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HPB
VOLUME 17
VOLUME 17
SUPPLEMENT 1
FEBRUARY 2015
PAGES 186
IN THIS ISSUE
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Editorial Board
P. Allen, USA
C. Bassi, Italy
K. Behrns, USA
J. Belghiti, France
G. Belli, Italy
M. G. H. Besselink, the Netherlands
A. Biankin, UK
M. Buechler, Germany
I. Di Carlo, Italy
R. Carter, UK
W. Chapman, USA
R. Chari, USA
M.-F. Chen, Taiwan
M. Choti, USA
J. Christein, USA
C. Christophi, Australia
Editors
M. P. Callery, USA
S. J. Connor, New Zealand
S. J. Wigmore, UK
Assistant Editors
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R. M. Minter, USA
A. Hemming, USA
T. J. Howard, USA
J. Izbicki, Germany
P. Jagannath, India
W. Jarnagin, USA
N. Kokudo, Japan
M. Krawczyk, Poland
P. Lai, China
J. Lendoire, Argentina
D. Mahvi, USA
M. Makuuchi, Japan
R. Martin, USA
J. McCall, New Zealand
M. Mercado, Mexico
D. Nagorney, USA
R. Padbury, Australia
T. Pappas, USA
R. Parks, UK
T. Pawlik, USA
W. Pinson, USA
H. Pitt, USA
M. Rees, UK
M. Ryska, Czech Republic
R. Schulick, USA
M. Selzner, Canada
M. Smith, South Africa
T. Takada, Japan
J. Tseng, USA
T. van Gulik, the Netherlands
B. Visser, USA
C. Vollmer, USA
J. Windsor, New Zealand
Aims and Scope. HPB is an international forum for clinical, scientific and educational communication. Twelve issues a year bring the reader leading articles, expert
reviews, original articles, images, editorials, and reader correspondence encompassing all aspects of benign and malignant hepatobiliary disease and its management.
HPB features relevant aspects of clinical and translational research and practice.
Specific areas of interest include HPB diseases encountered globally by clinical practitioners in this specialist field of gastrointestinal surgery. The journal addresses the
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benign conditions such as acute and chronic pancreatitis, and those relating to hepatobiliary infection and inflammation are also welcomed. There will be a focus on
developing a multidisciplinary approach to diagnosis and treatment with endoscopic
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will be of interest to specialists involved in the management of hepatobiliary
and pancreatic disease however will also inform those working in related fields.
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HPB
CONTENTS
Abstracts
Author Index
ABSTRACTS
FRIDAY, MARCH 13, 2015,
7:00AM8:00AM
PRESIDENTIAL PLENARY
PP.01 DEFINING THE PRACTICE OF
PANCREATODUODENECTOMY AROUND
THE WORLD
M. T. McMillan1, M. H. Sprys1, G. Malleo2, C. Bassi2,
C. M. Vollmer1
1
University Of Pennsylvania Perelman School Of Medicine,
Philadelphia, PA; 2University Of Verona, Verona, VERONA
Introduction: Pancreatoduodenectomy (PD) is a technically challenging operation characterized by numerous
management decisions. We hypothesize that there is significant variation in the contemporary global practice of
pancreatoduodenectomy.
Methods: A survey with native-language translation was
distributed to members of six international GI surgical societies (including AHPBA and IHPBA). Practice patterns and
surgical decision-making for PD were assessed. To evaluate
global variance, regions were clustered: North America,
South America/Mexico, Asia/Australia, and Europe/Africa.
Results: Surveys were completed by 864 surgeons, representing six continents and seven languages. Median age and
experience were 46 and 14 years. Surgeons performed a
median of 13 PDs in the past calendar year, and reported a
median career experience of 90, with only 54% surpassing
the published learning curve (>60). Significant regional differences were observed for annual and career PD volumes
(P < 0.001). Only 4% of respondents practice pancreas
surgery exclusively, but 57% perform HPB surgery
only greatest in Asia/Australia (70%, P < 0.0001). Worldwide, the preferred form of anastomotic reconstruction was
pancreaticojejunostomy (88%); however, this choice was
more common in North America compared with Europe/
Africa (97 vs. 81%, P < 0.0001). Regional variability was
also evident in terms of suture technique, stent use/type,
drain use/type/number, as well as the use of octreotide, sealants, and autologous patches (P < 0.02 for all). In particular,
there were stark differences in practice between North and
South American surgeons (Table).
Conclusion: Globally, there is significant variability in the
practice of pancreatoduodenectomy. Many of these choices
contrast with established randomized evidence and may contribute to variance in outcomes.
Abstracts
PP.04 INTRAHEPATIC
CHOLANGIOCARCINOMA AND
GALLBLADDER CANCER:
DISTINGUISHING MOLECULAR
PROFILES TO GUIDE
POTENTIAL THERAPY
M. Potkonjak, J. Miura, K. K. Turaga, F. M. Johnston,
S. Tsai, K. Christians, T. C. Gamblin
Division Of Surgical Oncology, Department Of Surgery,
Medical College Of Wisconsin, Milwaukee, WI
Chemotherapy regimens according to National Comprehensive Cancer Network (NCCN) guidelines for intrahepatic
cholangiocarcinoma (IHC) and gallbladder adenocarcinoma
HPB 2015, 17 (Suppl. 1), 181
Abstracts
(GC) are interchangeable; however, the molecular differences driving tumorigenesis for these cancers remain poorly
defined. The present study utilized biomarker analysis of
actionable targets for IHC and GC to distinguish them and
potentially refine current treatment strategies.
217 IHC and 28 GC specimens referred to Caris Life Sciences between 2009 thru 2012 were evaluated. Specific
testing by immunohistochemical analysis for 17 different
biomarkers was performed. In the collective cohort
(n = 245), actionable targets included: 95% low TS, 82% low
RMM1, and 74% low ERCC1, indicating potential susceptibility to fluoropyrimidines/capecitabine, gemcitabine, and
platinum agents, respectively. Additional non-NCCN compendium targets included TOPO1 (53.3% high, irinotecan),
MGMT (50.3% low, temozolomide), TOP2A (33% high,
anthracyclines), and PGP (30.1% low, taxanes). Subgroup
analysis by tumor origin demonstrated a differential
biomarker expression pattern with a higher frequency of IHC
tumors showing low levels of TS (99% vs. 72%, p < 0.0001),
and RRM1 (85% vs. 64%, p = 0.021) when compared to GC.
Conversely a greater frequency of GC demonstrated high
levels of TOPO1 (76% vs. 50%, p = 0.018) versus IHC,
indicating a potential increased benefit from irinotecan.
Biomarker analysis possesses the capacity to identify additional targets for which established agents are available. Differences in molecular profiles of IHC and GC provide
evidence that the two are distinct diseases and require different treatments.
Abstracts
Abstracts
IRE near the portal vein, and plastic stenting should be considered when performing IRE near the common bile duct.
IRE is a potentially crucial tool in the arsenal of surgeons
treating otherwise inoperable pancreatic cancer.
LO-A.04 IRREVERSIBLE
ELECTROPORATION (NANOKNIFE) FOR
PANCREATIC CANCER: A SINGLE
INSTITUTION SERIES OF 50
CONSECUTIVE PATIENTS
K. Mahendraraj, I. Epelboym, B. Schrope, J. A. Chabot,
M. D. Kluger
Department Of Surgery, College Of Physicians And
Surgeons, Columbia University Medical Center, New York,
NEW YORK
Introduction: The NanoKnife irreversible electroporation
system (IRE) uses electrical energy to destroy neoplastic
tissue invading surrounding neurovascular structures. Large
scale IRE for pancreatic cancer has yet to be reported. This
study examines a large cohort of IRE-treated pancreatic
cancer patients to evaluate the safety of this novel surgical
approach.
Methods: Data was abstracted on all T3 and T4 pancreatic
cancer patients who underwent IRE at a tertiary hepatobiliary
unit from 20122014. Standard statistical methodology was
used.
Results: 50 consecutive patients were treated with IRE by 3
pancreatic surgeons, with 36(72%) cases performed by a
single surgeon. Mean patient age was 65.8 7.8 years, with
31(62%) male patients. There were 45(90%) adenocarcinoma cases, most commonly involving the pancreatic head
(n = 16;32%) or body (n = 16;32%). IRE was used for
primary local control in 25(50%) cases and margin ablation
in 21(42%). Median survival was 11.8 6.2 months. Median
follow-up was 7.8 9.6 months, with length of stay
7.34 5.6 days and readmission rate of 20%(n = 10). 30- and
90-day complication rates were 36%(n = 18) and 6%(n = 3),
most commonly portal vein thrombosis(n = 4;8%), intraabdominal collection(n = 3;6%), and anemia requiring
transfusion(n = 3;6%). Overall mortality attributable to IRE
was 6%(n = 3). 3 additional mortalities were related to
disease progression.
Conclusions: IRE offers a feasible technique to manage
advanced pancreatic cancer. To reduce morbidity and mortality, anticoagulation should be considered when performing
HPB 2015, 17 (Suppl. 1), 181
Abstracts
including surgery vs. 11.7 months for the 66 pts not resected.
Among the 164 pts who completed all therapy, no difference
in median survival was observed between low CA199 and
elevated CA19-9 pts; 36.7 months vs. 33.1 months, p = 0.89.
Conclusions: An elevated CA19-9 at diagnosis did not
predict a failure to complete neoadjuvant therapy and was not
associated with inferior survival. These data suggest two
cautionary notes: an elevated CA19-9 at diagnosis should not
be considered synonymous with advanced (non-surgical)
disease; and, a low/normal CA19-9 should not be interpreted
as a predictor of favorable outcome (and used to justify a
surgery first strategy).
Abstracts
Abstracts
Abstracts
LO-C.02 INTRAOPERATIVE
HYPOTENSION DURING LIVER
TRANSPLANTATION IS ASSOCIATED
WITH DECREASED ONE YEAR PATIENT
AND GRAFT SURVIVAL
P. F. Sauer, D. A. DuBay, P. A. MacLennan,
J. H. Crawford, J. A. White, S. H. Gray, D. E. Eckhoff
University Of Alabama At Birmingham, Birmingham, AL
Introduction: Patients with end-stage liver disease experience peripheral vasodilatation and have lower mean arterial
blood pressure (MAP) at baseline. However, it is unclear how
intraoperative hypotension effects post-liver transplant
patient and graft survival. We hypothesized that increased
duration of MAP <60 mmHg (MAP <60) was associated
with decreased patient survival.
Methods: A retrospective study of adult liver transplant
patients from a single center was performed. Anesthesia
records were used to quantify the intraoperative duration of
MAP <60. Patients were stratified into 3 groups based on
cumulative duration MAP <60: <30 minutes, 3059 minutes
and 60+ minutes. Blood product usage, length of hospitalization, vasoactive drug administration, and 1-year patient
and graft survival were measured. MAP <60 duration groups
were compared using ANOVA, Chi-square tests, and LogRank tests for continuous and categorical variables, and survival curves, respectively.
Results: Overall 565 patients were included: <30 minutes
(N = 461, 81.6%), 3059 minutes (N = 42, 7.4%), and 60+
minutes (N = 62, 11.0%). Patients in the 60+ minutes group
had the highest MELD score (27.7, p = 0.0051), received
the most units of pRBCs (5.5, p < 0.0001), FFP (2.96,
p < 0.0001), platelets (1.5, p < 0.0001) and intravenous phenylephrine (14487 g, p < 0.0001), and had the lowest 1-year
patient (72.2%, p = 0.0060) and graft survival (72.2%,
p = 0.0063)(Table).
Conclusion: Intraoperative hypotension, i.e., MAP <60, for
60+ minutes was associated with increased intraoperative
phenylephrine, blood product usage, and decreased 1-year
patient and graft survival. Surgical technique, anesthetic
management, and the avoidance of hypotension are critically
important for patient outcomes.
10
Abstracts
Abstracts
Conclusions: Donor-recipient gender discordance does not
impact both GS and OS following LDLT. Living donor organ
allocation in an era of supply limitation should not be influenced by donor gender.
LO-C.06 RECCURRENT
HEPATOCELLULAR CANCER AFTER
LIVER TRANSPLANTION: THE ROLE OF
LIVER-DIRECTED THERAPY
V. Donchev, G. Voidonikolas, M. Sheckley, A. Annamalai,
I. Kim, A. Klein, A. Wachsman, M. Friedman,
S. Colquhoun, N. Nissen
Cedars-Sinai Medical Center, Los Angeles, CA
Introduction: Recurrence of hepatocellular cancer (HCC)
after liver transplant (LT) generally carries a poor prognosis.
We reviewed our experience to determine the role of liverdirected treatments.
Methods: Retrospective review of 10-year single center
experience. All patients were within radiographic Milan criteria for HCC at the time of LT. Of 201 patients undergoing
LT for HCC, 29 (14%) were identified with HCC recurrence.
Results: Mean and median time to recurrence after LT was
24 +/ 4 mo. and 15 mo. (range 3160 mo.) respectively.
Explant pathology showed that most patients (26/29) had
pathologic staging exceeding Milan criteria. The initial
recurrence was liver-only in 7 patients (24%), liver-dominant
in 5 patients (17%) and systemic in 17 patients (59%). Time
to recurrence was greatest in the liver-only group at mean
34 mo., followed by mean 24 mo. in the liver-dominant
group and mean 14 mo. in systemic group. Patients with
liver-only or liver-dominant tumor underwent a total of 57
loco-regional treatments (range 114). There were 3 significant treatment-related complications.
Survival: Mean survival after tumor recurrence in all
patients was 15 +/ 4 mo. The 1 and 3 year survival after
recurrence was 62% and 21% respectively. Patients undergoing liver-directed therapy had improved survival compared to
the remainder of patients (25 mo. vs 14 mo., p < .05, figure).
Conclusions: HCC recurrence after LT is heterogeneous.
Almost all recurrences are in patients with poor explant
pathology. Aggressive liver-directed therapies are safe and
effective in patients with liver-dominant recurrence and can
lead to improved survival.
11
12
Abstracts
ence in OS according to the presence of IPMN at margin (96
vs 123 months, p = 0.18). However, when present, degree of
IPMN dysplasia at the margin (low vs moderate vs high vs
invasive) impacted OS (84 vs 8 vs 13 vs 9 months, respectively p = 0.002). In addition, topography of positive margin
in the ductal system (main vs branch vs mixed) impacted
DFS (19 vs 65 vs 34 months, respectively p = 0.009).
Conclusion: Positive margin status in main-duct involved
IPMN may have effects on patient survival. Involvement of
the main duct at the margin, and higher degrees of IPMN
dysplasia at the margin predict a worse survival. Total pancreatectomy may need careful consideration in select patients
in these groups.
Abstracts
13
P. Varley, A. Tsung
University Of Pittsburgh, PITTSBURGH, PA
Background: Previous studies have identified structural
factors that may impact the failure to rescue rate after
pancreaticoduodenectomy (PD). The goal of this study is to
identify patient-level factors associated with failure to rescue
in order to guide interventions that prevent progression to
mortality.
Methods: Patients undergoing PD as the primary procedure
were identified from the 20052012 National Surgical
Quality Improvement Project (NSQIP) Participant Data Use
(PUF) files. Since NSQIP only measures mortality for 30
days post-operatively, we treated failure to rescue as time to
event data and analyzed it using Cox proportional hazards
methods.
Results: A total of 14,546 patients were available for analysis. Of these, 1137 (7.8%) experienced only a minor complication while 5321 (36.6%) experienced at least one severe
complication. Failure to rescue rate was 0% vs. 5.9%, respectively (p < 0.001). Failure to rescue rates were 1.2%, 4.2%
and 18.6% in patients experiencing a total of 1, 2 or 3+
serious complications (p < 0.001). Results from univariable
Cox regression were used to build a multivariable Cox model
which was refined by AIC criteria. Factors significantly influencing failure to rescue after serious complication included
number of complications, resident participation, age,
reoperation, and dyspnea (Table 1).
Conclusions: Essentially all patients who experience postoperative mortality after PD first had a serious complication.
Interestingly, our analysis shows that it is not the first postoperative complication, but instead the accumulation of
multiple events that results in failure to rescue. Preventing
this progression should be the focus of future quality
improvement efforts.
14
Abstracts
place. In univariate analysis, patients with RPSA had a significantly higher rate of postoperative SSIs, and this was
associated with longer length of postoperative stay, higher
postoperative hospital costs, and increased postoperative
30-day readmission rates (Table). In Multivariate analysis,
RPSA was an independent predictor of postoperative SSI
(OR = 1.68, p = 0.013), and the risk of SSI increased with
increasing RPSA length of stay (OR = 1.07 per day,
p = 0.001).
Conclusions: RPSA is an important risk factor for SSI after
pancreatectomy. Many patients with RPSA are not admitted
preoperatively to the same hospital where pancreatectomy
occurs; in such circumstances, SSI rates may not be a sole
reflection of the care provided by operating hospitals.
Abstracts
operative times (480 vs 401 min,p < 0.01) and increased
blood loss (1150 vs 600 mL,p < 0.05). Post-operative heparin
drip was used in only 7%. Prophylactic aspirin was used in
69% of the total cohort (66% of patent, 81% of thrombosed)
and showed no protective benefit.
Conclusions: Primary end-to-end and transverse venorrhaphy have better patency than the alternatives after
PV/SMV resection and should be the preferred techniques
for short (<3 cm reconstructions).
15
16
Abstracts
both groups, the predicted FLR was inversely correlated with
the % in liver regeneration only (p < 0.001).
Conclusion: Neoadjuvant chemotherapy does not seem to
affect the liver regeneration. The predicted FLR only is
inversely correlating with the amount of LR occurring after
major resection or after PVE.
Abstracts
17
18
Abstracts
51%, 41%, p < 0.0001). 90-day mortality (2%, 6%, 4%, 8%,
p < 0.001) was greatest among patients 75 years of age.
Overall survival at 5 years across the age groups was 49%,
40%, 47%, 28% (p < 0.0001).
Conclusions: Resection of CRC liver metastases is associated with greater risk of post-operative mortality among
elderly patients despite less aggressive treatment. Although
the long-term outcomes are inferior to younger patients, a
substantial proportion of elderly patients will have long-term
survival.
Abstracts
multivisceral resections in order to achieve optimal
cytoreduction, but are safe even when substantial parenchymal resection is being performed. Liver involvement at the
time of CRS/HIPEC is a marker of poor survival in CRC
patients.
19
20
Abstracts
Abstracts
(S, n = 626), surgery with adjuvant chemotherapy (AC,
n = 65), and surgery with both adjuvant chemotherapy and
radiation therapy (ACR, n = 146). Univariate and Cox
regression analysis were used to investigate the influence of
patient demographics, tumor characteristics and operative
details on receipt of adjuvant therapy and overall survival.
Results: Patients who received adjuvant treatment more
likely to have positive lymph nodes (S: 28.9%; AC: 47.5%;
ACR: 48.2%), positive surgical margins (S: 12.3%; AC:
17.0%; ACR: 38.0%), and pathologic stage 3 disease (S:
50.5%%; AC: 60.0%; ACR: 67.1%)(all p < 0.01). Multivariate analysis revealed that adjuvant chemotherapy alone was
not associated with a survival benefit in any patient groups
examined. Adjuvant chemotherapy and radiation did not
affect survival overall, but patients with positive lymph nodes
who received ACR did have improved survival compared to
surgery alone (HR 0.64, 95%CI 0.450.91).
Conclusion: Patients with high-risk IHC (positive lymph
nodes) appear to benefit from adjuvant chemotherapy and
radiation therapy, but lower risk patients do not. In the
absence of data from a randomized trial, these results can
guide application of adjuvant therapy following resection of
IHC.
OP-I.03 SUBTOTAL
CHOLECYSTECTOMY FOR THE
HOSTILE GALLBLADDER
M. E. Lidsky, A. W. Castleberry, A. Perez, T. N. Pappas
Department Of Surgery, Duke University Medical Center,
Durham, NC
Background: Outcomes following the inability to safely
control the cystic duct in the setting of a hostile triangle of
Calot during cholecystectomy remain unknown. The purpose
of this study was to analyze the safety and efficacy of subtotal
cholecystectomy, with specific attention to the necessity and
timing of secondary procedures.
Methods: Medical records of 16,585 cholecystectomies
from January 2002-August 2014 were reviewed, with identification of patients managed with subtotal cholecystectomy,
defined as the inability to isolate and transect the cystic duct.
We investigated surgical indications, intraoperative variables,
and 30-day postoperative mortality and morbidity. We also
analyzed the necessity for ERCP, percutaneous drainage procedures, and completion cholecystectomy.
Results: 69 (0.4%) patients underwent subtotal cholecystectomy, of which 57 (82.6%) were laparoscopic; 30 (43.5%)
required conversion to laparotomy. 1 (1.4%) patient died
postoperatively, and 26 (37.7%) patients suffered 35 complications, most frequently infectious (14 wound/surgical site
infections, 4 UTIs). Indication for cholecystectomy included
acute cholecystitis (69.6%), 10 (14.5%) of which had a
cholecystostomy tube, symptomatic cholelithiasis (23.2%),
chronic cholecystitis (13%), and biliary pancreatitis (10.1%).
Secondary interventions were required in the form of 49
ERCPs in 20 (29%) patients, percutaneous drainage for
biloma or abscess in 6 (8.7%), and completion cholecystectomy on average 13.75 months (527 months) after the index
operation in 4 (5.8%).
Conclusions: The hostile gallbladder represents a complicated disease process for which patient safety is of
paramount. Postoperative morbidity after subtotal cholecysHPB 2015, 17 (Suppl. 1), 181
21
22
Abstracts
Abstracts
Results: The independent practice element expanded in
each year of the fellowship (Table). Independent cases represented 36.6% of the fellows total operative volume from
201214. In the second year of the fellowship, the fellows
have increased the complexity of diagnoses seen in their
personal clinic with explicit recognition of their ability to
progress in this manner. The fellows do not participate in
either emergency or service call as an attending.
Conclusions: Our HPB fellows training included a significant independent practice component, with an expanding
scope of practice in each year of training. This method of
graduated autonomy in an advanced HPB fellowship may
represent a feasible blended model for advanced surgical
training, meeting both the need for specialty expertise and
preparation for independent practice.
23
24
Abstracts
has never been used in liver surgery. Our goal was to define
the place of NIRS oxymetry in liver resections.
Methods: 90 patients undergoing major hepatectomy were
included (45 men and 45 women). Oxymetry was obtained
by NIRS at 4 sites (cerebral right and left, arm and thigh)
before and during surgery. Baseline oxymetry (BaseO) and
desaturation (Desat) (Threshold = 80% baseline) values
were compared to peri-operative data.
Results: Median ICU stay was 2d and median hospital stay
(LOS) was 7d. Cerebral BaseO correlated significantly with
duration of stay in the intensive care unit (ICU) stay
(p = 0.04), in the hospital length of stay (LOS) (p = 0.01) and
respiratory insufficiency (p = 0.002). Arm BaseO correlated
with blood loss (p = 0.05), blood transfusion (p = 0.03), ICU
stay (p = 0.01) and surgical complications (p = 0.049). Also,
thigh BaseO correlated with surgical complications
(p = 0.0035) and LOS (p = 0.01). Cerebral Desat did not
correlate with any complication but thigh Desat did with
blood loss (p = 0.03), LOS (p = 0.05) and surgical complications (0.0132). Arm Desat inversely correlated with Pringle
duration (p = 0.01).
Conclusion: NIRS is a very simple approach for oxymetry
evaluation during major liver surgery. Baseline and systemic
values are correlated with some operative data and complications. These preliminary results should lead to a more
extensive study to determine whether correction of impaired
level of oxymetry will improve patients outcome.
Abstracts
5 or more metastases (OR 0.122, p = 0.023), and increased
size of the largest lesion (OR 0.647, p = 0.047) were less
likely to progress.
Conclusion: Patients with more aggressive tumors, as
reflected by a higher CRS, are less likely to have tumor
progression on chemotherapy. Conversely, patients with low
CRS are more likely to progress on chemotherapy, and therefore those with resectable disease upfront would benefit from
metastectomy (without pre-operative chemotherapy).
OP-I.13 INTRAOPERATIVE
RADIOFREQUENCY ABLATION VERSUS
SURGICAL RESECTION IN SOLITARY
SMALL HCC
A. M. Elgendi, M. Elshafey, E. Bdeawey
Faculty Of Medicine, Alexandria University,
ALEXANDRIA, SELECT A STATE/PROVINCE
Background: Percutaneous radiofrequency ablation (RFA)
is used for treatment of small HCC however surgeons are
frequently using intraoperative RFA for tumors at locations
difficult for the percutaneous procedure. The aim was to
evaluate the results of intraoperative RFA for small HCCs
(<2 cm) at locations difficult for percutaneous route.
Methods: 420 patients with small solitary HCC (<2 cm)
were treated; 328 via percutaneous RFA while 92 patients
presented at sites not amenable for percutaneous route. 48
out of 92 patients underwent surgical resection, while 44/92
patients underwent intraoperative RFA.
Results: The location and depth of the HCC from the liver
capsule was the only significant factors in the choice of the
surgeon between resection and RFA. RFA group acheived
complete ablation rate of 100% compared to the surgery
group, where all patients achieved R0 resection. Complication rate was comparable (p = 1.0). After a median follow-up
of 46 months (range, 1665 months), no tumors showed
neither local progression nor local recurrence and no significant difference was observed between two groups as regards
early recurrence and number of de novo lesions (p = 0.49).
One-year and 3-year survival rates were 92% and 83%,
respectively, in the resection group comparable to the corresponding rates of 91% and 76% in the RFA group (p = 0.8).
Conclusion: For small HCC in locations difficult for a percutaneous approach, intraoperative RFA can be an alternative
option for deep seated tumors necessitating more than one
segmentectomy achieving similar tumor control, overall and
disease-free survival.
25
26
Abstracts
OP-I.18 POST-HEPATECTOMY
HYPERBILIRUBINEMIA: THE POINT
OF NO RETURN
J. Y. Liu1, L. M. Postlewait1, J. W. Etra1, M. H. Squires1,
K. Cardona1, J. H. Winer1, J. M. Sarmiento2, C. A. Staley 1,
S. K. Maithel1, D. A. Kooby1, M. C. Russell1
1
Emory Winship Cancer Institute, Atlanta, GA; 2Emory
Department Of Surgery, Atlanta, GA
Background: Post-hepatectomy hyperbilirubinemia is associated with liver insufficiency and failure. The threshold of
the highest survivable total bilirubin (tbili) is not defined. Our
aim was to identify the peak postoperative tbili beyond which
is survival is improbable.
Methods: An institutional database of patients undergoing
major hepatectomy (3 segments), excluding biliary resections, from 20002012 was reviewed. A peak bilirubin of
18 mg/dL in the first 45 days post op was associated with
increasing 90-day mortality (90DM). Clinicopathologic
factors were assessed for association with 90DM. We also
examined predictors of elevated postoperative tbili.
Results: 607 patients were identified with a 90DM of 4.4%.
90DM for a peak tbili 18 (n = 16) was 81%, compared to
2.4% for a bilirubin <18 mg/dL (graph). All patients with a
tbili 30 died (n = 7). On multivariate analysis (MVA) for
90DM, post-operative tbili 18 (HR 24, CI 3.3174;p =
0.002), post-operative FFP (HR 4.8, CI 1.120.2;p = 0.034),
and cirrhosis (HR 5.9, CI 1.131.3;p = 0.038) were significant predictors. Furthermore, predictors of tbili 18 identified on MVA included: older age (HR 1.1, CI 1.01.2;
p = 0.001) and postoperative FFP (HR 10.1, CI 2.540.8;
p = 0.001).
Conclusion: Total bilirubin 18 is significantly associated
with an increase in 90-day mortality after major hepatectomy; there are no survivors for patients whose tbili rises
30.This information can help clinicians advise patients
and families who experience posthepatectomy hyperbilirubinemia; as well, it may be an important marker for intervention as supportive therapies improve.
Abstracts
27
28
Abstracts
OP-I.22 RADIOFREQUENCY-ASSISTED
LIVER PARTITION AND PORTAL VEIN
LIGATION (RALPP): COMPARATIVE
SERIES OF A MODIFIED ALPPS
TECHNIQUE FOR TWO-STAGE
LIVER RESECTION
M. H. Sodergren, T. M. Gall, M. Nagendran, L. R. Jiao
Imperial College, London, GREATER LONDON
Background: The introduction of portal vein embolization
and recently the ALPPS technique has rendered a greater
proportion of liver tumours surgically resectable by increasing the volume of future liver remnant (FLR) in selected
patients. The RALPP technique involves a laparoscopic first
stage portal vein ligation and in situ liver splitting using
ablation only without complete transection. We hypothesise
that this will rapidly increase the size of the FLR limiting any
associated morbidity from liver transection.
HPB 2015, 17 (Suppl. 1), 181
Abstracts
Methods: Consecutive patients who underwent RALPP
were compared to an age-sex- and liver function-matched
cohort of patients undergoing PVE prior to right hepatectomy. The primary endpoint was the percentage increase in
FLR volume. Secondary endpoints were morbidity, mortality, and postoperative liver function.
Results: There were 12 patients (6M : 6F) in the RALPP
group and 8 (4M : 4F) in the PVE group with a median age
of 62.5 and 65 yrs respectively. The mean % increase in the
FLR volume was 61.5 +/ 16.3 measured after a mean of
20.8 +/ 7.3 days following the first stage for RALPP compared to a % increase of 16.46 +/ 11.7 (p = 0.001) after
52.3 +/ 14.8 days (p < 0.001) following PVE. There was
one mortality in the RALPP group at day 19 following right
hepatectomy from bowel ischaemia and liver failure. There
was no difference in morbidity or post-operative liver
function.
Conclusion: The RALPP technique is feasible and safe in
this limited series, with a greater increase in FLR volume in
a shorter time period compared to PVE.
29
Conclusions: Resection of CRCLM and the use of perioperative chemotherapy increased during the study period.
Survival outcomes among patients treated in routine clinical
practice are comparable to institution-based studies.
30
Abstracts
Abstracts
male), percentage of patients who had a resection for a
malignancy (86.0%, 83.7%, 65.6%), and median operative
time (182 min, 190 min, 197 min). Complex procedures
(defined as: trisegmentectomies, left hepatectomies, right
hepatectomies or central hepatectomies) increased significantly over time (P = 0.007). One 90-day mortality occurred
in group A, while mortality in groups B and C was zero.
There was an improving trend in estimated blood loss (568.5,
563.9, 342.0 ml), in number of patients transfused (4, 3, 2
patients), conversion to open procedures (4, 2, 1 conversions), number of complications (8, 3, 4 complications,
Clavien grade III or higher). Median length of stay was
significantly reduced in groups B and C (6.4 days, 3.8 days,
3.8 days; P = 0.006).
Conclusions: Similar to other surgical procedures, LLR is
subject to a learning curve. Despite an increase in surgical
complexity, after the first 43 procedures there was an
improvement in blood loss, rate of conversion, morbidity,
and length of stay.
31
32
Abstracts
Abstracts
outcomes of patients in the general population managed with
simultaneous or staged resection of the primary tumor and
synchronous CRC LM.
Methods: All cases of CRC in Ontario who underwent
surgical resection of LM in 20022009 were identified using
the population-based Ontario Cancer Registry. Synchronous
disease was defined as having resection of CRC LM
within 12 weeks of surgery for the primary tumor. Pathology
reports were reviewed to identify extent of disease and
surgery.
Results: During 20022009, 1711 patients underwent resection of CRC LM; pathology reports were identified for 1252
cases. 283 patients had synchronous disease; 116 (41%)
patients had simultaneous resections and 167 (59%) had a
staged resection. For the simultaneous and the staged groups,
mean number of liver lesions resected was 1.7 and 2.3
(p < 0.001), mean size of the largest lesion was 3.1 and
4.7 cm (p < 0.001), major hepatic resection (3 Couinaud
segments) rate was 26% and 76% (p < 0.001) and the R1
resection margin rate was 10% and 8% (p = 0.46), respectively. 30- and 90-day post-operative mortality rates for simultaneous and staged groups were 0.9% and 2.4% (p = 0.65)
and 3.5% and 4.2% (p = 1.00), respectively.
Conclusions: Simultaneous resection of synchronous CRC
LM is common in routine clinical practice. Compared to a
staged approach, patients undergoing simultaneous resections had fewer and smaller liver metastases, less aggressive
resections and comparable post-operative mortality.
33
34
Abstracts
Introduction: Although non-traumatic emergent hepatectomies are rarely indicated, their burden to healthcare system
in terms of utilization of resources is likely to be high, though
has never been quantified.
Methods: Using the ACS-NSQIP participant use files
for 20052012, we identified hepatic resections by Current
Procedural Terminology (CPT) code and segregated all
non-traumatic hepatectomies into 2 groups: Emergent Hepatectomy (EH) and Non-emergent Hepatectomy(NEH).
Preoperative, intraoperative and postoperative factors were
analyzed to identify predictors of complications and
mortality.
Results: Of the 13227 non-traumatic hepatectomies from
the NSQIP data, 137 emergency hepatectomies were identified. African Americans required significantly increased EH
(2.0% vs 0.92%, OR 2.2, p < 0.001). The most common
diagnosis for EH overall, was primary and secondary malignant neoplasm of the liver (38%; n = 33). Preoperative and
perioperative transfusion requirements were higher in the EH
group compared to NEH (17.5% vs 0.49%, OR 42.5,
P < .001; and 52.7% vs 26.4%, OR 3.1, P < .001). Patients in
the EH group were significantly more likely to experience a
Clavien 4 complication (19.7% vs 7.2%, OR 3.2, p < .001).
Mortality rate was higher in the EH group compared to
NEH(8.8% vs 2.5%, OR 3.7, P < .001).A multivariate logistic regression analysis revealed ASA score, ascites, and emergent indication as poor outcome indicators. Surprisingly age
and length of operation were not significant factors.
(Table 1).
Conclusion: Emergent hepatectomy has a significantly
higher perioperative blood transfusion requirement, with
increased morbidity and mortality rate. ASA score, ascites,
and emergent indication as poor outcome indicators, while
age and length of operation were not significant factors.
HPB 2015, 17 (Suppl. 1), 181
Abstracts
35
36
Abstracts
4 (8.2%) versus 0 in the pre-POH group. Deaths were due to
amioderone related pulmonary fibrosis (1), cardiac arrest (1),
and severe multi-organ failure related to a leak(1) and a
postoperative bleed (1).
Conclusion: The introduction of a hospitalist who specializes in perioperative management of high-risk surgical
patients was associated with a decrease in 30-day readmissions and a similar overall complication rate, even in the
setting of a higher mean ASA. There was a trend toward a
higher mortality rate in the post-POH cohort. More study is
required to understand the overall quality and financial
impact of POH co-management.
Introduction: We hypothesize elderly patients, with multiple comorbidities, undergoing high risk surgical procedures
will benefit from pre- and postoperative co-management by a
hospitalist who specializes in this field. We report clinical
outcomes for two cohorts of patients undergoing pancreaticoduodenectomy (PD), pre and post introduction of a
perioperative hospitalist (POH) program.
Methods: Data was collected retrospectively on 89 consecutive patients undergoing PD between 2012 and 2014.
Analysis was performed on 40 patients prior and 49 patients
after the introduction of the POH program. Groups were
compared by chi-square and T-test.
Results: Results are summarized in the table below. 14
patients in the post-POH cohort were not seen by the POH
due to patient selection, distance and transportation issues.
Although the ASA was significantly higher in the post-POH
group, overall complication rates were similar. 30-day readmissions were also significantly lower in the post-POH
group. There were 4 deaths observed in the post-POH group,
2015 The Authors
HPB 2015 Americas Hepato-Pancreato-Biliary Association
Abstracts
p = 0.02) and low neuroticism (p < 0.001) independently correlated with job satisfaction. Job satisfaction was higher
among females (p = 0.004). While 91.9% of respondents
indicated that they would choose the specialty again, only
53.7% would recommend it to their child/family. Those who
would choose the specialty again were less neurotic
(p = 0.039) and more satisfied with their job (p = 0.003).
Additionally, those who would recommend the specialty
were more agreeable (p = 0.001), more satisfied (p = 0.002),
have been in practice longer (p = 0.006), and were more
likely to choose the specialty again (p < 0.001).
Conclusion: Extraversion and neuroticism correlate with job
satisfaction among HPB surgeons. Furthermore, female HPB
surgeons appear to have higher levels of job satisfaction.
These findings may aid in the recruitment of HPB trainees and
may have implications for job performance and patient care.
37
38
Abstracts
Data collected included clinical presentation, operative findings and histopathological data.
Results: 18 patients were identified that underwent surgical
management for duodenal endocrine tumors. This included 2
patient with transduodenal excision (11%), 2 patients with
duodenal resection (11%), 6 patients had antrectomy (33%)
and 8 underwent pancreaticoduodenectomy (44%). On analysis, peri-ampullary location was the most common site of
duodenal endocrine tumors (n = 9, 50%). 77% (n = 7) of
peri-ampullary lesions led to pancreaticoduodenectomy. The
odds of having a pancreaticoduodenectomy is 10 times higher
when the lesion is in peri-ampullary location. 6 patients had
positive lymph nodes. The odds of having a positive lymph
node are almost 9 times higher when the lesion is in ampulla.
83% (n = 5) of tumors with positive lymph nodes were greater
than T1 stage. The odds of having positive lymph node is 3
times higher when lesion is greater than T1.
Conclusions: Ampullary location of neuroendocrine tumor
in duodenum is associated with higher odds of lymph node
positivity and need for treatment with more extensive procedures like pancreaticoduodenectomy.
Abstracts
39
40
Abstracts
Abstracts
41
42
Abstracts
low volume hospitals (LVH). The relationship of inflationadjusted charges and outcomes were stratified by uncomplicated PD (length of stay <14 days) vs complicated PD (>14
days).
Results: A total of 15,599 PD were performed in 1,186
hospitals at a median cost of $87,444 (IQR $60,015$144,869). While only 94 (8%) hospitals performed >20
PD/year, 57% of all PD were performed in these HVH. HVH
had shorter hospital stay (11 vs 15 days, p < 0.001) and
mortality (3% vs 7.6%, p < 0.001). PD performed at LVH
had higher median charges compared to HVH ($97,923 vs.
$81,581, p < 0.001). The cost of uncomplicated PD was significantly lower than a complicated PD ($67,238 (IQR
51,11291,401) vs $138,325 (IQR 95,206224,919),
p < 0.001). When comparing uncomplicated PD between
HVH and LVH, the median cost was very similar ($67,389 vs
$66,922). Among uncomplicated PD, a multivariate analysis
controlling for demographics and co-morbidities revealed
that cost did not affect the risk of mortality (OR 1).
Conclusions: The cost of a Whipple (even uncomplicated)
remains surprisingly variable. PD at HVH are associated
with better outcomes, which is reflected in lower charges.
But ultimately, patients should choose volume over price.
Abstracts
remains unclear. We sought to examine the association
between RBCT and post-operative morbidity following pancreatectomy.
Methods: Using the ACS-NSQIP database, we identified
patients undergoing elective pancreatectomy from 2006 to
2012. Patients missing data on key variables were excluded.
We compared post-operative morbidity and length of stay
based on RBCT status using univariate and multivariate
analyses. A sensitivity analysis was conducted excluding
patients with higher baseline risk for RBCT.
Results: From 21,132 pancreatectomies, we included
14,322 patients of whom 1624 (11.3%) received RBCT.
Major morbidity (34.9% Vs. 21.6%; p < 0.0001) and mortality (15.7% Vs. 11.5%; p < 0.0001) were higher, and median
length of stay was prolonged (15.7 Vs. 11.5 days; p < 0.0001)
with RBCT. After adjustment for baseline characteristics
including comorbidities, malignant diagnosis, procedure,
and operative time, RBCT was independently associated
with increased major morbidity (Relative Risk RR 1.45;
p < 0.0001), post-operative infections (RR 1.30; p < 0.001),
thrombo-embolic events (RR 1.41; p = 0.01), cardiac events
(RR 2.41; p < 0.0001), respiratory failure (RR 2.60;
p < 0.0001), and mortality (RR 2.51; p < 0.0001). Length of
stay was prolonged with RBCT (adjusted mean estimate
1.22; p < 0.0001). Excluding patients with higher baseline
risk of RBCT did not substantially alter the results.
Conclusion: Perioperative RBCT is independently associated with worse short-term outcomes and prolonged length
of stay following pancreatectomy. This observation holds
true in patients with lower baseline risk of RBCT. Comprehensive multidisciplinary strategies to minimize and rationalize the use of RBCT are warranted.
43
44
Abstracts
Background: Tauroursodeoxycholic
acid
(TUDCA)
decreases endoplasmic reticulum (ER) stress, autophagy, and
cell death in cultured rat hepatocytes. We hypothesized that
TUDCA could reduce the injury caused by total warm
ischemia reperfusion (WIR) in steatotic mouse liver.
Methods: Male ob/ob mice underwent 100% hepatic warm
ischemia by clamping the portal triad for 30 minutes. For the
experiment group, 200 mg/kg TUDCA was injected IP 1
hour before the surgery. Animals were sacrificed at 12 hours
and 48 hours after reperfusion. Quantitative real time PCR
measured ER stress markers such as C/EBP homologous
protein (CHOP), glucose regulated protein 78 (GRP78),
protein kinase dsRNA-dependent-like ER kinase (PERK),
and activating transcription factor-6 (ATF6). Western blot
examined autophagy marker microtubule-associated protein
1 light chain 3 (LC3 II). ELISA determined interleukine-6
(IL6) levels (liver and serum).
Results: Compared to controls, WIR increased ER stress in
the liver [CHOP (3 fold, p = 0.004), GRP78 (4 fold,
p = 0.001), PERK (2 fold, p = 0.005), and ATF6 (1.5 fold,
p = 0.004)] at 12 but not 48 hours. LC3 II protein levels were
increased at both 12 (3 fold, p = 0.019) and 48 hours (4 fold,
p = 0.025). Serum IL6 levels were increased at 12 (40 fold,
p = 0.034) and 48 hours (33 fold, p = 0.034). TUDCA treatment decreased LC3 II at 12 (p = 0.018) and 48 hours
(p = 0.034), decreased serum IL6 at 12 (p = 0.025) and 48
hours (p = 0.025), and improved animal survival (median 26
hours vs 41 hours, p = 0.02). ER stress levels were not
changed.
Conclusion: TUDCA improves survival and reduces the
inflammation following WIR in steatotic liver through a
non-ER stress pathway.
Abstracts
LO-G.02 CHARACTERIZATION OF A
PORCINE MODEL FOR ASSOCIATING
LIVER PARTITION AND PORTAL VEIN
LIGATION FOR STAGED
HEPATECTOMY (ALPPS)
K. P. Croome, S. A. Mao, J. M. Glorioso, S. L. Nyberg,
D. M. Nagorney
Mayo Clinic, Rochester, MN
Background: Publications using the ALPPS procedure have
demonstrated a future liver remnant(FLR) growth of
40160% in only 69 days. The present study aimed to
develop and describe the first large animal model of ALPPS
that can be used for future studies.
Methods: A total of 13 female domestic swine were studied.
ALPPS stage 1 (portal vein division and parenchymal
transection) was followed by ALPPS stage 2 (completion left
extended hepatectomy) 7 days later. An abdominal CT scan
was performed immediately prior to ALPPS stage 1 surgery
and again 7 days later to assess hypertrophy immediately
prior to ALPPS stage 2 surgery. Blood samples as well as
tissue analysis were performed.
Results: On CT volumetric analysis mean size of the FLR
prior to ALPPS stage 1 was 21.4 1.8% and 39.8 4.6%
prior to ALPPS stage 2. Median degree of hypertrophy was
74.5% with a median kinetic growth rate of 10.6% per day.
Liver weights at autopsy correlated well with CT volumetric
analysis(p = 0.65). There was no significant difference in
mean lab values (AST,ALT,ammonia,INR or bilirubin) from
baseline until immediately prior to ALPPS stage 2. Post
ALPPS stage 2 there was a significant increase in INR from
baseline 1.1 0.1 and 1.6 0.1 (p = 0.005), respectively. No
post-operative deaths secondary to liver failure were
observed.
Conclusion: The present study describes the first reproducible large animal model of the ALPPS procedure. Degree of
hypertrophy and kinetic growth rate were similar to that which
has been demonstrated in human publications. This model
will be valuable as future laboratory studies are performed.
45
46
Abstracts
Results: AR-A014418 treatment had a significant dosedependent growth reduction (p < 0.001) in pancreatic cancer
cells compared to control. The growth suppression effect is
due to apoptosis. Importantly, reduction in GSK-3 phosphorylation leads to a reduction in Notch pathway members.
Over expression of active Notch1 in AR-A014418-treated
cells resulted in negation of growth suppression. Immunoprecipitation analysis revealed that GSK-3 binds to Notch1.
Conclusions: This study demonstrates for the first time
that the growth suppressive effect of AR-A014418 in pancreatic cancer cells is mainly mediated by reduction in
phosphorylation of GSK-3 with concomitant Notch1 reduction. GSK-3appears to stabilize Notch1 by binding and may
represent a target for therapeutic development. Furthermore,
down regulation of GSK-3 and Notch1 may be a viable
strategy for possible chemosensitization of pancreatic cancer
cells to standard therapeutics.
Abstracts
47
48
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49
50
Abstracts
60.8% for congenital anomaly, 46.1% for other nonmalignant and 37.8% for biliary injury (p < 0.0001.) 79.8%
of neoplasm discharges were from teaching hospitals vs.
62.3% for other non-malignant disease, 65.2% for biliary
injury and 66.1% for congenital anomaly (p < 0.0001.)
33.3% of total BDR discharges involved at least one complication and 84.8% were discharges to home. Median length of
stay was 9 days (IQR 6, 15) and median cost was $22,230
(IQR 14,399, 38,358.) Significant multivariate predictors of
inpatient death include indication of biliary injury or malignancy (figure), and predictors of any complication include
public insurance and non-elective admission.
Conclusion: This is the first national description of BDR
using a large database. In this diverse sampling, both procedure indication and patient characteristics influence morbidity and mortality.
Abstracts
51
LO-H.09 INTRAOPERATIVE
NEAR-INFRARED CHOLANGIOGRAPHY:
OPTIMIZATION OF TIMING AND DOSE
A. Zarrinpar, E. P. Dutson, C. Mobley, R. W. Busuttil,
C. E. Lewis, A. Tillou, A. Cheaito, O. J. Hines,
V. G. Agopian, D. T. Hiyama
Department Of Surgery, David Geffen School Of Medicine,
UCLA, Los Angeles, CA
Introduction: Intraoperative cholangiography is the gold
standard for clear delineation of biliary anatomy. However,
logistical difficulties lead to its low utilization. Near-infrared
fluorescence cholangiography (NIRFC) with indocyanine
green (ICG) has been developed for real-time, intraoperative
biliary imaging. While several studies have shown its feasibility, dosing and timing for its practical use have not been
systematically optimized.
Objective: We undertook a prospective observational study
with varying doses and elapsed times from injection of ICG
to visualization. Image quality of NIRFC and its utility to the
operating surgeon were assessed.
Methods: Adult patients undergoing laparoscopic biliary
and hepatic operations were enrolled. A single intravenous
dose of ICG (0.020.25 mg/kg) was administered at various
times (15180 mins) prior to planned visualization. The
porta hepatis was examined using a dedicated laparoscopic
system. Each operating surgeon evaluated the intraoperative
recognition of biliary structures using a qualitative scoring
system (1-poor to 5-excellent). Quantitation studies were
also performed on the images obtained during the operation.
Results: Thirty-four patients were enrolled. Visualization
scores of the extrahepatic biliary tract improved with increasing doses of ICG up to 0.08 mg/kg. The score also improved
with increased time up to 45 min after ICG administration.
Similarly the CBD-to-liver intensity ratio increased with
2015 The Authors
HPB 2015 Americas Hepato-Pancreato-Biliary Association
52
Abstracts
should be made to identify HCC-CC patients prior to transplant and if transplanted undergo close surveillance and consideration for immunosuppression modification and/or
adjuvant therapy.
Abstracts
53
54
Abstracts
score, diagnosis, and estimated blood loss, use of COX2inhibitors was independently associated with PF (odds ratio
2.32; p = 0.026).
Conclusions: COX2-inhibitors are associated with PF in the
early postoperative period. While ketorolac appears safe in
this setting, caution is warranted with the use of COX2inhibitors.
Abstracts
OP-II.05 PANCREATODUODENECTOMY
PROVIDES EFFECTIVE LONG-TERM
PAIN RELIEF FOR CHRONIC
PANCREATITIS IN SELECT PATIENTS AT
GREATER THAN 15 YEARS FOLLOW-UP
K. P. Croome, D. M. Nagorney, M. Tee, M. J. Truty,
K. Reid-Lombardo, F. G. Que, M. L. Kendrick,
M. B. Farnell
Mayo Clinic, Rochester, MN
Background: We
have
employed
pancreaticoduodenectomy (PD) for selected patients with small duct, headdominant chronic pancreatitis (CP) with intractable pain.
Information examining very long term outcomes in patients
undergoing PD for CP is lacking.
Patients and Methods: All patients who underwent PD for
CP from 1976 to 2013 were reviewed. Surviving patients
were contacted for a follow-up questionnaire and SF-12
Quality of Life Survey.
Results: A total of 166 patients were identified (Cohort 1:
19761999(N = 105) and Cohort 2: 20002013(N = 61)).
Median time from presentation until surgery was significantly longer in Cohort 2(2.09 years) compared to Cohort
1(1.13 years)(p = 0.017). A higher proportion of patients in
Cohort 2(98%) had intractable pain prior to surgery than in
Cohort 1 (82%)(p = 0.002). Prior to PD a higher proportion
of patients in Cohort 2 had undergone endoscopic stenting,
67% vs 10%(p < 0.001) and/or celiac plexus block 15% and
5%(p = 0.026). Median follow-up for all survey respondents
was 15 years. On the SF-12, mean physical component
score(PCS) was 43.8 11.8 and mental component
score(MCS) was 54.3 7.9. Patients were significantly
lower on the PCS(p < 0.001) and significantly better on the
MCS(p = 0.001) than the general US population. Mean pain
score out of 10 was significantly lower after surgery 1.6 2.6
than before surgery 7.9 3.5(p < 0.001). Diabetes developed
in 28% of patients who were not diabetic prior to surgery.
Conclusion: Although practice has changed so that patients
have a longer time from presentation until surgery as less
invasive techniques are attempted, PD appears to provide
effective long-term pain relief and acceptable quality of life
in appropriately selected patients with chronic pancreatitis
and intractable pain.
55
56
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57
58
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59
60
Abstracts
and lack of at least a 50% decrease in CA19-9 levels (OR
13.2 [2.569.1]) were. On sub-analysis, CA19-9 decrease
<50% remained predictive for any progression while tumor
size predicted distant progression only. A receiver operating
characteristic curve showed that tumor size >3 cm was 87%
sensitive for progression (AUC 0.785).
Conclusion: LAPD patients undergoing neoadjuvant
chemotherapy with tumors >3 cm or that exhibit less than
50% reduction in CA 19-9 maybe at higher risk for progression on chemotherapy. Patients with these risk factors may
benefit from additional treatment prior to an attempt at
resection.
Abstracts
61
Background: The
outcome
of
Pancreaticoduodenectomy(PD) has been closely linked to hospital
volume and experience. The low incidence of pancreatic
cancer, coupled with few specialized Hepato-PancreaticoBiliary teams and lack of referral patterns and service centralization, contribute to sparse data from the Indian
subcontinent.
Methods: Prospective database of PDs from 1992 to 2014
was evaluated retrospectively over 4 time periods based on
changing practice trends: A (19922001), B (2003-July
2009), C (August 2009-December 2011) and D (January
2012-August 2014). Peri-operative parameters were compared using SPSS v.21.0.
Results: 751 patients underwent PD. The average resections
increased from 14 to 94, over periods A to D, respectively.
While post-operative pancreatic fistula(POPF) rates increased
from 16% to 21.5% over periods A to D, the incidence of bile
leaks and post-pancreatectomy hemorrhage declined to 0.8%
and 3.9%, respectively. Morbidity and hospital stay was more
in period D compared to B and C, but mortality declined from
6.3% to 2.8% over periods A to D. Overall series morbidity
and mortality was 35.2% and 4.5%, respectively.
Conclusion: This series represents the largest single-centre
experience with PD from India and the surrounding region.
The higher morbidity in period D is likely attributable to a
combination of increasing surgical complexity and reduced
selection bias. The gradually increasing experience should
serve as a benchmark for developing dedicated pancreatic
surgery teams even in regions of low incidence of pancreatic
cancer where the need for training and centralization is
greater compared to high incidence regions, such as USA and
Europe.
62
Abstracts
OP-II.20 LEAKAGE OF AN
INVAGINATION
PANCREATICOJEJUNOSTOMY MAY
HAVE LETHAL CONSEQUENCES
H. Lavu1, S. W. Keith 1, E. M. Kilbane3, A. Parmar4,
B. L. Hall 5, H. A. Pitt2
1
Thomas Jefferson University, Philadelphia, PA; 2Temple
University School Of Medicine, Philadelphia, PA; 3Indiana
University Health, Indianapolis, IN; 4University Of Texas
Medical Branch, Galveston, TX; 5Washington University
School Of Medicine, St. Louis, MO
Background: No consensus exists regarding the
most effective form of pancreaticojejunostomy following
pancreatoduodenectomy. The aim of this analysis was to
determine whether the type of pancreaticojejunostomy influences morbidity or mortality.
Methods: Data were gathered through the American
College of Surgeons-National Surgical Quality Improvement
Program, Pancreatectomy Demonstration Project. Over 14
months, 1,781 patients underwent a pancreatoduodenectomy
(PD) at 43 institutions. After exclusion of patients undergoing minimally invasive PD and those without information on
gland texture or duct size, 890 patients were analyzed.
Patients were divided into duct-to-mucosa (n = 734, 82%)
and invagination (n = 156, 18%). Type of pancreaticojejunostomy (PJ) was then included in eight separate morbidity and mortality multivariable analyses.
Results: Invagination patients had higher serum albumin
(p < 0.01) lower BMIs (p < 0.01) and preoperative serum
bilirubin (p < 0.02), were less likely to have a preoperative
biliary stent (p < 0.01) or chemotherapy (p < 0.04), were
more likely to have a soft gland (p < 0.01) and were
less likely to undergo pylorus preservation (p < 0.01).
Multivariable analyses demonstrated that age, gender, BMI,
preoperative albumin and biliary stents, gland texture and
pancreatic duct size were related (p < 0.05) to multiple postoperative morbidity outcomes. PJ anastomosis type was not
associated with morbidity but did affect mortality (duct-tomucosa vs. invagination Odds Ratio 0.22, p < 0.01). Among
patients who developed a pancreatic fistula, none of the 119
duct-to-mucosa compared to five of 20 invagination patients
died (p < 0.01).
Conclusions: Patients who undergo a pancreaticojejunostomy (PJ) by duct-to-mucosa or invagination differ
with respect to pre- and intra-operative variables. When an
invagination PJ leaks, the consequences may be lethal.
Abstracts
incidence of venous involvement. This may be due to inherent limitations of these techniques versus a true downstaging
effect of neoadjuvant chemotherapy.
63
There were no differences in age or islet equivalents transplanted in patients with and without PVT. Mean BMI of
patients with PVT was lower than those without (21.8 vs
26.5 kg/m2,p = 0.03).Mean portal pressure post-islet
infusion was higher in patients with PVT (25.2 vs
16.0,p = 0.0007), with 4/9 having pressures over 30 mmHg.
The median time to diagnosis of PVT was 10.5 days
postoperative(range 7 to 210),with 7/9 having negative
duplex POD1. Eight of 9 patients with PVT were treated
with systemic anticoagulation and 7/8 had resolution on
repeat imaging. One patient died from complications of
anticoagulation. Two patients developed cavernous
transformation(CTPV), one untreated and one diagnosed
after CTPV. All patients with PVT were insulin-requiring at
latest follow-up versus 72/94 patients(77%) without PVT
with at least 1-year follow-up(p = 0.035).
Conclusions: PVT following TPIAT is an uncommon but
serious complication. It occurs late in the postoperative
period in women with a low BMI. A standardized follow-up
imaging protocol is suggested. The treatment for PVT is
anticoagulation. Patients with PVT can expect to be insulindependent.
64
Abstracts
OP-II.26 TITLE
D. P. Nussbaum, L. M. Youngwirth, R. R. White,
B. M. Clary, J. A. Sosa, D. G. Blazer
Duke University Medical Center, Durham, NORTH
CAROLINA
Introduction: Pancreatic acinar cell carcinoma (pACC) has
cure rates up to 40% following resection, yet many patients
with localized disease do not undergo surgery.
Methods: The 19982011 National Cancer Data Base was
queried for patients with pACC. Among patients with localized disease, multivariable analysis was used to predict the
likelihood of undergoing resection. Cox proportional hazards
modeling was then used to assess variables associated with
survival following resection.
Results: 933 patients were identified. Median age at diagnosis was 64 years. Tumors were most common in men
(66%) and white patients (88%), and occurred most frequently in the pancreatic head (57%). Mean size was 6.6 cm.
While 42% of patients presented with localized disease,
nearly one-quarter of these patients did not undergo resection. Median survival was 55 months following resection,
compared to 23 months without surgery (p < 0.01). Failure to
undergo surgery was associated with older age (OR 1.32,
p = 0.02), male sex (OR 2.30, p < 0.01), black race (OR 2.86,
p = 0.03), higher grade (OR 2.45, p = 0.03), location within
the head (OR 3.33, p < 0.01), and treatment at a nonacademic facility (OR 2.09, p < 0.01). Following adjustment,
only older age (HR 1.17, p = 0.01) and lymph node metastases (HR 2.58, p = 0.04) were associated with increased
mortality following resection (Table 1).
Conclusions: Survival following resection of pACC is
nearly five years, yet specific subsets of patients appear less
likely to undergo surgery. Of these groups, only older age is
independently associated with mortality. Efforts to increase
access to care could result in improvements in survival for
patients with pACC.
Abstracts
Methods: A retrospective review of a prospectively maintained database of all open PDs and RAPDs from March
2009 to June 2014 was performed. RAPD has been introduced selectively during this period. As the main outcome
assessment was infection rate (total/deep organ space and
surgical site [SSI]), patients converted from RAPD to open
were included in the open group.
Results: 69 patients underwent completed RAPD, and 372
open PD during the study period. There was a change in
disease etiology from predominantly premalignant lesions
and ampullary carcinomas to include all indications for PD.
There was a significant difference in BMI between groups
with RAPD preferentially used in obese patients (p = 0.004)
that evolved during the study. Comparing RAPD and open
PD, the SSI rate was less in the RAPD group (9% vs.14%)
with no difference in overall infective complication rate
(26% vs. 26%) or intra-abdominal infection (10% vs. 10%).
Estimated blood loss was significantly less (200 versus
400 cc (p < 0.001) in favor of RAPD.
Conclusion: Increasing experience with RAPD has led to a
change in utilization of the procedure and a transition to its
use in all pathologies. To maximize its benefits we have a
positive selection bias towards obese patients.
65
66
Abstracts
Surprisingly, recent literature suggests an increase in readmission rates after LDP, hence potentially negating any
gained length of stay (LOS) benefit compared to open distal
pancreatectomy (ODP). Therefore, we sought to examine
readmission rates and total cost of LDP versus ODP at a
high-volume community hospital.
Methods: Between January 2003 to December 2013, 81
distal pancreatectomies were performed at a community
teaching hospital. A retrospective analysis on demographics,
90-day outcomes, readmission rates, length of stay (LOS),
and total cost were collected.
Results: Eighty-one patients underwent distal pancreatectomy (41 open and 40 laparoscopic). Median age was 62
years. Two-thirds of patients were female. LDP had significantly shorter mean operative time (150 vs. 183 minutes;
p < 0.01) and decreased blood loss compared to ODP (135
vs. 568 mL; p < 0.001). Table 1 compares tumor characteristics, LOS, readmission rates, and costs. Pancreatic fistula
rates were comparable with no Grade C fistulae in either
group. Overall 90-day morbidity was lower in the LDP group
with no mortalities. The 30-day and 90-day readmission rate
was lower in LDP; hence LDP has lower total hospital days.
The overall costs for both the index admission and the total
hospital stay (including readmission) were lower for LDP
group.
Conclusion: LDP has significantly lower index LOS, fewer
total hospital days and lower overall costs compared to ODP.
LDP should be the standard of care for amenable lesions in
the body or tail of the pancreas.
OP-II.33 CHOLEDOCHODUODENOSTOMY
IS A SAFE AND EFFICIENT
ALTERNATIVE FOR BILE DUCT
RECONSTRUCTION DURING
LIVER TRANSPLANT
T. L. Nydam
University Of Colorado School Of Medicine, Aurora, CO
In our institution, choledochoduodenostomy (CDD) has
become the bile duct reconstruction of choice in liver transplants when a duct-to-duct choledochocholedocostomy
(D2D) is not possible. We provide evidence that CDD is a
safe option for bile duct reconstruction with significant
advantages during postoperative care.
2015 The Authors
HPB 2015 Americas Hepato-Pancreato-Biliary Association
Abstracts
Methods: All orthotopic liver transplants performed at The
University of Colorado Hospital from July 2006 to July 2013
were retrospectively reviewed. Patient demographics, donor
type, post-transplant complications, ERCP times, and biliary
percutaneous transhepatic interventions (PTC) were collected. Statistical analysis was performed using a paired
students t-test assuming equal variances.
Results: 632 liver transplants were performed. Eighty-two
patients underwent CDD, 28 patients underwent Roux en Y
choledochojejunostomy (CDJ), and 522 patients underwent
D2D. There was no statistical difference in cholangitis, bile
leak, anastomotic stricture, or other complications. However,
there was a statistically significant difference in mean length
of ERCP and number of PTCs between the CDD and CDJ
cohorts. (Table 1).
Conclusions: Contrary to traditional teaching, a CDD
reconstruction appears to have no difference in complications
compared to a CDJ reconstruction. In addition, the length of
time spent during ERCP and the number of PTCs required
were significantly lower in the CDD cohort. In our institution, CDD is a safe option for bile duct reconstruction during
liver transplant that provides improved postoperative access
to the graft biliary system.
67
68
Abstracts
Abstracts
69
70
Abstracts
Abstracts
Body Radiation (SBRT) safety and its influence on waitlist
dropout, perioperative LT complications, or recurrence
post-LT.
Aim: Whether adding SBRT to HCC LT waitlist patients having received Trans-Arterial-Chemo-Embolization
(TACE), impacts the safety/efficacy profile as measured by
waitlist dropout, perioperative complications or posttransplant HCC recurrence.
Methods: Retrospective analysis from a two-institution
transplant program, of 10 consecutive waitlisted HCC
patients receiving SBRT + TACE matched with 10 such
patients receiving TACE only.
Results: Median treatment follow-up: SBRT + TACE group
45 vs 43 mo TACE-only group; median LT follow-up: 34 and
38 mo, respectively. Mean wait-time for the SBRT-group was
330 d vs 150 d for the TACE-only group. At last follow-up
8/10 SBRT-group patients were alive vs 6/10 in the TACEonly group. One HCC recurrence occurred in the SBRTgroup vs two in the TACE-only group. All HCC recurrences
died. Pre-transplant median AFP was higher in the SBRTgroup. Tumor response by explant percent necrosis was
similar between groups. LOS, ICU days and median EBL
trended higher for the SBRT group (p = 0.60). There were no
waitlist drop-outs in either group.
Conclusions: Despite longer waitlist time, HCC patients
receiving SBRT + TACE had no waitlist drop-out, and lower
HCC recurrence post-LT. SBRT + TACE patients trended
toward more difficult operations, but no significant difference
in post-LT survival. Thus, addition of pre-LT SBRT to TACE
appears safe and effective as a bridge to LT. Future prospective randomized clinical trials are warranted.
71
72
Abstracts
Abstracts
73
74
Abstracts
V-B.05 ROBOTIC
PANCREATICODUODENECTOMY WITH
PORTAL VEIN RESECTION AND PATCH
VENOPLASTY
M. Girgis, M. Hogg, H. Zeh, A. Zureikat
University Of Pittsburgh School Of Medicine, Pittsburgh,
PA
Introduction: Robotic pancreaticoduodenectomy is safe
and feasible for resectable pancreatic head adenocarcinoma.
Vascular resection during pancreaticoduodenectomy for
borderline resectable PDAC may be associated with slightly
increased morbidity but provides good oncologic outcomes.
We describe a robotic pancreaticoduodenectomy with
planned portal vein resection and patch venoplasty in a
patient with borderline resectable pancreas cancer.
Methods: This patients operation was recorded by the Da
Vinci Surgical System. The file footage was compiled and
edited. The patients consent was obtained.
Results: This is the case of a 57-year-old patient with
locally advanced pancreas cancer. He underwent 6 cycles of
neoadjuvant chemotherapy. Restaging CT scan showed
down-staging of the tumor to borderline resectable status.
The procedure was completed robotically in 452 minutes
with an estimated blood loss of 900 ml. A large 4 cm partial
2015 The Authors
HPB 2015 Americas Hepato-Pancreato-Biliary Association
Abstracts
75
76
Abstracts
Abstracts
growth through ischemia-reperfusion injury. We sought to
examine the association between PPC and long-term survival
following hepatectomy for colorectal liver metastases
(CRLM).
Methods: We conducted a matched cohort study using our
prospective hepatectomy database to identify all patients
undergoing hepatectomy for CRLM from 2003 to 2013.
Cohorts were selected based on use of PPC, with 1 : 1 matching for age (5-year increments), time period (20032007 vs.
20072013), and Clinical Risk Score (0 to 5 scale). Primary
outcome was overall survival (OS). Conditional logistic and
Cox regression analyses determined odds ratios (OR) and
hazard ratios (HR).
Results: Of 481 hepatectomies for CRLM, 187 (39%)
patients underwent PPC. 110 pairs of patients were matched
in the cohorts, and the remainder excluded. Peri-operative
chemotherapy (p = 0.183), major hepatectomy (>= 3 segments) (p = 0.345) or resection status (R0 vs. R12)
(p = 0.132) did not differ. 30-day major morbidity (OR 0.73;
p = 0.332) and mortality (OR 2.4; p = 0.100) were not significantly associated with PPC. Median follow-up was 35
(range: 0130) months. When adjusting for extent of resection, blood loss, and operative time, no significant difference
was observed in OS (HR 1.76; p = 0.129) for PPC, with
5-year OS of 59.2% (95%CI: 54.059.2%) for PPC and
62.3% (95%CI: 61.867.3%) without PPC (log-rank
p = 0.415). Excluding 90-day deaths did not substantially
alter the results (log-rank p = 0.930).
Conclusions: PPC was not associated with a significant difference in OS in patients undergoing hepatectomy for
CRLM. It does not appear to adversely affect oncologic
outcomes.
77
LO-J.06 HEPATO-PANCREATECTOMY:
HOW MORBID? RESULTS FROM THE
NATIONAL SURGICAL QUALITY
IMPROVEMENT PROGRAM
T. B. Tran, M. M. Dua, D. A. Spain, B. C. Visser,
J. A. Norton, G. A. Poultsides
Stanford University School Of Medicine, Stanford, CA
Background: Simultaneous resection of both the liver and
pancreas carries significant complexity. The objective of this
study is to investigate perioperative outcomes following synchronous hepatectomy and pancreatectomy (SHP).
Methods: The American College of Surgeons National
Surgical Quality Improvement Program (ACS-NSQIP)
database was queried to identify patients who underwent
SHP. Resections were defined as follows: <hemihepatectomy, hemihepatectomy (hemihepatectomy and
trisectionectomy), PD (pancreaticoduodenectomy), and
distal (distal pancreatectomy and enucleation).
Results: From 2005 to 2012, 377 patients underwent SHP,
representing 1% of 38,568 patients who underwent hepatectomy and/or pancreatectomy. Median age was 60 years. Indications included pancreatic malignancy (60%), hepatobiliary
malignancy (10%), benign disease (6%), gastric cancer (4%),
retroperitoneal neoplasm (3%), colon cancer (2%), and other
(15%). Patients were stratified based on the extent of combined resection: <hemihepatectomy + distal (n = 170),
hemihepatectomy + distal (n = 37), <hemihepatectomy +
PD (n = 151), and hemihepatectomy + PD (n = 19).
Perioperative morbidity and mortality gradually increased as
resections became more extensive (Figure). Although the
first 3 groups had a reasonable morbidity and mortality
profile, in the latter group of hemihepatectomy + PD the
rate of any complication was 84%, septic shock 26%,
reintubation 16%, hemodialysis 10%, 30-day mortality 10%,
and in-hospital mortality 33%.
Conclusions: Liver resections less extensive than hemihepatectomy can be performed concurrently with any pancreatectomy resulting in an acceptable safety profile. Synchronous hemihepatectomy (or trisectionectomy) and
pancreaticoduodenectomy remains a highly morbid combination and should be reserved for patients who have undergone extremely cautious selection.
78
Abstracts
Abstracts
79
80
Abstracts
Conclusion: In addition to tumor cell death within the irreversible ablation zone the use of IRE could potentially reduce
local recurrence by allowing for increased drug administration to the cells on the periphery of the ablation zone.
Abstracts
colorectal (30.7%), neuroendocrine (6.9%) and other cancers
(6.9%). Resection was performed in 72 patients (71.3%;
40.6% major, 30.7% minor) and liver transplantation in 29
(28.7%). Mean interval between first SIRT and first hepatic
surgery was 8.7 months. Clavien-Dindo grade 3+ peri-/postoperative complications were: liver failure: 7 (6.9%); woundspecific: 4 (4.0%); cardiovascular: 0 (0%); pulmonary: 8
(7.9%); renal-specific: 2 (2.0%); other: 15 (14.9%). Cumulative 90-day all-cause mortality from first hepatic surgery
was 4 (4.0%). These 4 cases were all trisectionectomies
(colorectal: 3; cholangiocarcinoma: 1) and typically had 1
prior chemotherapy line, pre-surgical co-morbidities and
suffered post-hepatectomy multi-organ failure including
liver failure. Future liver remnant was targeted with SIRT in
1 of the 4 cases. The safety profile of post-SIRT resection and
transplantation appears similar to that previously reported for
hepatic surgery. No deaths appear to be directly related to
SIRT.
81
Author index
Aal, A. K.: 7
Abbott, D. E.: 20, 41
Abbott, D.: 10
Abdelhady, A.: 69
Abrams, P.: 16
Adams, D. B.: 63
Adams, R. B.: 19
Agle, S. C.: 80
Agopian, V. G.: 51
Ahmad, S. A.: 41
Ahmad, S.: 20
Ahuja, N.: 4, 41, 54
Aksoy, E.: 31
Akyuz, M.: 31
Alanazi, R.: 16
Albers, C.: 67
Aldakkak, M.: 5
Ali, N.: 53, 64
Aljiffry, M.: 16
Alkhalili, E.: 21
Allard, R.: 24
Allen, P. J.: 38, 74, 76
Allen, P.: 75
Allison, J.: 67
Almeida, M. A.: 27
Aloia, T. A.: 20, 39, 72, 73, 78
Alseidi, A.: 48, 60, 62, 64
Al-Shazly, M. A.: 69
Alshenaifi, J.: 16
Alsina, A. E.: 67
Alvarez, F.: 9
Amini, N.: 26
Anantha Sathyanarayana, S.: 34, 35,
65
Anaya, D. A.: 6
Anderson, C. D.: 44, 70
Anderton, A. C.: 29
Andreou, A.: 53, 68
Annamalai, A.: 11
Annigeri, P.: 35
Aoki, T.: 35
Armstrong, P. A.: 58
Arnoletti, P.: 21
Aryal, B.: 79
Attwood, K.: 57
Aucejo, F.: 31
Aviles, C.: 37
Aycart, S.: 18
Ayloo, S.: 68
Baker, E. H.: 8, 23, 59
Baker, E.: 37
Balaa, F. K.: 51
Balart, L. A.: 70
Ball, C. G.: 47
Barber, K.: 67
Bardeesey, N.: 78
Barin, B.: 52
Bassi, C.: 1
Bauer, T. W.: 19
Baumert, T.: 3
Bdeawey, E.: 25
Beal, E.: 69
Beane, J. D.: 15
Begnami, M. F.: 18
Behman, R.: 54
Behrman, S. W.: 61
Author index
Dong, M.: 53
Dorsett-Martin, W.: 44
Doughtie, C. A.: 80
Doussot, A.: 28, 76
Downs-Canner, S.: 57
Doyle, M. B.: 1
Drosdeck, J.: 36
Drummond, J.: 23, 37
Du, L.: 43
Dua, M. M.: 14, 42, 44, 77
DuBay, D. A.: 7, 9
Dural, C.: 31
Duran, H.: 71
Dutson, E. P.: 51
Earl, T. M.: 44, 70
Earle, C.: 65
Easler, J. J.: 12
Eaton, A. A.: 38
Eckhoff, D. E.: 7, 9
Edwards, G. C.: 43
Edwards, J. P.: 47
Ehrenfeld, J.: 43
Ehrenwald, E.: 25
Ejaz, A.: 32, 41
El-Bardeesy, N. M.: 79
Eldert, R. E.: 66
Elgendi, A. M.: 25
ElHayek, K.: 64
Ellison, C. E.: 36
El-mansy, M.: 69
Elmi, M.: 58, 65
El-Sedfy, A.: 58, 65
Elshafey, M.: 25
Enestvedt, K.: 70
Eng, C.: 72
Epelboym, I.: 5
Erickson, B. A.: 3, 5, 65
Erinjeri, J. P.: 28
Ertel, A.: 10, 20, 41
Eskander, M. F.: 49
Eskander, M.: 15
Etra, J. W.: 26
Eubanks, S.: 21
Evans, D. B.: 3, 5, 63, 65
Ewan, L. C.: 50
Fabra, I.: 71
Fairfull Smith, R.: 43
Falk, G. A.: 56
Farnell, M. B.: 13, 55
Farsad, K.: 70
Fathi, A.: 10
Fauda, M.: 9
Fernandez Del Castillo, C.: 55
Ferrone, C. R.: 27, 30, 55, 78, 79
Ferrone, S.: 79
Fields, R. C.: 11, 14, 39
Fino, N.: 51
Fleming, J. B.: 39
Flores, K.: 6
Fong, Y.: 38
Fonseca, V. H.: 18
Fowler, K. J.: 1
Franco, E. S.: 67
Franssen, B.: 73
Freedman, S. D.: 15
Freitas, H. C.: 29
Friedman, M.: 11
Friel, C. M.: 19
Fuchshuber, P.: 37
Fulp, W. J.: 58
Fung, A.: 72
Fung, J.: 31
Furoi, A.: 79
Fuss, M.: 70
Gabriel, E. M.: 57
Gabriel, E.: 60
Gall, T. M.: 28
Gallinger, S.: 43, 48
Gamblin, T. C.: 2, 7, 10
Gamblin, T.: 46
Garcia, S.: 49
Garcia-Monaco, R. D.: 17
Gasslander, T.: 33
Gedaly, R.: 2, 52
Gennaro, K. H.: 7
George, B.: 3, 5, 65
Gerst, S. R.: 76
Girgis, M.: 74
Glorioso, J. M.: 45
Goel, M.: 61
Gondolesi, G.: 9
Gonen, M.: 75
Goyal, L.: 27, 78, 79
Gray, S. H.: 7, 9
Greenbaum, A.: 21
Greig, P. D.: 72
Groeschl, R. T.: 7
Grondin, S. C.: 47
Groot Koerkamp, B.: 76
Gu, C.: 43
Gulenchyn, K. Y.: 43
Gupta, R.: 25
Gusani, N. J.: 81
Habashi, R.: 76
Habersetzer, F.: 3
Halac, E.: 9
Hall, B. L.: 15, 39, 61, 62
Hallet, J.: 3, 42, 54, 76
Halpern, E.: 55
Hammill, C. W.: 36, 40
Hammill, C.: 31
Hanna, E. M.: 53
Hanna, S.: 54, 76
Hanseman, D. J.: 41
Hansen, P. D.: 36, 40
Hansen, P.: 31
Harrigan, A. M.: 19
Harris, J. W.: 12
Hasegawa, K.: 35
Hashiguchi, T.: 79
Hassanain, M.: 16
Hauch, A. T.: 70
Hawkins, W. G.: 11, 14, 39
Haywood, N. S.: 7
He, J.: 4, 26, 54
Hedrick, T. L.: 19
Hefty, M. T.: 50
Helmy, A. S.: 69
Helton, S.: 60, 62, 64
Hemingway, K. T.: 55
Herbert, G.: 75
Hernandez-Alejandro, R.: 24
Hill, M.: 25
Hines, O. J.: 51
Hiotis, S.: 18
Hirose, K.: 26, 41, 54
83
Hiyama, D. T.: 51
Hochwald, S. N.: 38
Hochwald, S.: 57, 60
Hodul, P.: 58
Hoehn, R. S.: 20, 41
Hoehn, R.: 10
Hoen, H. M.: 40
Hoen, H.: 31
Hoffe, S.: 58
Hogg, M.: 57, 74
Hong, J. C.: 48
Hong, T. S.: 79
Hooper, J. E.: 70
Horeya, H. E.: 54
Hosny, A.: 69
Hotoyan, L.: 72
House, M. G.: 12, 15, 62, 66
Hruban, R. H.: 4
Hu, T.: 24
Huang, R.: 19
Hunter, S.: 20, 37
Husien, M.: 43
Hwa, K. J.: 14, 44
Iannitti, D. A.: 8, 53, 59
Iannitti, D.: 23, 37
Idrees, K.: 43
Ielpo, B.: 71
Illig, K.: 58
Imoto, Y.: 79
Imventarza, O.: 9
Inampudi, S.: 25
Inoue, M.: 79
Isaksson, B.: 33
Jacobs, M. J.: 34, 35, 65
Jacobs, M.: 47
Jalink, D. W.: 43
Jaques, D. P.: 39
Jarnagin, W. R.: 28, 38, 74, 76
Jarnagin, W.: 75
Jenkins, H.: 50
Jeong, J.: 79
Jernigan, P. L.: 41
Jeyarajah, D. R.: 20, 37, 47, 80
Jhaveri, K.: 30
Jiao, L. R.: 28
Johnson, B. L.: 58
Johnson, J.: 50
Johnston, C. W.: 40
Johnston, F. M.: 2, 3, 5, 7, 10, 63
Johnston, W. C.: 36
Johnstone, M.: 67
Joyce, D.: 56
Julian, J. A.: 43
Jutric, Z.: 40
Kadono, J.: 79
Kagedan, D. J.: 58, 65
Kandil, E.: 70
Kaneko, J.: 35
Karanicolas, P. J.: 42, 76
Karanicolas, P.: 54
Kather, R.: 34
Katsanos, G.: 80
Katz, M. H.: 39, 81
Kaugh, J.: 17
Kazantsev, G. B.: 37
Keith, S. W.: 62
Kelly, L. R.: 17
84
Kelly, P.: 72
Kelly, R. P.: 10
Kemmer, N.: 67
Kendrick, M. L.: 13, 55
Kendrick, M.: 73
Kent, T. S.: 15, 55, 56, 59
Khreiss, M.: 45
Khwaja, K.: 49
Kilbane, E. M.: 15, 61, 62
Kilbane, M.: 66
Killackey, M.: 70
Kim, I.: 11
Kim, K.: 17
Kim, Y.: 25
Kingham, P.: 28
Kingham, T. P.: 38, 74, 75, 76
Kirichenko, A.: 16
Kirks, R. C.: 53
Klausner, J. Q.: 14
Klein, A.: 11
Klein, R.: 4
Klompmaker, S.: 59
Kluger, M. D.: 5
Kohli, N. P.: 34
Kojouri, K.: 37
Kokudo, N.: 35
Kolbeck, K.: 70
Komokata, T.: 79
Konomos, M.: 48
Konstantinidis, I. T.: 27, 78, 79
Kooby, D. A.: 22, 26, 75
Krepline, A. N.: 5, 65
Krohmer, S.: 2
Krzywda, B. A.: 3
Krzywda, E. A.: 63
Kumar, R.: 24
Kunnimalaiyaan, M.: 46
Kunnimalaiyaan, S.: 46
Kuo, W.: 72
Kutlu, O. C.: 8, 49
Kuvshinoff, B. W.: 38
Kuvshinoff, B.: 57, 60
Labow, D.: 18
LaFemina, J.: 6
Lahiff, S. L.: 63
Lahiff, S. M.: 3
Laing, C. J.: 17
Lam, T.: 48
Lancaster, W. P.: 63
Lapointe, R.: 19, 24, 31
Lavu, H.: 62
Law, C. H.: 42, 43, 76
Law, C.: 54
Leal, J. N.: 74
Lee, J. E.: 39
Lee, K. K.: 57
Lee, K.: 79
Lee, S. J.: 62
Leiva Espinoza, J.: 9
Lemke, M.: 54
Lenarz, M.: 68
Lennon, A.: 4
Letourneau, R.: 19, 31
Levine, E.: 51
Levine, M. N.: 43
Lewis, C. E.: 51
Li, Q.: 58, 65
Li, Y.: 80
Lidsky, M. E.: 21
Author index
Lillemoe, K. D.: 27, 30, 55, 78, 79
Lin, B.: 60
Linehan, D. C.: 1
Litchman, T.: 28
Liu, J. Y.: 26
Liu, N.: 65
Luberice, K.: 4
Lundgren, L.: 33
Luo, T.: 25
Luque, C.: 9
Machado, M. A.: 71
Mackillop, W. J.: 17, 29, 32
MacLennan, P. A.: 9
Mahar, A. L.: 42
Mahendraraj, K.: 5
Maithel, S. K.: 22, 26, 48, 75
Makary, M. A.: 26, 41, 54
Makdissi, F. F.: 71
Makris, A.: 67
Malafa, M. P.: 58
Maleux, G. A.: 80
Malleo, G.: 1
Manas, D. M.: 80
Mancias, J.: 55
Mandeli, J.: 18
Mao, S. A.: 45
Maqsood, H.: 25
Marescaux, J.: 3
Marginean, C.: 51
Marques, M. C.: 18, 27, 29
Marshall, G.: 35
Martel, G.: 51
Martin, J. T.: 12
Martin, R. C.: 17, 22, 75, 78, 80
Martinie, J. B.: 8, 53, 59
Martinie, J.: 23, 37
Mason, M. C.: 6
Massarweh, N. N.: 6
Matlock, J. A.: 48
Mattera, J.: 9
Matus, D.: 9
Maupoey, J.: 71
Maurette, R.: 9
Maynard, E. C.: 12
Maynard, E.: 2, 52
McCormack, L.: 9
McDowell, D. M.: 3
McGilvray, I. D.: 72
McGrath, P. C.: 12
McIntyre, C. A.: 38
McMillan, M. T.: 1
McMurry, T. L.: 19
Medkhaly, A.: 16
Mehran, R. J.: 73
Meier, A. M.: 20
Merchant, N. B.: 43
Mercurio, N.: 39
Metrakos, P.: 16
Midura, E.: 41
Miller, C.: 31
Miller, J. R.: 43
Mimeault, R.: 51
Minter, R. M.: 22, 47, 48
Mir, H. R.: 43
Mise, Y.: 35
Misustin, S. M.: 63
Mitin, T.: 70
Mitra, A.: 61
Mittal, V. K.: 47
Author index
Pawlik, T.: 41
Payette, F.: 24
Pena, L.: 52
Peng, P. D.: 37
Perez, A.: 21
Perez, C. A.: 37
Pessaux, P.: 3
Petersen, B. D.: 67
Philips, P.: 17
Picozzi, V.: 60
Pimiento, J. M.: 58
Pitt, H. A.: 15, 61, 62
Pitt, S. C.: 15
Plasse, M.: 19, 31
Pomianowska, E.: 33
Postlewait, L. M.: 22, 26, 48, 75
Postow, M. A.: 28
Potkonjak, M.: 2
Pottel, H.: 33
Poultsides, G. A.: 14, 42, 77
Pratschke, J.: 53, 68
Prestera, A.: 71
Prussing, K.: 75
Qu, J.: 72
Quan, D.: 43
Que, F. G.: 13, 55
Quijano, Y.: 71
Quinonez, E.: 9
Quintini, C.: 31
Radomski, M.: 74
Raju, R.: 58, 65
Ramirez, R. M.: 37
Randhawa, S.: 35
Rashid, O. M.: 58
Redden, D. T.: 7
Reddy, S.: 25, 53
Redman, R. A.: 17
Reid-Lombardo, K.: 13, 55
Reidy-Lagunes, D.: 81
Rezaee, N.: 4, 54
Rheun-Chuan, L.: 80
Riall, R. S.: 61
Riall, T. S.: 15
Ribeiro, H. S.: 18, 27, 29
Rilling, W. R.: 17
Ritch, P. S.: 3, 5, 65
Rivera, M. N.: 78
Roach, L.: 38
Roch, A. M.: 12
Rocha, F. G.: 60
Rocha, F.: 62, 64
Rogers, R.: 52
Romero, P.: 9
Rong, Z.: 31
Rosas, E. E.: 37
Rose, J. B.: 60, 62, 64
Rosemurgy, A. S.: 4
Rosok, B. I.: 33
Ross, S. B.: 4
Ross, S. W.: 8, 53
Rouleau, E.: 6
Rowsell, C.: 58
Roy, A.: 19, 31
Rubenfeld, I. S.: 34
Ruo, L.: 43
Russell, M. C.: 26
Ryan, C.: 4
Saad, N. E.: 1
Sabbatino, F.: 30, 79
Saddekni, S.: 7
Sadot, E.: 38
Sadowitz, B.: 4
Sakamoto, Y.: 35
Salami, A.: 6
Salman, B.: 4
Sandstrm, P.: 33
Sanford, D. E.: 11, 14
Sangro, B.: 80
Sapisochin, G.: 72
Sarmiento, J. M.: 26
Sarpel, U.: 18
Sasadeusz, K.: 31
Sauer, P. F.: 9
Scally, C.: 22
Schenning, R. C.: 67
Schlieman, M. A.: 37
Schmidt, C. M.: 62, 66
Schmidt, C.: 12, 36, 69
Schoen, M.: 80
Schreeder, M. T.: 17
Schrope, B.: 5
Schwarz, L.: 39, 72
Scoggins, C. R.: 17, 22, 75, 80
Seawright, A.: 70
Seehofer, D.: 53, 68
Sela, N.: 24
Serrano, P. E.: 43
Seshadri, R. M.: 59
Seshadri, R.: 8, 23, 37, 53
Shah, M.: 2, 52
Shah, S. A.: 20, 41
Shah, S.: 10
Shahid, M.: 78
Sharma, V. R.: 17
Sheckley, M.: 11
Sheikh, M. R.: 20, 37
Shen, P.: 51
Shia, J.: 76
Shim, J.: 67
Shimizu, T.: 79
Shin, E.: 58, 65
Shridhar, R.: 58
Shrikhande, S. V.: 61
Shubert, C. R.: 13
Shyr, Y.: 43
Sielaff, T.: 25
Simoneau, E.: 16
Singh, N.: 44
Smith, A.: 70
Smith, T. J.: 70
Smoot, R. L.: 13
Smoot, R.: 30, 72
Soares, F. A.: 27
Sodergren, M. H.: 28
Soler, L.: 3
Sosa, J. A.: 64
Spain, D. A.: 77
Sparrelid, E.: 33
Spitzer, A. L.: 37
Spolverato, G.: 25, 26, 32, 41
Springett, G.: 58
Sprys, M. H.: 1
Squires, M. H.: 22, 26, 75
St. Martin, L.: 48
Stafford, A. T.: 64
Staley, C. A.: 26
Steve, J.: 57
85
Stilwell, K.: 50
Stock, P.: 52
Storino, A.: 55, 56, 59
Strasberg, S. M.: 17, 39
Stukenborg, G. J.: 19
Subar, D. A.: 50
Sugawara, Y.: 35
Suh, K.: 79
Sukharmwala, P.: 4
Sultenfuss, M. A.: 6
Surjan, R. C.: 71
Surraco, P.: 9
Sussman, J. J.: 20
Swan, R. Z.: 8, 53, 59
Swan, R.: 23, 37
Szramowski, M.: 16
Tabrizian, P.: 18
Tait, G.: 72
Takaki, H.: 28
Talbot, P.: 68
Tanabe, K. K.: 27, 30, 79
Tatum, C. M.: 17
Tee, M. C.: 13
Tee, M.: 55
TEH, S. H.: 37
Templin, M. A.: 59
Templin, M.: 8
Thai, N.: 16
Thiesing, J. T.: 31
Thirunavukarasu, P.: 38, 57, 60
Thomas, C.: 70
Thoolen, S. J.: 59
Tilak, J.: 47
Tillou, A.: 51
Ting, D. T.: 27, 78, 79
Tohme, S.: 45
Tolat, P.: 65
Tom, K.: 16
Tomalty, R. D.: 17
Torabi, R.: 30
Tran, T. B.: 14, 42, 77
Tremblay St-Germain, A.: 30
Treska, V.: 78
Truty, M. J.: 13, 55
Tsai, S.: 2, 3, 5, 7, 10, 63, 65
Tsang, M. E.: 76
Tsang, M.: 42
Tseng, J. F.: 15, 49, 56, 59
Tsung, A.: 13, 45
Turaga, K. K.: 2, 7, 10
Turcios, L.: 2
Turcotte, S.: 19, 31
Tzeng, C. D.: 12
Tzeng, C.: 2, 52
Uemoto, S.: 69
Uppal, R.: 31
Usatoff, V.: 34
Valsangkar, N.: 66
Van Der Vliet, W. J.: 59
Vandenbroucke-Menu, F.: 19, 24, 31
Vansteenkiste, F.: 33
Vargas, C. R.: 56
Vargas, C.: 55
Varley, P.: 13, 45
Varshney, N.: 47
Vauthey, J.: 20, 39, 72, 73, 78
Velduis, P.: 21
86
Vicente, E.: 71
Vilchez, V.: 2, 52
Villani, V.: 30, 79
Visser, B. C.: 14, 42, 44, 77
Vitale, A.: 32
Voidonikolas, G.: 11
Vollmer, C. M.: 1
Wachsman, A.: 11
Wachtel, M.: 8
Walsh, R. M.: 53, 64
Walsh, R.: 56
Wang, Y.: 79
Warner, S. G.: 22, 48
Warshaw, A. L.: 55
Wassef, W.: 6
Wasserman, J.: 51
Waters, J. A.: 62
Watkins, A. A.: 55, 56, 59
Weaver, J.: 51
Weber, S. M.: 22, 75
Weber, S.: 36
Wei, X.: 17, 29, 32
Weiss, M. J.: 4, 26, 41, 54
Author index
Welch, S.: 24
Welsh, M. T.: 12
Wey, J.: 64
White, J. A.: 7, 9
White, R. R.: 64
White, T.: 48
Williams, M. V.: 49
Wima, K.: 10, 20, 41
Winer, J. H.: 26
Winslow, E.: 22, 75
Wolf, R. F.: 36, 40
Wolf, R.: 31
Wolfgang, C. L.: 4, 26, 41, 54
Wong, L. L.: 29
Woo, S.: 63
Wood, L. D.: 4
Worhunsky, D. J.: 42
Worth, P.: 70
Wren, S. M.: 44
Wright, G.: 50
Wu, Y.: 31
Yamakuchi, M.: 79
Yang, C. J.: 15
Yazici, P.: 31
Yearley, J. H.: 79
Yi, N.: 79
Yoshihara, E.: 33
Yoshy, C. S.: 24
Youngwirth, L. M.: 64
Yousafzai, O. K.: 49
Yu, L.: 36
Zaki, A. M.: 54
Zarrinpar, A.: 51
ZarZaur, B. L.: 61
Zaydfudim, V. M.: 19
Zaytseva, Y.: 2
Zeh, H. J.: 57
Zeh, H.: 74
Zenoni, S.: 21
Zhang, J.: 44
Zhu, A. X.: 27, 78, 79
Zhu, X.: 21
Zilbert, N.: 48
Zureikat, A.: 57, 74
Zyromski, N. J.: 12, 62, 66