IHPBA 2020 - Session Planner

Poster
Liver

PL03 Liver: Surgical Outcomes (ePoster)

Selection of ePoster Presentations from Abstract Submissions

PL03-001

A Better Route to ALPPS: Minimally Invasive vs Open ALPPS
Michal Kawka, United Kingdom

M. Kawka, S. Mak, T.M.H. Gall, L.R. Jiao
Department of Surgery and Cancer, Imperial College London, United Kingdom

Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained interest and controversy, as an alternative to portal vein embolisation (PVE) by inducing future liver remnant hypertrophy in patients at risk of post hepatectomy liver failure. Open ALPPS induces more extensive hypertrophy in a shorter timespan than PVE, however, it is associated with higher complication rates and mortality. Minimally invasive surgery (MIS), with its known benefits, has been applied to ALPPS in the hope of reducing the surgical insult and improving functional recovery time, whilst preserving the extensive FLR hypertrophy.
Methods: PubMed, Medline, EMBASE and Cochrane Library databases were searched on 10^thJuly 2019. 19 open ALPPS studies, 3 MIS ALPPS and 1 study reporting on both were identified and included in the analysis.
Results: 1088 open and 46 MIS ALPPS cases were included in the analysis. There were significant differences in the baseline characteristic: open ALPPS patients had a more diverse profile of underlying pathologies (p=0.028) and more right extended hepatectomies (p=0.006) performed. Operative time and blood loss did not differ between the two groups. MIS ALPPS had a lower rate of severe Clavien-Dindo complications (≥IIIa) following stage 1 (p=0.063) and significantly lower median mortality (0.00% vs 8.45%) (p=0.007).
Conclusion: Although MIS ALPPS would seem to provide a potentially superior alternative to open ALPPS with reduced morbidity and mortality rates, the evidence on MIS ALPPS is still limited and more high-quality studies on MIS ALPPS need to be published before conclusions can be reached.

PL03-002

Surgical Resection for Hepatocellular Carcinoma in Patients with Chronic Hepatitis C Virus Infection: A Chinese Multicenter Experience
Tian Yang, China

H. Xing¹, L. Liang¹, C. Li¹, Y.-H. Zhou², W.-M. Gu³, H. Wang⁴, T.-H. Chen⁵, F. Shen¹, T. Yang¹
¹Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, China, ²Department of Hepatobiliary Surgery, Pu’er People’s Hospital, China, ³First Department of General Surgery, Fourth Hospital of Harbin, China, ⁴Department of General Surgery, Liuyang People’s Hospital, China, ⁵Department of General Surgery, Ziyang First People’s Hospital, China

Background and aims: There are very few studies on surgical resection for HCC in patients with HCV infection from China. Based on a multicenter database, we aimed to analyze clinical characteristics, short-term and long-term prognosis after HCC resection in Chinese patients with chronic HCV infection.
Methods: The records of all patients with HCV infection who underwent curative resection for initial HCC between 2004 and 2015 were reviewed. Perioperative mortality and morbidity, long-term overall survival (OS) and recurrence-free survival (RFS) were evaluated.
Results: Of the enrolled 382 patients, nearly half (46.1%) did not know their history of HCV infection before HCC diagnosis, and only 14.6% had received anti-HCV therapy before surgery. The 30-day morbidity and mortality were 44.8% and 2.9%, respectively. The 5-year OS and RFS rates were 45.0% and 34.4% respectively. Multivariable analyses showed that concurrent HBV infection, portal hypertension, tumor size > 5 cm, macrovascular and microvascular invasion, and none of postoperative anti-HCV therapy were independently associated with OS, while concurrent HBV infection, preoperative AFP level > 400ug/L, tumor size > 5 cm, multiple tumors, and macrovascular and microvascular invasion were independently associated with RFS after curative resection for HCC in patients with chronic HCV infection.
Conclusions: The proportion of patients with HCV infection receiving anti-HCV therapy is low in China. Although perioperative morbidity and mortality are acceptable, the long-term outcomes are unsatisfactory, which may be related to high concurrent HBV infection rate, aggressive liver- and tumor-related characteristics, and low proportion of postoperative anti-HCV therapy.

[Figure. Comparisons of OS and RFS]

PL03-003

European Society for Clinical Nutrition and Metabolism (ESPEN) Malnutrition Criteria for Predicting Major Complications after Hepatectomy and Pancreatectomy
Yasuyuki Fukami, Japan

Y. Fukami, T. Arikawa, T. Osawa, S. Kurahashi, T. Matsumura, T. Saito, S. Komatsu, K. Kaneko, T. Sano
Department of Surgery, Aichi Medical University, Japan

Introduction: Recently, the diagnostic criteria for malnutrition has been proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN). This study aimed to investigate the effect of ESPEN malnutrition criteria as a predictor for major complication following hepatectomy and pancreatectomy.
Methods: Data were reviewed from 176 consecutive patients who underwent hepatectomy (n=103) or pancreatectomy (n=73) between November 2017 and December 2019. Patients were divided into two groups according to the ESPEN malnutrition criteria using a prospectively collected database. The clinical data and the surgical outcomes of patients in the malnourished and normal groups were retrospectively analyzed.
Results: 35 (20%) patients diagnosed malnourished according to ESPEN criteria. Malnourished group was significantly low preoperative albumin concentration (p=0.001). After hepatectomy, major complications (Clavien grade > III) occurred significantly more frequently in the malnourished group (p=0.013). Multivariate analysis indicated that operative duration > 300 min (hazard ratio: 22.47, 95% CI: 2.17 to 232.73, p=0.009) and malnourished (hazard ratio: 14.56, 95% CI: 2.58 to 82.17, p=0.002) were independently associated with major complications after hepatectomy. On the other hand, malnutrition was not associated with major complications after pancreatectomy.
Conclusions: The ESPEN malnutrition criteria is valuable predictor for major complications following hepatectomy.

PL03-007

Low Level of Postoperative Plasma Antithrombin III Is Associated with Portal Vein Thrombosis after Liver Surgery
Masayuki Okuno, Japan

M. Okuno, K. Taura, Y. Kimura, S. Ogiso, K. Fukumitsu, T. Ishii, S. Seo, S. Uemoto
Surgery, Kyoto University, Japan

Background: Decreased antithrombin-III (AT-III) is a risk factor of portal vein thrombosis (PVT) in patients with liver cirrhosis. The association between PVT and postoperative AT-III is controversial in patients who underwent liver surgery. The efficacy of postoperative AT-III supplementation on PVT is also uncertain.
Methods: Patients who underwent hepatectomy for hepato-biliary disease between 2015-2018 were retrospectively analyzed. Donors and recipients for liver transplantation were excluded. Postoperative PVT was assessed on computed tomography on the day 6-9 after hepatectomy.
Results: Of the 325 patients included in this analysis, 19 patients (5.8%) were diagnosed as postoperative PVT. AT-III level on postoperative day (POD) 3 predicted postoperative PVT with a sensitivity/specificity of 74%/59% (area under the curve, 0.644; cut-off value, 60%; p=0.032). Univariate analysis revealed that AT-III level ≤60% on POD3 was the only significant risk factor for postoperative PVT (Table). Postoperative AT-III supplementation was not associated with reduced incidence of PVT. Although postoperative AT-III supplementation and major hepatectomy were the significant risk factors for postoperative hemorrhagic complications in univariate analysis, multivariate analysis revealed that major hepatectomy was the only significant risk factor for hemorrhagic complications.
Conclusion: Patients with AT-III level ≤60% on POD3 should be given careful attention to postoperative PVT. Although postoperative supplementation of AT-III is safe without increased risk of hemorrhagic complication, the efficacy of it on PVT is still controversial.

PL03-008

Oncological Superiority of Anatomic Resection at Initial Hepatectomy for Solitary Hepatocellular Carcinoma
Junichi Shindoh, Japan

J. Shindoh, Y. Kobayashi, S. Okubo, M. Hashimoto
Toranomon Hospital, Japan

Introduction: Optimal choice of surgical maneuver for small hepatocellular carcinoma (HCC) remains inconclusive. This study sought to investigate the oncological superiority and postoperative influence of anatomic resection (AR) at initial hepatectomy for HCC.
Methods: From a prospectively corrected database (n=1,175), 203 patients who underwent curative resection for primary, solitary HCC measuring up to 5 cm in diameter, which was confined to one Couninaud's segment and resectable either by AR or limited resection, were studied in detail.
Results: AR (i.e. monosegmentectomy) was completed in 38 patients and not completed in the remaining 165 patients (i.e., limited resection). In multivariate analysis, AR was correlated with better recurrence-free survival (hazard rate [HR], 0.45; P=0.008), longer time-to-interventional failure (HR, 0.24; P=0.003), and improved overall survival (HR, 0.24; P=0.006). Recurrence within the same segment was observed in 30.4% when AR was not completed, and in such cases, average number of recurrent lesions and incidence of unresectable recurrence were higher
(3.6 vs. 1.3 nodules; P=0.006 and 20.8% vs. 9.1%; P=0.16, respectively) compared to those who did not present local recurrence. Probability analysis using a Markov model showed that completion of AR at initial hepatectomy is associated with lower transition rates in both 1) from postoperative tumor-free status to resectable recurrence (5.1 vs. 12.5 /100 person-year, P=0.033) and 2) from resectable recurrence to progression to unresectable disease (9.0 vs. 35.6 /100 person-year, P=0.027).
Conclusion: Complete removal of tumor-bearing segment at initial hepatectomy is associated with better survival outcomes through decreased risk of multiple/unresectable recurrence in solitary HCC.

PL03-009

Plasma Metabolomics in Liver Tumor Patients and its Predictive Performance for Postoperative Disease-free Survival Assessment
Benedikt Rumpf, Austria

P. Jonas¹, D. Pereyra², J. Santol², B. Rumpf², G. Ortmayr², C. Brostjan², T. Grünberger¹, P. Starlinger^2,3
¹Department of Surgery, Kaiser Franz Josef Hospital, Austria, ²Department of Surgery, Medical University of Vienna, General Hospital Vienna, Austria, ³HPB Surgery, Mayo Clinic, United States

Introduction: Liver surgery still remains the only curative treatment for primary (HCC, CCC) and secondary (CRCLM) liver cancer. However, patients show significant differences in terms of postoperative disease-free status and recurrences often occur within first six months after surgery. There is emerging evidence that tumor biology is a huge and heterogenous field with many aspects and not easily comprehensible. Therefore, we try to elucidate differences in tumor biology and its impact on disease-free survival in this prospective cohort using an unbiased metabolomics approach.
Method: Plasma from 150 prospectively included patients was collected and each sample was analyzed for 180 metabolites using the Biocrates p180-kit on a mass spectrometry platform.
Results: We could identify three metabolites (PC ae C38:23, PC ae C36:3 and lyso PC C18:0) that showed decreased preoperative plasma concentrations and were significantly associated with early recurrence within six months after surgery.
Conclusions: Within this prospective study we could show that certain phosphatidylcholines and lyso-phosphatidylcholines could predict already preoperatively the risk of developing an early recurrence within six months after liver resection in a heterogenous collective.

PL03-010

Hepatic Resection in Low Resource Setting: A Single Centre Experience in Northwest Nigeria
Ibrahim Umar Garzali, Nigeria

I.U. Garzali¹, A.I. Elyakub², A.A. Sheshe²
¹Surgery, ATBUTH, Nigeria, ²Surgery, AKTH, Nigeria

Introduction: Hepatic resection is one of the technologically demanding surgeries in the field of surgery. Since the first liver surgery in 1886, hepatic surgeries have undergone intensive modification and advances, aimed at improving morbidity and mortality. However in low resource settings, these advances are not readily available to the surgeons resulting in increased morbidity.
We describe our experience with hepatic resection.
Methods: This is a single centre retrospective study conducted in the general surgical unit of Aminu Kano Teaching Hospital, Kano.
Data was collected from operative register from the year 2000 to 2018. All patients that had hepatic resection were included in the study.
The parameters recorded include sociodemographic feature of the patients, indication of the resection, and type of resection.
Results: A total of 29 hepatic resections were done for the period studied. The median age of the patients was 47±3.2 years. There were 17 male and 12 females. The indication for the hepatic resection were blunt abdominal injury in 16 patients, penetrating abdominal injury in 6 patients, hepatocellular carcinoma in 6 patients and one case of metastatic colonic cancer.
Anatomic resection was done in only 4 patients while 25 patients had non-anatomic resection. Three patients developed bile leak and one patient developed sub phrenic abscess.
Conclusions: Abdominal trauma is the commonest indication for hepatic resection in low resource setting with non-anatomic hepatic resection being the commonest form of hepatic resection in these settings.

PL03-011

Laparoscopic Hepatectomy for Hepatocellular Carcinoma
Atsushi Inukai, Japan

A. Inukai¹, J. Ueda¹, Y. Kawano¹, N. Taniai², M. Yoshioka³, A. Hirakata⁴, T. Shimizu³, H. Takata⁴, H. Yoshida³
¹Nippon Medical School Chiba Hokusou Hospital, Japan, ²Nippon Medical School Musashi Kosugi Hospital, Japan, ³Surgery, Nippon Medical School, Japan, ⁴Nippon Medical School Tamanagayama Hospital, Japan

Introduction: Laparoscopic hepatectomy has spread worldwide with the development of various medical devices. We analyzed the use of laparoscopic hepatectomy for hepatocellular carcinoma at our institution.
Materials and procedure: We analyzed 186 patients who underwent surgery for hepatocellular carcinoma from 2010 to 2019 at our institution. We divided these patients into two groups: the open hepatectomy group (OH) and the laparoscopic hepatectomy group (LH). We evaluated the clinicopathological findings, overall survival, and recurrence-free survival. In the LH group, there were more early-stage patients than in the OH group. We further analyzed the two groups by limiting groups to patients with Stage I and II cancer.
Results: In our study, 75 patients underwent laparoscopic hepatectomy (40.3%). The operation time, intraoperative bleeding, duration of hospital stay after surgery, and tumor diameter were significantly less in the LH group. Between the two groups, mortality rate, morbidity rate, overall survival rate, and recurrence-free rate did not significantly differ. We limited the patients to those in stages I and II. Intraoperative bleeding, duration of hospital stay after surgery, tumor diameter, and morbidity rate were significantly less in the LH group. Between the two groups, mortality rate, overall survival rate, and recurrence-free rate did not significantly differ.
Conclusion: Laparoscopic hepatectomy is a safe and feasible surgical method that results in less intraoperative bleeding and shorter hospital stay than open hepatectomy for both advanced and early-stage hepatocellular carcinoma.

PL03-013

Comparative Study of Propensity Score Matching Method and Benchmark Article Method on the Outcomes of Major Laparoscopic and Major Open Liver Resection for Hepatocellular Carcinoma
Hanisah Guro, Philippines

H. Guro^1,2, J.Y. Cho², H.-S. Han², Y.-S. Yoon², Y. Choi², B. Lee²
¹Surgery Department, Amai Pakpak Medical Center, Philippines, ²Surgery Department, Seoul National University Bundang Hospital, Korea, Republic of

Objective: To compare the outcomes of major laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC) with two methods.
Methods: We retrospectively reviewed a data of 177 patients who underwent major liver resection for HCC(LLR;n=67 vs.OLR;n=110). We performed 1:1 propensity score matching (PSM) between two groups and matched 65 patients for both groups. Another comparison was done with already published article as a benchmark after applying similar inclusion and exclusion criteria (LLR;n=30 vs.OLR;n=34).
Results: After PSM, there were no significant differences in blood loss (1407.2±2322.7 vs 1071.5±1160.6ml; P=0.299), and transfusion rate(32.2% vs 32.0%; P=0.574) between two groups. The mean operative time was significantly longer in LLR than in the OLR group (418.7±172 vs 335.1±121.6 min; P=0.002). Complication rate (21.5% vs 33.8%; P=0.085) was similar and the mean hospital stay was shorter in the LLR than in the OLR group (11.4±8.5 vs 17.6±21.4days; P=0.009). After benchmarking method, there were no significant differences in between two groups in terms of blood loss (780±822 vs 947±660.5 ml; P=0.382), transfusion rate (30.0 vs 32.4%; P=0.528), hospital stay (9±3.7 vs 10.4±3.59days; P=0.119), and complication rate (10.0% vs 20.6%; P=0.208). Operation time (395±166.6 vs 296±68.3min; P=0.002) was significantly longer in the LLR than in the OLR group. Benchmarking method showed significant loss of number of patients analysed, but results were quite similar to PSM method.
Conclusion: Both methods showed that major LLR was safe compared to major OLR. Benchmarking method can be easily used to compare with data of other published article.

PL03-014

Major Hepatectomy for Large Hepatocellular Carcinoma in the Elderly: A Large-Scale Multicenter Study
Tian Yang, China

Y.-J. Liang¹, Z.-L. Chen¹, C.-W. Zhang², L. Liang³, H. Wu⁴, W.-G. Zhang⁵, Y.-Y. Zeng⁶, Y.-K. Diao², T. Yang⁷
¹The First Affiliated Hospital of Harbin Medical University, China, ²Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, China, ³Eastern Hepatobiliary Surgery Hospital, China, ⁴Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, China, ⁵Tongji Hospital, Huazhong University of Science and Technology, China, ⁶Mengchao Hepatobiliary Hospital, Fujian Medical University, China, ⁷Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, China

Background: Due to the increase in life expectancy, more elderly patients with hepatocellular carcinoma (HCC) are considered for hepatectomy, even when the tumor was large. To clarify the impact of age on short-term and long-term outcomes after major hepatectomy (≥3 segments) for large HCC (≥5 cm).
Methods: Using a multicenter database, patients who underwent curative-intent major hepatectomy for large HCC between 2006 and 2016 were identified. Postoperative morbidity and mortality, overall survival (OS) and recurrence-free survival (RFS) were compared between the elderly (≥65 years) and the younger (< 65 years). Univariable and multivariable Cox-regression analyses were performed to identify risk factors of OS and RFS in the entire and elderly cohorts, respectively.
Results: Of 830 patients, 92 (11.1%) and 738 (88.9%) were elderly and younger aged, respectively. There were no differences in postoperative 30-day mortality and morbidity among elderly versus younger patients (5.4%vs.2.6% and 43.5%vs.38.3%, both P>0.05). The 5-year OS and RFS rates among elderly patients were also comparable to younger patients (35.0%vs.33.2% and 20.0%vs.20.8%, both P>0.05). Multivariable analyses identified that elder age was not independently associated with OS and RFS in the entire cohort, while preoperative alpha-fetoprotein level >400 µg/L, multiple tumors, macrovascular and microvascular invasion were independently associated with decreased OS and RFS in the elderly cohort.
Conclusions: Selected elderly patients can benefit from major hepatectomy for large HCC as much as younger patients. Long-term oncologic survival in the elderly was determined by preoperative alpha-fetoprotein level, tumor number and the presence of vascular invasion.

PL03-015

Population-Based Nationwide Study on Concomitant Hepatic Resection and Thermal Ablation for Colorectal Liver Metastasis in the Netherlands
Arthur K.E. Elfrink, Netherlands

A.K.E. Elfrink^1,2, S. Nieuwenhuizen³, P. van den Tol⁴, D.J. Grunhagen⁵, N.F.M. Kok⁶, J.M. Klaase², M.R. Meijerink³, R.-J. Swijnenburg⁷, Dutch Hepato Biliary Audit Group
¹Surgery, DICA, Netherlands, ²Surgery, UMCG, Netherlands, ³Radiology, Amsterdam UMC, VUmc, Netherlands, ⁴Surgery, Amsterdam UMC, VUmc, Netherlands, ⁵Surgery, Erasmus MC, Netherlands, ⁶Surgery, Netherlands Cancer Institute, Netherlands, ⁷Surgery, Amsterdam UMC, AMC, Netherlands

Introduction: Since combining hepatic resection and thermal ablation (HR+TA) appears to improve short-term postoperative outcomes in patients with colorectal liver metastasis (CRLM), this study assessed hospital variation and short-term postoperative outcomes after HR+TA in the Netherlands.
Methods: All patients who underwent liver resection for CRLM in the Netherlands during 2014-2018 were included. Multivariable logistic regression was used to assess case-mix variables and hospital variation in relation to HR+TA. Short-term postoperative outcomes were compared after propensity score matching (PSM) for age, ASA score, Charlson Comorbidity Index, diameter of CRLM prior to treatment, number of CRLM, and history of liver resection. Postoperative complicated course (PCC) was defined as no major complication or death and discharge within 14 days.
Results: In total 4639 patients were included of whom 3697 (80%) underwent HR and of whom 942 (20%) underwent HR+TA. Four or more CRLM and bilobar disease were positively associated with use of HR+TA. Decreasing diameter of CRLM was negatively associated with HR+TA. Unadjusted percentage of HR+TA per hospital ranged between 4% and 44%. After PSM, 734 patients were included in each group. Length of stay (LOS) (median 7 vs 6 days, p=0.01), postoperative complicated course (15% vs 11%, p=0.04) and 30-day mortality 2% vs. 1%, p=0.01) were significantly lower in the HR+TA group.
Conclusions: Significant hospital variation in the use of HR+TA is observed in the Netherlands. Short-term postoperative outcomes were significantly better regarding HR+TA and therefore HR+TA should be considered in patients with CRLM.

PL03-016

Open Hepatic Resection: Outcomes Audit from a Low Volume Tertiary Care Centre in Pakistan
Muhammad Rizwan Khan, Pakistan

M.R. Khan¹, S. Begum²
¹Surgery, Aga Khan University, Pakistan, ²Surgery, Shaukat Khanum Memorial Cancer Hospital, Pakistan

Objective: We are a tertiary care institution in a developing country where open surgery is the only option for hepatic resection due to low volumes and inadequate infra-structure. We conducted an audit of open hepatic resection at our hospital to review the short-term outcomes.
Methods: This was a retrospective review of 150 patients who underwent hepatic resection at Aga Khan University Hospital, Pakistan, from January 2008 to December 2018. The outcomes studies included in-hospital morbidity, 30-day and 90-day mortality. Mean and standard deviations were used to describe categorical data whereas frequencies and proportions to describe quantitative data. A univariate analysis was done to identify risk factors associated with morbidity and mortality.
Results: Mean age of the patients was 53±15 years including 83 (55%) males. Nearly half (51%) of the patients had at least one comorbid condition. Indication for surgery included primary hepatic malignancy in 89 (59%), metastatic malignancies in 35 (23%) and benign liver pathology in 26 (17%) patients. Major hepatic resections were performed in 54 (36%) patients. Mean estimated blood loss was 655±538ml and duration of surgery was 282±121minutes. Postoperative complications were observed in 51(34%) patients and mortality rate at 30-day and 90-day were 5 (3.3%) and 8 (5.3%) respectively. The presence of comorbid conditions (p=0.025) and longer duration of surgery (p=0.026) had significant association with postoperative morbidity.
Conclusion: Despite low volumes, short term outcomes of open hepatic resection at our center are comparable to international standards. Preoperative optimization of comorbid conditions is crucial to improve the overall morbidity.

PL03-018

Volume Reduction Hepatectectomy for Highly Advanced Hepatocellular carcinoma
Yoh Asahi, Japan

Y. Asahi, T. Kamiyama, T. Kakisaka, T. Orimo, S. Shimada, A. Nagatsu, Y. Sakamoto, H. Kamachi, A. Taketomi
Department of Gastroenterological Surgery I, Hokkaido University Hospital, Japan

Introduction: The aim of this report is to evaluate the effect of volume reduction hepatectomy in highly advanced hepatocellular carcinoma (HCC).
Methods: Thirty patients with highly advanced HCC underwent volume reduction hepatectomy after 2000. Clinical data (sex, age, tumor number, tumor size, tumor differentiation, extrahepatic metastasis, vascular invasion, blood checks, tumor number in the remnant liver, survival) of those patients were reviewed. The patients were divided into 2 groups, Group.1 (n=8): patients who achieved complete remission of the evaluable lesions by multidisciplinary treatment including tyrosine kinase inhibitors after the hepatectomy and Group 2 (n=22): patients who did not achieve complete remission after the hepatectomy.
Results: Average tumor size were 10.1 cm and all the cases had multiple tumor. 17 cases accompanied major vascular invasion. 3 cases had extra-hepatic metastasis in lung and bone (Table). The MST and survival rates at 5 years after the volume reduction hepatectomy were 2.37 years and 17.0% in All, 4.71 years and 37.5% in Group.1 and 1.24 years and 8.1% in Group.2 (Image). Comparing the clinical data between two groups, significant difference was detected in only number of remnant liver tumor (the ratio of 1-3/4over of Group 1 and Group 2: 7/1 and 5/17) (p=0.0025).
Conclusions: Volume reduction hepatectomy improved the survival of patients with highly advanced HCC when the complete remission of the tumor was achieved by multidisciplinary treatment after the hepatectomy. Reduction hepatectomy with less than/or 3 tumors in the remnant liver should be planed for highly advanced HCC.

PL03-020

A Nomogram Predicting Surgical Site Infection before Liver Resection, A Multicenter Cohort Study
Guus W de Klein, Netherlands

G.W. de Klein¹, M.J. Bruins², M.S.L. Liem³, H. Eker⁴, J.M. Klaase⁵, V.B. Nieuwenhuijs¹
¹Surgery, Isala, Netherlands, ²Laboratory of Clinical Microbiology and Infectious Diseases, Isala, Netherlands, ³Surgery, Medisch Spectrum Twente, Netherlands, ⁴Surgery, Medisch Centrum Leeuwarden, Netherlands, ⁵Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Netherlands

Background: Surgical site infections (SSI) after liver resection are associated with high morbidity and lower survival. This study aimed to analyze the incidence, risk factors, and consequences of SSI.
Methods: In this multicenter cohort study, all patients undergoing liver resection in four centers from 2013 to 2017 were retrieved from a prospectively held database. Logistic regression was used to identify independent predictors for SSI.
Results: In 982 liver resections, the incidence of SSI was 80 (8.1%), including 50 organ space SSI and 30 incisional SSI. Bile leakage (OR 6.644, p < 0.001), primary liver tumors
(OR 3.630, p = 0.001), concomitant radiofrequency ablation (OR 2.264, p = 0.024), simultaneous liver and colorectal resection (OR 2.914, p = 0.001), and abdominal/gastro-intestinal comorbidity (OR 4.471, p < 0.001) were independent predictors for SSI. Except for bile leakage, these factors were included in a nomogram in order to predict SSI preoperatively. Furthermore, SSI was associated with 42 re-interventions, prolonged median length of stay
(16 days versus 5 days, p < 0,001), and added hospital expenditure around € 8,500. In approximately half of SSI cases, cultures revealed resistance against standard preoperative antibiotic prophylaxis.
Conclusions: Surgical site infections after liver resection are common, and the consequences are extensive for both patient and hospital. Factors related to microbial exposure and compromised immune states are independent predictors of SSI. A nomogram and an online calculator (www.evidencio.com/models/show/2006) based on preoperative predictors were provided to identify high-risk patients. These patients can receive an extended immuno-nutritional and antiseptic work-up.

PL03-021

The Transitional Changes in Hormones that Have Water Retention Effect after Liver Resection
Yuto Aoki, Japan

Y. Aoki¹, M. Yoshioka¹, A. Matsushita¹, Y. Kawano², T. Shimizu¹, T. Kanda¹, R. Kondo¹, Y. Kaneya¹, H. Yoshida¹
¹Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Japan, ²Department of Surgery, Nippon Medical School Chiba Hokusou Hospital Inzai, Japan

Background: In Japan, the use of anti-aldosterone drugs for postoperative water retention caused by hyperaldosteronism after liver resection (LR) is standard. Increased values of arginine vasopressin (AVP) are also expected after LR. We examined the transitional changes in values of plasma aldosterone concentration (PAC) and AVP and volume of drained ascites after LR.
Methods: 56 patients underwent LR. PAC and AVP values were measured on before (baseline) and after LR, and postoperative-day (POD) 1, 2, 3, and 5.
Results: The PAC values on just after LR (p< 0.01), POD1 (p< 0.01) and POD2 (p = 0.02) were higher than baseline, but POD3 and POD5 were not significant. AVP values were higher on just after LR, POD1, POD2, and POD3 (all p< 0.01), and POD5 did not differ from baseline. When classified into two groups, impaired-liver (IL) group and normal-liver (NL) group, based on ICG_R15≥10%, AVP values were higher than baseline on just after LR, POD1 (p< 0.01), POD2
(p< 0.01), and POD3 (p=0.02 and 0.01, respectively) in both groups. On the other hand, though the PAC values in IL group were higher on just after LR (p< 0.01), POD1 (p< 0.01) and POD2 (p=0.04), these in NL group were not different from the baseline except on just after LR (p< 0.01). Ascites volume was significantly larger in cases of hemihepatectomy or larger (n=11) than other cases (p< 0.01).
Conclusions: The addition of the vasopressin-V2-receptor antagonists may be effective for water retention in the patients with hemihepatectomy or larger.

PL03-022

Experience of Cases for Hepatic Injury Surgery Treated with Uncrossmatched Red Blood Cell of Type O Transfusion
Masahiro Hagiwara, Japan

M. Hagiwara, Y. Saito, H. Takahashi, K. Imai, H. Yokoo, N. Matsuno, H. Furukawa
Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, Japan

Introduction: Patients with hemorrhagic shock need transfusion of uncrossmatched type O packed red blood cells (PRBCs) immediately on arrival at the hospital. Here, we report the outcomes of patients who received transfusion of uncrossmatched type O PRBCs for hepatic injury surgery in our hospital. This study was conducted to investigate effective management strategies for patients with severe blunt liver injuries.
Patients and methods: From January 2017 to December 2019, three patients who underwent emergency laparotomy for hepatic injury underwent transfusion of uncrossmatched type O PRBCs. Data, including age, sex, AAST(American Association for the Surgery of Trauma) liver injury scale, injury severity score (ISS), revised trauma score (RTS), probability of survival (Ps), time to hemostasis, and RBC transfusion volume in 24 hours, were compared between survivors and non survivors.
Results: Of the three patients, two were men and one was a woman (mean age: 73 years). The results are listed in the table1.Damage control surgery (DCS), open abdominal management, and interventional radiology (IVR) were performed in all patients. Of the three patients, one survived and two died. . One case was a case with acute myocardial infarction. The Ps of the surviving patient was 0.26. The survivor underwent operation more quickly when compared with the non survivors.
Conclusion: Early DCS combined with IVR may improve the outcome in patients with severe blunt hepatic injuries.

Case	liver injury scale(AAST )Grade	ISS	RTS	Ps	Time to hemostasis(min)	RBC transfusion volume in 24 hours (units)	Outcome
1	Ⅴ	21	7.84	0.92	288	40	death
2	Ⅲ	33	2.63	0.06	175	48	death
3	Ⅴ	38	3.19	0.26	22	100	survival

[Table1]

PL03-025

Skin Autofluorescence in Prediction of Acute Kidney Injury after Liver Resection
Michał Grąt, Poland

M. Grąt¹, M. Morawski¹, J. Borkowski¹, M. Krasnodębski¹, K. Grąt², P. Krawczyk¹, A. Zhylko¹, M. Krawczyk¹, K. Zieniewicz¹
¹Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland, ²Second Department of Clinical Radiology, Medical University of Warsaw, Poland

Introduction: Skin autofluorescence (SAF) reflects accumulation of advanced glycation end-products (AGEs), which is known to impair renal function. The aim of this study was to assess usefulness of SAF measurement in prediction of acute kidney injury (AKI) in patients undergoing liver resection.
Methods: This prospective observational study was performed on 130 patients undergoing liver resection in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw) between 2018 and 2019. The primary outcome measure was AKI, as defined by Kidney Disease Improving Global Guidelines criteria. SAF, the primary factor of interest, was based on 3 separate preoperative measurements on the anterior side of the forearm and expressed in arbitrary units (AU).
Results: AKI was observed in 26 of 130 patients (20.0%). SAF was an independent predictor of AKI (odds ratio [OR] 2.90; 95% confidence interval [95% CI] 1.33 - 6.32; p=0.008), along with the extent of liver resection (OR 2.91; 95% CI 1.68 - 5.04; p< 0.001). Optimal cut-off for SAF in prediction of AKI was 2.4 AU (area under the curve 0.676, 95% CI 0.564-0.787; p=0.002), with positive and negative predictive values of 28.3% and 87.1%, respectively. The rates of AKI were 2.5% and 11.8% in patients undergoing minor liver resection with low and high SAF, respectively, and 26.7% and 50.0% in patients undergoing major liver resection with low and high SAF, respectively
(p< 0.001).
Conclusions: SAF measurement is useful in prediction of AKI in patients undergoing liver resection and point towards the pathogenetic role of AGEs.

PL03-027

Hepatic Venous Outflow Obstruction in Polycystic Liver Disease
EeeLN Buckarma, United States

E. Buckarma¹, A. Glasgow², E. Habermann², S. Venkatesh³, J. Fidler³, D. Nagorney¹
¹Surgery, Mayo Clinic, United States, ²Kern Center for the Science of Health Care Delivery, Mayo Clinic, United States, ³Radiology, Mayo Clinic, United States

Background: The development of prolonged ascites in posthepatectomy polycystic liver disease (PCLD) patients is not well understood. The pathology may be related to hepatic vein outflow obstruction (HVOO). Herein we describe posthepatectomy patients with preoperative hepatic venous collateralization who developed prolonged ascites in the setting of polycystic liver disease.
Methods: A single institution cohort of 183 patients with PCLD undergoing partial hepatectomy between 1987 and 2014 was retrospectively reviewed. Of those, 90 patients had preoperative imaging available for analysis. Prolonged ascites was defined as greater than 200 cc of intraperitoneal drain (IP) output per day after postoperative day 5 or the need for an IP drain greater than 2 weeks. HVOO was defined as non-thrombotic obstructive involvement of the large HVs and or IVC.
Results: A total of 90 patients with preoperative imaging underwent liver resection. No patients presented with clinically significant ascites preoperatively. Among this cohort 88% were female and the mean age was 49 years. Posthepatectomy liver failure occurred in 8 (9%) of patients and was not significant in patients with prolonged ascites. All 90 patients demonstrated non-thrombotic HVOO (60% IVC, 94% HV and 76% IVC+HV involvement) on preoperative imaging. Prolonged postoperative ascites was seen in 71% of patients; this was significantly higher in those with hepatic venous collateralization (52 vs 12 p=0.001).
Conclusions: Patients with PCLD also had HVOO and frequently developed venous collateralization. Operative disruption of this may result in prolonged postoperative ascites. Collateralization is a strong parameter to be considered when electing a surgical intervention.

PL03-028

Radiofrequency Assisted Hepatic Resection Can Provide Cost-Effective Hepatectomies during a Financial Crisis in a National Health Care System
Andreas Tooulias, Greece

C. Christou¹, A. Tooulias², A. Mitsas², A. Tsolakidis², G. Tsoulfas², V. Papadopoulos²
¹First General Surgery Department, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece, ²First General Surgery Department, Papageorgiou General Hospital, Thessaloniki, Greece, Aristotle University of Thessaloniki, Greece

Introduction: Hepatectomy or hepatic resection is a key part of the management of several types of hepatobiliary disease. Our study aims to present our protocol which is based on radiofrequency assisted hepatectomy.
Methods: We created a highly standardized open hepatic resection protocol, which was implemented on every patient admitted in our department for a hepatectomy since 2010. Our protocol regulates the preoperative care, the surgical procedure and the postoperative management of the patients. Data regarding the cost of our protocol was collected from the electronic medical records of the hospital, the pharmacy department and the finance department.
Results: We included 80 hepatectomies performed for the treatment of benign (n=6, 7.5%) or malignant (n=74, 92.5%) tumors.We performed 35 major (≥3 Couinaudsegments) and 45 minor hepatectomies.Regarding postoperative complications, based on the Clavien - Dindo scale, our patients developed the following complications: 10 patients of scale I, 16 patients of scale II, 2 patients of IIIb and 6 patients of scale IV. Our 30-day mortality rate was 8.8% (7 patients). Regarding cost, the mean overall cost of preoperative care was €634.89±531.17, of the surgical procedure was €4082.08±1443.9 and of the postoperative care was €2971.25±1916.28. A detailed total cost analysis is included in the Table provided.
Conclusions: Minimally invasive techniques tend to gain ground against traditional open laparotomies. However, due to lack of financial resources, many countries fail to follow this strategy. Our protocol provides a cost-effective open laparotomy alternative with postoperative complications and mortality rates comparable to other studies.

Variable	Cost (mean± SD and % of total cost)
Surgery Materials	€2976.49±1238.37 (38.74%)
Ward Stay and ICU	€1329.43±1058.25 (17.30%)
Salaries	€551.75±173.60 (7.18%)
Drugs	€573.86±391.38 (7.47%)
Transfusion Cost	€955.13±1266.32 (12.43%)
Laboratory Tests	€1112.47±619.90 (14.48%)
Imaging	€184.35±214.26 (2.40%)
Total Hepatectomy Cost	€7683.48±2942.04

[Total Cost analysis]

PL03-029

Laparoscopic Liver Resection in Cirrhotics- Feasibility and Short-Term Outcomes Compared to Non-Cirrhotics
Sanket Srinivasa, United States

S. Srinivasa^1,2, M. Hughes², I. Azodo², E. Harrison², R. Ravindran², A. Adair², S. Wigmore²
¹HPB Surgery, Washington University in St Louis, United States, ²HPB Surgery, Royal Infirmary of Edinburgh, United Kingdom

Background: Laparoscopic liver resection(LLR) is increasingly common worldwide but its suitability in patients with cirrhosis is not clearly defined. There is minimal data in the western literature on this topic and previous work has compared LLR to open hepatectomy rather than to LLR in non-cirrhotics. This study compared short term outcomes of LLR in cirrhotics to LLR in non-cirrhotics.
Methods: Retrospective review of minor LLR at the Royal Infirmary of Edinburgh from Jan 2006-2018. Patients were stratified by whether they had cirrhosis- defined as per radiological appearances and liver function tests. Variables of interest included baseline clinicopathological information with short term outcomes (Length of stay (LOS), complications) regarded as the primary outcome of interest.
Results: Out of 1207 liver resections in the study period, there were 120 LLR with 30 patients having cirrhosis. Patients with cirrhosis were more likely to be male and have higher median ASA scores (3 vs. 2; p< 0.01). The commonest operation was left lateral sectionectomy (n=67). There was no difference in duration of surgery (Cirrhosis: 88 mins vs. No Cirrhosis: 99 mins; p=0.64) and patients in the cirrhosis arm had no conversions to open (0% vs 12%; P= 0.06). There was no difference in complications (12% vs 13%; p=0.75) or median LOS (4 vs. 4 days; p=0.14) and no difference in survival between both groups.
Conclusion: With careful patient selection, LLR is feasible in patients with cirrhosis and provides comparable outcomes to non-cirrhotic patients undergoing LLR.

PL03-031

When Does a Pringle Maneuver Cause Harm?
Alexander Fagenson, United States

A. Fagenson¹, E. Gleeson², N. Fatima³, K. Lau¹, H. Pitt⁴
¹Surgery, Temple University Hospital, United States, ²Surgery, Mt. Sinai, United States, ³Surgery, Crozer Health System, United States, ⁴Temple University Health System, United States

Introduction: The Pringle Maneuver (PM) is considered to be safe and effective despite scarce level one data to support its use. However, the PM has not been analyzed when stratified by extent of hepatectomy and pathology. Therefore, the aim of this analysis is to compare the outcomes of patients who have and have not undergone a PM in the North America.
Methods: Patients undergoing major hepatectomy (≥ 3 segments) or partial hepatectomy (≤ 2 segments) were identified in the 2014-17 ACS-NSQIP procedure-targeted database. Patients undergoing concomitant colon or another major resection were excluded. Subset analyses were performed based on hepatectomy extent and pathology type (metastatic disease and primary hepatobiliary malignancies). Outcomes of PM were compared to no PM after propensity score matching by chi-square and Mann-Whitney U tests.
Results: Prior to matching, 3,706 (24%) of 15,748 hepatectomy patients underwent a PM. PM was utilized in 1,445 (37%) of major hepatectomies and 2,261 (28%) of partial hepatectomies. After matching, patients undergoing a PM during a partial hepatectomy had significantly increased rates of post-hepatectomy liver failure (PHLF), reintubation and septic shock (p < 0.05), but these differences were not observed in major hepatectomy patients (Table). Patients with metastatic disease undergoing a PM had significantly increased rates of PHLF, septic shock and acute renal failure (p < 0.05) while adverse outcomes did not develop in patients with primary hepatobiliary malignancies.
Conclusions: Patients undergoing a partial hepatectomy and those with metastatic disease have worse outcomes when a Pringle Maneuver is performed.

[Table]

PL03-032

The Use of Local Destruction Methods in Combination with Liver Resection in Cases of Massive Malignant Lesion
Dmitry Ionkin, Russian Federation

D. Ionkin, A. Chzhao, Y. Stepanova, V. Vishnevsky
Oncology, A.V. Vishnevsky National Medical Research Center of Surgery, Russian Federation

Objective: To improve the results of surgical treatment of patients with massive malignant liver damage.
Materials and methods: RFA was performed in 387 patients (percutaneous -292, open approach-in 42). Liver resection with RFA of the remaining nodes was performed in 62 patients.
MVA was performed in 18 patients with percutaneous approach. Liver resection+MBA - in 6 patients.
Cryodestruction (CD) was performed in 60 cases (in primary cancer - in 14, and in mts - in 46). In 28 cases liver resection was combined with CD of the remaining nodes.
Laser destruction (LD) was performed.in 6 patients.
All of the patients underwent adjuvant chemotherapy after the intervention.
Results: After resection + RFA, 1 death was noted in connection with the development of multiple organ failure. There were no cases of hemorrhage and bile leakage after interventions.
RFA: the survival rate of 1 year - 84.2%, 2 - 56.7%, 3 - 47.2%, 4 - 28.4%, 5 - 24.2% (the median survival - 29.3 months).
CD: in primary liver cancer the survival rate of 1 year-76%, 3-52.4%, 5-26.4% (the median survival -34 months); in mts. the survival rate of 1 y/-72%, 3-36.4%, 5.-13.4% (the median survival - 24.4 months)
MBA: the survival rate of 1- 74.2%, 2- 68.4%, 3- 16.2% (the mediana-26.8 months).
Conclusions: Local destruction methods for unresectable liver cancer can be an alternative to surgical treatment. In combination with chemotherapy, there is an improvement in survival rates

PL03-033

Utilization of the Kawaguchi-Gayet Complexity Classification to Stratify Hepatectomy Patients for Distinct Enhanced Recovery Pathways Based on Anticipated Length of Stay
Bradford Kim, United States

B. Kim¹, C. Gaskill¹, E.M. Arvide¹, W. Dewhurst¹, T. Lee¹, T. Newhook¹, Y. Kawaguchi², J.N. Vauthey¹, C.W. Tzeng¹
¹Surgical Oncology, MD Anderson Cancer Center, United States, ²Tokyo University, Japan

The Kawaguchi-Gayet (K-G) Classification of laparoscopic hepatectomy complexity was recently validated for open liver resection. The objective of this study was to use the K-G classification to stratify patients based on anticipated length of stay for the creation of distinct enhanced recovery pathways.
A single-institution prospective database was queried to identify a continuous set of patients from 1/1/2017-12/31/2018. The 3-level K-G classification was utilized for open operations: Grades I (“low”: non-anatomic resection for anterolateral or posterosuperior segment and left lateral sectionectomy), II (“intermediate”: anterolateral segmentectomy and left hepatectomy), and III (“high”: posterosuperior segmentectomy, right posterior sectionectomy, right hepatectomy, central hepatectomy, and extended hepatectomy). All hepatectomies were classified into one of four categories: MIS, Low-Intermediate (Open K-G I-II), High (Open K-G III), and Combo.
Of 466 patients, the distribution of hepatectomies included: 86(18.5%) MIS, 168(36%) Low-Intermediate, 140(30%) High, and 72(15.5%) Combo. Modified Accordion Complications Grade ≥3 occurred more frequently with more complex hepatectomies (MIS: 3[4%], Low/Intermediate: 17[10%], High: 25[18%], and Combo: 9[13%], p< 0.001). Median LOS was associated with approach and difficulty (MIS:2d, Low:4d, High:5d and Combo:5d, p< 0.001, Figure 1). Multivariate analysis confirmed that K-G classification (Low/Intermediate: OR 5.5, High: OR 11.6, Combo: OR 11.8, p< 0.001) was the greatest predictor of LOS (LOS>median 4 days).
Kawaguchi-Gayet Classification grouped a contemporary cohort of patients undergoing hepatectomy into four strata with LOS between 2-5 days. Using surgical approach and K-G Classification, future patients can be grouped a priori into pathways at the time of surgical consent in clinic.

[Figure 1. Length of stay and rates of major complications between complexity of hepatectomy]

PL03-034

Safety of Hepatobiliary and Pancreatic Surgery in Patients Receiving Direct Oral Anticoaulants (DOACs)
Takahisa Fujikawa, Japan

T. Fujikawa, N. Nakamura, S. Naito, N. Takemoto, T. Furuya
Surgery, Kokura Memorial Hospital, Japan

Introduction: The safety and optimal perioperative management of patients receiving direct oral anticoagulants (DOACs) during hepatobiliary and pancreatic (HBP) surgery is still controversial.
Methods: Between 2012 and 2018, 115 anticoagulant-prescribed patients who underwent elective HBP surgery (65 benign and 50 malignant diseases, 69 laparoscopic and 46 open-fashioned operations) in our department were enrolled in this study. Patients undergoing emergency operations were excluded from the study. The patients were divided into two groups; patients receiving DOACs (DOAC group, n = 35) and patients undergoing warfarin therapy (WF group, n = 80). Background characteristics, surgical blood loss, and postoperative complications, including bleeding and thrombotic complications, were compared between the groups.
Results: In the DOAC group, dabigatran, apixaban, rivaroxaban, and edoxaban were used in 10, 8, 10, and 7 patients, respectively, and only 11 patients (31.4%) received perioperative heparin bridging. There were no differences in patients' background characteristics and mode of surgery (open or laparoscopic). The duration of operation (p = 0.148), surgical blood loss (p = 0.782), and the rate of intraoperative red blood cell transfusion (p = 1.000) were similar between the groups. Overall, any thromboembolic complications were not observed in the current cohort, and only 1 patient (2.9%) suffered from postoperative bleeding complication in the DOAC group. The mortality was zero, and the length of postoperative stay was also identical between the groups (p = 0.998).
Conclusion: HBP surgery is safely performed in patients receiving DOAC therapy, without increase in bleeding or thromboembolic complications compared with warfarin therapy.

PL03-036

Does Laparoscopic Liver Resection for Hepatocellular Carcinoma Reduce Posthepatectomy Liver Failure?
Yusuke Uemoto, Japan

Y. Uemoto, K. Taura, T. Nishio, Y. Kimura, N. Nam, K. Fukumitue, T. Ishii, S. Seo, S. Uemoto
Hepato Biliary Pancreatic Surgery and Transplantation, Graduate School of Medicine Kyoto University, Japan

Introduction: Several studies have suggested that laparoscopic liver resection (LapLR) is associated with fewer incidence of posthepatectomy liver failure (PHLF) than open liver resection (OLR) for hepatocellular carcinoma (HCC). However, this issue remains controversial since the results may have been attributable to selection bias.
Methods: We retrospectively analyzed 290 hepatectomies for HCC between 2011 and 2019. Difficulty of liver resection was based on the difficulty score (DS) proposed by Ban et al. (J Hepatobiliary Pancreat Sci. 2014) and the resection ratio was calculated using CT volumetry. Patient characteristics and operative outcomes were compared between LapLR and OLR groups. PSM was adopted to adjust the imbalance between the cohorts. Predictors of PHLF were analyzed by multivariate analysis.
Results: DS and RR were significantly lower in LapLR (n=112) than in OLR (n=178) (DS: 4.4 ± 2.4 vs. 7.8 ± 2.6, p < 0.001, RR: 11.4 ± 12.7 vs. 22.7 ± 17.2%, p < 0.001). Incidence of PHLF was lower in LapLR (9.8% vs. 21.4%, p = 0.011). PSM generated well-balanced 58 patients in each group and abolished the difference in the incidence of PHLF (10.3% v. 19.0%, p=0.189). By multivariate analysis, RR was one of the independent risk factors for PHLF but surgical approach (LapLR or OLR) was not (p=0.574).
Conclusion: The present study suggested imbalance of RR and DS, which have been hardly considered in the previous studies, may have resulted in the fewer PHLF in LapLR. Further data needs to be accumulated to prove LapLR reduces PHLF.

PL03-038

Tyrosine Phosphatase Inhibition Increases YAP Activity Augmenting Liver Regeneration in Murine Partial Hepatectomy
EeeLN Buckarma, United States

E. Buckarma¹, D. Pereyra², P. Starlinger^1,2, R. Smoot¹
¹Surgery, Mayo Clinic, United States, ²Surgery, Medical University of Vienna, Austria

Background: The liver can regenerate in response to surgical resection, and impaired regeneration is associated with morbidity and mortality. The Hippo pathway effector YAP is associated with liver regeneration and our group has demonstrated activation of YAP transcriptional co-activity utilizing a tyrosine phosphatase inhibitor.
Methods: Human primary hepatocyte and liver sinusoidal endothelial cell cultures were exposed to the tyrosine phosphatase inhibitor NSC87877(NSC). YAP localization was assessed by immunofluorescence. Male C57BL/6J mice were treated with NSC (7.5mg/kg) before and after a standard two‐thirds partial hepatectomy (PH). Liver regeneration was evaluated by liver to bodyweight ratio at 40 and 72 hours post PH, protein levels by immunoblot, and YAP target gene expression by RT-PCR. Mitotic figures were quantified.
Results: Primary human cell cultures demonstrated redistribution of YAP to the nucleus following exposure to NSC, demonstrating activation. Following treatment of mice with NSC and subsequent PH there was an increase in p-YAP^Y357 levels by immunoblot, and expression levels of the YAP target genes Ctgf and Nuak2 as compared to vehicle treatment. Hepatocyte mitotic activity at 40 and 72 hour time points was increased in the NSC treated group, and concordantly we observed an increased liver-to-body weight ratio in mice treated with NSC at both the 40 and 72 hour time points when compared to vehicle treated mice (p< 0.01).
Conclusion: Our data suggest that inhibition of tyrosine phosphatase activity with NSC increases the abundance of the activated Hippo effector protein YAP, which has the potential to augment regeneration in partial hepatectomy.

PL03-041

Minimally Invasive Microwave Ablation Provides Excellent Long-Term Outcomes for Otherwise Inaccessible Hepatocellular Cancer
Eric Jensen, United States

A. Altman¹, A. Coughlin¹, D. Shukla¹, R. Schat², B. Spilseth², S. Marmor¹, J. Hui³, E. Jensen³
¹Surgery, University of Minnesota Medical Center, United States, ²Radiology, University of Minnesota Medical Center, United States, ³Surgical Oncology, University of Minnesota Medical Center, United States

Background: Microwave ablation (MWA) can be used as a bridge to transplant or with curative intent for hepatocellular carcinoma (HCC). We report our experience with laparoscopic ablation of HCC in patients deemed inaccessible by percutaneous approach.
Methods: We performed a retrospective review of surgical ablations from 2009-2017. Demographics, disease and treatment characteristics, and outcomes were abstracted. Kaplan-Meier modeling was performed.
Results: We ablated 39 tumors in 33 patients with a median age of 62. Most patients were male (76%) and Caucasian (70%).Hepatitis C was the most common primary liver disease (22 patients, 67%) and 32 patients had underlying cirrhosis (97%). Median MELD-NA was 9.5 (IQR 8-12). The median tumor diameter was 2.6 cm (IQR 1.8-3.0). The median ablation zone diameter was 4.8 cm (3.8-5.7) with a median difference of ablation zone to tumor of 2.0cm (1.5-2.75). All cases were approached laparoscopically, 1 was converted to open. With a median follow up of 42.9 months, 13 patients (39%) developed recurrent disease. Two had recurrences at the site of a prior ablation (6%), 9 developed intrahepatic recurrences separate from previous ablation site (27%), and 2 developed metastases (6%). The rate of local failure per lesion ablated was 5% (2/39). Median recurrence free survival was 66.7 months. Median overall survival was not reached. The 1,3,5-year survival was 97% (CI 91-100%), 76% (CI 61-93%) and 66% (CI 49-88%).
Conclusion: Laparoscopic MWA of HCC provides excellent local control and overall survival. It should be the preferred treatment approach when percutaneous access is not possible.

PL03-043

The Impact of Body Mass Index on Asian Patients with Hepatocellular Carcinoma Undergoing Hepatectomy
Kevin Ka-Wan Chu, Hong Kong

K.K.-W. Chu, W.-H. She, K.-W. Ma, S.H.-Y. Tsang, W.-C. Dai, A.C.-Y. Chan, T.-T. Cheung, C.-M. Lo
Surgery, Queen Mary Hospital, the University of Hong Kong, Hong Kong

Background: Patients with malnutrition or low body mass index (BMI) are associated with a higher risk of complications after surgery while obesity were also associated with poor surgical outcomes. We aimed to investigate the perioperative outcome for Asian patients of hepatectomy in grouping with WHO BMI classification.
Methods: From our prospectively maintained database, we identified consecutive patients who underwent hepatectomy between January 2000 and December 2017. Perioperative outcomes and survival were analyzed
Results: In the study period, 1558 patients underwent hepatectomy in our center. According to WHO BMI classification, 109, 658, 604 and 187 patients were classified into under-weight, normal, over-weight and obesity classes respectively. Overall survival of the under-weight group were 59.2% and 44.4% in 3- and 5-year compared with the other groups (69.8%, 59.3%, p< 0.001). In the under-weight group, 58.7% patients received major hepatectomy compared with 50.2% (p=0.337) in the other groups. For pathological feature, the under-weight group patient had similar number of tumor, but larger tumor size 6cm vs 4.5cm (p< 0.001). The under-weight group had more complications (Clavien 3A or above) as 22.2% vs 10.8%, p=0.007. They also had a longer hospital stay with median 9 days (vs 8 days, p=0.002). Operation time, blood loss and the need for blood transfusion were comparable.
Conclusion: Hepatectomy in under-weight patients was associated with worse overall survival, more complication and longer hospital stay. Pre-operative optimization for the under-weight status is suggested.

PL03-045

Laparoscopic Versus Open Hepatectomy for Large Hepatocellular Carcinoma: A Randomized Controlled Study
Ahmed Elgendi, Egypt

A. Elgendi¹, M. Elshafei², S. Elgendi³, A. Shawky¹
¹Surgery, Alexandria University, Egypt, ²Radiology, Alexandria University, Egypt, ³Pathology, Alexandria University, Egypt

Background: Strong evidence from prospective studies for the superiority of either the open or laparoscopic approach in managing large HCC is still lacking. Aim was to compare surgical and oncologic efficiency of laparoscopic versus open hepatetcomy in solitary large (>5 cm) HCC in Child A cirrhotic patients.
Methods: 150 patients with large HCC met the inclusion criteria and were randomly assigned to either OH group (75 patients) or LH group (75 patients).
Results: LH had significantly less operative time (280.35 ± 24.69 versus 255.65 ± 22.63 minutes, P < .001), shorter duration of hospital stay (8.50 ± 0.78 versus 10.52 ± 0.78 days, P < .001), with comparable overall complications (43 versus 39%, P = .03). LH had comparative resection time (184.65 ± 47.50 versus 174.46 ± 29.35 minutes, P = .319), amount of blood loss (1060 versus 980mL, P = .817), transfusion rate (P = 1.00), and R0 resection rate when compared with OH. After median follow-up of 62.34 (34.52-89.47) months, LH achieved similar adequate oncological outcome of OH, no local recurrence, with no significant difference in early recurrence or number of de novo lesions (P = .42). One-year and 3-year disease free survival (DFS) rates, 69% and 39%, in the LH were comparable to corresponding rates of 65% and 36% in OH (P = .8).
Conclusion: LH is superior to the OH in solitary large HCC with significantly shorter duration of hospital stay. LH does not compromise the oncological outcomes and achieve similar disease-free survival compared to OH.

PL03-047

Minimally Invasive Microwave Ablation of Colorectal Cancer Liver Metastases: A Single Institution Experience with 135 Surgical Ablations
Eric Jensen, United States

K. McEachron¹, J. Ankeny², A. Robbins¹, A. Altman¹, S. Marmor¹, D. D'Souza³, R. Schat⁴, B. Spilseth⁴, E. Jensen²
¹Surgery, University of Minnesota Medical Center, United States, ²Surgical Oncology, University of Minnesota Medical Center, United States, ³Interventional Radiology, University of Minnesota Medical Center, United States, ⁴Radiology, University of Minnesota Medical Center, United States

Background: Percutaneous Microwave Ablation (MWA) is an effective therapy for non-resectable colorectal liver metastases (CRLM), but many are not percutaneously treatable. We report one of the largest single-institution experiences with laparoscopic, ultrasound-guided MWA of 135 unresectable CRLM.
Methods: We performed a retrospective review of ablated CRLM from 2009-2018. Demographics, disease and treatment characteristics were abstracted. Kaplan-Meier modeling was performed.
Results: We ablated 135 CRLM in 36 patients. Median age was 52 years and 58% of patients were male. The primary tumor was of colonic origin in 26 patients (72%), and the remainder (28%) were rectal cancer metastases. All patients received systemic chemotherapy. Non-resectability was due to inadequate future remnant in 25 cases (69%), physiologic frailty in 8 (22%), and complexity of concurrent rectal resection in 3 cases (8%). Ablation was combined with colon or rectal resection in 15 (38%) patients. Median number of ablations per patient was 2 (IQR 1-5, range 1-15). Median diameter of ablated lesions was 1.9 cm (IQR 1.3-2.3). During follow up, 18 patients experienced recurrence. Six had local recurrence (treatment failure), 11 had intra-hepatic recurrence, and 1 had systemic recurrence. Median follow up of the study was 28 months. Median disease-free survival was not reached. Of the 135 lesions ablated, the per-lesion local recurrence rate was 6/135 (4.4%). Median overall survival for the cohort was 81 months.
Conclusions: Surgical ablation of CRLM provides excellent local control and long-term survival outcomes in patients who may otherwise not be candidates for other liver-directed therapies.

[Overall Survival for Patients Undergoing Laparoscopic MWA of Colorectal Liver Metastases]

PL03-048

Middle-Term and Perioperative Outcomes of Laparoscopic Versus Open Major Hepatectomy for Hepatocellular Carcinoma: A Historical Control and Propensity Score Matched Study
Takahiro Yoshikawa, Japan

T. Yoshikawa, T. Nomi, D. Hokuto, N. Kamitani, Y. Matsuo, M. Sho
Nara Medical University, Japan

Background: Laparoscopic major hepatectomy (LMH) has been adopted as the standard procedure from April 2016 in Japan. The aim of this study is to clarify the middle-term outcomes and perioperative outcomes of LMH for hepatocellular carcinoma (HCC) compared with those of open major hepatectomy (OMH).
Methods: Ninety two patients who underwent primary major hepatectomy for HCC between January 2012 and April 2019 in our institution were divided into LMH (n=33) and OMH (n=59) groups. A one-to-one propensity case-matched analysis was used with covariates of baseline characteristics, including tumor characteristics.
Results: The two groups were well balanced by propensity score matching and 25 patients were matched. The median blood loss (277 vs. 825ml, P=0.005) was significantly less in the LMH group. The median postoperative hospital stay (9 vs. 10days, P=0.586) and severe complication rate (16 vs. 12%, P=0.440) were similar in the two groups. The median observation period in the LMH group was 21.5 months and that in the OMH group was 47.7 months. The cumulative 1-, 2- and 3-year overall survival (OS) rates were 95.7, 95.7 and 95.7% in the LMH group, 84.0 and 79.8, and 75.1% in the OMH group. The cumulative 1-, 2- and 3-year disease free survival (DFS) rates were 78.9, 43.2 and 43.2% in the LMH group, 66.7, 58.3 and 50.0% in the OMH group. There were no significant differences in OS (P=0.131) and DFS (P=0.826) between the matched two groups.
Conclusion: LMH might be safety procedure with acceptable middle-term outcomes.

PL03-049

Robotic Hilar Cholangiocarcinoma Radical Resection Compare with Laparotomy Radical Resection: 2-Years Follow-up
Sai Chou, China

S. Chou, Z. Chang, G. Zhao, R. Liu
Department of Hepato-Pancreatico-Biliary Oncology Surgery, Chinese PLA General Hospital, China

Introduction: To compare the long term and short term outcomes between robotic and open surgery for hilar cholangiocarcinoma radical resection.
Method: This is a single-center and retrospective case-control study. Patients underwent hilar cholangiocarcinoma radical resection between January 1st 2016 and December 31st 2016 at Department of HPB oncology Surgery of the PLA General Hospital were include. Evaluation of safety, effectiveness and long-term prognosis of tumors. Patients were were divided into robotic group (N=16) and open group (N=31).
Results: In this study, compared with the open group, the robotic group had a longer operation time [(338 ± 71) min than (256 ± 56) min, P = 0.001], but the intraoperative blood loss was less (100 ml is less than 200 ml, P = 0.040), the gastric tube removal time was earlier (3 d than 4 d, P = 0.011), and the postoperative hospital stay was shorter (9 d than 12 d, = 0.040), and the difference is statistically significant. There was no significant difference in the blood transfusion rate, R0 resection rate, and tumor size between the two groups. The recurrence rates in the robotic group and open surgery were 53.3% and 67.0%, respectively (P = 0.307). The median survival time of the robotic group and the open group was 22.0 months and 25.0 months. There was no significant difference in the overall survival rate between the two groups (P> 0.05).
Conclusions: Compared with laparotomy, robotic HCC radical resection could concluded as an equivalence or non-inferiority approach with acceptable long-term outcome.

PL03-051

Efficacy of Salvage Surgery for HCC Recurred with Vascular Invasion after Long-term Non-surgical Therapies
Hiroyuki Tsukayama, Japan

H. Tsukayama, K. Sano, S. Minezaki, S. Kawamura, K. Takahashi, Y. Ikeda, M. Shibuya, K. Wada, F. Miura
Department of Surgery, Teikyo University School of Medicine, Japan

Introduction: In patients of hepatocellular carcinoma (HCC) with good liver function and without vascular or extra-hapatic metastasis, hepatectomy or non surgical therapies such as radiofrequency ablation and transcatheter arterial chemo-embolization are recommended. However, non surgical therapies may cause local recurrence, and the recurrence may repeatedly be treated non-surgically, and finally vascular invasion or extrahepatic metastasis may occur. In such cases, definitive therapy is only hepatectomy, which is called salvage surgery. But it's pros and cons of this salvage surgery are still unclear.
Methods: Between April 2010 and December 2018, 274 patients underwent hepatectomy for HCC at our institution. Out of 10 patients who underwent non-surgical therapies for more than 2 years before hepatectomy, 8 patients who recurred with vascular invasion were enrolled in this study.
Results: The median survival duration after hepatectomy was 13.5 months, and the 1- and 3-year survival rates were 62 % and 37.5 %, respectively. Six patients died because of recurrence or extra-hepatic metastases. The median postoperative hospital stay was 20 days (11-44) and the perioperative mortality was 0%. Complications of Clavien-Dindo Class Ⅲa and Ⅲb were observed in 4 patients (bile fistula, postoperative bleeding).
Conclusion: Although liver function is often deteriorated in recurrent cases with vascular invasion after long-term non-surgical therapies against HCC, salvage surgery can be safely performed by adding preoperative treatments such as portal vein embolization, and may lead better prognosis.

PL03-053

Significance of Anatomic Resection for the Patients with Primary Solitary Hepatocellular Carcinoma Located on the Liver Surface
Daisuke Hokuto, Japan

D. Hokuto, T. Nomi, T. Yoshikawa, Y. Matsuo, N. Kamitani, T. Akahori, K. Nakagawa, K. Nakamura, M. Sho
Nara Medical University, Japan

Introduction: It is unclear whether anatomic resection achieves better outcomes than non-anatomic resection in patients with hepatocellular carcinoma (HCC). This study aimed to compare the outcomes of anatomic resection and non-anatomic resection for hepatocellular carcinoma located on the liver surface via one-to-one propensity score-matching analysis.
Methods: Data from all consecutive patients who underwent liver resection for primary solitary hepatocellular carcinoma at Nara Medical University Hospital, Japan, January 2007- December 2015 were retrieved. Superficial hepatocellular carcinomas were defined as hepatocellular carcinoma that extended to a depth of < 3 cm from the liver surface and measured < 5 cm in diameter. The prognoses of the patients with superficial hepatocellular carcinoma who underwent anatomic resection and non-anatomic resection were compared.
Results: In this study 23 patients with superficial hepatocellular carcinoma underwent anatomic resection, while 70 patients underwent non-anatomic resection. The recurrence-free survival rate of the patients who underwent anatomic resection was better than that of the patients who underwent non-anatomic resection (P = .006), while no such difference was observed for non-superficial hepatocellular carcinoma. After the propensity score-matching procedure, the resected liver volume and operation time were the only background or clinical characteristics to exhibit significant differences between the anatomic resection (n = 20) and non-anatomic resection groups (n = 20). The recurrence-free survival rate of the patients who underwent anatomic resection was significantly better than that of the patients that underwent non-anatomic resections (P = .030), but overall survival did not differ significantly between the groups (P = .182).
Conclusions: Anatomic resection improves recurrence-free survival compared with non-anatomic resection in patients with superficial hepatocellular carcinoma.

PL03-054

Effectiveness of the Albumin-bilirubin Score as a Prognostic Factor for Early Recurrence after Curative Hepatic Resection for Hepatocellular Carcinoma
Yun Ho Lee, Korea, Republic of

Y.H. Lee¹, Y.S. Koh¹, C.K. Cho¹, H.J. Kim²
¹Department of Surgery, Chonnam National University Hwasun Hospital, Korea, Republic of, ²Department of Surgery, Chonnam National University Hospital, Korea, Republic of

Introduction: The albumin-bilirubin (ALBI) score has been validated as a predictor of disease-free survival and overall survival in hepatocellular carcinoma (HCC). The purpose of this study was to assess the ALBI score as a risk factor for early recurrence (ER) after curative liver resection in HCC.
Methods: Patients who underwent liver resection with curative intent for HCC without previous treatment between January 2004 and December 2014 were included in this retrospective study. The utility of the ALBI score in predicting ER and late recurrence (LR) was evaluated.
Results: A total of 465 HCC patients were enrolled; multivariate analysis identified ALBI grade ≥2 (p=0.003) as a risk factor for ER, in addition to hepatitis B virus surface antigen (HBsAg)-positive status (p < 0.001), tumor size ≥3.5cm (p≤0.001), lymph-vascular invasion (p=0.001), and the presence of satellite lesions (p=0.009). In subgroup analysis for ALBI grade 1, Model for End-stage Liver Disease score >9 (p=0.046), HBsAg positive status (p=0.004), tumor size ≥3.5 cm (p < 0.001), lymph-vascular invasion (p=0.001), presence of satellite lesions (p=0.002), and poor tumor differentiation (p=0.007) were independent risk factors for ER; however, in subgroup analysis for ALBI grade 2, no significant associations with ER were found. Kaplan-Meier curve analysis showed that long-term survival in HCC with ER was significantly shorter than in patients with LR.
Conclusions: The ALBI score was a preoperative risk factor for ER and may be useful in determining appropriate management according to liver function when recurrence develops.

PL03-057

Accuracy of Volumetric and Functional Pre-operative Tests for Predicting Post-hepatectomy Liver Failure - A Systematic Review and Meta-analysis
Kurt Carabott, Malta

K. Carabott^1,2, J. Dalli¹, J.E. Abela¹
¹Department of Surgery, Mater Dei Hospital, Malta, ²University of Edinburgh, United Kingdom

Introduction: Pre-operative measurements of remnant liver volume or function are performed to predict which patients are at risk of developing post-hepatectomy liver failure (PHLF) after liver resection. It is uncertain which measures are better at predicting PHLF and clinical practices vary widely. The aim of this study is to determine whether volumetric or functional pre-operative measures best predict PHLF.
Methodology: The index tests chosen for comparison were CT/MRI volumetry, indocyanine green (ICG), 99mTc-GSA scintigraphy, 99mTc-GSA mebrofenin scintigraphy and gadolinium-enhanced (Gd-Eob-Dtpa) MRI. CENTRAL, MEDLINE, EMBASE and Web of Science were searched. Hand-searching of conference abstracts and references was performed. The most common (dominant) formula reported for each index test was chosen for comparison between index tests. Statistical analysis was performed using a hierarchical model in RevMan and SAS.
Results: 1 prospective and 32 retrospective cohort studies were included, with 5195 participants. The dominant formula for each index test were R15 (ICG), FLRV% (volumetry), eFRLF (99mTc-mebrofenin scintigraphy) and RLE (whole liver) (Gd-Eob-Dtpa MRI). 99mTc-GSA mebrofenin scintigraphy was excluded from analysis as few studies were retrieved. eFRLF showed the highest predictive accuracy for PHLF (Diagnostic Odds Ratio = 29.1) and was significantly higher than FLRV% (p = 0.003) and R15 (p = < 0.001). eFRLF did not perform better than RLE (whole liver) (p = 0.217). Pooled sensitivity and specificity for eFRLF were 84% (95%CI, 71% - 92%) and 85% (95%CI, 74% - 91%).

Index Test	Summary Sensitivity (95% CI)	Summary Specificity (95% CI)	Positive Likelihood Ratio (95% CI)	Negative Likelihood Ratio (95% CI)	Diagnostic Odds Ratio (95% CI)
ICG	59% (51 - 66)	63% (50 - 74)	1.6 (1.1 - 2.3)	0.7 (0.5 - 0.9)	2.4 (1.2 - 4.7)
Volumetry	67% (60 - 73)	80% (71 - 87)	3.4 (2.2 - 5.4)	0.4 (0.3 - 0.5)	8.3 (4.3 - 16.0)
99mTc-meb. scintigraphy	84% (71 - 92)	85% (74 - 91)	5.5 (3.1 - 9.6)	0.2 (0.1 - 0.4)	29.1 (10.2 - 82.9)
Gd-Eob-Dtpa MRI	81% (64 - 91)	69% (47 - 85)	2.6 (1.3 - 5.1)	0.3 (0.1 - 0.6)	9.6 (2.4 - 37.8)

[Summary Measures for Predicting Post Hepatectomy Liver Failure]

[Summary ROC Curves for R15, FLRV%, eFRLF and RLE (Whole Liver) with Pooled Sensitivity and Specificity Points (solid circles)]

Conclusions: Functional pre-operative measures perform better than volumetric measures alone for predicting PHLF.

PL03-058

Laparoscopic Combined Resection of Liver Metastases and Colorectal Cancer: Single Center Experience
Te Hung Chen, Taiwan, Republic of China

T.H. Chen, T.-W. Ke, H.R. Yang, L.B. Jeng, M.D. Yang, H.-M. Wang, H.-C. Chen, W.T.-L. Chen
China Medical University Hospital, Taichung, Taiwan, Republic of China

Introduction: We aim to report a series of laparoscopic combined resection of liver metastases and colorectal cancer in one center.
Methods: Between 2011 and 2018, 71 patients underwent curative laparoscopic combine resection of liver metastases and colorectal cancer for synchronous colorectal liver metastases. We retrospectively reviewed the surgical and postoperative variables
Results: The median number of liver lesions was 1 (1-12) and the median larger diameter at diagnosis was 15 (3-50) mm. Procedures of laparoscopic liver resection included wedge resection (n=52), two segmentectomy (n=4), left lateral sectionectomy (n=6), right hepatectomy (n=3), left hepatectomy (n=2), extended right hepatectomy (n=1), extended left hepatectomy (n=1), central bisectionectomy (n=1), and right posterior sectionectomy (n=1). The median operative time was 437 (269-1183) min and median blood loss was 150 (13-2220) ml. Six cases required blood transfusion (8.5%). Conversion to open surgery was required in 5 cases (7.0%). The median length of stay was 7 (4-26) days. Overall complication rate was 25.4 % and major complication rate was 11.3 %. The mortality rate was 1.4 %. After a median follow-up of 28.4 (1-95) months, 47 patients (66.2 %) developed tumor recurrence. Curative treatment of recurrence was possible in 23 patients (48.9 %), including a second liver resection in 17 patients (36.2 %). Overall 1-, 3-, and 5-year survivals were 98.6, 72.8, and 57.4 %, respectively.
Conclusion: Simultaneous laparoscopic approach is technically feasible, safe, and associated with good oncological outcomes.

PL03-059

Short Term Safety and Efficacy of Robotic Versus Laparoscopic Liver Resection: A Systematic Review and Meta Analysis
Sau Mak, United Kingdom

S. Mak¹, M. Kawka¹, S. Froghi², T.M.H. Gall¹, L.R. Jiao¹
¹HPB Surgical Unit, Department of Surgery & Cancer, Imperial College London, London, United Kingdom, ²HPB & Liver Transplantation, Royal Free Hospital, University College London, London, United Kingdom

Introduction: Laparoscopic liver resection (LLR) remains technically challenging with its use limited to experienced surgeons. Robotic liver resection (RLR) may potentially produce favorable peri- and postoperative outcomes when compared to LLR.
Methods: MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL databases were systematically reviewed to identify studies comparing robotic and laparoscopic partial hepatectomy (last search 5^th August 2019). Quantitative comparative studies in English published since the introduction of RLR were identified for inclusion. Outcomes extracted include operative time (OT), estimated blood loss (EBL), conversion to open, perioperative transfusion requirement, post-operative complications, length of stay, R0 resection rate, and mortality. Sub-groups were defined as major, and minor resections. Meta-analysis and subgroup meta-analysis was carried out using a random effects model. Effect measures were odds ratio (OR) for dichotomous data and mean weighted difference (MWD) for continuous data.
Results: Twenty-two non-randomised comparative studies with a total of 1890 patients (Robotic; n=836, Laparoscopic; n=1054) was included in analysis. Operative time was significantly longer for RLR [MWD=+39.8 minutes, 95% CI (21.1, 58.6), p< 0.001], but not significantly different in sub-group analysis. EBL, length of stay, conversion rate, transfusion, complication rate, R0 resection rate, and mortality was not significantly different between RLR and LLR nor in major or minor sub-groups [p>0.05].
Conclusion: RLR provides comparable peri- and postoperative outcomes to LLR, potentially being a preferable approach in complex and major liver resections due to the inherent advantages of the robotic platform. Further randomised controlled studies are required in establishing the role of robotics in liver resection.

PL03-061

Effect of Perioperative Antiplatelet Management on Thromboembolic Coplications after Liver Resection
Naoto Nakamura, Japan

N. Nakamura, T. Fujikawa, S. Naito
Kokura Memorial Hospital, Japan

Aim: The aim of the study is to specify the effect of perioperative antiplatelet (APT) management on postoperative thromboembolism (TE) after liver resection.
Methods: Consecutive 398 patients undergoing liver resection at our hospital from 2005 to 2017 were retrospectively reviewed. Our perioperative antithrombotic management protocol includes preoperative aspirin monotherapy for patients with high thromboembolic risks. Among them, 125 patients (31.4%) had atherosclerotic thromboembolic risk and received APT. The cohort was classified into three groups; patients without APT (N-APT group), APT-discontinued patients (D-APT group), and aspirin-continued patients (C-APT group), The predicted risk of each group was assessed by CHADS2 score, and the rates of TE were compared between the groups.
Results: Significantly lower CHADS2 score of N-APT group was observed compared to those of other groups, although the D-APT and C-APT groups had similar distribution of the scores. Among 398 patients, postoperative TE was found in 6 cases (1.5%). Three cases resulted in in-hospital death and other 3 patients were discharged with moderate to severe sequelae. More TE occurred in the D-APT group (4.2%), whereas only one case in the C-APT group (1.9%) and three cases in the N-APT group (0.7%) were observed (p=0.038). Although having high CHADS2 scores, patients in C-APT group showed a relatively low rate of postoperative TE events, mainly due to the preventive effect of preoperative aspirin continuation against TE.
Conclusion: Especially in patients with APT for thrombotic risks, it is suggested that management with continued preoperative single aspirin therapy should be considered regardless of TE risks.

PL03-062

Laparoscopic Liver Resection in Patients with Previous Upper Abdominal Laparotomy
Taro Aoba, Japan

T. Aoba, K. Hiramatsu, K. Omiya
General Surgery, Toyohashi Municipal Hospital, Japan

Introduction: Laparoscopic Liver Resection (LLR) is now performed worldwide. However, LLR is sometimes difficult in patients with previous upper abdominal laparotomy.
Methods: We did 78 LLRs in our institution from January 2012 to December 2019. In our cases, 7 patients were performed upper abdominal laparotomy previously. We did pure LLR and partial hepatetomy in the patients. We report the surgical outcomes of LLR in the patients.
Results: The history of the upper abdominal surgery was as follows: gastrectomy in 2 cases, cholecystectomy in 1, and hepatectomy in 4. LLRs were performed for hepatocellular carcinoma in 5 cases and metastasis of gastro intestinal stromal tumor in 2. Their Child-Pugh Score was as follows: A in 5 cases and B in 2. There were no cases of conversion to open hepatectomy. Median intraoperative blood loss was 75ml and operative time was 151 minutes. Blood transfusion was performed in only one case. No postoperative complication was seen. Average duration postoperative hospital stay was 8 days.
Conclusion: We investigated surgical outcome of LLR in patients with previous upper abdominal laparotomy. While our outcomes seems favorable and safety, further number of cases would be required to determine whether LLR is superior to open hepatectomy in patients with previous upper abdominal laparotomy.

PL03-064

Short-term Outcomes of Laparoscopic Anatomical Liver Resections with Glissonian Approach
Kohei Mishima, Japan

K. Mishima, K. Igarashi, T. Ozaki, M. Honda, N. Funamizu, G. Wakabayashi
Surgery, Ageo Central General Hospital, Japan

Background: Anatomical liver resections (ARs) have been shown to improve oncological outcomes in patients with liver malignancies. Few experiences on laparoscopic ARs (Lap-ARs) have been reported. This study aimed to evaluate the feasibility of Lap-ARs with Glissonian approach.
Method: A total of 111 patients who underwent Lap-ARs with Glissonian approach from April 2016 to December 2019 were retrospectively reviewed.
Results: Median age was 73 (19-91). 67 patients had hepatocellular carcinoma (HCC) while 30 had colorectal liver metastasis (CRLM) and 14 had others. 13 anatomical subsegmentectomies (HrS-), 48 segmentectomies (HrS), and 50 sectionectomies (Hr1, 2, and 3) were performed. Median difficulty score (IWATE criteria) was 7 (5-11). Surgical time was 342 min (102-639) and blood loss was 130 ml (5-1523). Conversion rate was 1.8%. Resected liver volume was 192 g (23-974). 13 patients (11.7%) experienced morbidities (≥ Clavien-Dindo IIIa) and 90-day mortality rate was 0.9%. Negative surgical margin was achieved in 94.2%. IWATE criteria ≥8 was associated with increased operative time, blood loss and postoperative morbidities.
Conclusions: Lap-ARs with Glissonian approach are feasible procedures that integrate radicality and safety with the parenchymal-sparing principle.

PL03-065

Advanced Age Is Not a Contraindication to Pancreaticoduodenectomy
Elan Novis, Australia

E. Novis^1,2, K. Haghighi^1,2,3
¹Upper Gastrointestinal Surgery, Prince of Wales Hospital, Australia, ²Prince of Wales Clinical School, UNSW, Australia, ³Upper Gastrointestinal Surgery, St Vincent's Hospital, Australia

Introduction: With a growing elderly population, the pancreatic surgeon is increasingly required to determine whether older patients with pancreatic cancer should undergo a pancreaticoduodenectomy. This operation offers the only potentially curative treatment, however questions remain as to the safety and feasibility of PD in this elderly population.
This study aims to provide evidence from a high-volume single-centre for the safety and feasibility of pancreaticoduodenectomy in patients aged 75 years and above.
Method: A retrospective review of a prospectively maintained database was performed, including all patients who underwent pancreaticoduodenectomy by a single surgeon between 2007-2019. Patients were divided into two groups, those 75 years or older and patients younger than 75. Patient characteristics, operative and post-operative outcomes were reviewed and compared between the two groups.
Results: Of the 282 patients who underwent pancreaticoduodenectomy, 67 (24%) patients were 75 years or above. This included, 20 (30%) elderly patients who also underwent portal vein reconstruction, compared with 78 (36%) patients in the younger group. Overall perioperative mortality was low at 1/67 (1.5%) in the elderly group, compared with 1/215 (0.5%) in the younger group. Overall complication and major complication rates were 17/67 (25%) and 3/67 (4%) in the elderly group respectively, which were comparable to the younger group with 28/215 (13%) and 1/215 (0.5%) respectively.
Conclusion: Carefully selected elderly patients can safely undergo pancreaticoduodenectomy with low rates of morbidity and mortality. Although higher than the younger patients, morbidity and mortality rates remain low for an operation which provides the only potential curative treatment.

PL03-067

Porto-caval Shunt Is a Salvage Manoeuvre to Reduce de Novo Portal Hypertension after Major Hepatectomy
Michele Tedeschi, France

M. Tedeschi, O. Ciacio, N. Golse, G. Pittau, D. Castaing, R. Adam, A. Sa Chuna, D. Cherqui, E. Vibert
Hopital Paul Brousse, France

Background: Extended hepatectomy offers the only possibility of cure to patients with large or multifocal hepatic cancers. Post-hepatectomy de novo portal hypertension is a known risk factor of post-operative liver failure (PHLF).
Intra-operatively pharmacological (somatostatin infusion) and surgical (splenic artery ligation) management of post hepatectomy portal hypertension have already been described.
Objectives: We present here 3 cases where major hepatectomy was followed by intra- or post-operative creation of a porto-caval shunt in order to avoid de novo portal hypertension and subsequently PHLF. To our knowledge, no other similar cases have been reported in the literature.
Case reports: In one case, the porto-caval shunt was performed intra-operatively after discovering a high portal pressure and porto-caval gradient at the end of the surgery. In the other 2 cases the shunt was performed post-operatively as a rescue procedure to treat a portal thrombosis related to portal hypertension. In all cases the porto-caval shunt managed to reduce the portal pressure and subsequently the porto-caval gradient and no post-hepatectomy liver failure occurred.
Conclusion: In the event of de novo portal hypertension after major hepatectomy and in case of fail of peri-operative pharmacological treatment or splenic artery ligation, a porto-caval shunt may be a salvage manoeuvre to avoid post-operative liver failure.

PL03-068

Laparoscopic Liver Resection Can Be a Standard Treatment for Hepatocellular Carcinoma of Low and Intermediate Difficulty
Ruoh-Yun Gau, Taiwan, Republic of China

R.-Y. Gau, M.-C. Yu, K.-M. Chan, W.-C. Lee, C.-C. Chiu, C.-W. Lee
Surgery, Chang-Gung Memorial Hospital, Taiwan, Republic of China

Introduction: To investigate the feasibility of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) with various difficulty, we compared LLR and open liver resection (OLR) in serial patient groups with matched difficulty level.
Methods: We retrospectively reviewed 607 patients with HCC undergoing liver resection (81 of LLR, 526 of OLR) in our hospital from 2012 to 2019. Propensity score-matched (PSM) analysis was used to balance LLR and OLR with characteristics and difficulty levels by IWATE criteria. We compared the matched patients, and further analyzed the results in patient groups stratified by difficulty score (DS).
Results: After 1:1 PSM process, 146 patients were selected. Compared to OLR, LLR had shorter hospital stay (9.4 vs. 11.5 days, p=0.071), less surgical complications (16.4% vs. 30.1%, p=0.049), lower inflow control rate (42.5% vs. 65.8%, p=0.005), while comparable disease-free and overall survival. Among the 73 matched patients of each group, 13, 41, 13 and 6 patients were classified as low, intermediate, advanced and expert DS group, respectively. Accordingly, LLR was associated with shorter hospital stay and less surgical complications in low and intermediate DS groups. The disease-free survival of LLR in intermediate DS group was superior to OLR (p=0.020). In advanced and expert DS groups, the peri-operative and oncologic outcomes between LLR and OLR were comparable.
Conclusions: With careful patient selection, LLR for HCC had promising outcome in comparison to OLR. Our data suggest that LLR should be considered a standard procedure in HCC case of low and intermediate difficulty according to IWATE criteria.

	Matched-LLR (n=73(100%))	Matched-OLR (n=73(100%))	P value
Hepatic inflow control (Yes (n(%))	31 (42.5)	48 (65.8)	0.005
Grade ≧II complication (n(%))	12 (16.4)	22 (30.1)	0.049
Grade ≧III complication (n(%))	2 (2.7)	7 (9.6)	0.166
In-hospital mortality (n(%))	0 (0.0)	2 (2.7)	0.497
Surgical time (min) (mean±SD)	288.6±102.1	276.0±106.7	0.501
Blood loss (ml) (mean±SD)	342.5±394.4	400.7±531.9	0.456
Post-OP length of hospital stay (day) (mean±SD)	9.4±5.3	11.5±9.8	0.071
Positive resection margin (n(%))	1 (1.4)	4 (5.5)	0.172
Follow up period (month) (mean±SD)	38.4±26.9	46.2±24.2	0.083

[Comparison of clinical and oncologic outcomes between LLR and OLR after propensity score matching analysis]

PL03-069

Prognosis and Risk of Long-term Recurrence after Liver Resection for Hepatocellular Adenoma with Malignant Transformation
Sophie Chopinet, France

S. Chopinet¹, F. Cauchy¹, C. Hobeika¹, A. Beaufrère², S. Dokmak¹, M. Bouattour³, M. Ronot⁴, V. Paradis², O. Soubrane¹
¹Liver and Pancreatic Surgery and Liver Transplantation, Beaujon Hospital, France, ²Anatomopathology, Beaujon Hospital, France, ³Hepatology, Beaujon Hospital, France, ⁴Radiology, Beaujon Hospital, France

Introduction: The aim of the study was to compare the long-term outcomes of resected hepatocellular adenomas with malignant transformation (MT-HCA) and well-differentiated hepatocellular carcinoma on normal liver parenchyma (WD-HCC) and HCA without malignant transformation (HCA).
Methods: From 2001-2018 all patients undergoing hepatectomy for M-HCA were included in this monocentric retrospective study. MT-HCA were classified as borderline HCA (Bo-HCA) in case of small malignant foci and as Malignant-HCA (M-HCA) in case of predominant HCC component. Overall (OS) and recurrence-free (RFS) survivals after LR for HCA, Bo-HCA, M-HCA and WD-HCC were compared.
Results: Thirty-nine patients (23 men, 16 women) underwent LR for MT-HCA (22 Bo-HCA, 17 M-HCA) and were compared to 90 patients with WD-HCC and 30 patients with HCA. Among the 39 patients with MT-HCA, 14 were ß-catenin mutated (b-HCA), 21 were inflammatory (I-HCA), and 4 were unclassified (U-HCA). After a median follow-up of 67 months, 10 patients (25%) experienced tumor recurrence, including 9 M-HCA and one Bo-HCA (p< 0.001). Five-year RFS were 83%, 46%, 25% for the Bo-HCA, M-HCA, WD-HCC groups respectively (p< 0.001). On univariate analysis, risk factors for recurrence were age (p=0,010), Tumor size > 5cm (p=0,028), presence of satellite nodules (p=0.001), microvascular invasion (p=0.001), and the U-HCA subtype (p=0.038). On multivariate analysis, only age and tumor size > 5cm were independently associated with recurrence following LR.
Conclusion: HCA with malignant transformation yield a better long-term prognosis than WD-HCC. Among MT-HCA, Bo-HCA have a better prognosis than M-HCA.

[5 years Recurrence free survival according to HCA subtypes]

PL03-071

Major Liver Resections: An Audit of Developing HPB Unit
Ramesh Singh Bhandari, Nepal

R. Singh Bhandari^1,2
¹Surgery, TU Teaching Hospital, Kathmandu, Nepal, ²TU Teaching Hospital, Kathmandu, Nepal

Background: With proper training and improved perioperative care, major liver resections are being safely performed even in low volume center of the underdeveloped country. Here, we the present the outcome of major liver resections performed in developing HPB unit of T U Teaching Hospital, Kathmandu, Nepal.
Methods: The Chief surgeon of the unit received two years of HPB training at high volume centers in Melbourne. The surgeon had received general surgical training in Nepal and had worked for few years prior to receiving HPB training. Retrospective review of the medical records of major liver resections performed by single unit were reviewed. Indications, extent of hepatectomy and perioperative outcomes were analyzed.
Results: Total 79 liver resections have been performed by the single unit out of which 54 were major liver resections (Three or more segments) over 6 years period. Out of them, total 3 were for right donor hepatectomy, 2 for trauma and remaining 49 were for other benign and malignant conditions. There were 16 Right hepatectomy, 14 left, 9 extended right, 13 non anatomical, 1 HPD and 1 ALPPS procedure. Two patients were operated following right portal vein ligation. There was 25% morbidity (Clavien Dindo Grade 1-3, SSI, Chest infection, UTI, Transfusion, bile leak). Post hepatectomy liver failure (PHLF) was 1.8% and mortality was 3.7% (1 Post AlPPS Sepsis, 1 PHLF).
Conclusion: With proper training and improved perioperative care, major liver resection can be performed safely with acceptable outcome even in low volume centers of developing nations.

PL03-072

The Feasibility and Efficacy of Repeat Laparoscopic Liver Resection: A Propensity-matched Analysis of Short-term Outcomes
Takashi Onoe, Japan

T. Onoe^1,2, T. Sudo¹, N. Hadano¹, H. Sada¹, H. Tazawa¹, W. Shimizu¹, T. Suzuki¹, Y. Shimizu¹, H. Tashiro^1,2
¹Surgery, National Hospital Organization, Kure Medical Center/Chugoku Cancer Center, Japan, ²Surgery, Hiroshima University, Japan

Background: Repeat hepatectomy has been widely accepted for liver tumors due to progress of anti-viral or anti-cancer drugs. However, repeat laparoscopic liver resection (LLR) is technically more difficult. The aim of this study is to assess the feasibility and efficacy of repeat LLR, as compared with repeat open liver resection (OLR).
Methods: We performed 45 repeat OLR and 28 LLR from 2007 to 2018. This study retrospectively compared the patients' clinico-pathological characteristics and operative and short-term outcomes of the 2 groups.
Results: There were no significant differences in patient characteristics between the 2 groups, excluding Child-Pugh grade. The repeat LLR group had less blood loss during operation (median 224 ml vs. 578 ml; P < 0.001) and shorter postoperative hospital stays (median 11.5 days vs. 20.9 days; P < 0.01). The other results including operating time and postoperative complications (> Clavien-Dindo grade 3) were comparable between the 2 groups. A propensity score-matched analysis resulted in 27 one-to-one patient pair comparisons with repeat OLR and LLR. Child-Pugh grade or liver damage of all selected patients was grade A. In this analysis, the repeat LLR group had less blood loss during operation (median 190 ml vs. 580 ml; P < 0.001) and shorter postoperative hospital stays (median 11.5 days vs. 22.2 days; P < 0.05), while the other results including operation time and postoperative complications were comparable between the 2 groups.
Conclusions: Repeat LLR is feasible and useful with good short-term outcomes, at least, for patients with good reserve capacity.

PL03-073

Short Term Outcome of Repeat Laparoscopic Compared to Open Hepatectomy after an Initial Open Hepatectomy
Nasser Abdul Halim, France

N. Abdul Halim^1,2, X. Liang³, A. Laurent⁴, A. Sa Cunha⁵, G. Pittau⁵, E. Vibert⁵, R. Adam⁵, X. Cai³, D. Cherqui⁵
¹Hepato-Biliary Centre, Paul Brousse Hospital - Paris South University, France, ²General Surgery, Beilinson Hospital, Israel, ³General Surgery, Sir Run Run Shaw Hospital, the Zhejiang University College of Medicine, China, ⁴General Surgery, Henri Mondor Hospital, France, ⁵Hepato-Biliary Centre, Paul Brousse Hospital - Paris South University, France

Background: Repeat laparoscopic hepatectomy (RLH) is safe and feasible, with favorable oncologic outcome for recurrent liver malignancies after curative intent resection, however it is rarely performed after an initial open hepatectomy (OH). The aim of the study is to evaluate the outcome of RLH compared to repeat OH (ROH) following initial OH.
Methods: Patients who underwent RH after initial OH were retrieved from prospective data bases at Paul Brousse and Henri Mondor hospitals, France and Sir Run Run Shaw Hospital, China from 2012 to 2019. The patients were divided into two groups according to their RH, RLH (group A) and ROH (group B).
Results: Sixty-four patients matched the criteria, 20 in group A and 44 in group B. Diagnoses were primary hepatic lesions in 59%, CRLM in 39% and others in 2% of cases. Median operative time and blood loss were significantly lower in group A (199 vs 260 minutes, p< 0,001 and 100 vs 400 ml, p= 0,011 respectively), as well as overall postoperative complications (20% vs 50%, p=0,024). One patient died in group A of postoperative pancreatitis; this patient had been converted to open. Another case was converted due to exposure difficulties. Median hospital stay was as well lower in group A (5 vs 8,5 days, p= 0,001). R1 resection was 10% and 22,7%, respectively (p=0,312).
Conclusion: LRH is a feasible, safe technique and a realistic option to be considered in selected patients after previous OH.Conversion should be considered when adhesions are more severe than expected.

PL03-074

Systematic Review on Percutaneous Aspiration and Sclerotherapy versus Surgery as First-line Treatment in Symptomatic Simple Hepatic Cysts
Alicia Furumaya, Netherlands

A. Furumaya¹, B. van Rosmalen¹, J.J. de Graeff¹, M. Haring², V. de Meijer², J. Verheij³, J. Erdmann¹, O. van Delden⁴, M. Besselink¹, Dutch Benign Liver Tumour Group
¹Surgery, Amsterdam UMC, University of Amsterdam, Netherlands, ²University Medical Center Groningen, Netherlands, ³Pathology, Amsterdam UMC, University of Amsterdam, Netherlands, ⁴Interventional Radiology, Amsterdam UMC, University of Amsterdam, Netherlands

Background: Simple, non-parasitic, non-polycystic hepatic cysts (SHCs) may cause pain and bloating which impairs quality of life (QoL). Treatment options include percutaneous aspiration and sclerotherapy (PAS), and laparoscopic or open surgical management. Current guidelines recommend laparoscopic deroofing as primary treatment. This review assesses the effect of PAS and surgery on the symptoms and QoL in patients with SHCs.
Methods: A systematic search in MEDLINE (PubMed) and Embase was performed according to PRISMA guidelines. Studies reporting symptoms before and after treatment of SHCs were included. Methodological quality of included studies was assessed by the MINORS-tool. Primary outcomes were symptom relief and QoL. Secondary outcomes were recurrence and complications. Pooled estimates were produced using the Mantel-Haenszel method.
Results: In total, 764 patients from 34 studies with SHCs were included, of which 294 (38.5%) underwent PAS, 348 (45.5%) laparoscopic, and 122 (16.0%) open surgical management. Prior to surgical management, 9.9% (95% CI: 9.1-10.6%) of patients underwent other treatment. Symptom relief (percentage with 95% CI) was accomplished in 92.5% (91.7-93.3%), 91.4% (90.6-92.2%), 86.9% (84.9-88.9%) of patients treated with PAS, laparoscopic or open surgery, respectively. QoL was rarely examined. Cyst recurrence rates were 0.3% (0.3-0.4%), 16.4% (14.9-17.8%) and 13.1% (11.1-15.1%). Major complication rate was 0.7% (0.6-0.8%), 1.7% (1.6-1.9%) and 2.5% (2.0-2.9%), respectively.
Conclusions: Similar results were found for PAS and surgery with respect to symptom relief and complications. PAS was associated with lower cyst recurrence rates than surgery. We advocate PAS as primary treatment in a step-up protocol for SHCs.

PL03-076

Radical Surgery Reduces Risk of Recurrence in Liver Hydatid Cyst
Pinar Tasar, Turkey

P. Tasar, K. Senol, I. Tirnova, B. Bakar, E. Kaya, Y. Ozen, S. Kilicturgay
General Surgery, Bursa Uludag University, Turkey

Background and aims: Effects of conservative surgical procedures applied in cyst hydatid surgery and radical surgical interventions on emergence of postoperative biliary complications and recurrence were examined.
Methods: Data of 804 patients operated with the diagnosis of liver cyst hydatid were examined retrospectively. Demographic features, preoperative imaging methods, cyst type, location, complication and type of surgery were recorded. The patients were divided into two groups according to the difference of the surgical methods applied (conservative / radical) and the period of hospitalization, morbidity and mortality in the first 30 postoperative days and long-term recurrence rates were compared.
Results: Conservative surgery was applied to 605 patients while radical surgery was applied to 199 patients of the total 804 patients. The demographic characteristics of the patients were similar in the two groups. In the postoperative period, there was no statistically significant difference between the two groups in terms of period of hospitalization, morbidity and mortality rates. However, biliary complications observed as 4.1% in conservative surgery know was found to be 3% in radical surgery. The mean follow-up period was 50.66 ± 23.9 (3-147) months and recurrence developed in 86 patients. The recurrence rate, which was 13.2 % in the conservative surgical group, was found to be 3% in the radical surgical group (p = 0.0001) (Table 1).
Conclusions: Radical surgery decreases biliary complications including primarily bile leakage without causing additional morbidity in patients, makes follow-up easier but most importantly it decreases recurrence rate significantly.

	Conservative Surgery Group (n = 605)	Radical Surgical Group (n = 199)	P
Period of hospitalization (day)	6.5±6.1 (2-60)	5.2±1.7(3-11)	> 0.05
Morbidity (30 days )	106 (% 17.5)	37 (% 18.6 )	=0.754
Reoperation(30 days)	4 (% 0.66)	1 (% 0.50)	=1.000
Mortality (30 days )	5 (% 0.82)	1 (% 0.5)	=1.000
Recurrence	80 (% 13.2)	6 (% 3.01)	= 0.0001

[Table 1. Period of hospitalization, morbidity, mortality and recurrence rates]

PL03-077

Association of the Change of Alkaline Phsophatase Level and Liver Regeneration in Partial Hepatectomies
Chun-Wei Huang, Taiwan, Republic of China

C.-W. Huang^1,2, C.-W. Lee², M.-C. Yu^1,2, T.-H. Wu²
¹Surgery, New Taipei Municipal Tucheng Hospital, Taiwan, Republic of China, ²Surgery, Chang-Gung, Taiwan, Republic of China

Introduction: The level of alkaline phosphatase (100U/L) was an independent prognostic factor in our studies. (J Gastrointest Surg. 2011 Aug;15(8):1440-9. ) The biological analyssis for the impact on HCC outcome was unknown.
Methods: Based on the surgical analysis of liver cancer patients from 2015 to 2018, we selected two groups of patients, namely patients with right hepatectomies (group 1) and lateral segmentectomies (group 2).T
Results: differences in gender, AST, and alkaline phosphatase (ALKP) between the two groups. There is no statistical difference in BMI, ICG-R15, cirrhosis, and other biochemical indicators. There were no mortality in the cases included in this study. One month later, PTLV (postoperative liver volume) is 997.5 ± 204.2 and 1138.8 ± 241.7ml (p = 0.019), although the right The regeneration volume of hepatic lobe resection is still slightly smaller than the original volume (0.65 ± 0.14 and 0.89 ± 0.11), but the regeneration ratios (PTLV / est. Preserved) are 1.88 ± 0.59 and 1.18 ± 0.15 (p < 0.001), respectively. Moreover, the regeneration ratio at AlkP> = 100 and < 100 U / L has a regeneration ratio (PTLV / est. Preserved) of 1.80 ± 0.68 and 1.39 ± 0.32 (p = 0.003), and correlation analysis shows that the regeneration ratio is related to AlkP (pearson correlation = 0.301, p = 0.049), has nothing to do with other liver function indicators.
Conclusion: The result showed the serum change of ALKP was association with liver regeneration.

PL03-080

Identification of High-risk Patients of Clinically Relevant Postoperative Pancreatic Fistula
Yutaka Endo, Japan

Y. Endo^1,2, M. Kitago¹, M. Shinoda¹, H. Yagi¹, Y. Abe¹, G. Oshima¹, S. Hori¹, T. Yokose¹, Y. Kitagawa¹
¹Keio University, Japan, ²Tama Kyuryo Hospital, Japan

Background: Pancreatic fistula (POPF) remains a significant concern after pancreaticoduodenectomy (PD). Recently, there have been the development of risk-stratification and increasing needs in the management base on such risk-model. The purpose of this study was to examine the identification of risk factor and the invention of risk-model using these risk factors.
Methods: Patient characteristics, preoperative laboratory, and radiographic findings and their association with postoperative pancreatic fistula after pancreaticoduodenectomy were analyzed for 158 patients who underwent resection between 2011 and 2017. CR-POPF was defined as Grade B or C pancreatic fistula based on the International Study Group of Pancreatic Surgery (ISGPS) 2016 consensus.
Results: CR-POPF developed in 38 patients (24.2%). On multivariate logistic analysis, abdominal fat area (ORs=1.006; P=0.05), main pancreatic duct diameter (ORs=0.72; P=0.0008), diabetes mellitus (ORs=4.8; P=0.0038) and the pathology of non-pancreatic cancer (ORs=6.3; P=0.0002). The risk-model based on these factors classified the high risk group, whose discriminant score was above 0.70. To prevent the development and deterioration of POPF, modified Blumgart method, external stenting of bile and pancreatic secretion and continuous irrigation after POPF were instituted. After 2018, 5 patients out of 60 patients in total was the high-risk group. Among them, 1 patient underwent CR-POPF. No patients experienced Grade C POPF.
Conclusions: The risk assessment based on preoperative factors for the prediction of POPF after PD was considered as effective in view of the identification of high risk patients and intervention to them. However, the rate of POPF remains high despite several improvement of perioperative management.

PL03-081

Routine Application of Laparoscopic Surgery for Hepatocellular Carcinoma Located in the Anterolateral Segments of the Liver: Outlier Analysis
Hyojin Shin, Korea, Republic of

H. Shin, J.Y. Cho, H.-S. Han, Y.-S. Yoon, Y. Choi, J.S. Lee, B. Lee, J. Kim
Department of Surgery, Seoul National University Bundang Hospital, Korea, Republic of

Introduction: The aim of this study was (1) to compare the perioperative outcomes of laparoscopic anterolateral liver resection (LALLR), open anterolateral liver resection (OALLR) and open conversion anterolateral liver resection (OCALLR) (2) to analyze the risk factors for open conversion.
Methods: We retrospectively reviewed the data of 374 patients who underwent laparoscopic (N=299) or open (N=62) or open conversion (N=13) liver resection for hepatocellular carcinoma located in anterolateral segments between 2004 and 2018.
Results: Among preoperative factors, tumor size (cm) (4.11 ± 2.01 vs. 4.98 ± 3.49 vs. 2.82 ± 1.52, p = 0.000) and proportion of other organ invasion (23% vs. 15.4% vs. 1.7%, p = 0.001) were significantly higher in OCALLR and OALLR than LALLR group.
In operative outcome analysis, estimated blood loss (ml) (1596.1 ± 1604.8 vs. 812.5 ± 977.6 vs. 411.3 ± 614.3, p = 0.003), postoperative hospital days (10.38 ± 5.69 vs. 11.82 ± 9.31 vs. 6.48 ± 6.71, p = 0.000) and complication (38.5% vs. 29.0% vs. 12.5%, p = 0.001) were significantly higher in OCALLR and OALLR than LALLR group.
Conclusion: Laparoscopic approach showed better operative outcomes than open surgery in anterolateral liver resection in selected patients. Moreover, OCALLR showed even poorer operative outcomes than OALLR and risk factors for open conversion were bigger tumor size and other organ invasion.

PL03-082

Surgical Outcomes after Microscopic Incomplete Resection (R1) of Colorectal Liver Metastases in the Era of Aggressive Surgical Approach
Essam Alhothaifi, Korea, Republic of

E. Alhothaifi^1,2, G.H. Choi¹, D.H. Han¹, K.S. Kim¹, J.S. Choi¹
¹HPB Department, Yonsei Severance Hospital, Korea, Republic of, ²HPB Department, King Saud Medical City, Saudi Arabia

Backgroud and purpose: A ≥ 1-mm margin is standard for resection of colorectal liver metastases (CRLM). However, microscopic incomplete resection (R1) is not rate because aggressive surgical resection has been attempted in multiple and bilobar CLM. In this study, we analyzed surgical outcomes after R1 resection of CRLM.
Method: From 2005 to 2018, 371 consecutive patients undergoing liver resection for CRLM were included. R1 resection was defined to have zero tumor free margin at the pathologic report. All patients were divided into R0 (tumor free margin more than 0mm) and R1 group. Recurrence pattern and disease-free survival were analyzed between the two groups.
Results: A total of 371 patients included in the study. Among them, R1 resection was found in 42 (11.3%) patients. The median age at diagnosis was 59 years (range, 22 to 86). There were 246 (33.7%) men and 125 women (66.3%). The incidence of intrahepatic recurrence was not significantly different between R0 and R1 resection. Similarly, there was no significant difference in term of surgical margin recurrences between patients with R0 and R1 resections (42% [35/84] vs 35% [6/17], respectively, P = 0.788). When comparing R0 and R1 resection, the 1-, 3-, and 5-year disease-free survival rates was not statistically significant.
Conclusion: R1 resection showed similar marginal recurrence rate and comparable disease-free survival compared to R0 resection. R1 resection should be part of the modern multidisciplinary, aggressive approach to CRLM.

PL03-083

Prognostic Significance of the Postoperative Neutrophil-to-lymphocyte Ratio in Solid Tumors: A Systematic Review and Meta-analysis
Meilong Wu, China

M. Wu^1,2, S. Yang^1,2, X. Feng^1,2, F. Yu^1,2, J. Dong^1,2
¹School of Clinical Medicine, Tsinghua University, Beijing, China, ²Center of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China

Inflammation plays a critical role in tumorigenesis, progression and metastasis. A high preoperative neutrophil-to-lymphocyte ratio has been reported to be a worse prognostic indicator in malignancies. However, the association between postoperative NLR (postNLR) elevation and survival outcome in patients with solid tumors remains controversial.
A systematic review was conducted to explore the association between the postNLR and survival outcome, including overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS), in solid tumors. Relevant literature was identified using PubMed, Embase, and the Cochrane Library from the initiation of the databases to October 2019. Data were extracted from included studies reporting hazard ratios (HRs) and 95% confidence intervals (CIs) and were pooled using generic inverse-variance and random-effects modeling. All statistical tests were two-sided.
Ten studies reporting on 5653 patients were included in the analysis. Elevated postNLR was associated with worse OS (HR 1.93, 95% CI = 1.33-2.79; P = 0.0005) and CSS (HR 1.34, 95% CI, 1.03-1.74; P = 0.03).
Elevated postNLR might be a readily available and inexpensive biomarker for OS and CSS in solid tumors. Multicenter and prospective studies are needed to explore the impact of the postNLR, especially in immunotherapy, on the prognosis of solid tumors.

PL03-084

Peri-operative Predictors of Within 1-year Mortality in Patients with Hepatocellular Carcinoma Treated by Hepatectomy with Curative Intent
Kah Wai Lai, Singapore

K.W. Lai¹, S. Sheriff², S. Marhavan², Y.H. Chan³, S.P. Junnarkar⁴, C.W. Huey⁴, J.K. Low⁴, V.G. Shelat⁴
¹National University of Singapore, Singapore, ²Ministry of Health Holdings, Singapore, ³Biostatistics Unit, National University Health System, Singapore, ⁴Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore

Introduction: Investigators routinely report short term(30 or 90 days mortality) or long term(1,3,5 year Disease Free Survival and Overall Survival) outcomes. Intermediate outcomes between 90days and 1 year are also important as it puts into question the surgical risk assessment. We study the risk factors predicting 1-year mortality following elective liver resection for hepatocellular carcinoma (HCC).
Method: This is a retrospective study of 400 patients who underwent liver resection from January 2007 to April 2016. Univariate and multivariate analysis were performed on peri-operative variables using Cox-Regression analysis. Kaplan-Meier Survival curves and hazard ratios were obtained.
Result: 163 patients had curative hepatectomy for HCC. The median tumour diameter was 40mm (1-200mm) with 68 patients(41.7%) having tumors ≥50mm. 17(10.4%) were of Child-Pugh Class B/C, and over half (51.5%) had Hepatitis B. 71 patients (43.6%) underwent major HR and 101(62.0%) had laparoscopic hepatectomy. 30-day mortality was 3.7% (n=6) and 90-day mortality was 4.9% (n=8). Fifteen patients (9.1%) experienced 1-year mortality. Multivariate analysis identified five risk factors (Table 1). A prognostic algorithm calculating the total number of identified risk factors in patients shows that patients with >3 risk factors do not survive 1-year (p< 0.001).
Conclusions: We identified five peri-operative risk factors that predict 1-year mortality following elective liver resection for HCC. Pre-operative factors are Child score, multinodularity and macrovascular invasion and it remains to be determined if patients with two or more of these three factors are better managed with a combination of radiofrequency ablation and liver directed chemotherapy instead of surgical resection.

Peri-Operative Risk Factor	HR	95% Confidence Interval (CI)	p-value
Child Score (B/C)	5.5	1.130-26.551	0.035
Multi-nodularity (>1 Tumor)	7.1	2.305-21.899	0.001
Macrovascular Invasion	4.2	1.046-17.191	0.043
Acute Renal Insufficiency	5.8	1.009-33.294	0.049
Post-Hepatectomy Liver Failure	9.6	1.778-51.320	0.009

[Table 1: Identified independent risk factors for predicting 1-year mortality]

PL03-086

High FIB-4 Index Predicts Poor Prognosis in Alcoholic Drinkers with Hepatocellular Carcinoma
Mitsuru Yanagaki, Japan

M. Yanagaki^1,2, Y. Shirai^1,2, T. Taniai^1,2, R. Hamura^1,2, T. Horiuchi^1,2, N. Saito^1,2, T. Gocho¹, H. Shiba¹, K. Yanaga¹, Surgery
¹Department of Surgery, The Jikei University School of Medicine, Japan, ²Division of Gene Therapy, Research Center for Medical Science, The Jikei University School of Medicine, Japan

Background: Hepatocellular carcinoma (HCC) is one of the most aggressive cancer with a poor prognosis. Prediction of the prognosis is important to determine the treatment strategy. Alcohol consumption is a well-known major risk factor for liver fibrosis and HCC. FIB-4 index is a non-invasive and easily applicable indicator of liver fibrosis based on age, AST, ALT and platelets, which is a highly predictive risk factor for HCC. The aim of this study is to evaluate the association between preoperative FIB-4 index and prognosis in patients with HCC among alcohol drinkers.
Methods: Consecutive 197 patients who underwent surgical resection of HCC between 2000 and 2018 were included. The cut off value of FIB-4 was determined by ROC analysis. We analyzed the relationship between clinicopathological variables including FIB-4 and survival after hepatectomy. Survival data were analyzed using the Log-rank test for univariate analysis and Cox proportional hazards for multivariate analysis. P value of < 0.05 was judged as significant.
Results: A univariate analysis revealed that HCV positive (p=0.023), high preoperative ICG retention rate at 15 minutes (p=0.020), high AFP (p=0.030), high PIVKA-Ⅱ (p=0.005) and high FIB-4 index (≥2.6; p< 0.001) were significant poor prognostic factors for OS. FIB-4 index retained its significance on multivariate analysis for OS (HR 2.281, 95%CI 1.309-3.975) along with PIVKA-Ⅱ (p=0.0006). High FIB-4 index was also an independent prognostic factor for DFS (HR 1.772 95%CI 1.231-2.552).
Conclusion: Preoperative high FIB-4 index is an independent prognostic factor for OS and DFS in resected HCC.

PL03-087

Outcomes of Robotic Hepatectomy in a New Community-hospital Based HPB Program. Lessons Learned and ACS Risk Comparison to Open Surgery Outcomes
Imran Siddiqui, United States

I. Siddiqui
Surgical Oncology and HPB Surgery, Hartford Healthcare St. Vincent Medical Center, Bridgeport, United States

Introduction: Robotic hepatectomy is safe and feasible when performed by trained surgeons. Universal adoption is limited due to the complexity of the operation and the steep learning curve as well as inherent risks associated with liver resection including bleeding. We describe in our series consecutive robotic hepatectomies performed in a community hospital using ACS score.
Methods: Consecutive patients undergoing liver resection surgery by a robotic fellowship trained HPB surgeon at a community hospital setting were evaluated. ACS NISQUIP risk score for any and serious complications, 90-day mortality, 30-day readmission, preoperative embolization as well as conversion to open surgery.
Results: 22 consecutive patients underwent robotic hepatectomy surgery. Median: Age was 56.5y, BMI was 29.5. Median expected LOS was 6 days and actual LOS 3 days. Median ACS risk for any complications was 20% and for serious complications was 18%. Median for observed rates of any complications was 13.7%. Major hepatectomy was performed in 31.5% and post-operative bleeding occurred in 4.5% and infection in 13.7%. There was an associated major procedure (Colon resection, pancreaticoduodenectomy etc. ) in 18.7% of patients. There was no mortality and 4.5% readmission rates. There was 87.7% R0 resection rates in this cohort.R0 resection rates.
Conclusion: Robotic hepatectomy is safe to perform even in a community hospital setting provided there is technical expertise to do. The outcomes are superior to open surgery as predicted by the ACS NISQUIP risk calculator. In addition, the outcomes are seen even in the learning curve phase of a fellowship trained HPB surgeon.

PL03-093

Long-term Outcomes of Laparoscopic versus Open Liver Resection for Combined Hepatocellular - Cholangiocarcinoma
YoungRok Choi, Korea, Republic of

Y. Choi^1,2, S.H. Kang², J.Y. Cho², Y.-S. Yoon², H.-S. Han²
¹Surgery, Seoul National University College of Medicine, Korea, Republic of, ²Seoul National University Bundang Hospital, Korea, Republic of

Background: Combined hepatocellular-cholagiocarcinoma (cHCC-CCA) is a rare primary hepatic neoplasm. Liver resection is still the preferred method for curative treatment. This study aims to compare the long-term survival and postoperative complications of LLR with open liver resection (OLR) in cHCC-CCA.
Study design: Patients who underwent liver resection for cHCC-CCA from August 2004 to June 2015 were enrolled. Those who received palliative surgery, and those who had follow-up of less than 3 years were excluded. Medical records of these patients were
retrospectively reviewed. Primary endpoint was 3-year disease-free survival (DFS) and
3-year overall survival (OS). Kaplan-Meier survival analysis was performed to compare
survival.
Results: A total of 40 patients were enrolled with 23 in the laparoscopic group and 17 in the open group. The 3-year OS was 81.6% in the laparoscopic group and 72.1 % in the
open group (p=0.641). The 3-year DFS was 63.3% in the laparoscopic group and
48.2% in the open group (p=0.742). Mean operation time for the laparoscopic group
was 326.1 ± 152.0 minutes and open group was 313.9 ± 135.7 minutes (p=0.795).
Hospital stay was significantly shorter in the laparoscopic group (7.8 ± 2.7 days) than
the open group (16.1 ± 11.7 days, p=0.010). Complication (Clavien-Dindo grade II or
more) was also less in the laparoscopic group (2, 8.7%) than the open group (8,
47.1%, p=0.016).
Conclusion: Laparoscopic liver resection for cHCC-CCA is technically feasible and safe, providing short-term benefits without affecting long-term survival

PL03-094

Evaluation of Iwate Criteria Model to Predict Difficulty of Laparoscopic Liver Resection
Arpad Ivanecz, Slovenia

A. Ivanecz¹, T. Magdalenić¹, I. Plahuta¹, I. Peruš², M. Mencinger², S. Potrč¹
¹Department of Abdominal and General Surgery, University Medical Center Maribor, Slovenia, ²Faculty of Civil Engineering, Transportation Engineering and Architecture, University of Maribor, Slovenia

Background: Iwate criteria is a recently proposed classification system for assessing the surgical difficulty of laparoscopic liver resection (LLR). The aim of the present study was to externally validate this scoring system.
Methods: All consecutive patients who underwent pure LLR between April 2008 and October 2019 at a single tertiary referral center were included. Iwate criteria was calculated according to original proposition which includes four difficulty levels based on six risk factors. Both intra- and postoperative complications were compared according to the difficulty scores.
Results: The difficulty of 142 LLR were scored as low, intermediate, advanced and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%) and 16 (11.3%) patients, respectively. Intraoperative complication was detected in 26 (18.3%) patients. The rates of intraoperative complications (2.4, 7.5, 34.3, and 62.5%) increased gradually with statistically significant values among difficulty levels (P ˂ 0.001). 90-day major postoperative complications occurred in 19 (13.4%) patients where rates were also statistically significant among difficulty levels (P ˂ 0.001). We analysed our results and proposed mean risk curves/assessments for intraoperative complications and postoperative complications, based on the original proposal and the improved proposal with the new tumor size threshold (n = 3,8 cm) to validate the Iwate criteria and its practical application.
Conclusion: We observed associations between the Iwate criteria and intraoperative and postoperative outcomes on our database. Additionally we proposed different tumor size threshold, which gives better results especially for intraoperative complications.

PL03-096

Long-term Outcome of Intraoperative Radiofrequency Ablation for Hepatocellular Carcinoma
Kwang-Sik Chun, Korea, Republic of

S. Han, K.-S. Chun, I.-S. Song, S.-H. Kim
Surgery, Chungnam National University Hospital, Korea, Republic of

Introduction: We conducted this study to identify long-term outcomes following intraoperative radiofrequency ablation (IO-RFA) for hepatocellular carcinoma (HCC) and to reveal independent prognostic factors for survival.
Method: From December 1998 to February 2019, 183 patients underwent IO-RFA for HCC. These patients were divided into two groups according to whether RFA was done as a first-line (1-RFA group, n=106) or secondary-line (2-RFA group, n=77) treatment. Furthermore, we compared the survival outcomes between the 1-RFA and 2-RFA groups.
Result: There were no significant differences in type of surgical approaches between the two groups (p=0.079). The number of tumors and largest tumor size were not significantly different between the two groups. Overall recurrence rate was 53%, and the 2-RFA group showed a higher recurrence rate (46.2% in 1-RFA group versus 62.3% in 2-RFA group; p=0.031). The 5-year overall survival (OS) and disease-free survival (DFS) rates of all the patients were 75.2% and 27.9%, respectively. The OS and DFS rates were significantly higher in the 1-RFA group. The 5-year OS rates were 83.6% and 64.9% in the 1-RFA and 2-RFA groups, respectively (p=0.010), whereas the 5-year DFS rates were 32.2% and 21.6%, respectively (p=0.012). On multivariate analysis, HBV-LC, 2-RFA, recurrence, and postoperative complications were independent predictive factors for survival.
Conclusion: Therapeutic outcomes of IO-RFA were comparable to those of surgical resection. Additionally, 1-RFA might be an alternative treatment for naïve HCC in patients with uncompensated liver function and severe comorbidities.

PL03-098

Results of Hepatic Trisectionectomy for Hilar Cholangiocarcinoma
Dungfun Ieamsuwan, Thailand

B. Sirichindakul, B. Nonthasoot, D. Ieamsuwan, W. Taesombat, M. Sutherasan, A. Vorasittha
Department of Surgery, Chulalongkorn University, Thailand

Objective: Aim of this study was to describe results of Hilar cholangiocarcinoma after trisectionectomy in Department of Surgery, Chulalongkorn Hospital, from July 2015 to December 2019.
Study design: Descriptive study.
Results: From 23 patients who underwent trisectionectomy, median age was 50.7 (31-80) years. Sixteen patients (69.5%) had left trisectionectomy, 7 patients had right trisectionectomy. Portal vein reconstruction was performed 5 and 4 patients in left and right trisectionectomy, respectively. While hepatic reconstruction was performed only in right trisectionectomy group ( 4 patients). Median length of hospital stay was 22.9 (11-63) days. Pathologically margin negative was 10 and 2 patients (62.5% and 28.5%). Node positive for malignancy was 43.75% and 42.85%. Median times to recurrence was 471 days.
Conclusion: Most hilar cholangiocarcinoma patients were diagnosed in advanced stage. Even hepatic trisectionectomy is aggressive surgical approach but increase resectability and complete resection with negative margin.

PL03-099

Impact of Neutrophil Lymphocyte Ratio (NLR) Platelet Lymphocyte Ratio(PLR), Albumin Globulin Ratio (AGR) and Aspartatetranaminase Platelet Ratio Index (APRI) on Predicting Outcomes after Liver Resection
Shraddha Patkar, India

S. Patkar, A. Gupta, S. Solanki, S. Patel, M. Goel
Tata Memorial Hospital, India

Introduction: The presence of various biomarkers like NLR, PLR, AGR and APRI has been associated with increased morbidity and mortality in several malignancies.
Methods: Retrospective analysis of a prospectively maintained database of 309 patients undergoing liver resection for benign and malignant indications during January 2013 to December 2016 was performed. The association of preoperative NLR, PLR, AGR. APRI with clinicopathological characteristics and prognosis were assessed. Receiver operating characteristic (ROC) curve with Youden index was used to establish the cut-off value of NLR (3.6 for preoperative value and 8.6 for post-operative value) in predicting morbidity and mortality.
Results: Median age was 52.57±13.99 years (Range; 7-84 years). The high-NLR, PLR group had a significantly higher morbidity (40.2 % vs 28.4% P=< 0.044) High NLR was also associated with decrease disease-free survival (37.7 % vs 52.7 %, P = 0.04) and overall survival (59 % vs 80.1 %, P < 0.001) than the low-NLR group. AGR did not affect peri-operative as well as long term outcomes. High APRI group was associated with increased post-operative mortality (p=0.052) without influencing overall outcomes.
Conclusion: Preoperative NLR had a statistically significant association with preoperative morbidity and mortality and also OS and DFS at 3 years and may be considered as a low cost, reliable marker for predicting postoperative morbidity and oncological outcomes.

PL03-101

Sarcopenia Predicts the Poor Prognosis of Patients with Hepatocellular Carcinoma under Hepatectomy
Tzu Hao Huang, Taiwan, Republic of China

T.-T. Li, T.H. Huang
Chia Yi Chang Gung Memorial Hospital, Taiwan, Republic of China

Background: Sarcopenia was a poor prognostic factor for various types of malignancies. This study evaluated the prevalence and prognostic significance of sarcopenia and its association with survival in hepatocellular carcinoma (HCC) patients who underwent hepatectomy.
Materials and Methods: Between April 2010 and December 2017, 251 patients with HCC that underwent hepatectomy were retrospectively studied. Sarcopenia was defined as an L3 skeletal muscle index of < 49 cm2/m2 for men and < 41 cm2/m2 for women. Sarcopenia was identified preoperatively (within 2 months from operation).
Results: Pre-OP sarcopenia occurred in 113 (45.0%) patients and was significantly associated with older age, lower body weight, lower body-mass index, higher post-op length of hospital stay. At a median follow-up of 42 months, median overall survival (OS) was significantly lower in patients with pre-OP sarcopenia than in those without (p =0.01). In multivariate analysis [reporting hazard ratio (HR): 95% confidence interval (CI)], sarcopenia (1.84:1.01-3.35; p = 0.04), post-op complication (2.28: 1.19-4.39; p = 0.01), and recurrence (5.96: 0.31-32.42; p < 0.001) were independent OS prognostic factors.
Conclusion: Sarcopenia was an independent adverse prognostic factor for OS of patients with HCC underwent hepatectomy. This result
suggests the possibility that early intervention such as nutritional support and exercise therapies before operation could prevent muscle wasting and may be effective in improving the prognosis of HCC patients.

PL03-103

Defining the Role of Laparoscopic Liver Resection in Elderly Hepatocellular Carcinoma Patients: A Propensity Score Matched Analysis
Wai Yan Phoenix Wong, Hong Kong

W.Y.P. Wong, K.W. Ma, W.H. She, T.T. Cheung, A.C.Y. Chan, W.C. Dai, C.M. Lo
Department of Surgery, The University of Hong Kong, Hong Kong

Objective: To elucidate the role and efficacy of laparoscopic liver resection for elderly patients with hepatocellular carcinoma(HCC).
Method: A retrospective comparative analysis between laparoscopic and open liver resection was performed. Consecutive HCC patients aged 65 or above at the time of operation were recruited. Patients with recurrent HCC and pathology other than HCC were excluded. Short term and long-term outcomes of laparoscopic liver resection were compared with that of open group. Propensity score matching of patients in a ratio of 1:2 were conducted before comparison.
Results: There were 911 patients who underwent hepatectomy for primary HCC from year 2008 to 2018. Among them, 320 elderly patients aged over 65 years old were eligible for analysis. Heterogeneities between laparoscopic and open group were identified namely pre-operative albumin level, aspartate transaminase and proportion of hepatectomy (major vs minor). After propensity score matching of 1:2, there were 46 patients and 92 patients in the laparoscopic group and the open group respectively for comparison.
The laparoscopic group had less blood loss (326 vs 735 ml; P< 0.001), shorter operative time (223 vs 324 minutes; P< 0.001), and shorter hospital stay (6.3 vs 10.5 days; P< 0.001). There were no significant differences in post-operative morbidity and hospital mortality. Laparoscopic group had a superior disease-free survival (59.7% vs 44.5%, P=0.041), and a trend towards better overall survival. (78.4% vs 64.8% P=0.110).
Conclusion: Laparoscopic liver resection is a safe approach for elderly patients with HCC with benefits from faster recovery and better oncological outcomes.

PL03-104

Outcomes of Liver Resections by Trainee Surgeons versus Consultant Surgeons - A Single Centre Experience
Umasankar Mathuram Thiyagarajan, United Kingdom

U. Mathuram Thiyagarajan, A. Al-Mohammad, S. Goh, R. Praseedom, E. Huguet, S. Harper, S. Liau, A. Balakrishnan, A. Jah
Department of Surgery, Addenbrookes Hospital and University of Cambridge, United Kingdom

Introduction: Liver resection is a most effective treatment for patients with operable primary or certain secondary cancer deposits. The role of trainee as a lead surgeon versus consultant surgeon performing liver resections and its impact on surgical outcomes had never been reported.
Methods and materials: This study was aimed to assess the liver resection outcomes including operative time, acute kidney injury (AKI), bile leak, sepsis, mortality and hospital readmission within 3 months. A total of 320 liver resections from Addenbookes Hospital at Cambridge between 2015 to 2017 were included in this study.
All liver resections were performed under supervision of the consultant surgeon who is either scrubbed or unscrubbed in theatre. Trainee surgeons have performed 116 of 320 as lead surgeon and the consultant surgeons performed the remaining 204.
Results: The mean operative time was 413±129 versus 383±110 (P=0.41) minutes in trainee surgeons and consultant surgeons respectively. The incidence of postoperative AKI were similar in between the groups (5/116 versus 11/204;P=0.79). Although the bile leak was numerically high in the trainee group, did not reach statistical difference (13/116 versus 12/204;P=0.12); similar results noted in the incidence of sepsis too (3/116 versus 4/204;P=070). Mortality, hospital readmission at 3 months were (1/204 versus 1/116;P=1) and (2/116 versus 4/204;P=1) respectively. No significant difference was observed.
Conclusion: Liver resections performed by the trainee surgeons under supervision appeared to be safe without increasing the operative time, morbidity, mortality and hospital readmission at 90 days. Further multicentre prospective study with long-term follow up is recommended.

PL03-105

Laparoscopic Hepatic Lobectomy for Symptomatic Polycystic Liver Disease
Amy Li, United States

A. Li, J. Bergquist, M. Dua, G. Poultsides, B. Visser
Stanford University, United States

Introduction: Laparoscopic fenestration has largely replaced open fenestration of liver cysts. However, most hepatectomies for polycystic liver disease (PCLD) are performed open. Data on laparoscopic hepatectomy for PCLD is lacking. We present a series of patients who underwent laparoscopic hepatectomy for symptomatic PCLD.
Methods: A retrospective review of patients who underwent surgery for PCLD at a single institution between 2010 and 2019 was performed. Patients were grouped based on operative approach. Pre- and post-operative volumes were calculated for patients who underwent resection. The primary outcomes were: volume reduction, re-admission and postoperative complications.
Results: Twenty-six patients were treated for PCLD: 13 (50%) with laparoscopic fenestration, nine (34.6%) with laparoscopic formal hepatectomy, three (11.5%) with open formal hepatectomy and one (3.8%) with liver transplantation. Average length of stay for the patients who underwent laparoscopic resection was 3 days (IQR 2-3.5), with no readmissions. One patient developed postoperative atrial fibrillation. There were no other complications. Overall volume reduction was 51.4% (22.3-68.5), 32.2% (range 22.3-46.7) after open resection and 56% (range 38.8-68.5) after laparoscopic resection. Average length of follow-up for the patients who underwent laparoscopic resection was 26 months (IQR 4-102).
Conclusion: Performing hepatectomy for PCLD is challenging as anatomic planes and vasculature are distorted. The laparoscopic approach even more so due to limited working domain from hepatomegaly. Volume reduction achieved through laparoscopic approach is comparable to volume reduction in previously published open resection series, and exceeded open volume reduction at our institution. Adequate volume reduction can be accomplished by laparoscopic means with acceptable postoperative morbidity.

[PCLDFigure 1(Liver Volumes)]

PL03-106

Outcomes of Liver Resections for Primary Liver Pathology Versus Secondary Cancer Deposits- a Single Centre Experience
Umasankar Mathuram Thiyagarajan, United Kingdom

U. Mathuram Thiyagarajan¹, S. Goh², A. Al-Mohammad², R. Praseedom³, E. Huguet³, S. Harper³, S. Liau³, A. Balakrishnan², A. Jah⁴
¹Addenbrooke's Hospital and University of Cambridge, United Kingdom, ²Addenbrookes Hospital and University of Cambridge, United Kingdom, ³Department of Surgery, Department of Surgery, United Kingdom, ⁴Department of Surgery, Addenbrookes Hospital and University of Cambridge, United Kingdom

Introduction: Liver resection is a most effective treatment for patients with operable primary or secondary liver tumours. This study assesses the outcomes of liver resection performed for primary liver lesions (PLL) versus secondary/metastatic liver lesions (SLL).
Methods and Materials: The parameters were operative time, acute kidney injury (AKI), bile leak, sepsis, mortality and hospital readmission within 3 months. After excluding 12 cholangiocarcinomas resections, a total of 308 liver resections from Addenbrookes Hospital between 2015-2017 were included in this study. 66 liver resections were performed for PLL and remaining of 242 for SLL group. Relevant parameters were collected from a prospective electronic patient database.
Results: The mean operative time was 403±139 versus 417±122 (P=0.38) minutes PLL group and SLL groups respectively. The incidence of postoperative AKI were not different in between the groups (6/66 versus 9/242; P=0.10). But the incidence of bile leak was significantly high in PLL group (11/66 versus 14/242; P=0.008). Similarly high incidence of postoperative sepsis noted in the PLL group compared to SLL (4/66 versus 3/242; P=0.04). Mortality, hospital readmission at 3 months were (1/66 versus 1/242; P=1) and (1/66 versus 3/242; P=0.38) respectively.
Conclusion: Liver resections performed for primary liver lesions were associated with the risk of postoperative bile leak and sepsis compared to metastatic liver diseases. Further multicentre prospective study with long-term follow up is recommended.

PL03-107

Pure Vs. Hand-Assisted Laparoscopic Hepatectomy in HPB Center of Argentina
Pablo Barros Schelotto, Argentina

M.F. Fernandez, S. Almanzo, F. Pattin, L. Montes, P. Barros Schelotto, D. Ramisch, G. Gondolesi
Cirugia HPB y Trasplante Multiorganico, Hospital Universitario Fundacion Favaloro, Argentina

Hand-assisted laparoscopic (HAL) and pure laparoscopy (PL) are two effective methods to perform mini invasive laparoscopy liver surgery. The aim of this study was to assess the advantage of one technique over the other one.
Retrospective analysis of clinical outcomes for patients who underwent a laparoscopic hepatectomy (LH) between August 2010 and January 2020. 112 LH were performed: 47 PL (42%) and 65 HAL (58%). Variables included were: demographics, diagnostic, benign or malignant disease, operative time (OT), hospital stay (HS), postoperative 90-day mortality and complications. To overcome selection bias, a 1:1 propensity score matching (PSM) analysis was performed, each group containing 27 LH.
After PSM, there were no significant differences in age (PL 53+15 vs HAL 55+16), sex (16 females in each group), benign/malignant disease (PL 14/10 vs HAL13/17) and major hepatectomy (PL 7 vs HAL 9). There were no statistical difference in OT between PL and HAL (PL: 225 min + 90 vs HAL, 262 min + 111) (p=0.17). Global and major complication were also similar for both groups:3 complications for the PL group (all minor) and 5 for the HAL, 3 of which were major (Dindo-Clavien IIIb-IV) (p=NS). 90-day mortality was 0% in both groups. There was a significantly shorter HS in the PL group (2,8+1 vs HAL 4,81+3,7) (p=0.002).
We observed that ower result suggests that PL had shorter HS, probably due to a lower number of complications.
We could not find any significant differences in this study probably due to the small patient sample size.

PL03-109

Usefulness of Complexity Classification as a Predictor of Postoperative Outcomes in Patients with Hepatocellular Carcinoma
Ikuo Nakamura, Japan

I. Nakamura, R. Romero, A. Kurimoto, H. Iwama, K. Toriguchi, K. Iida, H. Sueoka, M. Tada, E. Hatano
The Department of Hepato-Biliary-Pancreatic Surgery, Hyogo College of Medicine, Japan

Background: Recently, complexity classification to classify the types of hepatic resection was proposed in predicting the perioperative outcomes. The aim of this study is to validate the utility of this classification comparing with the other predictive models in patients with hepatocellular carcinoma (HCC).
Methods: Four hundred forty patients were retrospectively reviewed who received hepatic resection for hepatocellular carcinoma from January 2006 to December 2015. Liver resections were separated into three categories of complexity (low, medium, or high).
Results: There was a significant difference between three groups by complexity classification in severe complication (P=0.001) and PHLF with grade BC (P< 0.001) although there was no significant difference between two groups by conventional classification. Complexity classification was only a risk factor for severe complication (P=0.008) and PHLF with grade BC (P=0.006). The ability to predict PHLF with grade BC was not significantly different between the major/minor classification and the complexity classification [area under the curve (AUC) 0.634 vs 0.553, respectively; P=0.0628). However, the complexity classification showed stronger correlations with severe complication (AUC 0.630 vs 0.542, respectively; P=0.0122), blood loss (>=655ml)(AUC 0.667 vs 0.561, respectively; P < 0.0001) , operation time (>=445 min)(AUC 0.744 vs 0.601, respectively; P < 0.0001), and hospital stay (>=18 days)( AUC 0.651 vs 0.578, respectively; P < 0.0021) compared with the major/minor classification.
Conclusion: Complexity classification is more useful than conventional classification and holds all the characteristics of an ideal classification for hepatic resection to predict severe complication and PHLF.

PL03-110

Short-Term Outcomes of Laparoscopic Repeat Hepatectomy
Keigo Tani, Japan

K. Tani, Y. Seyama, M. Matsumura, S. Nemoto
Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan

Background: Although repeat hepatectomy is an effective treatment for recurrence hepatocellular carcinoma and metastatic liver tumor, laparoscopic repeat hepatectomy (LRH) is not widely accepted and its indication has not been established. The aim of this study was to clarify feasibility and safety of LRH.
Methods: Seventy-eight patients who underwent repeat hepatectomy from January 2013 to December 2019 were retrospectively reviewed. Short-term outcomes of LHR and open repeat hepatectomy (ORH) were investigated.
Result: LRH and ORH were applied for 42 (53.8%) and 36 (46.2%) patients, respectively. Among LRH group, conversions to open surgery including mini laparotomy were needed for 4 patients (9.5%) due to severe adhesion (n=2) and tumor status (n=2). As compared to ORH group, number of tumors was small (median 1 vs. 2; P=0.0003), tumor size was small (median 1.95 vs. 2.45; P=0.0388) in LRH group. Previous open hepatectomy had undergone for 9 patients (21.4%) in LRH group and 27 patients (75.0%) in ORH group (P< 0.0001). Liver resection more than 2 Couinaud`s segment was performed for 21.4% in LRH group and 78.5% in ORH group (P=0.25). There was no significant difference in operation time and postoperative complication rate between two groups. Intraoperative blood loss was smaller (median 60 ml vs. 310 ml; P< 0.0001) and postoperative hospital stay was shorter (median 7 days vs. 9 days; P< 0.0001) in LRH group.
Conclusion: LHR is feasible and safety option for patient with recurrent liver tumors.

PL03-111

Predictive Nomograms for 90-Day Post-Operative Morbidity and Mortality in Patients Undergoing Hepatectomy for Various Hepatobiliary Diseases
Muthukumarassamy Rajakannu, India

M. Rajakannu, D. Cherqui, O. Ciacio, G. Pittau, A. Sa Cunha, D. Castaing, R. Adam, E. Vibert
Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, France

Background: Post-operative complications affect the long-term survival and quality of life in patients undergoing liver resection (LR). No model has yet been validated to predict 90-day severe morbidity and mortality after LR.
Methods: Patients planned LR was prospectively recruited. Pre-operative clinical and laboratory data including liver stiffness (LS), and intra-operative parameters were analyzed to determine predictors of morbidity and mortality. Nomograms were developed using independent predictors in the study (training) cohort and validated using an external cohort by testing the Goodness of fit in calibration plots.
Results: The most common indications in 418 LRs performed were colorectal metastases [35.6%], hepatocellular carcinoma [25.4%] and benign liver tumors [14.3%] with 39.2% of patients undergoing major LR. Post-operative severe morbidity and mortality rates were 20.8% and 2.2%, respectively. Independent predictors of severe morbidity were age [Odds ratio (OR):1.02, p=0.06], LS [OR:1.23, p=0.04], number of resected segments [OR:1.28, p=0.004], and operative time [OR:1.01, p=0.01]. Independent predictors of mortality were diabetes mellitus [OR:6.6, p=0.04], tumor size ≥51 mm [OR:4.8, p=0.08], LS ≥22 kPa [OR:7.0, p=0.04], and operative time ≥6 hours [OR:6.1, p=0.05]. Nomogram for severe morbidity had an excellent Goodness of fit in the study cohort (p=0.64) and an external validation cohort (p=0.70). Goodness of fit for mortality nomogram in both the study cohort (p=0.80) and the external cohort (p=0.60).
Conclusion: In the era of personalized medicine, proposed nomograms would enable surgeons to adapt surgical strategy in patients undergoing LR according to their clinical profile and the center's expertise.

PL03-112

Minimally Invasive Approach for Liver Resections in Patients with Hepatocellular Carcinoma and Child-Pugh B Cirrhosis: Shifting the Paradigm? Long-Term Outcomes from an International Multicentre Study
Giammauro Berardi, Italy

G. Berardi, R. Troisi
Hbp Surgery, Federico Secondo University, Italy

Aim: To compare the short- and long-term outcomes between open (OLR) and laparoscopic resection for HCC in the setting CP-B cirrhosis.
Methods: Between January 2002 and December 2018, 382 liver resections in CP-B cirrhosis were gathered from 17 international centres. A 1:1 propensity score matching (PSM) was performed according to age, sex, BMI, ASA, comorbidities, Child-Pugh score, previous treatment, previous surgery, preoperative portal hypertension, ascites and varices, position of lesions, distance from major vessels, number and size of lesions, year of operation, type of resection and additional procedure.
Results: 100 LLR and 100 OLR were analysed. Conversion rate was 6%. LLR group displayed lower blood loss (110 ml vs. 400 ml; p=0.004) and number of blood transfusions (1 vs. 3; p=0.006), lower morbidity rate (38% vs. 51%; p=0.04) and less major complications (7% vs. 21%; p=0.01). Postoperative ascites was lower at postoperative day 1, 3 and 5. Median hospital stay was 7.5 days (2-243) in LLR and 18 days (3-104) in OLR (p=0.05). R0 resection rate was comparable (96% OLR vs. 95% LLR p= 0.50). Recurrence rate was 50% in OLR and 57% in LLR (p=0.39). The 5 years OS was 47% in OLR and 65% in LLR (p=0.14). The 5 years DFS was 32% in OLR and 37% in LLR (p=0.74).
Conclusions: LLR is associated with reduced blood loss, overall morbidity and a lower chance of postoperative liver decompensation in CP-B patients eventually leading to shorter hospital stay maintaining comparable oncological outcomes to OLR.

PL03-113

Pathophysiology of Bile Acids Affects Liver Regeneration in Patients Undergoing Liver Resection
Thomas Sorz, Austria

T. Sorz¹, D. Pereyra¹, J. Santol¹, F. Fritsch¹, D. Ammonn¹, C. Fuchs², M. Trauner², P. Starlinger^1,3
¹Department of Surgery, Medical University of Vienna, General Hospital Vienna, Austria, ²Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, General Hospital Vienna, Austria, ³HPB Surgery, Mayo Clinic, United States

Introduction: Bile acids (BAs) are known initiators of liver regeneration (LR) after partial hepatectomy. Previous data shows that BAs positively influence LR through induction of pro-regenerative proteins and via a direct effect on proliferation. However, BAs are known to be toxic in high concentrations. As the majority of the data regarding BAs during LR derives from experimental studies, the present investigation aimed to elucidate the influence of these effectors during human LR.
Method: In our cohort of 46 patients undergoing liver resection, circulating BAs were measured and profiled preoperatively and on the first postoperative day (POD1). Additionally, liver biopsies were taken at baseline and during LR in a subset of 8 patients. Postoperative liver dysfunction (LD) was prospectively recorded.
Results: While BAs were found to increase significantly during early LR in liver tissue, they seem to decrease from prior to the operation to POD1 in circulation (p=0.001). Interestingly, higher levels were found in patients with LD on POD1. This difference was found to obtain a striking predictive potential with an area under the ROC-curve of 0,860. A cut-off for postoperative BAs was set at 7.7ng/mL, which could identify all patients with LD in the postoperative period (0% in BAs< 7.7ng/mL vs 38% in BAs≥7.7ng/mL, p< 0.001). Ultimately, not only concentration but also the profile of BAs in circulation differed markedly between the two groups.
Conclusions: This data suggests that BAs are important initiators of LR, while a BA-overload might ultimately lead to liver toxicity and impaired LR after liver resection.

PL03-114

Histological Severity of Cirrhosis, an Ignored Prognostic Factor Deteriorating Surgical Outcomes of Hepatocellular Carcinoma
Jin Gu, China

Z.-Y. Huang¹, B.-Y. Liang¹, J. Gu²
¹Tongji Hospital, Huazhong University of Science and Technology, China, ²huazhong University of Science and Technology, China

Background: The impact of cirrhotic severity of the liver on long-term survival of patients with hepatocellular carcinoma undergoing hepatotectomy has been previously reported in the quite small cohorts by our center. This study aimed to investigate the impact of histological severity of cirrhosis on long-term surgical outcomes for HCC in a large cohort.
Methods: The consecutive patients who underwent curative liver resection(LR) for HCC between 2001 and 2015 were retrospectively studied. The severity of liver cirrhosis was histologically staged by the Laennec staging system. The short- and long-term outcomes were analyzed.
Results: Of 1524 patients, mild, moderate, and severe cirrhosis were identified in 575(37.7%), 597(39.2%), and 132(8.7%) patients, respectively. The remaining 220(14.4%) patients were non-cirrhotic. Patients in the severe cirrhosis group had significantly higher morbidity and mortality rates than those in the mild, moderate and non-cirrhosis groups. The 5-year recurrence-free survival(RFS) and overall survival(OS) rates were 36.8% and 64.5% in the non-cirrhosis group, compared with 34.8% and 60.4% in the mild, 17.3% and 43.4% in the moderate, and 6.1% and 24.1% in the severe cirrhosis groups, respectively. The RFS and OS rates did not differ significantly between the non-cirrhosis and the mild cirrhosis groups. However, long-term survival were significantly worsen as the degree of cirrhosis was upgraded. On multivariate analysis, moderate and severe cirrhosis were independent risk factors of decreased RFS and OS.
Conclusions: Histological severity of cirrhosis significantly affected the short- and long-term outcomes of HCC patients after LR.