Institute of Vaccines and Serums, and 4Moscow Clinical Scientific Center, Russian Federation Aim: To compare the immunological status in patients after laparoscopic and open liver resections. Material and methods: The study cohort consists of 40 rabbits (Chinchilla), of mixed sexes, weighing up to 3 kg. Each group have been divided into two subgroups: primary laparoscopic liver resection (extensive, “small” wedge resections), and the control group: open liver resection (extensive, “small” wedge resections). Blood samples collected before surgery, 4 hours after surgery, and 1, and 7 days after surgery. Total leukocyte count, proliferative, phagocytic activity and lytic activity peripheral blood mononuclear leukocytes have been measured at each time point. The laboratory animals (rabbits) of control group placed in supine position; an incision made across the right upper abdomen, below the ribcage. The liver resections of experimental group performed laparoscopically using three trocars. Laparoscopic liver resections performed using LigaSure 5mm. Clinical part of the study presented with the comparison of postoperative stress responce paramerters in patients according to the desighn, before used in the experiment. Results: The phagocyte activiny was practically the same before and after the procedure in main group and significantly decreased in postoperative period in control group (neutrofiles e 35%, monocytes e 50%). Cytotoxic activity of mononuclear leucocytes to NK-sensible line K562 eryrhroblast leucosis decreased in control group more then on 45%, in main group e on about 20%. This data indirectly demonstrates decreasing of antivirus and antitumor potential of NK-cells. First clinical results, based on the group of 22 patients show the similar results in both groups of patients.
EP01C-111 TOLERABILITY OF EVEROLIMUS AFTER LIVER TRANSPLANT B. Bandeira de Andrade1, M. Ferranti Smaniotto1, C. Novello Batzner1, C. Casmierchcki Picollo1, L. Bandeira de Andrade1, G. Sartori1 and M. A. Scheidemantel Nogara1,2 1 Medicina, Universidade Regional de Blumenau, and 2 Gastroenterologia e Hepatologia, Hospital Santa Isabel, Brazil