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Percutaneous cholecystostomy for patients with ASA classification more than 3
Electronic Poster Abstracts choosing the best surgical plan in patients with intrahepatic calculi. Methods: MI-3DVS was used to process computed tomography (CT) scanning data collected from four cases of intrahepatic calculi. Models of liver and bile ducts in standard template library format were processed by a freeform modeling system and reconstructed three-dimensionally. Accurate digital information about the bile duct system, lesions, calculi distribution, and adjacent organs from all directions, multiple angles, and multi-strata were used to choose the best surgical plan. Then, visible simulation surgery with MI-3DVS was performed with simulation operation software. Results: MI-3DVS provide clarity with strong relief perception and a user-friendly interface. Visible simulation surgery performed based on MI-3DVS led to optimal operation planning. Conclusion: Visible simulation surgery is more objective and complete than routine preoperative examinations to choose the best operation plan for intrahepatic calculi.
EP03C-026 CHEMICAL COMPOSITION ANALYSIS OF BILIARY STONE BY THE USE OF ENERGY DISPERSIVE X-RAY SPECTROSCOPY (EDS) H. Almarshad Clinical Laboratory Sciences, Aljouf University, Saudi Arabia Introduction: Gallstones are categorized by their chemical compositions. Cholesterol, bilirubin, or mixed stones are the most common type of gallstones. This study aims to determine the chemical compositions of gallstones by the use of elemental mapping analysis. Method: Energy Dispersive X-ray Spectroscopy EDS attached to Scanning Electron Microscopy SEM was used. Although hydrogen element couldn’t be detected by EDS microanalytical technique, the presence of certain elements in EDS microanalysis indicated qualitatively the elemental compositions. By associating resultant elements with their concentrations (weight percentages) in different phases in the sample, it was possible to determine target compounds. Comparison of the obtained gallstone elemental map with standard reference compounds, allowed us to confirm the results. Results: The presence and the ratio of carbon C and oxygen O and absence of nitrogen N were used as an indication for the type of stone under analysis. Since gallstones mainly consist from either Cholesterol (C27H46O) or Bilirubin (C33H36N4O6), the sample under analysis found to have EDS elemental ratio of 4.9:95.1 = 19.4 which matches with cholesterol composition. The ratio in cholesterol between O:C, (O1 8 = 8) and (C27 6 = 162), 8:162 = 1:20, this gave an indication that the expected sample is Cholesterol stone. Conclusion: The study recommends further investigations with higher sample size and detailed sample elemental analysis to confirm the provided results. The study illustrates the effectiveness of applying a SEM-EDS technique to assess and diagnose the chemical compositions of gallstones.
HPB 2016, 18 (S1), e385ee601
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EP03C-027 EARLY VERSUS LATE CHOLECYSTECTOMY AFTER CLEARANCE OF COMMON BILE DUCT STONES BY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A PROSPECTIVE RANDOMIZED STUDY W. Askar and A. El Nakeeb Mansoura University, Gastroenterology Surgical Center, Egypt Background: The time interval between ERCP and laparoscopic cholecystectomy (LC) is a matter of debate. This study was planned to compare early LC (within admission) versus late LC (after 1 month) after ERCP Patient and methods: This is a prospective randomized study on patients who are presented with concomitant gall bladder (GB) and common bile duct (CBD) stone. The study population was divided into two groups; group (A) managed by early laparoscopic cholecystectomy (LC) within 3 days after ERCP and group (B) managed by late LC one month after ERCP. The primary outcome is the conversion to open surgery. Secondary outcomes will include recurrent biliary symptoms, postoperative morbidity, and hospital stay. Results: 110 patients included in this study. The conversion rate from LC to open occurred in 11 (10%) cases. No significant difference between both groups as regards the conversion rate, the degree of adhesion, cystic duct diameter, and intraoperative CBD injury or bleeding. Recurrent biliary symptoms were significantly more in delayed LC group in 7 (12.7I%) patient versus one patient in early LC (P = 0.03). Four (7.3%) patients developed postoperative bile leakage from the cystic duct stump in delayed LC group and all patients managed conservatively. Conclusion: LC after ERCP and ES is more difficult, it must be operated by an experienced laparoscopic surgeon to reduce the conversion rate and decrease the morbidity rate. No significant difference between both groups as regards the conversion rate. Recurrent biliary symptoms were significantly more in delayed LC while waiting LC.
EP03C-030 PERCUTANEOUS CHOLECYSTOSTOMY FOR PATIENTS WITH ASA CLASSIFICATION MORE THAN 3 S. S. Yun, D. S. Lee and H. J. Kim Surgery, Yeungnam University Hospital, Republic of Korea Introduction: Percutaneous Cholecystostomy (PC) has been proposed as an effective bridge procedure before elective cholecystectomy for acute cholecystitis. We designed this study to evaluate the efficacy of PC in patients with acute cholecystitis and ASA classification more than 3. Method: For recent 3 years, we did PC in 29 patients with acute cholecystitis and ASA classification more than 3. We did PC as a bridge procedure before elective cholecystectomy (bridge group) in 20 patients and as a palliation of symptom in 9 patients (palliation group). We evaluated patients
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Electronic Poster Abstracts
characteristics, complication rate after PC, ASA classification change before and after PC, resumption of oral intake after PC and success rate of laparoscopic cholecystectomy (LC) etc. Results: Mean ASA classification before and after PC were 3.7 0.5, 2.3 0.8 and 4.0 0.8, 3.4 0.7, respectively in both group. There was only one complication after PC (peritonitis after PC, 3.4%), who is one of two mortality cases in palliation group (22.2%). Resumption of oral intake was possible 3.2 2.1 days after PC in bridge group and 3.0 2.4 days in palliation group except two mortalities due to underlying diseases. We tried 12 LC and one failed due to bile duct injury (success rate was 91.6%). Mean operation time for LC was 106.8 32.5 which is a little bit longer. Conclusion: PC is a good procedure for bridge procedure before elective LC and palliation of symptom in patients with acute cholecystitis and ASA classification more than 3.
EP03C-031 LAPAROSCOPIC CHOLECYSTOSTOMY AS AN ALTERNATIVE TO OPEN CHOLECYSTECTOMY AND PERCUTANEOUS CHOLECYSTOSTOMY IN A RURAL SETTING S. P. Han Department of Surgery, Dubbo Base Hospital, Australia Introduction: Emergency cholecystectomy in critically ill patients carries a high risk of morbidity and mortality. Laparoscopic cholecystostomy (LC) can be used as a temporising measure in those patients where cholecystectomy is deemed technically difficult for safe removal, or in those patients who present to a hospital without interventional radiology services, such as in many rural settings. Methods: A retrospective review was undertaken of consecutive patients who underwent LC at Dubbo Base Hospital over a five-year period. In each case, LC was performed by placing a 10 mm port in the right subcostal margin and the gallbladder was decompressed with a trocar and a 20Fr Foley catheter was placed in the gallbladder body. Results: Ten patients underwent LC. (Male = 5, median age = 67 and range = 43e88) The main indication was severe acute cholecystitis, not amenable to laparoscopic cholecystectomy. One of the patients has significant morbidity (ASA 4) and had laparoscopic cholecystostomy as he was not responding to antibiotics and there was no interventional radiologist in the hospital. Seven patients had interval laparoscopic cholecystectomy in six months time and there was no complication during or after the procedure. Mean length of stay is five days. There are two patients readmitted to the hospital within thirty days with sub capsular collection around the right lobe of liver and postural hypotension. Conclusion: It appears that the data suggest that laparoscopic cholecystostomy is a viable alternative to open cholecystectomy in technically difficult cases and alternative to percutaneous cholecystostomy in rural hospitals without interventional radiology services.
EP03C-034 PSEUDO ANEURISM OF RIGHT HEPATIC ARTERY. UNCOMMON COMPLICATION M. Goitia-Durán and M. Saavedra Pozo Universidad del Valle, Bolivia Hepatic artery pseudoaneurism is a rare complication of uneventful cholecystectomy, when present is potentially fatal. Common pathogenic factors are acute cholecystitis, biliary tree injury, bilioma, direct manipulation of biliary tree, use of titanium clips, excessive use of electrocautery. Clinical course is not typical, most refer acute abdominal pain, ictericia, or hemobilia and acute GI bleeding. Angiography is the choice for diagnosis and for placement of stents as treatment. Eventually, laparotomy is needed as emergency treatment. A 32 year-old male patient, operated 3 months before of total thyroidectomy and iodine radiation for papilar thyroid carcinoma, was referred for an elective laparoscopic cholecystectomy for chronic cholecystitis, procedure was uncomplicated. Twenty days later, patient complained of acute abdominal pain, diarrhea and diagnosed giardiasis and treated. Pain didn’t improve and localized in right upper quadrant, US was done, no alteration was found. CT scan showed infra hepatic collection with peripheral contrast, that was proved pulsatile on Doppler. Two days after diagnosis patient referred acute and sudden back and right upper quadrant pain, on Doppler the pseudoaneurism showed expansion. He was operated on immediately. On laparotomy right hepatic pseudoameurism was ligated. Posterior recovery was normal. Right hepatic artery pseudoaneurism is rare after uneventful cholecystectomy and must always be suspected when patient present sudden right upper quadrant pain, however, recognition is not always simple. Most diagnostic methods are ineffective, but angiography is diagnostic and therapeutic as well. For that reason, treatment must be elective whenever possible and reserve laparotomy for failure of stents or when rupture presents.
EP03C-035 INTRAMURAL GALLBLADDER LITHIASIS: REPORT OF 2 CASES G. Stavrou1, D. Paramythiotis2, K. Kofina1, P. Bangeas1, V. Papadopoulos2 and A. Michalopoulos2 1 1st Propedeutic Surgical Department, AHEPA University Hospital, and 21st Propedeutic Surgical Department, AHEPA University Hospital, Aristotelian University of Thessaloniki, Greece Introduction: The presence of intramural gallstones is a rare entity with unclear etiology. Chronic inflammation due to cholelithiasis, as well as the presence of adenomyosis is some of the suggested pathogenetic mechanisms. We present 2 cases of intramural gallbladder lithiasis and a review of the literature. Case report: A 73-year-old male patient presented in our Emergency Department with right upper quadrant pain. Clinical examination, laboratory and radiology work-up set the diagnosis of acute cholecystitis and the patient
HPB 2016, 18 (S1), e385ee601
EP03C-026 CHEMICAL COMPOSITION ANALYSIS OF BILIARY STONE BY THE USE OF ENERGY DISPERSIVE X-RAY SPECTROSCOPY (EDS) H. Almarshad Clinical Laboratory Sciences, Aljouf University, Saudi Arabia Introduction: Gallstones are categorized by their chemical compositions. Cholesterol, bilirubin, or mixed stones are the most common type of gallstones. This study aims to determine the chemical compositions of gallstones by the use of elemental mapping analysis. Method: Energy Dispersive X-ray Spectroscopy EDS attached to Scanning Electron Microscopy SEM was used. Although hydrogen element couldn’t be detected by EDS microanalytical technique, the presence of certain elements in EDS microanalysis indicated qualitatively the elemental compositions. By associating resultant elements with their concentrations (weight percentages) in different phases in the sample, it was possible to determine target compounds. Comparison of the obtained gallstone elemental map with standard reference compounds, allowed us to confirm the results. Results: The presence and the ratio of carbon C and oxygen O and absence of nitrogen N were used as an indication for the type of stone under analysis. Since gallstones mainly consist from either Cholesterol (C27H46O) or Bilirubin (C33H36N4O6), the sample under analysis found to have EDS elemental ratio of 4.9:95.1 = 19.4 which matches with cholesterol composition. The ratio in cholesterol between O:C, (O1 8 = 8) and (C27 6 = 162), 8:162 = 1:20, this gave an indication that the expected sample is Cholesterol stone. Conclusion: The study recommends further investigations with higher sample size and detailed sample elemental analysis to confirm the provided results. The study illustrates the effectiveness of applying a SEM-EDS technique to assess and diagnose the chemical compositions of gallstones.
HPB 2016, 18 (S1), e385ee601
e489
EP03C-027 EARLY VERSUS LATE CHOLECYSTECTOMY AFTER CLEARANCE OF COMMON BILE DUCT STONES BY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A PROSPECTIVE RANDOMIZED STUDY W. Askar and A. El Nakeeb Mansoura University, Gastroenterology Surgical Center, Egypt Background: The time interval between ERCP and laparoscopic cholecystectomy (LC) is a matter of debate. This study was planned to compare early LC (within admission) versus late LC (after 1 month) after ERCP Patient and methods: This is a prospective randomized study on patients who are presented with concomitant gall bladder (GB) and common bile duct (CBD) stone. The study population was divided into two groups; group (A) managed by early laparoscopic cholecystectomy (LC) within 3 days after ERCP and group (B) managed by late LC one month after ERCP. The primary outcome is the conversion to open surgery. Secondary outcomes will include recurrent biliary symptoms, postoperative morbidity, and hospital stay. Results: 110 patients included in this study. The conversion rate from LC to open occurred in 11 (10%) cases. No significant difference between both groups as regards the conversion rate, the degree of adhesion, cystic duct diameter, and intraoperative CBD injury or bleeding. Recurrent biliary symptoms were significantly more in delayed LC group in 7 (12.7I%) patient versus one patient in early LC (P = 0.03). Four (7.3%) patients developed postoperative bile leakage from the cystic duct stump in delayed LC group and all patients managed conservatively. Conclusion: LC after ERCP and ES is more difficult, it must be operated by an experienced laparoscopic surgeon to reduce the conversion rate and decrease the morbidity rate. No significant difference between both groups as regards the conversion rate. Recurrent biliary symptoms were significantly more in delayed LC while waiting LC.
EP03C-030 PERCUTANEOUS CHOLECYSTOSTOMY FOR PATIENTS WITH ASA CLASSIFICATION MORE THAN 3 S. S. Yun, D. S. Lee and H. J. Kim Surgery, Yeungnam University Hospital, Republic of Korea Introduction: Percutaneous Cholecystostomy (PC) has been proposed as an effective bridge procedure before elective cholecystectomy for acute cholecystitis. We designed this study to evaluate the efficacy of PC in patients with acute cholecystitis and ASA classification more than 3. Method: For recent 3 years, we did PC in 29 patients with acute cholecystitis and ASA classification more than 3. We did PC as a bridge procedure before elective cholecystectomy (bridge group) in 20 patients and as a palliation of symptom in 9 patients (palliation group). We evaluated patients
e490
Electronic Poster Abstracts
characteristics, complication rate after PC, ASA classification change before and after PC, resumption of oral intake after PC and success rate of laparoscopic cholecystectomy (LC) etc. Results: Mean ASA classification before and after PC were 3.7 0.5, 2.3 0.8 and 4.0 0.8, 3.4 0.7, respectively in both group. There was only one complication after PC (peritonitis after PC, 3.4%), who is one of two mortality cases in palliation group (22.2%). Resumption of oral intake was possible 3.2 2.1 days after PC in bridge group and 3.0 2.4 days in palliation group except two mortalities due to underlying diseases. We tried 12 LC and one failed due to bile duct injury (success rate was 91.6%). Mean operation time for LC was 106.8 32.5 which is a little bit longer. Conclusion: PC is a good procedure for bridge procedure before elective LC and palliation of symptom in patients with acute cholecystitis and ASA classification more than 3.
EP03C-031 LAPAROSCOPIC CHOLECYSTOSTOMY AS AN ALTERNATIVE TO OPEN CHOLECYSTECTOMY AND PERCUTANEOUS CHOLECYSTOSTOMY IN A RURAL SETTING S. P. Han Department of Surgery, Dubbo Base Hospital, Australia Introduction: Emergency cholecystectomy in critically ill patients carries a high risk of morbidity and mortality. Laparoscopic cholecystostomy (LC) can be used as a temporising measure in those patients where cholecystectomy is deemed technically difficult for safe removal, or in those patients who present to a hospital without interventional radiology services, such as in many rural settings. Methods: A retrospective review was undertaken of consecutive patients who underwent LC at Dubbo Base Hospital over a five-year period. In each case, LC was performed by placing a 10 mm port in the right subcostal margin and the gallbladder was decompressed with a trocar and a 20Fr Foley catheter was placed in the gallbladder body. Results: Ten patients underwent LC. (Male = 5, median age = 67 and range = 43e88) The main indication was severe acute cholecystitis, not amenable to laparoscopic cholecystectomy. One of the patients has significant morbidity (ASA 4) and had laparoscopic cholecystostomy as he was not responding to antibiotics and there was no interventional radiologist in the hospital. Seven patients had interval laparoscopic cholecystectomy in six months time and there was no complication during or after the procedure. Mean length of stay is five days. There are two patients readmitted to the hospital within thirty days with sub capsular collection around the right lobe of liver and postural hypotension. Conclusion: It appears that the data suggest that laparoscopic cholecystostomy is a viable alternative to open cholecystectomy in technically difficult cases and alternative to percutaneous cholecystostomy in rural hospitals without interventional radiology services.
EP03C-034 PSEUDO ANEURISM OF RIGHT HEPATIC ARTERY. UNCOMMON COMPLICATION M. Goitia-Durán and M. Saavedra Pozo Universidad del Valle, Bolivia Hepatic artery pseudoaneurism is a rare complication of uneventful cholecystectomy, when present is potentially fatal. Common pathogenic factors are acute cholecystitis, biliary tree injury, bilioma, direct manipulation of biliary tree, use of titanium clips, excessive use of electrocautery. Clinical course is not typical, most refer acute abdominal pain, ictericia, or hemobilia and acute GI bleeding. Angiography is the choice for diagnosis and for placement of stents as treatment. Eventually, laparotomy is needed as emergency treatment. A 32 year-old male patient, operated 3 months before of total thyroidectomy and iodine radiation for papilar thyroid carcinoma, was referred for an elective laparoscopic cholecystectomy for chronic cholecystitis, procedure was uncomplicated. Twenty days later, patient complained of acute abdominal pain, diarrhea and diagnosed giardiasis and treated. Pain didn’t improve and localized in right upper quadrant, US was done, no alteration was found. CT scan showed infra hepatic collection with peripheral contrast, that was proved pulsatile on Doppler. Two days after diagnosis patient referred acute and sudden back and right upper quadrant pain, on Doppler the pseudoaneurism showed expansion. He was operated on immediately. On laparotomy right hepatic pseudoameurism was ligated. Posterior recovery was normal. Right hepatic artery pseudoaneurism is rare after uneventful cholecystectomy and must always be suspected when patient present sudden right upper quadrant pain, however, recognition is not always simple. Most diagnostic methods are ineffective, but angiography is diagnostic and therapeutic as well. For that reason, treatment must be elective whenever possible and reserve laparotomy for failure of stents or when rupture presents.
EP03C-035 INTRAMURAL GALLBLADDER LITHIASIS: REPORT OF 2 CASES G. Stavrou1, D. Paramythiotis2, K. Kofina1, P. Bangeas1, V. Papadopoulos2 and A. Michalopoulos2 1 1st Propedeutic Surgical Department, AHEPA University Hospital, and 21st Propedeutic Surgical Department, AHEPA University Hospital, Aristotelian University of Thessaloniki, Greece Introduction: The presence of intramural gallstones is a rare entity with unclear etiology. Chronic inflammation due to cholelithiasis, as well as the presence of adenomyosis is some of the suggested pathogenetic mechanisms. We present 2 cases of intramural gallbladder lithiasis and a review of the literature. Case report: A 73-year-old male patient presented in our Emergency Department with right upper quadrant pain. Clinical examination, laboratory and radiology work-up set the diagnosis of acute cholecystitis and the patient
HPB 2016, 18 (S1), e385ee601