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The use of autologous peritoneal grafts for vascular reconstruction
Electronic Poster Abstracts Introduction: The increasing numbers of high volume centers leaded to a decrease in mortality after PD the last decades. However complications such a post-operative pancreatic fistula (POPF) still occur. Inadequate draining of POPF and abscesses can lead to severe late (>24 h after surgery) hemorrhage (post-pancreatectomy hemorrhage (PPH)). PPH is one of the contributors of post-operative mortality. In earlier days surgical re-intervention was the treatment of choice in case of PPH and the failure to rescue rate was high. A mortality up to 50% of PPH grade C (ISGPS) is reported in literature. Methods and results: Techniques and strategies to manage different types of PPH will be shown. Intra-operative management: Placing a double clip on the gastro-duodenal artery remnant as a guidance during endovascular procedure. Post-operative treatment choices in PPH: How to manage a sentinel bleed in the drain or gastric tube, a decrease in Hb level, and a HD unstable patient. Endovascular tips and tricks: Examples of successful endovascular treated PPH, using the endovascular Atrium v12 Balloon expandable covered stent will be illustrated. Conclusion: A comprehensive sum-up to manage PPH and decrease the failure to rescue rate. Encouragement of a nonoperative endovascular treatment of PPH seems justified.
EPTT-050 THE MANAGEMENT OF LIVER CYSTS. MAS ES MAS. A. Castillo and S. L. Orloff Abdominal Organ Transplant/Hepato-Pancreato-Biliary Surgery, Oregon Health and Science University, United States Background: Liver Cystic lesions including simple liver cysts, polycystic liver disease, cystadenomas and echinococcal cysts are commonly encountered benign lesions. Their incidence vary from 0.01% to 3e5%. Liver cysts are often found during workup of other abdominal diseases and are usually asymptomatic, but when symptoms exist they are due to size, vital structure compression, abnormal liver enzymes, bleeding, and infection. Complications (hemorrhage, infection, torsion, rupture, biliary obstruction, or portal hypertension) are more common in giant cysts (>10 cm). Technique: After a hockey stick incision, liver mobilization of the desired lobe is done. In giant cysts, initial decompression with a purse-string sutured gallbladder trocar is warranted. Fluid is sent for cytologic analysis/ culture. After mobilization and assessment of vasculature and biliary tree proximity with intra-operative ultrasound, the cyst(s) in question are approached. Aspiration by a small fenestration, then partial cyst wall resection (approximately 50%) with linear staplers is performed to prevent wall regrowth. Biliary communications are assessed, over-sewn with 5-0 Maxon, then sclerosis with lap pads soaked in a mix of betadine/5% hydrogen peroxide, or 70% ETOH, for 10 minutes per cavity, careful protection of surrounding tissues is done. Conclusion: Percutaneous/laparoscopic cyst aspiration or simple fenestration have a high rate of recurrence (up to 85% in polycystic liver disease and 29% in simple cyst). Our 20 year experience of >150 cyst treated shows a single recurrence attributed to a complex biliary cystadenoma. Aspiration, partial resection, marsupialization and sclerosis
HPB 2016, 18 (S1), e385ee601
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of liver cysts is an effective and long-term solution to a commonly encountered problem.
EPTT-051 PORTACAVAL SHUNT FOR VENOOCCLUSIVE DISEASE AFTER ALLOGENEIC STEM CELL TRANSPLANTATION FOR THE TREATMENT OF KRABBE DISEASE: AN OLDIE BUT GOODIE A. Castillo, T. Asturias, E. C. Maynard, C. K. Enestvedt and S. L. Orloff Abdominal Organ Transplant/Hepato-Pancreato-Biliary Surgery, Oregon Health and Science University, United States Background: Krabbe disease is an autosomal recessive disorder of deficiency in glactosylceramidase, presenting in newborns with non-specific symptoms. Treatment is stemcell transplantation with a preconditioning regimen that is known to cause veno-occlusive disease (VOD) resulting in portal hypertension. We describe the surgical treatment of VOD. Technique: PCS: patient is positioned in Trendelenburg with modified right lateral decubitus. A Kocher incision is made, an extended Kocher maneuver exposes the retroperitoneum/inferior vena cava (IVC). The supra-renal IVC is mobilized, isolated (ligate the right adrenal vein/lumbar veins). The portal vein (PV) is exposed, mobilized circumferentially (to the level of the pancreatic head). The pre-shunt porta-systemic gradient is measured (assessing the degree of hepatic outflow obstruction). A Satinsky clamp partially occludes the IVC and two angled vascular clamps are applied to the PV. A 2.5 cm elliptical venotomy is cut in the PV and IVC. A side-to-side anastomosis is made with running 5-0 Prolene in the posterior wall and an everting continuous horizontal mattress in the anterior wall. A single interrupted suture is placed just beyond each anastomosic corner to remove tension from the suture line. Post-shunt pressures are measured in the portal and caval side of the anastomosis, a >50 mm saline gradient indicates anastomotic obstruction, which would require revision. Conclusions: PCS is the optimal choice for management of the sequelae of VOD/Budd-Chiari, due to the long-term patency, low morbidity/mortality, and prevention of progressive liver failure. We endorse the strategy of surgical PCS as a long-term solution in patients with VOD.
EPTT-052 THE USE OF AUTOLOGOUS PERITONEAL GRAFTS FOR VASCULAR RECONSTRUCTION S. Balzan1,2, V. Gava3, M. Magalhaes2, A. Schwengber2 and M. Dotto2 1 Digestive Surgery, Moinhos de Vento Hospital, 2University of Santa Cruz do SueUNISC, and 3Oncological Surgery, Moinhos de Vento Hospital, Brazil Introduction: Resection and reconstruction of inferior vena cava (IVC), hepatic veins, or portal vein (PV) is occasionally required in oncological surgery. Venous reconstruction
e600
Electronic Poster Abstracts
is usually by primary repair or autologous venous patch for small defects and with synthetic prostheses after major resections. Venous reconstruction with autologous peritoneal patch or peritoneal tube has been rarely used, despite its advantages compared to synthetic implants. Objective: Description of peritoneal patch and peritoneal tube to reconstruction of IVC, HV, and PV. Method: Five cases of vascular reconstruction using autologous peritoneal grafts. One reconstruction with peritoneal tube (IVC) and 4 reconstructions with peritoneal patch (1 IVC, 1 PV, and 2 HV) are described. Peritoneal tube was made using a syringe as mold to replace a 5 cm IVC sarcoma resection. PV reconstruction was required after resection of a Klatskin tumor with vascular involvement. Middle hepatic vein reconstruction was required in 2 cases after right hepatectomy for colorectal liver metastases with involvement of HV. IVC patch was used to repair defect after retroperitoneal sarcoma resection. Results: Adequate blood flow in the reconstructed vein was confirmed by Doppler and/or contrast enhanced computed tomography. Conclusion: Venous reconstruction with autologous peritoneal graft (peritoneal tube or patch) represent a safe low cost technique and avoid the disadvantages of synthetic prostheses.
EPTT-053 PROXIMAL SPLENOADRENORENAL SHUNT: A SAFE AND EFFECTIVE ALTERNATIVE IN NON CIRRHOTIC PORTAL HYPERTENSION N. Prithiviraj, M. N. Saravanan, A. Agarwal and A. Javed GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India Introduction: Proximal splenorenal shunt (PSRS) is an established option in the management of Non cirrhotic portal hypertension (NCPH) including Extrahepatic portal vein obstruction (EHPVO) and Non cirrhotic portal fibrosis (NCPF).An end to end splenoadrenal shunt (PSARS) has been selectively used at our centre instead of PSRS with the potential advantage of better reach and the avoidance of looping and/or clamping the main left renal vein. We sought to review our experience with PSARS and their outcomes. Methods: Retrospective analysis of consecutive cases of PSARS done between January 2010 and January 2015 from a prospectively maintained database. Demography, preoperative indications, hematologic, endoscopic and Doppler findings, intraoperative data and postoperative outcomes were recorded. Results: Seventeen patients who underwent PSARS formed the study group (12 -EHPVO; 5 -NCPF). Median (range) age of patients was 18 (7e40) years. Bleed was the most common indication seen in 13 (76.5%) patients. Three of 13 patients with hypersplenism were symptomatic; while only 1 out of 8 patients was symptomatic for portal biliopathy. Median (range) adrenal vein size was 6 (4e8) mm. Median (range) intraoperative blood loss was 80 (50e500) ml. Postoperatively 1 patient underwent reexploration for intraabdominal bleed with no perioperative mortality in any of the patients. All patients showed improvement in pancytopenia. Variceal grade decreased in 14 (82.4%) patients with no subsequent rebleed at a median follow up of 32 (8e48) months.
Conclusion: PSARS is a good alternative to PSRS in NCPH when the adrenal vein diameter is reasonable.
EPTT-054 ULTRASONIC SURGICAL ASPIRATOR IN PANCREATIC SURGERY M. N. Saravanan, A. Agarwal and B. G. Vageesh GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India Ultrasonic surgical aspirator has been routinely used in hepatic surgeries. It selectively fragments & aspirates parenchymal tissue while sparing vascular & ductal structures and this property has been used in various extrahepatic surgeries. We describe our experience of three cases, 2 of pancreatic lesion and one residual intrapancreatic choledochal cyst excision using ultrasonic aspirator device. In one of the pancreatic lesion was resected by minimal invasive approach. The modality was extremely useful in carrying out the procedures.
EPTT-055 EUS (ENDOSCOPIC ULTRASOUND) GUIDED FNAC OF THE INTERAORTOCAVAL LYMPH NODE HELPS IN SELECTING PATIENTS FOR CUREATIVE SURGERY IN GALLBLADDER CANCER A. Agarwal, M. N. Saravanan and R. Kalayarasan GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India Involvement of the 16b1 (interaortocaval) lymphnode (LN) in gallbladder cancer (GBC) is considered to represent metastatic disease. IAC nodes are difficult to target percutaneously, especially when small. Routine frozen-section histopathological examination (HPE) of the 16b1 LN is advocated at laparotomy before proceeding for radical cholecystectomy. Endoscopic Ultrasonography (EUS) is a good modality to visualise the interaortocaval region. We routinely utilize EUS in assessing 16b1 lymphnode and thereby avoid laparotomy in cases positive on HPE. Conclusion: Endoscopic Ultasonography is an extremely useful modality to assess involvement of the 16b1 (interaortocaval) lymph node in gallbladder cancer and thereby avoid non therapeutic laparotomy in significant proportion of patients.
EPTT-056 RETRIEVING A LARGE 10 CM LAPAROSCOPIC LIVER RESECTION SPECIMEN THROUGH A SMALL PERIUMBILICAL INCISION A. Agarwal GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India A brief video clip depicts how we removed a large 10 cm HCC from a very small periumbilical incision.
HPB 2016, 18 (S1), e385ee601
EPTT-050 THE MANAGEMENT OF LIVER CYSTS. MAS ES MAS. A. Castillo and S. L. Orloff Abdominal Organ Transplant/Hepato-Pancreato-Biliary Surgery, Oregon Health and Science University, United States Background: Liver Cystic lesions including simple liver cysts, polycystic liver disease, cystadenomas and echinococcal cysts are commonly encountered benign lesions. Their incidence vary from 0.01% to 3e5%. Liver cysts are often found during workup of other abdominal diseases and are usually asymptomatic, but when symptoms exist they are due to size, vital structure compression, abnormal liver enzymes, bleeding, and infection. Complications (hemorrhage, infection, torsion, rupture, biliary obstruction, or portal hypertension) are more common in giant cysts (>10 cm). Technique: After a hockey stick incision, liver mobilization of the desired lobe is done. In giant cysts, initial decompression with a purse-string sutured gallbladder trocar is warranted. Fluid is sent for cytologic analysis/ culture. After mobilization and assessment of vasculature and biliary tree proximity with intra-operative ultrasound, the cyst(s) in question are approached. Aspiration by a small fenestration, then partial cyst wall resection (approximately 50%) with linear staplers is performed to prevent wall regrowth. Biliary communications are assessed, over-sewn with 5-0 Maxon, then sclerosis with lap pads soaked in a mix of betadine/5% hydrogen peroxide, or 70% ETOH, for 10 minutes per cavity, careful protection of surrounding tissues is done. Conclusion: Percutaneous/laparoscopic cyst aspiration or simple fenestration have a high rate of recurrence (up to 85% in polycystic liver disease and 29% in simple cyst). Our 20 year experience of >150 cyst treated shows a single recurrence attributed to a complex biliary cystadenoma. Aspiration, partial resection, marsupialization and sclerosis
HPB 2016, 18 (S1), e385ee601
e599
of liver cysts is an effective and long-term solution to a commonly encountered problem.
EPTT-051 PORTACAVAL SHUNT FOR VENOOCCLUSIVE DISEASE AFTER ALLOGENEIC STEM CELL TRANSPLANTATION FOR THE TREATMENT OF KRABBE DISEASE: AN OLDIE BUT GOODIE A. Castillo, T. Asturias, E. C. Maynard, C. K. Enestvedt and S. L. Orloff Abdominal Organ Transplant/Hepato-Pancreato-Biliary Surgery, Oregon Health and Science University, United States Background: Krabbe disease is an autosomal recessive disorder of deficiency in glactosylceramidase, presenting in newborns with non-specific symptoms. Treatment is stemcell transplantation with a preconditioning regimen that is known to cause veno-occlusive disease (VOD) resulting in portal hypertension. We describe the surgical treatment of VOD. Technique: PCS: patient is positioned in Trendelenburg with modified right lateral decubitus. A Kocher incision is made, an extended Kocher maneuver exposes the retroperitoneum/inferior vena cava (IVC). The supra-renal IVC is mobilized, isolated (ligate the right adrenal vein/lumbar veins). The portal vein (PV) is exposed, mobilized circumferentially (to the level of the pancreatic head). The pre-shunt porta-systemic gradient is measured (assessing the degree of hepatic outflow obstruction). A Satinsky clamp partially occludes the IVC and two angled vascular clamps are applied to the PV. A 2.5 cm elliptical venotomy is cut in the PV and IVC. A side-to-side anastomosis is made with running 5-0 Prolene in the posterior wall and an everting continuous horizontal mattress in the anterior wall. A single interrupted suture is placed just beyond each anastomosic corner to remove tension from the suture line. Post-shunt pressures are measured in the portal and caval side of the anastomosis, a >50 mm saline gradient indicates anastomotic obstruction, which would require revision. Conclusions: PCS is the optimal choice for management of the sequelae of VOD/Budd-Chiari, due to the long-term patency, low morbidity/mortality, and prevention of progressive liver failure. We endorse the strategy of surgical PCS as a long-term solution in patients with VOD.
EPTT-052 THE USE OF AUTOLOGOUS PERITONEAL GRAFTS FOR VASCULAR RECONSTRUCTION S. Balzan1,2, V. Gava3, M. Magalhaes2, A. Schwengber2 and M. Dotto2 1 Digestive Surgery, Moinhos de Vento Hospital, 2University of Santa Cruz do SueUNISC, and 3Oncological Surgery, Moinhos de Vento Hospital, Brazil Introduction: Resection and reconstruction of inferior vena cava (IVC), hepatic veins, or portal vein (PV) is occasionally required in oncological surgery. Venous reconstruction
e600
Electronic Poster Abstracts
is usually by primary repair or autologous venous patch for small defects and with synthetic prostheses after major resections. Venous reconstruction with autologous peritoneal patch or peritoneal tube has been rarely used, despite its advantages compared to synthetic implants. Objective: Description of peritoneal patch and peritoneal tube to reconstruction of IVC, HV, and PV. Method: Five cases of vascular reconstruction using autologous peritoneal grafts. One reconstruction with peritoneal tube (IVC) and 4 reconstructions with peritoneal patch (1 IVC, 1 PV, and 2 HV) are described. Peritoneal tube was made using a syringe as mold to replace a 5 cm IVC sarcoma resection. PV reconstruction was required after resection of a Klatskin tumor with vascular involvement. Middle hepatic vein reconstruction was required in 2 cases after right hepatectomy for colorectal liver metastases with involvement of HV. IVC patch was used to repair defect after retroperitoneal sarcoma resection. Results: Adequate blood flow in the reconstructed vein was confirmed by Doppler and/or contrast enhanced computed tomography. Conclusion: Venous reconstruction with autologous peritoneal graft (peritoneal tube or patch) represent a safe low cost technique and avoid the disadvantages of synthetic prostheses.
EPTT-053 PROXIMAL SPLENOADRENORENAL SHUNT: A SAFE AND EFFECTIVE ALTERNATIVE IN NON CIRRHOTIC PORTAL HYPERTENSION N. Prithiviraj, M. N. Saravanan, A. Agarwal and A. Javed GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India Introduction: Proximal splenorenal shunt (PSRS) is an established option in the management of Non cirrhotic portal hypertension (NCPH) including Extrahepatic portal vein obstruction (EHPVO) and Non cirrhotic portal fibrosis (NCPF).An end to end splenoadrenal shunt (PSARS) has been selectively used at our centre instead of PSRS with the potential advantage of better reach and the avoidance of looping and/or clamping the main left renal vein. We sought to review our experience with PSARS and their outcomes. Methods: Retrospective analysis of consecutive cases of PSARS done between January 2010 and January 2015 from a prospectively maintained database. Demography, preoperative indications, hematologic, endoscopic and Doppler findings, intraoperative data and postoperative outcomes were recorded. Results: Seventeen patients who underwent PSARS formed the study group (12 -EHPVO; 5 -NCPF). Median (range) age of patients was 18 (7e40) years. Bleed was the most common indication seen in 13 (76.5%) patients. Three of 13 patients with hypersplenism were symptomatic; while only 1 out of 8 patients was symptomatic for portal biliopathy. Median (range) adrenal vein size was 6 (4e8) mm. Median (range) intraoperative blood loss was 80 (50e500) ml. Postoperatively 1 patient underwent reexploration for intraabdominal bleed with no perioperative mortality in any of the patients. All patients showed improvement in pancytopenia. Variceal grade decreased in 14 (82.4%) patients with no subsequent rebleed at a median follow up of 32 (8e48) months.
Conclusion: PSARS is a good alternative to PSRS in NCPH when the adrenal vein diameter is reasonable.
EPTT-054 ULTRASONIC SURGICAL ASPIRATOR IN PANCREATIC SURGERY M. N. Saravanan, A. Agarwal and B. G. Vageesh GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India Ultrasonic surgical aspirator has been routinely used in hepatic surgeries. It selectively fragments & aspirates parenchymal tissue while sparing vascular & ductal structures and this property has been used in various extrahepatic surgeries. We describe our experience of three cases, 2 of pancreatic lesion and one residual intrapancreatic choledochal cyst excision using ultrasonic aspirator device. In one of the pancreatic lesion was resected by minimal invasive approach. The modality was extremely useful in carrying out the procedures.
EPTT-055 EUS (ENDOSCOPIC ULTRASOUND) GUIDED FNAC OF THE INTERAORTOCAVAL LYMPH NODE HELPS IN SELECTING PATIENTS FOR CUREATIVE SURGERY IN GALLBLADDER CANCER A. Agarwal, M. N. Saravanan and R. Kalayarasan GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India Involvement of the 16b1 (interaortocaval) lymphnode (LN) in gallbladder cancer (GBC) is considered to represent metastatic disease. IAC nodes are difficult to target percutaneously, especially when small. Routine frozen-section histopathological examination (HPE) of the 16b1 LN is advocated at laparotomy before proceeding for radical cholecystectomy. Endoscopic Ultrasonography (EUS) is a good modality to visualise the interaortocaval region. We routinely utilize EUS in assessing 16b1 lymphnode and thereby avoid laparotomy in cases positive on HPE. Conclusion: Endoscopic Ultasonography is an extremely useful modality to assess involvement of the 16b1 (interaortocaval) lymph node in gallbladder cancer and thereby avoid non therapeutic laparotomy in significant proportion of patients.
EPTT-056 RETRIEVING A LARGE 10 CM LAPAROSCOPIC LIVER RESECTION SPECIMEN THROUGH A SMALL PERIUMBILICAL INCISION A. Agarwal GI Surgery & Liver Transplant, GB Pant Hospital & MAM College, India A brief video clip depicts how we removed a large 10 cm HCC from a very small periumbilical incision.
HPB 2016, 18 (S1), e385ee601