Su1594 Diagnostic Utility of Magnetic Resonance Cholangiopancreatography (MRCP) in Patients With Intermediate Probability of Cholidocholithiasis

Su1591

matched to 116 patients in whom cystic duct was divided between metal clips (MC). Differences in age, gender, race, ASA status, admission diagnosis, as well as in presence of leukocytosis, hyperbilirubinemia, or elevation in pancreatic enzymes were not statistically significant (p.0.05) between LS and MC groups, though LS was used more often in acute compared with elective cases (40% vs. 24%, p=0.05). Compared with MC, average intraoperative blood loss (50 vs 25ml, p ,0.001) and postoperative length of stay (2 vs 1 day, p=0.016) were both significantly greater for LS. When intraoperative cholangiography (IOC) was attempted, successful cannulation was achieved in only 2 of 8 (25%) LS cases, versus 28 of 31 (90%) controls (p ,0.001) . Patients in the LS group required post-operative ERCP for clinically evident post-operative choledocholithiasis at twice the rate of those in the MC group (p=0.009). Controlling for preoperative and demographic factors, LS remained the only statistically significant predictor of requiring postoperative ERCP (OR=4.0, p=0.03). There were no bile duct injuries. Conclusions: Stapling of the cystic duct during laparoscopic cholescystectomy is associated with an increased need for unintended postoperative ERCP. We suspect this is secondary to passage of stone fragments into the common bile duct after crushing by the stapler, or leaving a remnant infundibulum/neck after incomplete dissection and stapling. Prior to using a stapling device, we advocate for more meticulous dissection or conversion to open cholescystectomy in order to complete the operation safely and with minimal postoperative complications.

Diagnostic Accuracy of Preoperative Multidetector-Row Computed Tomography Imaging in Predicting Microscopic Curative Resection of Hepatobiliary and Pancreatic Malignancy: A Prospective Multi-Institutional Study Kazuaki Shimada, Yoshito Takeuchi, Masaru Konishi, Tatsushi Kobayashi, Akio Saiura, Kiyoshi Matsueda, Tsuyoshi Sano, Hideyuki Kanemoto, Katsuhiko Uesaka Purpose: To assess the accuracy of preoperative diagnosis of hepatobiliary and pancreatic malignancy with multidetector-row computed tomography (MDCT) to predict microscopic curative resection. Design and settings: Prospective observational study of hepatobiliary and pancreatic malignancy resected between November 2007 and December 2008, in 5 Cancer Center Hospitals in Japan. Participants: 271 consecutive patients with highly suspected and potential resectable hepatobiliary and pancreatic malignancy undergoing MDCT judged fit for laparotomy were studied. Main outcomes measures: Sensitivity and specificity of MDCT predicting a microscopic curative resection based on the histopathological examination of presence or absence of tumors at the margin of the specimen. Results: 164 patients of 217 macroscopic resectable patients (75.6%) with hepatobiliary and pancreatic malignancy underwent microscopic curative resection. MDCT predicted clear margin resections in 146 patients (89.0%). Sensitivity for prediction of microscopic curative resection by MDCT in perihilar cholangiocarcinoma, gallbladder carcinoma, middle/lower bile duct carcinoma, and pancreatic carcinoma was 64.7%[CI,52.3-78.9%], 90.9%[CI,90.9-97.29%], 95.5%[CI,97.799.1%], and 89.7%[CI,86.3-93.1%], respectively. On the other hand, specificity was 30.8% [CI, 14.5-49.3%], 0%, 33.3% [CI, 14.4-42.4%], and 36.4% [CI, 21.5-51.6%], respectively. Conclusions: Expert radiologists in hepatobiliary and pancreatic disease could not predict microscopic curative resection in patients with perihilar cholangiocarcinoma. Even if MDCT predict a possibility of surgical margin positive resections, surgery seems to be not always contraindicated in hepatobiliary and pancreatic malignancy, because the accurate preoperative diagnosis with MDCT has still remained difficult.

Su1594 Diagnostic Utility of Magnetic Resonance Cholangiopancreatography (MRCP) in Patients With Intermediate Probability of Cholidocholithiasis Hari P. Sayana, Dany Jacob, Mir Fahad Faisal, An-Lin Cheng, Sreenivasa S. Jonnalagadda

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SSAT Abstracts

Elevated Perioperative Serum CA 19-9 Level Is an Independent Predictor of Poor Outcome in Patients With Resectable Cholangiocarcinoma Naru Kondo, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Yasushi Hashimoto, Hayato Sasaki, Kenjiro Okada, Taijiro Sueda Background: Prognosis of cholangiocarcinoma is still unsatisfactory, and identification of predictive marker of survival after surgical resection is important to establish the perioperative therapeutic strategy for cholangiocarcinoma. Impact of perioerative serum carbohydrate antigen 19-9 (CA19-9) levels on survival of patients with resectable cholangiocarcinoma is still unclear. Purpose: The purpose of this study was to investigate whether perioerative serum CA19-9 levels can predict survival of patients underwent surgical resection for cholangiocarcinoma. Methods: One hundred and six patients with cholangiocarcinoma including 33 with intrahepatic, 48 with perihilar and 25 with distal cholangiocarcinoma who underwent surgical resection between 2002 and 2012 were eligible for this study. Preoperative biliary drainage was performed for the patients with obstructive jaundice. Preoperative serum CA199 levels were measured after biliary drainage, and postoperative serum CA19-9 levels were measured about 4 weeks after operation. The relationships between clinicopathological factors including perioperative serum CA19-9 levels and overall survival (OS) were analyzed with univariate and multivariate analyses. Results: Preoperative CA19-9 levels were significantly higher in patients with moderately and poorly differentiated adenocarcinoma than in those with well differentiated adenocarcinoma (P = 0.009), and in patients with UICC stage I/II than those with III/IV (P = 0.008). In contrast, there was no significant difference between postoperative CA19-9 and any other clinicopathological factors. Univariate analysis revealed postoperative adjuvant chemotherapy (P = 0.03), residual tumor factor status (P = 0.01), pathological differentiation (P = 0.02), UICC pT stage (P = 0.009), lymph node metastasis (P , 0.001) and UICC final stage (P = 0.001) were significantly associated with OS. In addition, differences in OS were significant between groups divided on the basis of two preoperative CA19-9 cutoff values (37 and 200 U/ml), and three postoperative CA199 cutoff values (37, 100 and 200 U/ml). In multivariate analysis, no postoperative adjuvant chemotherapy (odds ratio [OR], 3.02: 95% confidence interval [CI], 1.54 - 5.89; P = 0.001), lymph node metastasis (OR, 3.96; 95% CI, 1.91 - 8.48; P , 0.001), preoperative CA19-9 (≥200 IU/ml) (OR, 2.27; 95% CI, 1.10 - 4.61; P = 0.03) and postoperative CA19-9 ( ≥37 IU/ml) (OR, 6.88; 95% CI, 3.36 - 14.41; P , 0.001) were identified as independent predictors for OS. Conclusion: Perioperative serum CA19-9 levels predict the survival of patients with resectable cholangiocarcinoma, and they may contribute to establishment of new therapeutic strategy, as perioperative treatment can be optimized based on its value. Su1593 Stapling the Cystic Duct During Laparoscopic Cholecystectomy Results in Increased Rates of Unintended Post-Operative ERCP Irene Epelboym, Florita Martin, Megan Winner, Zachary L. Gleit, Michael D. Kluger Background: Since the advent of laparoscopic cholescystectomy in 1987, there have not been noteworthy changes in technique for ligation and transection of cystic artery and duct: metal clips and sharp transection. Laparoscopic staplers (LS) have been suggested as a safe alternative in severe inflammation or when the cystic duct appears too wide for complete clip occlusion. We hypothesized an increased rate of adverse postoperative events following use of LS. Methods: All patients who underwent laparoscopic cholecystectomy for biliary colic, cholecystitis, pancreatitis or choledocholithiasis at our institution were identified using billing records. Operative notes were reviewed for use of LS. A 2:1 control group was selected using propensity score matching on age, gender and operative diagnosis. Presenting features, operative characteristics and postoperative outcomes were analyzed. Continuous variables were compared using Student's t-test. Categorical variables were compared using chi-square or Fisher's exact test. Prediction models were constructed using logistic regression. Results: Between 1997 and 2009 , LS was used in 58 (0.9%) of 6272 patients. These were

SSAT Abstracts

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Background: Patients with symptomatic cholelithiasis and suspected choledocholithiasis can be risk stratified into a low ( ,10%), intermediate (10-50%) or high probability ( .50%) of having CBD stone disease based on clinical predictors. Guidelines recommend laparoscopic cholecystectomy for patients with low probability of common bile duct (CBD) stone, preoperative Endoscopic retrograde cholangiopancreatography (ERCP) for high probability of CBD stone and pre-operative Endoscopic ultrasound (EUS) or Magnetic resonance cholangiopancreatography (MRCP) or Intra-operative cholangiography (IOC) for intermediate probability of cholidocholithiasis. In patients with intermediate probability, ERCP is often deferred due to its potential complications and MRCP is commonly performed as EUS is not widely available. However, the diagnostic utility of MRCP in this sub set of patients is not well defined in clinical practice. Methods: Charts of all patients admitted with symptomatic cholelithiasis that had cholecystectomy and underwent prior MRCP for cholidocholithiasis between the periods of Jan 2007 and Oct 2012 at an academic tertiary referral center were reviewed. Of these, patients who met the criteria for intermediate likelihood of CBD stone and underwent preoperative MRCP, IOC or pre/post- operative ERCP were included in the study. Patients with any intrinsic liver disease, or hepato-biliary malignancy or , 18 years of age were excluded. Pertinent demographic, clinical, biochemical and ultrasound parameters were collected by three investigators. Results: Of a total of 330 patients, 125 met the inclusion criteria for intermediate probability and were included in final analysis. Mean age of all patients was 52±21 years with 37 % males (n=46). Eighty four patients had IOC and sixty patients had ERCP. MRCP was positive for CBD stone in only 26.4% of patients (n= 33/125). CBD stone was present in 33% (n=41/125) patients as confirmed by either IOC (n=11/84) or ERCP (n=32/60). False positive rate of MRCP was 36% (12/33) and false negative rate was 21% (n=20/92). Sensitivity and specificity of MRCP in detection of impacted stone was 51% and 85% respectively. Positive predictive and negative predictive values were 63% and 78 % respectively. Conclusion: MRCP has a poor sensitivity in patients with intermediate likelihood of cholidocholithiasis. Intraoperative cholangiography is recommended for definitive evaluation for a residual bile duct stone in this sub group. Su1595 Trends in Liver Biochemistries - Are They a Better Predictors Than MRCP in Evaluation of Patients With Intermediate Probability of Choledocholithiasis? Hari P. Sayana, Dany Jacob, Mir Fahad Faisal, An-Lin Cheng, Sreenivasa S. Jonnalagadda Background: Patients with symptomatic cholelithiasis and suspected choledocholithiasis can be risk stratified into a low ( ,10%), intermediate (10-50%) or high probability ( .50%) based on clinical predictors. Liver biochemistries are the first line tests and any abnormal liver test raises suspicion for impacted common bile duct stone. A bilirubin level . 4 mg/ dl is considered a very strong predictor with high probability of CBD stone ( .50%). Likewise, bilirubin level between 1.8-4 mg/dl along with dilated ducts on ultrasound is considered a very strong predictor. All other abnormal liver biochemistries other than bilirubin are considered moderate predictor with low probability ( ,10%). However, predictive value of liver biochemistry trends in detecting choledocholithiasis in intermediate probability group is not known. Methods: Charts of all patients admitted with symptomatic cholelithiasis that had cholecystectomy and underwent work up including MRCP for CBD stone evaluation between the periods of Jan 2007 and Oct 2012 at a tertiary referral center were reviewed. All patients who received preoperative work up for suspected CBD stone including liver biochemistries on 2 occasions with at least 12 hours apart, and underwent either pre/postoperative endoscopic retrograde cholangiography (ERC) or intraoperative cholangiography (IOC) were included in the study. Patients with any intrinsic liver disease, or hepato-biliary malignancy were excluded. Results: Of a total of 330 patients, 125 met the criteria for intermediate risk group and were included in final analysis. Mean age of all patients was 52±21 years with 37 % males (n=46). MRCP was positive for CBD stone in 26.4% of patients (n=33/125). CBD stone was present in 33% (n=41/125) patients as confirmed by either IOC (n=11/84) or ERCP (n=32/60). Sensitivities, specificities, positive and negative predictive values and accuracy of the tests were calculated for preoperative MRCP, trends in total bilirubin alone, alkaline phosphatase (ALP) alone, AST/ALT alone, total bilirubin in combination with ALP, total bilirubin in combination with AST/ALT, ALP in combination with AST/ ALT, and total bilirubin in combination with ALP and AST/ALT for patients with intermediate risk group and for all patients (Table -1) Conclusion: The sensitivity of an upward trend in hepatic transaminases, alkaline phosphatase and total bilirubin alone and in different combinations is low although some of them are comparable to that of MRCP in detecting