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Preoperative biliary drainage in patients undergoing pancreatoduodenectomy in the Netherlands
e146
Electronic Poster Abstracts
81.2% mild); jaundice was observed in 62 patients. Preoperative radiologic imaging was done in 43 patients (CT scan in 7.1%, MRI in 31.3%). There were 70 transcystic and 42 transductal choledochoscopies with a median IQR operative time of 77.5 (110e65) vs. 122.5 (140e94) minutes, p < 0.001. T-tubes were placed only in 13 (11.5%) patients. Complete clearance of the bile duct was achieved in 91.1% leading to a conversion rate of 2.7%; in 6.2% of cases additional postoperative ERCP was performed. Readmission and ERCP for missed stones was needed in 3.6% of all cases. The overall postoperative complication rate reached 6.3%. The median IQR overall hospital stay was 9 (14e7) days. Conclusions: One-stage surgical approach is rational in the management of patients with a high risk of CBD stones.
TP14-2 ROLES OF SPHINCTER OF ODDI LAXITY IN BILE DUCT MICROENVIRONMENT IN PATIENTS WITH CHOLANGIOLITHIASIS: FROM THE PERSPECTIVE OF THE MICROBIOME AND METABOLOME T. Liang1,2, W. Su1, Q. Zhang1, G. Li1, S. Gao1, J. Lou1, Y. Zhang1, T. Ma1 and X. Bai1 1 Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, and 2Zhejiang University, Collaborative Innovation Center for Cancer Medicine, China Introduction: Bile duct microenvironment plays key roles in cholangiolithiasis occurrence. Sphincter of Oddi laxity (SOL) is associated with cholangiolithiasis, probably due to enhanced reflux of intestinal content that changes the microenvironment. However, the microenvironment has not been comprehensively investigated. Methods: We recruited 47 patients with cholangiolithiasis and collected their bile intraoperatively for culture and high-throughput experiments. Pyrosequencing of 16S ribosomal RNA gene was performed to depict the microbiota in the bile. Bile composition was profiled by using liquid chromatography-mass spectrometry-based method. Clinical manifestation, microbiome, and bile composition were compared between patients with and without SOL. Results: Patients with SOL showed higher inflammation. Bacteria in bile duct were overwhelmingly aerobes and facultative anaerobes. Proteobacteria and Firmicutes were the most widespread phylotypes, especially Enterobacteriaceae. Patients with SOL shared more operational taxonomic units. Pathobionts were richer in patients with SOL while probiotics were reduced. All the key bile components distinguishing samples from patients with or without SOL were associated with inflammation and were increased in patients with SOL. Besides, the increased abundance of Bilophila that is involved in taurine metabolism was associated with a reduced content of four taurine and its derivatives in the bile of patients with SOL. Conclusions: SOL clearly affected bile duct microenvironment and can facilitate calculi formation by enhancing reflux of intestinal content that results in bacterial infection and chemical damage of bile duct. These results suggest a possible mechanism of cholangiolithiasis and provide the basis for future strategies for prevention of recurrence of cholangiolithiasis.
TP14-3 USE OF ANTIBIOTICS IN ACUTE CALCULOUS CHOLECYSTITIS e DO TOKYO GUIDELINES IMPROVE THE PRACTICES? H. Bari and R. Khan Surgery, Aga Khan University Hospital, Pakistan Introduction: The treatment for acute cholecystitis consists of antibiotics followed by surgery. We conducted a study to audit our practices of antibiotic use in patients with acute cholecystitis and to compare the outcomes after implementation of Tokyo guidelines. Methods: All patients with histologically proven acute calculous cholecystitis managed at Aga Khan University Hospital during the year 2009 were enrolled in the study. Subsequently, the hospital staff was educated about Tokyo guidelines on various educational forums. The data were collected again for the year 2014 and compared with the previous data. The major variables included patient’s demographics, antibiotics used and surgical outcomes. Results: The study population consisted of 356 patients including 96 patients in 2009 and 260 patients in 2014. Mean age was 48.9 14 years and 52% were females. Comparison of the data from 2 years showed no difference in gender, ASA level, grade of acute cholecystitis and frequency of use of empiric antibiotics. However, there was a significant less use of combination therapy (43.8 vs. 69.8%, p = 0.00), and metronidazole (37.7% vs. 66.7%, p = 0.00) in the year 2014. On the other hand, monotherapy was more frequently used in the later year (54.6% vs. 27.1%, p = 0.00). Interval cholecystectomy was significantly less practiced in 2014 (8.1% vs. 16.7%, p = 0.03) resulting in shorter hospital stay (p = 0.00). Conversion rates were comparatively less in 2014 (7.3% vs 13.5%, p = 0.09). Conclusion: Our data suggests that implementation of Tokyo guidelines simplified and standardized the choice of antibiotics in patients with acute cholecystitis without compromising the outcomes.
TP14-4 PREOPERATIVE BILIARY DRAINAGE IN PATIENTS UNDERGOING PANCREATODUODENECTOMY IN THE NETHERLANDS M. Bakens1,2, B. van Rijsen3, M. Besselink3, D. Boerma4, O. Busch3, C. Dejong5, M. Gerhards6, J. Klaase7, I. Molenaar8, D. Gouma3 and I. de Hingh1 1 Surgery, Catharina Hospital, 2Research, Netherlands Comprehensive Cancer Organisation, 3Surgery, Academic Medical Center, 4Surgery, Antonius Hospital, 5Surgery, Maastricht University Medical Centre, 6Surgery, Onze Lieve Vrouwe Gasthuis, 7Surgery, Medical Spectrum Twente, and 8Surgery, University Medical Center Utrecht, Netherlands Patients with a periampullary tumour and obstructive jaundice have a higher rate of complications after preoperative biliary drainage (PBD) compared to early surgery. The current study investigated the use of early surgery without PBD. HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts A retrospective cohort study was performed in patients undergoing pancreatoduodenectomy for suspected periampullary malignancy in 2013 and 2014. Data were collected from seven Dutch high-volume centers. Reasons for PBD were recorded and the use of plastic PBD was further analyzed. Differences between groups were analyzed using chi-square tests. Of 609 patients undergoing pancreatoduodenectomy, 401 presented with obstructive jaundice, of which 263 (66%) underwent PBD. A plastic stent was used in 70% of patients undergoing PBD and in 19% a metal or metalcovered stent (11% missing). The rate of PBD varied from 58.8%e77.2% between centers (p = 0.005). In 64% of the plastic-stent-PBD patients the procedure was performed prior to referral to a pancreatic center. Cholestasis was the most common reason. In only 32% of these patients bilirubin level was above 250 mmol (24% missing). About half of the patients presenting with obstructive jaundice and bilirubin levels under 250 mmol still underwent PBD prior to surgery using a plastic stent. There is a clear practice variation between pancreatic centers, although most stents are placed in referring hospitals. Optimizing logistics in the referral for pancreatic surgery and expending the awareness of early surgery without PBD as the preferred treatment might result in improvement in care.
TP14-5 CHOLEDOCHAL MALFORMATION IN THE NETHERLANDS: A SURVEY FROM THE NETHERLANDS STUDY GROUP ON CHOLEDOCHAL CYSTSMALFORMATION REGISTRY (NeSCHoC) R. De Kleine1, M. Van Den Eijnden2, J. Wilde3, C. Sloots4, M. Oomen5, E. Van Heurn6, I. De Blaauw7, D. Van Der Zee8, H. -J. Verkade9, P. Peeters1 and J. Hulscher2 1 Department of Hepato-Pancreatico-Biliairy Surgery and Liver Transplantation, 2Pediatric Surgery, University Medical Center Groningen, Netherlands, 3Pediatric Surgery, Hopitaux Universitaires Geneve, Switzerland, 4 Pediatric Surgery, Erasmus MC, 5Pediatric Surgery, University Medical Center Amsterdam, 6Pediatric Surgery, Maastricht University Medical Centre, 7Pediatric Surgery, Radboud University Medical Center, 8Pediatric Surgery, University Medical Center Utrecht, and 9 Department of Pediatric Gastroenterology and Hepatology, University Medical Center Groningen, Netherlands A choledochal malformation (CM) is a rare biliary entity in the Western world. We gathered all data of children who underwent surgery for CM in the Netherlands between 1989 and 2015. We aimed to identify possible predictive factors associated with complications after surgery. Data was collected on all patients ( < 18 yrs) with a resection. We tested the relation between surgical techniques, age/weight at the time of surgery, presence of a
HPB 2016, 18 (S1), e1ee384
e147
common channel and the development of short- and longterm complications ( < 30days>). In 25 years 96 children underwent surgery for CM (M:F1:2.8). There were 67 Todani type I (70%), two type II (2%), 16 type IVa (17%), one type IVb (1/96, 1%), five type V (5%) and five unknown type (5%). Severe comorbidity was present in four patients (4%). Thirty-one patients (32%) were operated before the age of 1 year. Laparoscopic resection was performed in 12 patients (12%). No malignancy was found (FU 12.9 years 0.1e 25.3). Short-term complications were not different between groups. Long-term complications (cholangitis, stricture, stones, ileus, re-operation) occurred in 17 patients (18%) after a median of 1.4 years (range 0.8e23.01). and were tested univariately. The laparoscopic resection (p = 0.02) and surgery before 1 year of age (p < 0.001) proved to be predictive. The low numbers prohibit the meaningful use of multivariate analysis. In this retrospective pediatric cohort no malignancies were found. Long-term complications occur in almost one fifth of patients. Laparoscopic surgery and surgery before 1 year of age were associated with long-term complications. Odds Ratio
95% confidence interval
Age <24 months
3.4
1.1-10.5
Age <12 months
7.3
2.3-23.5
Laparoscopic technique
4.2
1.1-15.3
Occurrence of a short-term complication
1.2
0.3-4.2
[Risk factors for long-term complications]
TP15 e Talking Poster Session 15 e Liver 4
TP15-1 BILE DUCT AND PORTAL VEIN LIGATION INDUCES FASTER ATROPHY/HYPERTROPHY COMPLEX THAN PVL, AND IMPROVE PROGNOSIS AFTER STAGED HEPATECOMY: BILE ACIDS ACTIVATING FXR SIGNALING PATHWAY W. Ren1 and J. Dong2 1 Hepatobiliary Department, PLA General Hospital, and 2 Tsinghua Medical Center, Beijing Tsinghua Changgung Hospital, China Portal vein ligation (PVL) could induce atrophy/hypertrophy complex (AHC). Bile acid retention could enhance liver regeneration via activating FXR signaling pathway and could induce caspase-3 mediated apoptosis. We hypothesised that simultaneous bile duct and portal vein ligation (BPL) might induce proper bile acid (BA) retention to enhance AHC by promoting the regeneration of the intact liver and apoptosis of the ligated liver. We established rat models of 90% BPL and 90% PVL and found that BPL was well-tolerated and significantly accelerated AHC. The enhanced BA retention in the intact liver promoted
Electronic Poster Abstracts
81.2% mild); jaundice was observed in 62 patients. Preoperative radiologic imaging was done in 43 patients (CT scan in 7.1%, MRI in 31.3%). There were 70 transcystic and 42 transductal choledochoscopies with a median IQR operative time of 77.5 (110e65) vs. 122.5 (140e94) minutes, p < 0.001. T-tubes were placed only in 13 (11.5%) patients. Complete clearance of the bile duct was achieved in 91.1% leading to a conversion rate of 2.7%; in 6.2% of cases additional postoperative ERCP was performed. Readmission and ERCP for missed stones was needed in 3.6% of all cases. The overall postoperative complication rate reached 6.3%. The median IQR overall hospital stay was 9 (14e7) days. Conclusions: One-stage surgical approach is rational in the management of patients with a high risk of CBD stones.
TP14-2 ROLES OF SPHINCTER OF ODDI LAXITY IN BILE DUCT MICROENVIRONMENT IN PATIENTS WITH CHOLANGIOLITHIASIS: FROM THE PERSPECTIVE OF THE MICROBIOME AND METABOLOME T. Liang1,2, W. Su1, Q. Zhang1, G. Li1, S. Gao1, J. Lou1, Y. Zhang1, T. Ma1 and X. Bai1 1 Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, and 2Zhejiang University, Collaborative Innovation Center for Cancer Medicine, China Introduction: Bile duct microenvironment plays key roles in cholangiolithiasis occurrence. Sphincter of Oddi laxity (SOL) is associated with cholangiolithiasis, probably due to enhanced reflux of intestinal content that changes the microenvironment. However, the microenvironment has not been comprehensively investigated. Methods: We recruited 47 patients with cholangiolithiasis and collected their bile intraoperatively for culture and high-throughput experiments. Pyrosequencing of 16S ribosomal RNA gene was performed to depict the microbiota in the bile. Bile composition was profiled by using liquid chromatography-mass spectrometry-based method. Clinical manifestation, microbiome, and bile composition were compared between patients with and without SOL. Results: Patients with SOL showed higher inflammation. Bacteria in bile duct were overwhelmingly aerobes and facultative anaerobes. Proteobacteria and Firmicutes were the most widespread phylotypes, especially Enterobacteriaceae. Patients with SOL shared more operational taxonomic units. Pathobionts were richer in patients with SOL while probiotics were reduced. All the key bile components distinguishing samples from patients with or without SOL were associated with inflammation and were increased in patients with SOL. Besides, the increased abundance of Bilophila that is involved in taurine metabolism was associated with a reduced content of four taurine and its derivatives in the bile of patients with SOL. Conclusions: SOL clearly affected bile duct microenvironment and can facilitate calculi formation by enhancing reflux of intestinal content that results in bacterial infection and chemical damage of bile duct. These results suggest a possible mechanism of cholangiolithiasis and provide the basis for future strategies for prevention of recurrence of cholangiolithiasis.
TP14-3 USE OF ANTIBIOTICS IN ACUTE CALCULOUS CHOLECYSTITIS e DO TOKYO GUIDELINES IMPROVE THE PRACTICES? H. Bari and R. Khan Surgery, Aga Khan University Hospital, Pakistan Introduction: The treatment for acute cholecystitis consists of antibiotics followed by surgery. We conducted a study to audit our practices of antibiotic use in patients with acute cholecystitis and to compare the outcomes after implementation of Tokyo guidelines. Methods: All patients with histologically proven acute calculous cholecystitis managed at Aga Khan University Hospital during the year 2009 were enrolled in the study. Subsequently, the hospital staff was educated about Tokyo guidelines on various educational forums. The data were collected again for the year 2014 and compared with the previous data. The major variables included patient’s demographics, antibiotics used and surgical outcomes. Results: The study population consisted of 356 patients including 96 patients in 2009 and 260 patients in 2014. Mean age was 48.9 14 years and 52% were females. Comparison of the data from 2 years showed no difference in gender, ASA level, grade of acute cholecystitis and frequency of use of empiric antibiotics. However, there was a significant less use of combination therapy (43.8 vs. 69.8%, p = 0.00), and metronidazole (37.7% vs. 66.7%, p = 0.00) in the year 2014. On the other hand, monotherapy was more frequently used in the later year (54.6% vs. 27.1%, p = 0.00). Interval cholecystectomy was significantly less practiced in 2014 (8.1% vs. 16.7%, p = 0.03) resulting in shorter hospital stay (p = 0.00). Conversion rates were comparatively less in 2014 (7.3% vs 13.5%, p = 0.09). Conclusion: Our data suggests that implementation of Tokyo guidelines simplified and standardized the choice of antibiotics in patients with acute cholecystitis without compromising the outcomes.
TP14-4 PREOPERATIVE BILIARY DRAINAGE IN PATIENTS UNDERGOING PANCREATODUODENECTOMY IN THE NETHERLANDS M. Bakens1,2, B. van Rijsen3, M. Besselink3, D. Boerma4, O. Busch3, C. Dejong5, M. Gerhards6, J. Klaase7, I. Molenaar8, D. Gouma3 and I. de Hingh1 1 Surgery, Catharina Hospital, 2Research, Netherlands Comprehensive Cancer Organisation, 3Surgery, Academic Medical Center, 4Surgery, Antonius Hospital, 5Surgery, Maastricht University Medical Centre, 6Surgery, Onze Lieve Vrouwe Gasthuis, 7Surgery, Medical Spectrum Twente, and 8Surgery, University Medical Center Utrecht, Netherlands Patients with a periampullary tumour and obstructive jaundice have a higher rate of complications after preoperative biliary drainage (PBD) compared to early surgery. The current study investigated the use of early surgery without PBD. HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts A retrospective cohort study was performed in patients undergoing pancreatoduodenectomy for suspected periampullary malignancy in 2013 and 2014. Data were collected from seven Dutch high-volume centers. Reasons for PBD were recorded and the use of plastic PBD was further analyzed. Differences between groups were analyzed using chi-square tests. Of 609 patients undergoing pancreatoduodenectomy, 401 presented with obstructive jaundice, of which 263 (66%) underwent PBD. A plastic stent was used in 70% of patients undergoing PBD and in 19% a metal or metalcovered stent (11% missing). The rate of PBD varied from 58.8%e77.2% between centers (p = 0.005). In 64% of the plastic-stent-PBD patients the procedure was performed prior to referral to a pancreatic center. Cholestasis was the most common reason. In only 32% of these patients bilirubin level was above 250 mmol (24% missing). About half of the patients presenting with obstructive jaundice and bilirubin levels under 250 mmol still underwent PBD prior to surgery using a plastic stent. There is a clear practice variation between pancreatic centers, although most stents are placed in referring hospitals. Optimizing logistics in the referral for pancreatic surgery and expending the awareness of early surgery without PBD as the preferred treatment might result in improvement in care.
TP14-5 CHOLEDOCHAL MALFORMATION IN THE NETHERLANDS: A SURVEY FROM THE NETHERLANDS STUDY GROUP ON CHOLEDOCHAL CYSTSMALFORMATION REGISTRY (NeSCHoC) R. De Kleine1, M. Van Den Eijnden2, J. Wilde3, C. Sloots4, M. Oomen5, E. Van Heurn6, I. De Blaauw7, D. Van Der Zee8, H. -J. Verkade9, P. Peeters1 and J. Hulscher2 1 Department of Hepato-Pancreatico-Biliairy Surgery and Liver Transplantation, 2Pediatric Surgery, University Medical Center Groningen, Netherlands, 3Pediatric Surgery, Hopitaux Universitaires Geneve, Switzerland, 4 Pediatric Surgery, Erasmus MC, 5Pediatric Surgery, University Medical Center Amsterdam, 6Pediatric Surgery, Maastricht University Medical Centre, 7Pediatric Surgery, Radboud University Medical Center, 8Pediatric Surgery, University Medical Center Utrecht, and 9 Department of Pediatric Gastroenterology and Hepatology, University Medical Center Groningen, Netherlands A choledochal malformation (CM) is a rare biliary entity in the Western world. We gathered all data of children who underwent surgery for CM in the Netherlands between 1989 and 2015. We aimed to identify possible predictive factors associated with complications after surgery. Data was collected on all patients ( < 18 yrs) with a resection. We tested the relation between surgical techniques, age/weight at the time of surgery, presence of a
HPB 2016, 18 (S1), e1ee384
e147
common channel and the development of short- and longterm complications ( < 30days>). In 25 years 96 children underwent surgery for CM (M:F1:2.8). There were 67 Todani type I (70%), two type II (2%), 16 type IVa (17%), one type IVb (1/96, 1%), five type V (5%) and five unknown type (5%). Severe comorbidity was present in four patients (4%). Thirty-one patients (32%) were operated before the age of 1 year. Laparoscopic resection was performed in 12 patients (12%). No malignancy was found (FU 12.9 years 0.1e 25.3). Short-term complications were not different between groups. Long-term complications (cholangitis, stricture, stones, ileus, re-operation) occurred in 17 patients (18%) after a median of 1.4 years (range 0.8e23.01). and were tested univariately. The laparoscopic resection (p = 0.02) and surgery before 1 year of age (p < 0.001) proved to be predictive. The low numbers prohibit the meaningful use of multivariate analysis. In this retrospective pediatric cohort no malignancies were found. Long-term complications occur in almost one fifth of patients. Laparoscopic surgery and surgery before 1 year of age were associated with long-term complications. Odds Ratio
95% confidence interval
Age <24 months
3.4
1.1-10.5
Age <12 months
7.3
2.3-23.5
Laparoscopic technique
4.2
1.1-15.3
Occurrence of a short-term complication
1.2
0.3-4.2
[Risk factors for long-term complications]
TP15 e Talking Poster Session 15 e Liver 4
TP15-1 BILE DUCT AND PORTAL VEIN LIGATION INDUCES FASTER ATROPHY/HYPERTROPHY COMPLEX THAN PVL, AND IMPROVE PROGNOSIS AFTER STAGED HEPATECOMY: BILE ACIDS ACTIVATING FXR SIGNALING PATHWAY W. Ren1 and J. Dong2 1 Hepatobiliary Department, PLA General Hospital, and 2 Tsinghua Medical Center, Beijing Tsinghua Changgung Hospital, China Portal vein ligation (PVL) could induce atrophy/hypertrophy complex (AHC). Bile acid retention could enhance liver regeneration via activating FXR signaling pathway and could induce caspase-3 mediated apoptosis. We hypothesised that simultaneous bile duct and portal vein ligation (BPL) might induce proper bile acid (BA) retention to enhance AHC by promoting the regeneration of the intact liver and apoptosis of the ligated liver. We established rat models of 90% BPL and 90% PVL and found that BPL was well-tolerated and significantly accelerated AHC. The enhanced BA retention in the intact liver promoted