Oral (pre-recorded)
OB04 Biliary: Surgical Outcomes 
Selection of Presentations from Abstract Submissions
OB04-01 Feasibility and Efficacy of Stent Placement Above the Papilla (Inside-Stent) as a Bridging Treatment for Perihilar Biliary Malignancy: A Single-Center Prospective Study
Yu Takahashi, Japan

Y. Takahashi1, H. Ito1, Y. Inoue1, Y. Mise1,2, T. Sato1, Y. Ono1, A. Saiura1,2
1Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japan, 2Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Japan

Introduction: Few studies have reported the outcome of stent placement above the Oddi (inside-stent) for preoperative biliary drainage in patients with hilar malignant biliary obstruction (HMBO). Herein, we conducted this single-center, prospective study which evaluated the safety and efficacy of inside-stent as a bridging treatment (UMIN000025463).
Methods: Patients with resectable HMBO, which located at the distance of 3cm or greater from the biliary stricture to the sphincter of Oddi, were enrolled. First, endoscopic-naso biliary drainage (ENBD) catheter was placed as an initial drainage. ENBD was then replaced with an inside-stent when their serum total bilirubin decreased < 5 mg/dL. Primary endpoint was a time to recurrent biliary obstruction (TRBO), and secondary endpoints included technical success rate, adverse event, the incidence of recurrent biliary obstruction (RBO), and postoperative severe complication rate.
Results: A total of 32 patients were enrolled and the most of them (27 [84%]) had cholangiocarcinoma. Three patients (9%) developed RBO and non-RBO rate at 30 days were 87%. The stent was successfully placed for 97% with acceptable adverse event (9%). Among the patients who developed RBO, the cause of RBO included cholangitis (3%), stent occlusion (3%) and stent dislocation (3%). Twenty-nine patients (92%) underwent resection median 27.5 days after inside-stent was placed. Major hepatectomy with bile duct resection was the operation for all but one who underwent bile duct resection only. Their postoperative severe complication rate was 17% and there was no mortality.
Conclusions: Inside-stent is safel and useful as a bridging treatment for patients with HMBO.
OB04-02 Comparison of Laparoscopic Common Bile Duct Exploration Combine with Cholecystectomy and Laparoscopic Cholecystectomy with Preoperative Endoscopic Sphincterotomy: In Terms of Surgical Outcomes and Recurrences
Seung Jae Lee, Korea, Republic of

S.J. Lee, I.S. Choi, J.I. Moon
Surgery, Konyang University, Korea, Republic of

Introduction: It is controversial whether Laparoscopic common bile duct exploration (LCBDE) combine with laparoscopic cholecystectomy(LC) is better than LC with preoperative endoscopic sphincterotomy (pre-EST) for management of choledocholithiasis.
Methods: 157 patients who underwent LCBDE+LC and 278 patients who underwent pre-EST+LC from January 2010 to December 2018 in single institution were retrospectively reviewed the preoperative characteristics, surgical outcomes, and recurrence of choledocholithiasis.
Results: The maximum CBD diameter (13.2 vs 9.5mm, p< 0.001) and the maximum stone size (11.4 vs 6.3mm, p< 0.001) was significantly larger in patients who underwent LCBDE+LC than pre-EST+LC. Multiple stones were also frequently found in LCBDE group (54.8 vs 43.0%, p=0.017). The operative time (111.4 vs 55.6 minutes, p< 0.001) was significantly longer in LCBDE group, while duration of hospital stays after first procedure (6.2 vs 9.8days, p< 0.001) was significantly shorter in LCBDE group. There is no statistical significance in conversion to open surgery (1.9 vs 0.4%, p=0.104), retained stones rate (3.2 vs 1.4%, p=0.219), and recurrence rate of choledocholithiasis (8.3 vs 9.4%, p=0.707) between the two groups. In multivariate analysis, old age (over 70years) and CBD dilatation (over 8mm) were risk factor for recurrence of choledocholithiasis.
Conclusion: In our experience, LCBDE+LC can be a safe and feasible management for choledocholithiasis, if appropriate experience and when expertise is available. High risk group of recurrence of CBD stone with old age and dilated CBD should carefully follow-up.
OB04-03 Early Predictor Using Comprehensive Complication Index of Lethal Surgical Outcome in Perihilar Cholangiocarcinoma
Shoji Kawakatsu, Japan

S. Kawakatsu, T. Ebata, N. Watanabe, S. Onoe, J. Yamaguchi, T. Mizuno, T. Igami, Y. Yokoyama, M. Nagino
Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan

Background: Patients who underwent resection for perihilar cholangiocarcinoma often have lethal postoperative course. The present study attempted to seek early predictor to trace life-threatening course.
Methods: Consecutive 377 patients who underwent hepatectomy for perihilar cholangiocarcinoma from 2010 to 2017 were reviewed. Predicting ability of daily cumulative comprehensive complication index (CCI) for Clavien-Dindo classification (CDC) grade IV/V was assessed using receiver operating characteristics curve analysis.
Results: Twenty-five (6.6%) patients finally had CDC grade IV and V (n=8, 2.1%); the causes of death were liver failure (n=6), pneumonia (n=1), and intraabdominal bleeding (n=1). In the 25 patients, a total of 29 complications > CDC grade III occurred until day 5 after surgery, represented by liver failure (n=13), pleural effusion (n=4), atelectasis (n=3), cholangitis (n=3) and bleeding (n=3) etc. Cumulative CCI increased day by day: 8.7 on day 1, 15.0 on day 3, 17.3 on day 5, 29.8 on day 7, and 38.7 on day 14, in median. CCI on day 5 (CCI-5) was 17.3 in patients with CDC I-III and 43.2 in those with CDC IV/V (P< 0.001). Divided by CCI-5 with cut-off value of 30.2, 19 (29.2%) of 65 patients with higher CCI-5 and 6 (1.9%) of 312 patients with lower CCI-5 had conclusive CDC grade IV/V (P< 0.001). Mortality was 10.8% versus 0.3%, respectively (P< 0.001).
Conclusion: CCI score on day 5 >30.2 worked as an early predictor to lethal complications including surgical death.
OB04-04 Surgical Outcomes of Perihilar Cholangiocarcinoma - Especially on Postoperative Portal Vein Thrombosis
Manh Thau Cao, Japan

M.T. Cao, R. Higuchi, T. Yazawa, S. Uemura, W. Izumo, Y. Matsunaga, M. Yamamoto
Department of Surgery, Tokyo Women's Medical University Hospital, Japan

Background: There are limited reports of portal venous thrombosis (PVT) following hepatectomy for perihilar cholangiocarcinoma (PHC)
Methods: 263 patients with PHC undergoing hepatectomy at our institution between 2002 and 2018 were retrospectively studied
Results: Median age was 70 years and 69% of patients was male. Bismuth types 1,2,3a,3b and 4 were seen in 6%,8%,27%,23% and 36%, respectively. The right hepatectomy, left hepatectomy, right trisectionectomy and left trisectionectomy and central bisegmentectomy were performed in 42%,38%,4%,4%,and 3%, respectively. PV and hepatic artery (HA) resection were performed in 27% and 7%. The mortality rate was 3.4%, the complication rate of CD3 or more was 35%. 6 patients developed PVT(2.3%). Multivariate analysis revealed that right hepatectomy (OR 6.46;p=0.09) and PVR (OR 13.7;p=0.017) are independent risk factors for postoperative PVT. PVT was diagnosed on postoperative day 6,7,6,0,7,22. Thrombectomy with PV reconstruction were performed in 4 patients, in which 3 patients with markedly stenosis of the left PV, thrombus extension to SMV, twisting of the PV; 1 patient combined with the internal hernia of the Y loop. Other 2 patients were successfully treated with anticoagulation drugs. The mortality resulting from PVT did not occur, all 6 patients subsequently recovered and discharged on POD25 to POD70.
Conclusion: Right hepatectomy and PVR are independent risk factors for postoperative PVT. Early detection with US and CT is pivotal in the management of PVT. Thrombectomy and PV re-reconstruction should be considered in case of early diagnosis with markedly stenosis of remnant PV or clearly evidence of bending or twisting
OB04-05 Safety and Oncological Benefit of Hepatopancreatoduodenectomy for Advanced Bile Duct Cancer with Horizontal Tumor Spread: Shinshu University Experience
Yuji Soejima, Japan

Y. Soejima, A. Shimizu, K. Kubo, T. Notake, T. Ikehara, K. Yasukawa, A. Mita, Y. Ohno, Y. Masuda
Department of Surgery, Shinshu University School of Medicine, Japan

Introduction: Although hepatopancreatoduodenectomy (HPD) is the only option to achieve R0 resection for widespread bile duct cancer (BDC), its safety and oncological benefit remains controversial due to its inherent high risk of mortality and morbidity. The aim of this study is to retrospectively analyze short- and long-term outcomes and evaluate the safety and oncological benefit of this advanced procedure.
Method: Consecutive 36 patients who underwent HPD were included. Portal vein embolization was applied before surgery in 19 (53%) patients with the future remnant liver volume < 35%.
Results: The median operative time and blood loss were 868 min and 1,025 ml, respectively. Concomitant vascular resection was performed in 5 patients (14%). The overall morbidity and mortality rates were 100% and 5.6% (n=2), respectively, where 18 patients (50%) had major (Grade III≤) complications. The most common complications were post-hepatectomy liver failure (83%, grade B/C:33%/6%) and intra-abdominal infection (44%), followed by postoperative pancreatic fistula (25%, grade B/C) and surgical site infection (22%). R0 resection was achieved in 29 patients (81%). The 1-, 3-, and 5-year over all survival (OS) were 83%, 45% and 34%, respectively. In patients who achieved R0 resection, 5-year OS were comparable between patients who underwent HPD and major hepatectomy alone (38% vs. 40%, p=NS).
Conclusion: HPD for extensive BDC is a valid option which can offer a long-term survival benefit at the cost of a relatively high but acceptable morbidity and mortality rates. HPD in selected patients should be advocated provided that R0 resection is to be achieved.
OB04-06 Spectrum of Laparoscopy in Common Bile Duct Pathologies - A Single Centre Experience
Vimalakar Reddy, India

V. Reddy1, K.V. Dinesh Reddy1, R. Musham1, G. Shroff2
1Surgical Gastroenterology, Sunshine Hospital, India, 2Sunshine Hospital, India

Introduction: In the era of minimally invasive surgery,laparoscopic CBD exploration is the best choice for addressing different difficult CBD pathologies.
Laparascopic CBD exploration is needed when:
- failed ERCP for CBDcalculi
- retained stent
- CBD injuries.
Approach may be transcystic /transductal(rendezvous,milking,fogarty balloon trawal,choledochoscopic/ureteroscopic extraction,laser lithotripsy)
The successful cbd exploration requires:
-surgical expertise
-knowledge over biliary anatomy
-adequate equipment
With the available technology,laparoscopic biliary surgery has become safe, efficient and cost effective in experienced hands.
Method: We report a series of different approaches for LAP CBD exploration done at our institute With Difficult CBD pathologies.
A prototype of each case has been explained in detail.
Results are compared to other studies on lap/open CBD explorations.
Results: 10 cases has been included in the study with different CBD pathologies.
Out of ten cases 8 are difficult CBD calculi failed on ERCP extraction,1 is retained stent,Other is CBD injury.
Different approaches were done like rendezvous ,milking,ureteroscopic extraction and laser lithotripsy.


All our cases are closed over stent.
Intraop/post op cholangiogram was not done in any of our cases. Complete CBD clearence achieved in all of our cases.
Length of stay,pain score was minimal with nil post op complications.
Conclusion: Laparoscopic CBD exploration is A standard method with high efficacy and low morbidity and mortality in experienced hands.
We recommend that even in failed ERCP cases first laparoscopic approach is RENDEZVOUS wich can avoid choledochotomy.
In the absence of CHOLEDOCHOSCOPE which is expensive URETEROSCOPE is considered for addressing difficult CBD pathologies.
OB04-07 Primary Closure after Laparoscopic CBD Exploration- Experience of More than 400 Cases over 12 Years at a Tertiary Care Center
Mayank Jain, India

V. Bansal1, A. Krishna1, P. Om1, M. Jain1, A. Baksi1, P. Garg2, S. Kumar1, M. Misra3
1Department of Surgical Disciplines, AIIMS, India, 2Department of Gastroenterology, AIIMS, India, 3Department of Surgical Disciplines, Mahatma Gandhi University of Medical Sciences, India

Introduction: T tube placement after common bile duct (CBD) exploration has been the standard since the era of open CBD exploration. We hereby report our experience and long term outcomes of over 400 cases of laparoscopic CBD exploration where in primary closure of CBD was done without T -Tube placement.
Methods: All patients with CBD stones undergoing laparoscopic common bile duct exploration (LCBDE) in a single surgical unit at a tertiary care center were studied from April 2007 to October 2019. MRCP served as a road map and patients were taken up for LCBDE if the CBD diameter was more than 10 mm. Intraoperative details including the mode of closure of bile duct (primary, T Tube or endobilliary stent) were noted. The post-operative recovery, complications, hospital stay, antibiotic usage and post-operative intervention if any were also recorded.
Results: 414 patients underwent LCBDE during this period. The mean age was 50 ± 15.2 years and majority were females (68.8%). 180 (43.47%) patients had failed ERCP. CBD was closed primarily in 97.58% (n=404) cases. Endobiliary stent was placed in 90 (21.73%) patients and only primary closure in 314 cases. T tube was used in 5 cases with a total of 34 conversion to open CBD exploration. Successful laparoscopic CBD clearance was achieved in 380 patients (success rate 91.80%).
Conclusion: Primary closure of CBD following laparoscopic CBD exploration is safe and associated with minimal complications. The routine use of primary CBD closure after laparoscopic CBD exploration is recommended based on our experience.
OB04-08 Laparoscopic Intra-abdominal Pressure Study: A Double Blinded Randomised Control Trial
Elliot Gin, Australia

E. Gin1, D. Lowen2, M. Tacey3, R. Hodgson2,4
1The Northern Hospital, Australia, 2The Northern Hospital, Australia, 3Northern Hospital, Australia, 4The University of Melbourne, Australia

Background: Laparoscopic surgery is regarded as the gold standard for the surgical management of cholelithiasis. To improve patient post-operative pain (POP), low pressure laparoscopic cholecystectomies (LPLC) have been trialled. A recent systematic review found that LPLC reduced POP, however many of the randomised control trials were at a high risk of bias and the overall quality of evidence was low.
Methods: 100 patients undergoing elective laparoscopic cholecystectomy were randomised to a LPLC (8mmHg) or a standard pressure laparoscopic cholecystectomy (12mmHg) (SPLC) with surgeons and anaesthetists blinded to the pressure. Primary outcomes were POP and shoulder tip pain (STP) at 4-6hours and 24hours, as recorded by a blinded assessor. Secondary outcomes included length of operation, post-operative complications and intra-operative visibility.
Results: 51 patients were randomised to LPLC. Although pain scores were comparable, post-operative opiate requirements were greater in the SPLC when compared to LPLC (total fentanyl in recovery 10µg vs 60µg, p=0.016), suggesting that LPLC reduces POP. Intra-operative visibility was significantly reduced in LPLC (p< 0.001) resulting in a higher number of operations requiring the pressure to be increased (34.0% vs 8.2%, p< 0.01), however there were no differences in length of operation or post-operative outcomes. Interestingly, when surgeons guessed the operating pressure, they were right in only 69% of cases.
Conclusion: LPLC reduced post-operative pain as evidenced by reduced analgesia requirements. Although LPLC compromised intra-operative visibility there was no difference in complications, suggesting LPLC is safe. Surgeons were not reliably able to guess the operating pressure.