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T1650 Complicated Umbilical Hernias in Cirrhotic Patients With Refractory Ascites: Management and Outcome
T1650
years after liver resection. Survival of patients with non-GI LM was significantly better than in patients with GI LM (5-SURV 52% vs 18%; p<0.02). Survival was also better in marginfree patients without extrahepatic disease (5-SURV 57% vs 26% with residual disease; p<0.01). Conclusions: In selected patients with liver metastasis of various noncolorectal nongastrointestinal malignancies complete tumor resection can result in clearly prolonged survival. Patients with LM from noncolorectal gastrointestinal adenocarcinomas and/or patients with incomplete tumor removal rarely benefit from resection.
Complicated Umbilical Hernias in Cirrhotic Patients With Refractory Ascites: Management and Outcome Dana A. Telem, Thomas Schiano, Celia M. Divino Purpose: To determine optimal management of and outcome following umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites. Methods: A retrospective chart-review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at a single institution from 2002-2008. Univariate, multivariate and Kaplan-Meier analysis was performed. Results: Twenty-one patients had advanced cirrhosis with refractory ascites, of which 15 presented with incarceration and 6 spontaneous umbilical rupture. Fifteen patients were taken to the operating room urgently, and 6 (2 incarceration, 4 umbilical rupture) semi-urgently following placement of a transjugular intrahepatic portosystemic shunt (TIPS). Closed suction drains were utilized in 7 patients. The perioperative mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation and 5 developed ascites related wound complications. Follow-up at a mean of 36-months demonstrated a 20% mortality rate, 5% liver transplantation requirement and 6% hernia recurrence rate. A trend towards decreased wound complications was demonstrated in patients who underwent preoperative TIPS and semi-urgent repair (17% vs. 27%, p=NS). Additionally, TIPS placement postoperatively adequately controlled ascites without additional complication in 2 patients. Use of closed-suction drain versus no drain, did not decrease development of ascites related wound complications (40% vs. 20%, p=0.4), respectively. Following multivariate analysis, spontaneous umbilical rupture was demonstrated to independently correlate with adverse outcome(odds ratio (OR) of 25.0 and 95% confidence interval [1.2-521], p=0.02). Patients with spontaneous umbilical hernia rupture had significantly decreased 36-month transplant-free survival as compared to those with incarcerated hernia (50% vs. 86%, p=0.03). For the 6 patients presenting with umbilical rupture, improved perioperative and 36-month outcome was demonstrated in the 4 patients who underwent preoperative TIPS and semi-urgent repair. Conclusion: Preoperative TIPS placement for patients undergoing semi-elective hernia repair may decrease wound complications, without significantly influencing short or long-term mortality. We recommend semielective umbilical herniorrhaphy with preoperative TIPS placement in cirrhotic patients with refractory ascites when feasible.
T1653 Microwave Ablation (MWA) of Hepatocellular Carcinoma (HCC) David Sindram, Kwan N. Lau, John D. Whitfield, John B. Martinie, David A. Iannitti Introduction: Microwave is an emerging ablation technology in the treatment of HCC. We have used MWA for treatment of HCC with curative intent or as a bridge to transplantation since 2003 clinically. Currently, there are two MWA systems commercially available in the US. We here report our recent experience and short-term follow up. Method: A retrospective analysis in our MWA database was performed. All patients undergoing microwave ablation for HCC were included. Ablations were performed with a 915 MHz or a 2.45 GHz WA system. Results: 32 patients (28 M, 4 F, mean age 59.6 (range 46-83) underwent MWA for HCC from 3/2007 until 9/2009. The 2.45 GHz system was used in 19 patients, the 915 MHz system in 12 patients. Both systems were used in 1 patient. 28 (88%) cases were performed laparoscopically and 4 open. Average tumor size was 3.24cm (range 0.7-8cm). Using the 2.45 GHz system, 26 tumors were ablated with 51 applications, mean tumor size 3.3 cm, averaging 1.9 applications/tumor. The 915 MHz system was applied 32 times to 14 tumors, mean tumor size 3.1 cm, averaging 2.3 applications/tumor. One patient, undergoing a combination of liver resection and ablation died from a transection bed bleed. There was no other significant morbidity or mortality. Follow-up was obtained through 10/2009. Mean follow-up was 7.5 months (range 1-20 months). One patient was lost to follow-up. One local recurrence was noted at 15 months, and was re-ablated percutaneously. There were 4 regional recurrences at an average of 9.7 months. 2 patients were transplanted, 2 and 3 months respectively after ablation. The explants did not contain any viable tumor. Six patients died at an average of 5.5 months, without evidence of HCC. Conclusion: Microwave ablation is a safe and effective modality in the treatment of HCC, with limited morbidity in a high-risk patient population. Most patients can be treated with minimally invasive techniques.
T1651 Soft Tissue Navigation: An Ex-Vivo Porcine Liver Model for Multimodality Imaging of Deformations to Validate Techniques for Image-Guided Liver Surgery Anne vom Berg, Matthias Peterhans, Stefan Weber, Daniel Inderbitzin, Daniel Candinas, Lutz P. Nolte
T1654
Objective: Our investigations on a porcine liver model adress the integration of a clinically applicable navigation system for enhancing spatial orientation during complex hepatic resections. Methods: The system being developed consists of an interface to preoperative planning (MeVis Distant Services) and contains an integrated ultrasound transducer (Terasion 8lOA), and an optical tracking system (NDI Vicra/Atracsys InfiniTrack) for spacial referencing of transducers and surgical instruments. The navigated ultrasound is used for acquiring 3Dinformation on organ motion during surgery for updating the planning data. The actualised planning datasets are then visualised together with navigated surgical tools. This enables tool guidance and provision of information on the location of critical structures. For data aquisition controlled deformations were induced on porcine livers with simulated blood flow during image aquisition by CT scanner. Ultrasound images were acquired using a calibrated and optically tracked ultrasound probe. From the resulting CT datasets, portal and hepatic veins where segmented semi-automatically using a 2D region-growing algorithm. Surface models were created and vessel centerlines were calculated using a skeletonization algorithm. The ultrasound images were segmented using our automatic vessel segmentation algorithm which provides a parametric vessel representation. Results: The deformation predicted from ultrasound imaging can be validated quantitatively using the corresponding CT dataset to develop an integrated hardware/software framework for navigation and interactive display. Conclusion: Computer assisted surgery is the future of liver surgery by combining CT scans with real time ultrasound images allowing the surgeon to identify the exact position of surgical instruments
Background: Despite its benign nature, hepatocellular adenomas (HA) have a potential for malignant degeneration or spontaneous rupture and bleeding. Surgical resection has been the treatment of choice for the management of HA in selected patients. However, radiofrequency ablation (RFA) could offer a viable alternative, and might prevent these patients from undergoing major hepatic surgery with associated morbidity and costs. Objective: To investigate the safety and efficacy of RFA for the treatment of HA Methods: From 2000 to 2009, 168 patients diagnosed with HA in a tertiary hepato-biliary centre were included in a database. Medical records of patients undergoing RFA were retrieved and clinicopathologic data with regard to diagnosis, treatment and outcome were collected and analyzed. RFA was considered successful if no residual HA tissue could be visualized on contrast enhanced CT or MRI scan 4-6 weeks post-RFA. Results: Of 61 patients undergoing treatment for HA, 17 patients (28%) underwent RFA for HA. Mean age was 29 years. All patients were female and had a history of hormonal contraceptive use, which was discontinued at the time of diagnosis. Nine patients (53%) had multiple HA, with a median number of 2 lesions (range 1-10) per patient. Median size of the largest HA at the time of diagnosis was 4.3 cm (range 2.3-14.0) and median size of the largest HA at the time of RFA was 3.9 cm (range 1.5-6.7). A total of 39 lesions were ablated in 25 sessions (open n=5, percutaneous n=20). RFA was successful at the first attempt in 4 patients (24%). Seven patients underwent additional sessions of RFA resulting in adequate treatment in 4 patients (24%). Five patients (29%) had radiological evidence of small residual HA tissue (≤15 mm) bordering the thermal lesion, but due to low clinical importance no further treatment was administered. All of these lesions have remained stable or regressed during follow-up. Four patients are currently awaiting further therapy or follow-up. Post-operatively, one patient developed a liver abscess requiring re-intervention and one patient suffered from a major but reversible complication related to concomitant hemi-hepatectomy. Median hospital stay was 7 days in the open group and 2 days in the percutaneous group. Conclusion: HA can be safely treated using both open and percutaneous RFA. However, multiple sessions are often required and signs of residual adenoma might persist in some patients despite repetitive treatment. RFA might be especially beneficial for patients not amenable for surgery or those that would require major hepatic resection otherwise.
T1652 Results of Hepatectomy for Noncolorectal, Nonneuroendocrine Liver Metastasis Oliver Drognitz, Hannes P. Neeff, Tobias Keck, Oliver G. Opitz, Ulrich T. Hopt, Frank Makowiec Liver resection has gained wide acceptance in selected patients with colorectal liver metastasis. However the role of hepatectomy for noncolorectal liver metastasis (LM) is less well defined because of the scarcity of published data and the inhomogenity of underlying malignancies. In this study we present our perioperative and survival data of 77 patients undergoing liver resection for noncolorectal, nonneuroendocrine LM during the last decade. Methods: Since 1999 77 patients (61% female, median age 61 years) underwent liver resection for noncolorectal nonneuroendocrine LM at our institution. The origin of tumors were classified as gastrointestinal adenocarcinomas (GI; n=18; 23%, consisting of pancreatic, esophageal or gastric primaries) or non-gastrointestinal (non-GI; n=59; 77%, consisting of 12 breast cancers, 9 renal cancers, 6 melanomas, 6 ovarian cancers and 26 other or unknown primaries). Perioperative and outcome data were documented prospectively (hepatic database). Median postoperative follow-up was 1.6 (up to 9.9) years. Survival information was available in 73 patients. Results: Of 77 hepatectomies 33% were wedge resections, 27% segmental resections and 40% normal or extended hemihepatectomies. Mortality was 3/77 (3.9%) and total morbidity 46%. 4 patients (5%) developed liver failure, and 8 (10%) required relaparotomy for complications. Hepatic resection led to free hepatic margins in 72%. Overall 5- year survival (5-SURV) was 44%. Of 9 patients surviving more than 5 years 8 are still alive up to 9.9
T1655 Differences Between Bipolar-Compression and Ultrasonic Devices for Parenchymal Transection During Laparoscopic Liver Resection Russell E. Brown, Matthew Bower, Charles R. Scoggins, Kelly M. McMasters, Robert C. Martin BACKGROUND: Laparoscopic liver resection has become a safe and essential technique in the management of hepatic tumors. Multiple options for parenchymal transection techniques exist; however, none has emerged as superior. We aimed to compare operative characteristics and outcomes between bipolar-compression and ultrasonic devices used for parenchymal transection during laparoscopic liver resection. METHODS: Review of a prospective hepatopancreato-biliary database from December 2002 to August 2009 identified 54 patients who
S-887
SSAT Abstracts
SSAT Abstracts
Radiofrequency Ablation for Hepatocellular Adenoma: End of the Resection Era? Mark G. van Vledder, Sanne M. van Aalten, Turkan Terkivatan, Robert A. De Man, Trude C. Leertouwer, Jan N. IJzermans
years after liver resection. Survival of patients with non-GI LM was significantly better than in patients with GI LM (5-SURV 52% vs 18%; p<0.02). Survival was also better in marginfree patients without extrahepatic disease (5-SURV 57% vs 26% with residual disease; p<0.01). Conclusions: In selected patients with liver metastasis of various noncolorectal nongastrointestinal malignancies complete tumor resection can result in clearly prolonged survival. Patients with LM from noncolorectal gastrointestinal adenocarcinomas and/or patients with incomplete tumor removal rarely benefit from resection.
Complicated Umbilical Hernias in Cirrhotic Patients With Refractory Ascites: Management and Outcome Dana A. Telem, Thomas Schiano, Celia M. Divino Purpose: To determine optimal management of and outcome following umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites. Methods: A retrospective chart-review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at a single institution from 2002-2008. Univariate, multivariate and Kaplan-Meier analysis was performed. Results: Twenty-one patients had advanced cirrhosis with refractory ascites, of which 15 presented with incarceration and 6 spontaneous umbilical rupture. Fifteen patients were taken to the operating room urgently, and 6 (2 incarceration, 4 umbilical rupture) semi-urgently following placement of a transjugular intrahepatic portosystemic shunt (TIPS). Closed suction drains were utilized in 7 patients. The perioperative mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation and 5 developed ascites related wound complications. Follow-up at a mean of 36-months demonstrated a 20% mortality rate, 5% liver transplantation requirement and 6% hernia recurrence rate. A trend towards decreased wound complications was demonstrated in patients who underwent preoperative TIPS and semi-urgent repair (17% vs. 27%, p=NS). Additionally, TIPS placement postoperatively adequately controlled ascites without additional complication in 2 patients. Use of closed-suction drain versus no drain, did not decrease development of ascites related wound complications (40% vs. 20%, p=0.4), respectively. Following multivariate analysis, spontaneous umbilical rupture was demonstrated to independently correlate with adverse outcome(odds ratio (OR) of 25.0 and 95% confidence interval [1.2-521], p=0.02). Patients with spontaneous umbilical hernia rupture had significantly decreased 36-month transplant-free survival as compared to those with incarcerated hernia (50% vs. 86%, p=0.03). For the 6 patients presenting with umbilical rupture, improved perioperative and 36-month outcome was demonstrated in the 4 patients who underwent preoperative TIPS and semi-urgent repair. Conclusion: Preoperative TIPS placement for patients undergoing semi-elective hernia repair may decrease wound complications, without significantly influencing short or long-term mortality. We recommend semielective umbilical herniorrhaphy with preoperative TIPS placement in cirrhotic patients with refractory ascites when feasible.
T1653 Microwave Ablation (MWA) of Hepatocellular Carcinoma (HCC) David Sindram, Kwan N. Lau, John D. Whitfield, John B. Martinie, David A. Iannitti Introduction: Microwave is an emerging ablation technology in the treatment of HCC. We have used MWA for treatment of HCC with curative intent or as a bridge to transplantation since 2003 clinically. Currently, there are two MWA systems commercially available in the US. We here report our recent experience and short-term follow up. Method: A retrospective analysis in our MWA database was performed. All patients undergoing microwave ablation for HCC were included. Ablations were performed with a 915 MHz or a 2.45 GHz WA system. Results: 32 patients (28 M, 4 F, mean age 59.6 (range 46-83) underwent MWA for HCC from 3/2007 until 9/2009. The 2.45 GHz system was used in 19 patients, the 915 MHz system in 12 patients. Both systems were used in 1 patient. 28 (88%) cases were performed laparoscopically and 4 open. Average tumor size was 3.24cm (range 0.7-8cm). Using the 2.45 GHz system, 26 tumors were ablated with 51 applications, mean tumor size 3.3 cm, averaging 1.9 applications/tumor. The 915 MHz system was applied 32 times to 14 tumors, mean tumor size 3.1 cm, averaging 2.3 applications/tumor. One patient, undergoing a combination of liver resection and ablation died from a transection bed bleed. There was no other significant morbidity or mortality. Follow-up was obtained through 10/2009. Mean follow-up was 7.5 months (range 1-20 months). One patient was lost to follow-up. One local recurrence was noted at 15 months, and was re-ablated percutaneously. There were 4 regional recurrences at an average of 9.7 months. 2 patients were transplanted, 2 and 3 months respectively after ablation. The explants did not contain any viable tumor. Six patients died at an average of 5.5 months, without evidence of HCC. Conclusion: Microwave ablation is a safe and effective modality in the treatment of HCC, with limited morbidity in a high-risk patient population. Most patients can be treated with minimally invasive techniques.
T1651 Soft Tissue Navigation: An Ex-Vivo Porcine Liver Model for Multimodality Imaging of Deformations to Validate Techniques for Image-Guided Liver Surgery Anne vom Berg, Matthias Peterhans, Stefan Weber, Daniel Inderbitzin, Daniel Candinas, Lutz P. Nolte
T1654
Objective: Our investigations on a porcine liver model adress the integration of a clinically applicable navigation system for enhancing spatial orientation during complex hepatic resections. Methods: The system being developed consists of an interface to preoperative planning (MeVis Distant Services) and contains an integrated ultrasound transducer (Terasion 8lOA), and an optical tracking system (NDI Vicra/Atracsys InfiniTrack) for spacial referencing of transducers and surgical instruments. The navigated ultrasound is used for acquiring 3Dinformation on organ motion during surgery for updating the planning data. The actualised planning datasets are then visualised together with navigated surgical tools. This enables tool guidance and provision of information on the location of critical structures. For data aquisition controlled deformations were induced on porcine livers with simulated blood flow during image aquisition by CT scanner. Ultrasound images were acquired using a calibrated and optically tracked ultrasound probe. From the resulting CT datasets, portal and hepatic veins where segmented semi-automatically using a 2D region-growing algorithm. Surface models were created and vessel centerlines were calculated using a skeletonization algorithm. The ultrasound images were segmented using our automatic vessel segmentation algorithm which provides a parametric vessel representation. Results: The deformation predicted from ultrasound imaging can be validated quantitatively using the corresponding CT dataset to develop an integrated hardware/software framework for navigation and interactive display. Conclusion: Computer assisted surgery is the future of liver surgery by combining CT scans with real time ultrasound images allowing the surgeon to identify the exact position of surgical instruments
Background: Despite its benign nature, hepatocellular adenomas (HA) have a potential for malignant degeneration or spontaneous rupture and bleeding. Surgical resection has been the treatment of choice for the management of HA in selected patients. However, radiofrequency ablation (RFA) could offer a viable alternative, and might prevent these patients from undergoing major hepatic surgery with associated morbidity and costs. Objective: To investigate the safety and efficacy of RFA for the treatment of HA Methods: From 2000 to 2009, 168 patients diagnosed with HA in a tertiary hepato-biliary centre were included in a database. Medical records of patients undergoing RFA were retrieved and clinicopathologic data with regard to diagnosis, treatment and outcome were collected and analyzed. RFA was considered successful if no residual HA tissue could be visualized on contrast enhanced CT or MRI scan 4-6 weeks post-RFA. Results: Of 61 patients undergoing treatment for HA, 17 patients (28%) underwent RFA for HA. Mean age was 29 years. All patients were female and had a history of hormonal contraceptive use, which was discontinued at the time of diagnosis. Nine patients (53%) had multiple HA, with a median number of 2 lesions (range 1-10) per patient. Median size of the largest HA at the time of diagnosis was 4.3 cm (range 2.3-14.0) and median size of the largest HA at the time of RFA was 3.9 cm (range 1.5-6.7). A total of 39 lesions were ablated in 25 sessions (open n=5, percutaneous n=20). RFA was successful at the first attempt in 4 patients (24%). Seven patients underwent additional sessions of RFA resulting in adequate treatment in 4 patients (24%). Five patients (29%) had radiological evidence of small residual HA tissue (≤15 mm) bordering the thermal lesion, but due to low clinical importance no further treatment was administered. All of these lesions have remained stable or regressed during follow-up. Four patients are currently awaiting further therapy or follow-up. Post-operatively, one patient developed a liver abscess requiring re-intervention and one patient suffered from a major but reversible complication related to concomitant hemi-hepatectomy. Median hospital stay was 7 days in the open group and 2 days in the percutaneous group. Conclusion: HA can be safely treated using both open and percutaneous RFA. However, multiple sessions are often required and signs of residual adenoma might persist in some patients despite repetitive treatment. RFA might be especially beneficial for patients not amenable for surgery or those that would require major hepatic resection otherwise.
T1652 Results of Hepatectomy for Noncolorectal, Nonneuroendocrine Liver Metastasis Oliver Drognitz, Hannes P. Neeff, Tobias Keck, Oliver G. Opitz, Ulrich T. Hopt, Frank Makowiec Liver resection has gained wide acceptance in selected patients with colorectal liver metastasis. However the role of hepatectomy for noncolorectal liver metastasis (LM) is less well defined because of the scarcity of published data and the inhomogenity of underlying malignancies. In this study we present our perioperative and survival data of 77 patients undergoing liver resection for noncolorectal, nonneuroendocrine LM during the last decade. Methods: Since 1999 77 patients (61% female, median age 61 years) underwent liver resection for noncolorectal nonneuroendocrine LM at our institution. The origin of tumors were classified as gastrointestinal adenocarcinomas (GI; n=18; 23%, consisting of pancreatic, esophageal or gastric primaries) or non-gastrointestinal (non-GI; n=59; 77%, consisting of 12 breast cancers, 9 renal cancers, 6 melanomas, 6 ovarian cancers and 26 other or unknown primaries). Perioperative and outcome data were documented prospectively (hepatic database). Median postoperative follow-up was 1.6 (up to 9.9) years. Survival information was available in 73 patients. Results: Of 77 hepatectomies 33% were wedge resections, 27% segmental resections and 40% normal or extended hemihepatectomies. Mortality was 3/77 (3.9%) and total morbidity 46%. 4 patients (5%) developed liver failure, and 8 (10%) required relaparotomy for complications. Hepatic resection led to free hepatic margins in 72%. Overall 5- year survival (5-SURV) was 44%. Of 9 patients surviving more than 5 years 8 are still alive up to 9.9
T1655 Differences Between Bipolar-Compression and Ultrasonic Devices for Parenchymal Transection During Laparoscopic Liver Resection Russell E. Brown, Matthew Bower, Charles R. Scoggins, Kelly M. McMasters, Robert C. Martin BACKGROUND: Laparoscopic liver resection has become a safe and essential technique in the management of hepatic tumors. Multiple options for parenchymal transection techniques exist; however, none has emerged as superior. We aimed to compare operative characteristics and outcomes between bipolar-compression and ultrasonic devices used for parenchymal transection during laparoscopic liver resection. METHODS: Review of a prospective hepatopancreato-biliary database from December 2002 to August 2009 identified 54 patients who
S-887
SSAT Abstracts
SSAT Abstracts
Radiofrequency Ablation for Hepatocellular Adenoma: End of the Resection Era? Mark G. van Vledder, Sanne M. van Aalten, Turkan Terkivatan, Robert A. De Man, Trude C. Leertouwer, Jan N. IJzermans