- Email: [email protected]
Preliminary insight on ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) mechanisms: Activation of mTOR pathway
Electronic Poster Abstracts respectively. Ischemic heart disease, cirrhosis, major hepatectomy, and RBC transfusion 3 U were independent risk factors of both severe morbidity and 90day/in-hospital mortality. Biliary tract-associated procedure was an independent risk factor only for severe morbidity. Risk factors identified were used to develop a predictive risk classification of postoperative outcome based on age groups and number of risk factors. Particularly, in patients 75 years severe morbidity was 4.3%, 16.9% and 40.0% and mortality was 0.0%, 1.6% and 25.0% in patients with zero, one and 2 risk factors, respectively (p < 0.001 and p < 0.001). Conclusion: Liver resection can be safely performed with low mortality and morbidity rates in elderly patients. Moreover, we identified clinical factors that can be useful to stratify the risk of severe morbidity and mortality per age group of patients.
TP15-5 LAPAROSCOPIC LIVER RESECTION OF HEPATOCELLULAR CARCINOMA WITH A TUMOR SIZE LARGER THAN 5CM: REVIEW OF 45 CASES IN A TERTIARY INSTITUTION E. Gil1, C. H. D. Kwon2, W. Cho2, S. H. Lee2, J. Y. Choi2, G. -S. Choi2, J. -W. Joh2 and J. M. Kim2 1 Department of Critical Care Medicine, and 2Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea Introduction: Although laparoscopic liver resection has developed rapidly, its usefulness for the treatment of large tumors is less clear, due to concerns about compromising oncological principles and patient safety. The purpose of this study was to explore the feasibility and safety of laparoscopic liver resection for the treatment of hepatocellular carcinoma (HCC) with a tumor size larger than 5 cm. Methods: From January 2007 to December 2014, we performed laparoscopic liver resection in 45 patients with HCC with a tumor size 5 cm. Perioperative outcome, tumor recurrence and overall patient survival were analyzed. Results: Median age was 60.0 (range 18e83) and 64.4% (29/45) was male. Seven patients (15.6%) had larger than 10cm of HCC. No operative deaths occurred and six of the laparoscopic procedures were converted to open resection (conversion rate 13.3%). Median operation time was 365 minute (range 109e619) and median estimated blood loss (EBL) was 400.0 ml (range 50e4500). There was no R1 or R2 resection and median resection margin was 1.90cm (range 0.1e6.5). Complications above Clavien-Dindo classification grade III occurred in four patients (8.9%). The median overall follow-up time was 10.7 month (range 1.1e62.1). 1year recurrence free survival (RFS) and overall survival (OS) were 86.0% and 95.5%, and 3-year RFS and OS were 70.7% and 86.0%. Conclusions: Laparoscopic liver resection seems safe and feasible in patients with HCC with a tumor size larger than 5 cm. Expansion of indication for laparoscopic liver resection in patients with HCC may be considered.
HPB 2016, 18 (S1), e1ee384
e149
TP16 e Talking Poster Session 16 e Liver 5
TP16-1 ABANDONING PROPHYLACTIC DRAINAGE AFTER HEPATIC SURGERY: 10 YEARS OF NO-DRAIN POLICY IN AN ERAS ENVIRONMENT V. van Woerden1, E. M. Wong-Lun-Hing1, T. M. Lodewick1, M. H. Bemelmans1, S. W. M. Olde Damink1,2, C. H. C. Dejong1,2,3 and R. M. van Dam1 1 Department of Surgery, Maastricht University Medical Centre, 2NUTRIM School of Nutrition and Translational Research in Metabolism, and 3Grow School for Oncology and Developmental Biology, Maastricht University, Netherlands Background: Routine prophylactic abdominal drainage after hepatic surgery is still debated, may be unnecessary, possibly harmful and uncomfortable for patients. This study evaluated the safety of a no-drain policy after liver resection with an ERAS-programme. Methods: All partial hepatectomies without biliary reconstructions performed during 2005 e 2014 were included. Primary endpoints were 90-day resection-surface-related (RSR) morbidity (Dindo-Clavien grade 3a) and RSR-reinterventions. Secondary endpoints were hospital length of stay (LOS), 90-day total postoperative morbidity, composite endpoint of liver surgery-specific complications (CEP), readmission rate and 90-day mortality. Uni- and multivariable analyses were performed to identify independent risk factors for RSR-morbidity. Results: A total of 538 resections were included in the study. The RSR-complication and reintervention rate was 15% and 12%, respectively. 88% of all high-risk patients did not require a drain. 90-day mortality was 2.8%. Major liver resection (3 segments) was an independent risk factor for the development of RSR-morbidity (OR = 3.01, 95% CI 1.61e5.62; P = 0.001) and need for RSR-reintervention (OR = 3.02, 95% CI 1.59e5.73; P = 0.001). Discussion: RSR-morbidity, mortality and reintervention rates after partial liver resection without prophylactic drainage in patients, treated within the context of an ERAS programme were comparable to previously published data. A no-drain policy after partial hepatectomy seems safe and feasible.
TP16-2 PRELIMINARY INSIGHT ON ALPPS (ASSOCIATING LIVER PARTITION AND PORTAL VEIN LIGATION FOR STAGED HEPATECTOMY) MECHANISMS: ACTIVATION OF mTOR PATHWAY C. B. Mandiola1, R. V. Vargas1, M. I. F. Zapata1, S. A. Uribe-Echevarría2, M. M. Uribe2, E. U. Muñoz1, F. M. Riquelme2 and P. Romanque1 1 Faculty of Medicine, and 2Servicio de Cirugía, Hospital del Salvador, University of Chile, Chile Introduction: ALPPS has been introduced for liver volume augmentation in cases of extended hepatectomies with small future remnant liver volume (RLV). The magnitude of increase in RLV with ALPPS is greater and faster than
e150
Electronic Poster Abstracts
with portal embolization/ligation. However, the biological mechanisms are unknown. Method: Patients with liver metastases from colorectal cancer were included. In first stage, right portal vein was ligated and liver split in the limit of IIeIII segments along falciform ligament. Volume gain was followed-up with CTscan. In first and second stages of ALPPS, samples of the deportalized liver tissue and of liver remnant were taken, which were subjected to histological analysis, Ki-67 immunostaining and mRNA expression analysis of mTOR, S6K1 and AMPK by qPCR. Results: 8 ALPPS procedures were performed and their respective liver samples taken. The preoperative RLV range from 180e473 ml. After ALPPS the RLV increased up to 107% (35e214%, p < 0.05) in 13 days (7e21). Ki-67 immunostaining in hepatocytes of the remnant regenerating liver increased at the second stage of ALPPS (p < 0.05), while levels of both mTOR and S6K1 mRNA in liver regeneration augmented after ALPPS (p < 0.05), associated with mild, but not statistically significant, decrease in AMPK mRNA levels (p = 0.26). There was no significant changes in these variables in deportalized lobes.
stored >80 days were considered old. Most patients underwent surgery for cancer (n = 319, 79.2%), and 236 (58.6%) were female. Patients that received new (versus old) FFP had a significantly lower 30-day (2.2% versus 14.3%, p = 0.005) and 60-day mortality rate (4.5% versus 17.9%, p = 0.008). This effect persisted in adjusted logistic regression models of 30-day mortality (Table 1). Transfusion of older PRBCs was associated with an increased rate of bile leaks (2.7% vs 0%, p = 0.04) and lower 30-day mortality (3.3% vs 9.5%, p = 0.01); however, neither of these associations remained significant in adjusted models. Conclusion: Storage age of PRBCs appeared to have minimal impact on morbidity or mortality after hepatectomy. Although clinically relevant storage-related degeneration is not well-described for FFP, the higher mortality rate associated with older plasma in this study warrants further investigation. Odds Ratio
95% Confidence p Interval
Patient age
1.02
0.98–1.05
0.36
Female
0.30
0.11–0.81
0.02
0.14–1.17
0.10
Storage age of PRBCs 24 days
reference
> 24 days
0.41
Storage age of FFP
[Liver expression of mTOR, S6K1 and AMPK by qPCR] Conclusions: The significant RLV enlargement with ALPPS is associated with increase in cell proliferation markers, involving an increase in hepatocellular mass. A possible mechanism involved in this response corresponds to activation of mTOR/AMPK pathway, associated with macromolecules biosynthesis and cell growth.
TP16-4 DOES STORAGE AGE OF TRANSFUSED BLOOD PRODUCT COMPONENTS AFFECT SHORT-TERM OUTCOMES AFTER MAJOR HEPATECTOMY? R. Groeschl, A. Glasgow, E. Habermann, D. Nagorney, M. Kendrick, M. Farnell, M. Truty and R. Smoot Mayo Clinic, United States Background: Stored blood products undergo degenerative changes with time, which have been associated with adverse patient outcomes in some clinical settings. The aim of this study was to evaluate the impact of transfusion storage age on perioperative clinical outcomes after major hepatectomy. Methods: Patients receiving perioperative transfusion for hemihepatectomy or trisectionectomy (2006e2014) were included for retrospective analysis. Separation of packed red blood cells (PRBCS) and fresh frozen plasma (FFP) into “new” and “old” groups was based on median values for storage time. Analyses included Fisher’s exact test and multivariable logistic regression. Results: Of 403 patients included for analysis, 393 received PRBCs, 145 received FFP, 50 received platelets and 31 received cryoprecipitate. PRBCs stored >24 days and FFP
80 days
reference
> 80 days
5.50
1.05–28.88
0.02
no FFP administered
1.82
0.29–8.53
0.63
[Factors influencing 30-day mortality]
TP16-5 TECHNICAL DETAILS OF ALPPS: ROLE OF RAW LIVER SURFACE COVERAGE. DOES GOOD COVER MEANS GOOD RECOVER? M. Enne1, M. D’Oliveira2, P. Herman3, O. Torres4, E. Shadde5, R. Hernandez Alejandro6, S. Nadalin7, S. Govil8, M. Malago9, R. Robles Campos10, E. De Santibanes11, P. -A. Clavien12 and on behalf of ALPPS Registry Group 1 Surgery, Ipanema Federal Hospital / UNESA, 2HPB Team, General Surgery, Ipanema Federal Hospital, 3Liver Surgery Unit, University of São Paulo Medical School, 4 Department of Surgery, Maranhão Federal University, Brazil, 5Department of Surgery e Division of Transplantation, Rush University Medical Center Chicago, United States, 6HPB Surgery, Liver Transplantation, London Health Sciences Centre, Western University, Canada, 7Universitätsklinik für Allgemein-, Viszeral- und Transplantationschirurgie, HBP-Chirurgie Universitätsklinikum Tübingen, Germany, 8Hepatobiliary Pancreatic Surgery and Liver Transplantation, Global Health, India, 9University College London, Royal Free Hospital, United Kingdom, 10Virgen de la Arrixaca University Hospital, Spain, 11Liver Transplant Unit, Hospital Italiano, Argentina, and 12Swiss HPB ans Transplant Center, University Hospital Zurich, Switzerland Background: ALPPS is still controversial due to high complication and mortality rate. Technical modifications HPB 2016, 18 (S1), e1ee384
TP15-5 LAPAROSCOPIC LIVER RESECTION OF HEPATOCELLULAR CARCINOMA WITH A TUMOR SIZE LARGER THAN 5CM: REVIEW OF 45 CASES IN A TERTIARY INSTITUTION E. Gil1, C. H. D. Kwon2, W. Cho2, S. H. Lee2, J. Y. Choi2, G. -S. Choi2, J. -W. Joh2 and J. M. Kim2 1 Department of Critical Care Medicine, and 2Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea Introduction: Although laparoscopic liver resection has developed rapidly, its usefulness for the treatment of large tumors is less clear, due to concerns about compromising oncological principles and patient safety. The purpose of this study was to explore the feasibility and safety of laparoscopic liver resection for the treatment of hepatocellular carcinoma (HCC) with a tumor size larger than 5 cm. Methods: From January 2007 to December 2014, we performed laparoscopic liver resection in 45 patients with HCC with a tumor size 5 cm. Perioperative outcome, tumor recurrence and overall patient survival were analyzed. Results: Median age was 60.0 (range 18e83) and 64.4% (29/45) was male. Seven patients (15.6%) had larger than 10cm of HCC. No operative deaths occurred and six of the laparoscopic procedures were converted to open resection (conversion rate 13.3%). Median operation time was 365 minute (range 109e619) and median estimated blood loss (EBL) was 400.0 ml (range 50e4500). There was no R1 or R2 resection and median resection margin was 1.90cm (range 0.1e6.5). Complications above Clavien-Dindo classification grade III occurred in four patients (8.9%). The median overall follow-up time was 10.7 month (range 1.1e62.1). 1year recurrence free survival (RFS) and overall survival (OS) were 86.0% and 95.5%, and 3-year RFS and OS were 70.7% and 86.0%. Conclusions: Laparoscopic liver resection seems safe and feasible in patients with HCC with a tumor size larger than 5 cm. Expansion of indication for laparoscopic liver resection in patients with HCC may be considered.
HPB 2016, 18 (S1), e1ee384
e149
TP16 e Talking Poster Session 16 e Liver 5
TP16-1 ABANDONING PROPHYLACTIC DRAINAGE AFTER HEPATIC SURGERY: 10 YEARS OF NO-DRAIN POLICY IN AN ERAS ENVIRONMENT V. van Woerden1, E. M. Wong-Lun-Hing1, T. M. Lodewick1, M. H. Bemelmans1, S. W. M. Olde Damink1,2, C. H. C. Dejong1,2,3 and R. M. van Dam1 1 Department of Surgery, Maastricht University Medical Centre, 2NUTRIM School of Nutrition and Translational Research in Metabolism, and 3Grow School for Oncology and Developmental Biology, Maastricht University, Netherlands Background: Routine prophylactic abdominal drainage after hepatic surgery is still debated, may be unnecessary, possibly harmful and uncomfortable for patients. This study evaluated the safety of a no-drain policy after liver resection with an ERAS-programme. Methods: All partial hepatectomies without biliary reconstructions performed during 2005 e 2014 were included. Primary endpoints were 90-day resection-surface-related (RSR) morbidity (Dindo-Clavien grade 3a) and RSR-reinterventions. Secondary endpoints were hospital length of stay (LOS), 90-day total postoperative morbidity, composite endpoint of liver surgery-specific complications (CEP), readmission rate and 90-day mortality. Uni- and multivariable analyses were performed to identify independent risk factors for RSR-morbidity. Results: A total of 538 resections were included in the study. The RSR-complication and reintervention rate was 15% and 12%, respectively. 88% of all high-risk patients did not require a drain. 90-day mortality was 2.8%. Major liver resection (3 segments) was an independent risk factor for the development of RSR-morbidity (OR = 3.01, 95% CI 1.61e5.62; P = 0.001) and need for RSR-reintervention (OR = 3.02, 95% CI 1.59e5.73; P = 0.001). Discussion: RSR-morbidity, mortality and reintervention rates after partial liver resection without prophylactic drainage in patients, treated within the context of an ERAS programme were comparable to previously published data. A no-drain policy after partial hepatectomy seems safe and feasible.
TP16-2 PRELIMINARY INSIGHT ON ALPPS (ASSOCIATING LIVER PARTITION AND PORTAL VEIN LIGATION FOR STAGED HEPATECTOMY) MECHANISMS: ACTIVATION OF mTOR PATHWAY C. B. Mandiola1, R. V. Vargas1, M. I. F. Zapata1, S. A. Uribe-Echevarría2, M. M. Uribe2, E. U. Muñoz1, F. M. Riquelme2 and P. Romanque1 1 Faculty of Medicine, and 2Servicio de Cirugía, Hospital del Salvador, University of Chile, Chile Introduction: ALPPS has been introduced for liver volume augmentation in cases of extended hepatectomies with small future remnant liver volume (RLV). The magnitude of increase in RLV with ALPPS is greater and faster than
e150
Electronic Poster Abstracts
with portal embolization/ligation. However, the biological mechanisms are unknown. Method: Patients with liver metastases from colorectal cancer were included. In first stage, right portal vein was ligated and liver split in the limit of IIeIII segments along falciform ligament. Volume gain was followed-up with CTscan. In first and second stages of ALPPS, samples of the deportalized liver tissue and of liver remnant were taken, which were subjected to histological analysis, Ki-67 immunostaining and mRNA expression analysis of mTOR, S6K1 and AMPK by qPCR. Results: 8 ALPPS procedures were performed and their respective liver samples taken. The preoperative RLV range from 180e473 ml. After ALPPS the RLV increased up to 107% (35e214%, p < 0.05) in 13 days (7e21). Ki-67 immunostaining in hepatocytes of the remnant regenerating liver increased at the second stage of ALPPS (p < 0.05), while levels of both mTOR and S6K1 mRNA in liver regeneration augmented after ALPPS (p < 0.05), associated with mild, but not statistically significant, decrease in AMPK mRNA levels (p = 0.26). There was no significant changes in these variables in deportalized lobes.
stored >80 days were considered old. Most patients underwent surgery for cancer (n = 319, 79.2%), and 236 (58.6%) were female. Patients that received new (versus old) FFP had a significantly lower 30-day (2.2% versus 14.3%, p = 0.005) and 60-day mortality rate (4.5% versus 17.9%, p = 0.008). This effect persisted in adjusted logistic regression models of 30-day mortality (Table 1). Transfusion of older PRBCs was associated with an increased rate of bile leaks (2.7% vs 0%, p = 0.04) and lower 30-day mortality (3.3% vs 9.5%, p = 0.01); however, neither of these associations remained significant in adjusted models. Conclusion: Storage age of PRBCs appeared to have minimal impact on morbidity or mortality after hepatectomy. Although clinically relevant storage-related degeneration is not well-described for FFP, the higher mortality rate associated with older plasma in this study warrants further investigation. Odds Ratio
95% Confidence p Interval
Patient age
1.02
0.98–1.05
0.36
Female
0.30
0.11–0.81
0.02
0.14–1.17
0.10
Storage age of PRBCs 24 days
reference
> 24 days
0.41
Storage age of FFP
[Liver expression of mTOR, S6K1 and AMPK by qPCR] Conclusions: The significant RLV enlargement with ALPPS is associated with increase in cell proliferation markers, involving an increase in hepatocellular mass. A possible mechanism involved in this response corresponds to activation of mTOR/AMPK pathway, associated with macromolecules biosynthesis and cell growth.
TP16-4 DOES STORAGE AGE OF TRANSFUSED BLOOD PRODUCT COMPONENTS AFFECT SHORT-TERM OUTCOMES AFTER MAJOR HEPATECTOMY? R. Groeschl, A. Glasgow, E. Habermann, D. Nagorney, M. Kendrick, M. Farnell, M. Truty and R. Smoot Mayo Clinic, United States Background: Stored blood products undergo degenerative changes with time, which have been associated with adverse patient outcomes in some clinical settings. The aim of this study was to evaluate the impact of transfusion storage age on perioperative clinical outcomes after major hepatectomy. Methods: Patients receiving perioperative transfusion for hemihepatectomy or trisectionectomy (2006e2014) were included for retrospective analysis. Separation of packed red blood cells (PRBCS) and fresh frozen plasma (FFP) into “new” and “old” groups was based on median values for storage time. Analyses included Fisher’s exact test and multivariable logistic regression. Results: Of 403 patients included for analysis, 393 received PRBCs, 145 received FFP, 50 received platelets and 31 received cryoprecipitate. PRBCs stored >24 days and FFP
80 days
reference
> 80 days
5.50
1.05–28.88
0.02
no FFP administered
1.82
0.29–8.53
0.63
[Factors influencing 30-day mortality]
TP16-5 TECHNICAL DETAILS OF ALPPS: ROLE OF RAW LIVER SURFACE COVERAGE. DOES GOOD COVER MEANS GOOD RECOVER? M. Enne1, M. D’Oliveira2, P. Herman3, O. Torres4, E. Shadde5, R. Hernandez Alejandro6, S. Nadalin7, S. Govil8, M. Malago9, R. Robles Campos10, E. De Santibanes11, P. -A. Clavien12 and on behalf of ALPPS Registry Group 1 Surgery, Ipanema Federal Hospital / UNESA, 2HPB Team, General Surgery, Ipanema Federal Hospital, 3Liver Surgery Unit, University of São Paulo Medical School, 4 Department of Surgery, Maranhão Federal University, Brazil, 5Department of Surgery e Division of Transplantation, Rush University Medical Center Chicago, United States, 6HPB Surgery, Liver Transplantation, London Health Sciences Centre, Western University, Canada, 7Universitätsklinik für Allgemein-, Viszeral- und Transplantationschirurgie, HBP-Chirurgie Universitätsklinikum Tübingen, Germany, 8Hepatobiliary Pancreatic Surgery and Liver Transplantation, Global Health, India, 9University College London, Royal Free Hospital, United Kingdom, 10Virgen de la Arrixaca University Hospital, Spain, 11Liver Transplant Unit, Hospital Italiano, Argentina, and 12Swiss HPB ans Transplant Center, University Hospital Zurich, Switzerland Background: ALPPS is still controversial due to high complication and mortality rate. Technical modifications HPB 2016, 18 (S1), e1ee384