PL05 Liver: Miscellaneous (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PL05-01 Outcomes of Gas-Forming Pyogenic Liver Abscess (PLA) Are Comparable to Non-Gas-Forming PLA in the Era of Multimodal Care: A Propensity Score Matched Study
Kai Siang Chan, Singapore

K.S. Chan1, C.B. Thng2, Y.-H. Chan3, V.G. Shelat4
1Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 2Ministry of Health Holdings, Singapore, 3Yong Loo Lin School of Medicine, Biostatistics Unit, National University of Singapore, Singapore, 4Department of General Surgery, Tan Tock Seng Hospital, Singapore

Gas-forming pyogenic liver abscess (GFPLA) occurs in 7-24% of all pyogenic liver abscess (PLA) and has been traditionally associated with high mortality. Studies suggest that use of a proactive approach of prompt resuscitation, parenteral antibiotics, percutaneous drainage and a dedicated multidisciplinary team may improve clinical outcomes. Hence, we aim to investigate if the clinical outcomes of PLA are determined by gas formation.
This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes, presence of septic shock, haemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Demographics, clinical profile and perioperative data were compared.
213 patients had PLA: 41(19.2%) patients had GFPLA and 172(80.8%) patients had non-GFPLA. 1:2 PSM resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Clinical profile and microbiology are shown in Table 1. Median duration of parenteral antibiotics was significantly lower in the GFPLA group (9.5 days vs 14 days, p=0.044), but median total duration of antibiotics use was comparable (GFPLA 39 days vs non-GFPLA 37 days, p=0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs 15, p=0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36(72.2%) vs 47/72(65.3%) respectively, p=0.467) and in-hospital all-cause mortality (4/36(11.1%) vs 7/72(9.7%), p=0.822).
Outcomes of GFPLA are comparable to non-GFPLA in the era of multimodal care.
 Overall cohort (n=213)Matched cohort (n=108)
 GFPLA (n=41)Non-GFPLA (n=172)p-valueSMD (standardised mean difference)GFPLA (n=36)Non-GFPLA (n=72)p-valueSMD
Age (interquartile range)61 (53 - 69)62 (51 - 74)0.7870.01061.5 (52.3 - 68.8)62.5 (53.3 - 73.8)0.6460.047
Gender, male (%)27 (65.9)104 (60.5)0.524-24 (66.7)45 (62.5)0.671-
Diabetes mellitus, yes (%)18 (43.9)56 (32.6)0.1700.23313 (36.1)24 (33.3)0.7740.058
Pus culture, yes (%)21 (70)61 (66.3)0.7080.30717 (65.4)37 (78.7)0.2140.083
Klebsiella pneumoniae (%)17 (81)51 (82.3)  13 (76.5)33 (89.2)  
Clostridium perfringes (%)1 (4.8)1 (1.6)  1 (5.9)1 (2.7)  
Others (%)3 (14.3)9 (14.8)  3 (17.6)3 (8.1)  
Size of largest abscess (cm)6.6 (4.9 - 8.3)5.4 (3.6 - 7.0)0.0050.4886.3 (4.5 - 7.5)6.1 (5.0 - 7.6)0.6690.131
[Table 1: Clinical profile and microbiology of patients with gas-forming pyogenic liver abscess (GFPLA) and non-GFPLA before and after matching]
PL05-02 Astaxanthin Attenuates Hepatic Damages and Mitochondrial Dysfunction in Nonalcoholic Fatty Liver Disease by Regulating the FGF21/PGC-1α Pathway
Liwei Wu, China

L. Wu, C. Guo, J. Feng
Tongji University School of Medicine, China

Introduction: Non-alcoholic fatty liver disease(NAFLD) is considered to be one of the most common chronic liver diseases across worldwide. Inflammation, cell apoptosis and fibrogenesis are all typical lipotoxicity-associated changes during NAFLD. Beneficial effects of astaxanthin(Ax) have been identified,including anti-oxidative, anti-inflammatory, and anti-tumor activity. The present study aimed to elucidate the protective effect of Ax against NAFLD and its underlying mechanism.
Method: Mice were fed either a high fat or control diet, with or without AX, for up to 12 weeks. L02 cells were treated with free fatty acids combined with different doses of Ax for 48 h. Histopathology, expression of lipid metabolism, inflammation, apoptosis, and fibrosis-related genes were assessed.
Results: The results indicated that Ax attenuated HFD- and FFA-induced lipid accumulation and its associated oxidative stress, cell apoptosis, inflammation, and fibrosis both in vivo and in vitro. Ax upregulated FGF21 and PGC-1α expression in damaged hepatocytes, which suggested an unrecognized mechanism of Ax on ameliorating NAFLD.
Conclusions: Ax prevented hepatic triglyceride accumulation,and attenuated hepatocyte damage and mitochondrial dysfunction.And Ax decreased the severity of experimental steatohepatitis via mechanisms likely to involve the up-regulation of FGF21/PGC-1α.
PL05-03 Who Can Benefit from Adjuvant Transcatheter Arterial Chemoembolization after Surgical Resection of Hepatocellular Carcinoma? A Systematic Review and Meta-Analysis
Tian Yang, China

L. Liang1, C. Li1, H. Xing1, Y. Lau Wan2, T.M. Pawlik3, T. Yang4
1Eastern Hepatobiliary Surgery Hospital, China, 2Chinese University of Hong Kong, China, 3Ohio State University, Wexner Medical Center, United States, 4Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, China

Background: Although adjuvant transcatheter arterial chemoembolization (TACE) has been used to prevent postoperative recurrence after hepatocellular carcinoma (HCC) resection, the survival benefits of adjuvant TACE remain controversial. To evaluate the effectiveness of adjuvant TACE for HCC, as well as identify patient populations that might benefit from adjuvant TACE.
Methods: The PubMed, Embase and Cochrane library were systematically searched. The primary endpoints were overall survival (OS) and disease-free survival (DFS). Patients with large HCC (≥ 5 cm), multinodular HCC, microvascular invasion (MVI), or portal vein tumor thrombosis (PVTT) were analyzed in subset analyses.
Results: Twenty-four studies with 6,912 patients were included. The pooled analysis demonstrated that adjuvant TACE was associated with a better OS and DFS (HR: 0.67, 95% CI 0.61-0.74 and 0.71, 0.61-0.84). In subgroup analyses, pooled results revealed that adjuvant TACE was associated with an improved OS and DFS in patients with multinodular HCC, MVI, or PVTT, but not among patients with single large HCC (≥ 5 cm).
Conclusion: Postoperative adjuvant TACE may be effective to improve OS and RFS in selected patients with multinodular HCC, or HCC with MVI or PVTT. Future randomized controlled trials are needed to better define the benefit of adjuvant TACE.
[Figure. Forest plots comparing the overall survival stratified by different risk factors.]
PL05-04 A Novel Scoring System for the Difficulty Level in the Lysis of Adhesions Around the Liver for Safe Repeat Hepatectomy in Patients with Hepatic Malignancies
Yuta Kobayashi, Japan

Y. Kobayashi, J. Shindoh, S. Okubo, H. Masaji
Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Japan

Introduction: Repeat hepatectomy (ReHx) for recurrent hepatic malignancies reportedly provides oncological benefit for patients. However, severe adhesions at ReHx may preclude safe and curative resection and there has been no reliable measure to estimate the surgical risk at ReHx. This study sought to create a new scoring system for evaluating the severity of adhesion after hepatectomy and tested its performance looking at the correlation with morbidity rate.
Methods: 66 operative videos of second hepatectomy were reviewed and the difficulty levels in lysis of adhesion around the hepatic hilum (A score) and surrounding the liver (B score) were scored by two examiners and validated by additional two reviewers.
Results: Very high interobserver agreement was confirmed between the two examiners (k value, 0.960-0.963) and reproducibility of results were validated with weighted kappa values of >0.8 in both surgical resident and hepatobiliary surgery. Linear correlation was confirmed between the difficulty score and postoperative morbidity rate. Multivariate analyses confirmed that previous cholecystectomy or transection of visceral surface of segment 4 or 5 was independent factor predicting hard to extreme adhesions at the hepatic hilum regardless of the use of anti-adhesion materials.
Conclusions: The new difficulty scoring system for the lysis of adhesion at ReHx showed good interobserver agreement and reproducibility of the results. Given the strong correlation with postoperative morbidity rate, the present score could be used for evaluating the technical difficulties in ReHx and may offer a reliable measure for estimating the efficacy of anti-adhesion materials in future analysis.
[TORAD score and morbidity rates]
PL05-05 Development and External Validation of Prognostic Nomograms in Hepatocellular Carcinoma Patients: A Population Based Study
Yongcong Yan, China

Y. Yan, K. Mao, C. He, R. Chen, J. Wang, Z. Xiao
Sun Yat-sen University, China

Background: We attempted to construct and validate novel nomograms to predict overall survival (OS) and cancer-specific survival (CSS) in patients with hepatocellular carcinoma (HCC).
Methods: Models were established using a discovery set (n=10262) obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Based on univariate and multivariate Cox regression analyses, we identified independent risk factors for OS and CSS. Concordance indexes (c-indexes) and calibration plots were used to evaluate model discrimination. The predictive accuracy and clinical values of the nomograms were measured by decision curve analysis (DCA).
Results: Our OS nomogram with a c-index of 0.753 (95% confidence interval (CI), 0.745-0.761) was based on age, sex, race, marital status, histological grade, TNM stage, tumor size, and surgery performed, and it performed better than TNM stage. Our CSS nomogram had a c-index of 0.748 (95% CI, 0.740-0.756). The calibration curves fit well. DCA showed that the two nomograms provided substantial clinical value. Internal validation produced c-indexes of 0.758 and 0.752 for OS and CSS, respectively, while external validation in the Sun Yat-sen Memorial Hospital (SYMH) cohort produced a c-indexes of 0.702 and 0.686 for OS and CSS, respectively..
Conclusions: We have developed nomograms that enable more accurate individualized predictions of OS and CSS to help doctors better formulate individual treatment and follow-up management strategies.
PL05-06 Large Benign Non Parasitic Hepatic Cyst: A Case Report
Rodrigo Miguel Jocson, Philippines

R.M. Jocson1, M.-A. Casupang2, C. Teh1
1Department of Surgery, Makati Medical Center, Philippines, 2Surgery, National Kidney and Transplant Institute, Philippines

Large none parasitic hepatic cysts are an uncommon disease entity and often evade the clinical eye because majority will present with non-specific symptoms until the cyst is large enough to cause compressive symptoms. Patients will most often present with vague abdominal pain, palpable abdominal mass, jaundice with compression of the biliary ducts, or portal hypertension secondary to compression of the portal vein. This is a case of 63 year old male, known case of hepatic cyst presenting with vague abdominal pain. Patient was then advised to undergo surgery due to progressive enlargement of the hepatic cyst with the latest dimensions measuring 114 x 180 x 210 mm hence patient was admitted. Patient was scheduled for laparoscopic cystectomy and intraoperative findings were noted to include a large hepatic cyst containing approximately 3 liters serous fluid, completely replacing segment IVA, IVB and V with the cyst capsule noted to be adherent to the gallbladder wall. Patient underwent Laparoscopic resection of segment IVA,IVB and V, cholecystectomy and intraoperative cholangiogram. Histopath results revealed a simple biliary cyst with a fibrous cyst wall measuring 24.2 x 8.0 x 0.2 cm with 6 cystic tissues measuring from 0.3 x 0.3 x 0.3cm to 1.2x 1.6 x 0.6cm. Gallbladder was noted to have no pathologic changes. Patient tolerated the procedure well and was discharged 2 days after with unremarkable post-operative course.
PL05-09 Aggressive Clinical Behavior of Pure Squamous Cell Carcinoma (SCC) of the Liver
Yoshihiko Kadowaki, Japan

Y. Kadowaki, H. Fujii, Y. Okubo, S. Komoto, N. Kubota, N. Ishido
Surgery, Japanese Red Cross Kobe Hospital, Japan

Introduction: Primary SCC of the liver is extremely rare. According to a few sporadic reports, surgical resections seem to be selected as an initial treatment, if it resectable; however, the prognosis is universally unfavorable.
Methods: We presented one case of pure SCC of the liver. A total of 41 cases of primary SCC of the liver previously reported in the English literatures were reviewed.
Results: A 57-year-old man with history of right flank pain presented with 1 week of high grade fever. On physical examination, his abdomen was tender, with the most severe pain in the right upper quadrant. Contrast-enhanced computed tomography revealed that there was 14x10cm irregular mass with central necrosis at S4+5 of the liver and swollen nodes, which were compatible with his symptoms. The patient underwent S4+5 segmentectomy with extended resection of gall bladder, transverse colon, and diaphragm. Histological examination revealed pure squamous cell carcinoma of the intrahepatic biliary tract. On the POD 44 prior to discharge, relapse was found around the common bile duct and liver resection edge. Although chemotherapy was proposed, his severe fatigue refused it. He was died of multiple metastasis including bones on the 52nd day after discharge. We made Kaplan-Meier survival curves of the patients divided by with and without surgery from the review of previous reports. One year survival rate with surgery is better than without surgery (63.4% vs 15.4%, p=0.0024).
Conclusion: Radical resection should be firstly recommended; however, case collections and data analysis may be needed to establish better treatments.
PL05-11 Disease Control Biomarker to Predict Sorafenib Susceptibility in Advanced Stage Hepatocellular Carcinoma
Hee-Jung Wang, Korea, Republic of

H.J. Wang1, C.-M. Kim2, Y.-S. Yu2, J.-Y. Park2, Y.-B. Seo2, G.-D. Kim3
1Surgery, Ajou University School of Medicine, Korea, Republic of, 2CbsBioscience Inc., Korea, Republic of, 3Microbiology, College of Natural Science, Pukyung National University, Korea, Republic of

Background: Hepatocellular carcinoma (HCC) has two first-line treatments, those are sorafenib and lenvatinb. But because of predictive biomarker's absence, these two agents have poor response rates and overall survival period. Disease control biomarker could be a method that potentially improves the effectiveness of sorafenib, one of two agents. Here, we aimed to develop a clinical useful biomarker that predicts disease control of sorafenib.
Methods: Using nanostring nCounter, we analyzed expression levels of 770 genes in 73 advanced-stage HCC patients with sorafenib trearment. With the 770 genes expression levels of 73 patients, we identified differentially expressed genes (DEGs) and computed combination of weighted gene expression for disease control biomarker. To validate gene signature, we analyzed cross validation and meta-analysis. For predicted poor responders, we listed up recommended medicine, analyzing individual DEGs by meta-analysis.
Results: 8-gene signature showed 0.90 of area under the curves (AUC), 91.78% of accuracy. In cross validation, 8-gene signature showed well-performance with 83.67% of cross validation accuracy. Also, when classification with 8-gene signature, median overall survival (median OS) was improved 27.3 months from 11.3months. In promising alternative agents for predicted poor responders, recommended agents were listed up individually based on individual gene expression.
Conclusions: 8-gene signature provides a best compromise between sorafenib effectiveness and coverage of sorafenib treatment patients. In perspective of precision medicine, our process of precision medicine recommendation can be drive the precision medicine one step forward.
PL05-12 Re-Evaluation of Couinaud's Classification for Right Liver Segmental Anatomy with Particular Attention to the Relevance of Cranio-Caudal Boundaries
Hirofumi Ichida, Japan

H. Ichida, H. Imamura, Y. Mise, A. Saiura
Juntendo University School of Medicine, Japan

Introduction: Although the Couinaud's classification of liver segment has been challenged by several studies, whether the cranio-caudal boundaries can be delineated in the right liver has not yet been assessed. This study sought to scrutinize the third-order branching pattern of the portal vein in the right liver with particular attention to the validity of cranio-caudal segmentation.
Methods: Three-dimensional reconstruction of the portal vein and hepatic vein using non-contrast-enhanced MRI was performed in fifty healthy volunteers.
Results: In the right paramedian sector, the portal vein ramified into two thick P8s (P8vent and P8dor) in all the subjects. Additional thick P8s that ran laterally and/or medially (P8lat and/or P8med) were found in 18 (32%) subjects. In contrast, multiple thin P5s, ranging in number from 2-6 (median, 4), branched from the right paramedian trunk, the right portal trunk, and/or even from P8s. In the right lateral sector, an arch-like type in which multiple P6s ramified from a single thick P7 was observed in 26 (52%) subjects. A bifurcation type composed of a single P7 and a single P6 was found in 23 (46%) subjects, while a trifurcation type composed of P7vent, P7dor, and P6 was observed in one subject.
Conclusion: No clear cranio-caudal intersegmental plane could be delineated in the right paramedian sector of any of the subjects, nor was it observed in the right lateral sector in 52% of the subjects. The systematic resection of Couinaud's segment in the right liver might not be relevant in the majority of subjects.
PL05-13 Sphingosine-1- Phosphate(S1P) Export Is Associated with Progression of Hepatocellular Carcinoma(HCC)
Vikas Satyananda, United States

V. Satyananda1, M. Oshi1, K. Takabe1,2,3
1Department of Surgical Oncology, Roswell Park Cancer Institute, United States, 2Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, United States, 3Liaison Professor, Department of Surgery, Niigata University Graduate School of Medical and Dental Sciences, Japan

Introduction: Sphingosine-1-Phosphate (S1P), a lipid mediator, is generated by enzyme Sphingosine Kinase1 (SphK1) in cytosol, and is transported out of the cell by multidrug resistance transporter, ABCC1, working in autocrine/paracrine fashion. Thus tumor with high expression of both SphK1 and ABCC1 (high K1C1) are assumed to have higher levels of S1P. We hypothesize that high K1C1 will lead to progression of HCC and worse outcomes.
Methods: HCC cohorts of TCGA(The Cancer Genome Atlas) n= 371 were divided into high K1C1 expression(n=120) and low K1C1 expression(n=119). Kaplan Meir curves were used for disease specific and overall survival.
Results: We found significantly higher expression of SphK1 and ABCC1 in HCC versus normal liver and higher levels in clinically aggressive tumors. The Disease specific survival (p< 0.03) and overall survival (p< 0.003) were significantly worse in high K1C1 group. With regards to tumor immune microenvironment, high group had higher tumor associated lymphocytes, TCR Shannon and richness scores, with higher dendritic cells (anticancer activity), but also high Th2 cells and CD4 T memory activated cells (procancer activity). GSEA looking at mechanism of action, showed significantly enhanced cell proliferation(E2F targets, mTOR, G2Mcheckpoint, Myc) angiogenesis and increased aggressiveness(TGFβ, epithelial mesenchymal transition, Wnt-βCatenin, IL6/JAK-STAT3). It also showed increased immune cell attraction, and anti-proliferation activity(increased apoptosis, p53).
Conclusion: S1P export is associated with both pathways of cancer progression and anti-proliferation. However, the pro-cancer pathways overwhelm the anticancer pathways, leading to HCC progression. We conclude that high S1P levels promote growth and proliferation of HCC.
[SphK1/ABCC1 high group is significantly associated with better survival]

[SphK1/ABCC1 high group is significantly associated with better survival]
PL05-14 Improved Surgical Outcomes in Liver Resection under Enhanced Recovery after Surgery (ERAS) Program: Is Better Pain Control the Only Contributing Factor?
Julie Hoi Yan Ng, Hong Kong

J.H.Y. Ng, E.Y.J. Lo, A.K.Y. Fung, H.T. Lok, Y.S. Cheung, K.K.C. Ng, K.F. Lee, P.B.S. Lai, C.C.N. Chong
Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Prince of Wales Hospital, Chinese University Hong Kong, Hong Kong

Introduction: The association of Enhanced Recovery after Surgery (ERAS) Program and better surgical outcome has been shown in liver resection. Some may argue that better postoperative outcomes are a result of better pain control only. The aim of this study is to compare the surgical outcomes of open hepatectomy with and without ERAS protocol in patients who received continuous local anaesthesia wound infiltration (On-Q Pain Buster system) as postoperative pain control.
Method: Clinical data of patients receiving open hepatectomy following ERAS protocol (ERAS with On-Q) were compared to a historical cohort of patients that received open hepatectomy following conventional perioperative programs supplemented with postoperative On-Q system for wound pain control (On-Q alone). The primary outcome was length of hospital stay. Secondary outcomes were complications and readmission.
Results: A total of 25 patients in ERAS with On-Q group and 35 patients in On-Q alone group were identified and studied. The ERAS with On-Q group was associated with a significantly shorter hospital stay ( P< 0.05). However, there was no significant difference in complication rate (P=0.301) and post-operative readmission (P =0.708) in ERAS with On-Q group when compared with On-Q alone group.
Conclusions: ERAS program is a multimodality program and ERAS with On-Q system as postoperative pain control provides better surgical outcomes than use of On-Q system alone in patients undergoing hepatectomy. The use of ERAS in hepatectomy should be encouraged and further studies should be done to optimize a standard ERAS programme specific for hepatectomy.
PL05-15 Management of a Giant Hepatic Cyst by Total Cyst Enucleation in Uganda. A Case Report and Review of Literature
Michael Okello, Uganda

M. Okello1,2, M. Kiconco2, A.T. Ainembabazi2, E. Nabwire2, M. Nalweyiso2, E. Anyanzo2, N. Ssentaza2
1Anatomy, Makerere University College of Health Sciences, Uganda, 2Surgery, Lubaga Hospital, Uganda

Introduction: Giant hepatic cysts are uncommon and cause symptoms due to compression effects. Symptoms include early satiety, abdominal discomfort, abdominal mass and rarely pain in case of haemorrhage, rupture or cyst infection. Aetiology is unknown but liver cysts are thought to be congenital. Management if liver cysts is debatable but options include sclerotherapy, fenestration or deroofing, open or laparoscopic partial or total cyst excision, cyst enucleation and rarely liver resection. There is paucity of data on management of Giant liver cysts in Uganda and the East African region and to the best of our knowledge, this is the first reported case in our country and region.
Method: We present a sixty one year old female Ugandan who was admitted due to an increasing abdominal mass with associated discomfort and early satiety. Contrasted abdominal computed tomography (CT) scan revealed a 28 x 26 cm simple liver cyst.
Results: She underwent open total cyst enucleation after initial cyst decompresion. Postoperative recovery was uneventful and she was discharged on the 8th postoperative day.
Conclusion: It is easier to perform a total cyst excision or enucleation for Giant liver cyst with a thick wall or cyst capsule.
Figure 1: Abdominal CT scan of the giant liver cyst (top left), intraoperative intact cyst (top middle), cyst dissection (top right), detaching cyst from inferior vena cava (bottom left), atrophied right lobe and hypertrophied left lobe (bottom middle), after total cyst excision/enucleation (bottom right)
PL05-16 Serum Metabolic Biomarkers of Liver Failure after Liver Resection
Hye-Sung Jo, Korea, Republic of

H.-S. Jo1, D.-S. Kim1, K.C. Yoon1, D.Y. Lee2
1Division of Hepatobiliary, Pancreas Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Korea, Republic of, 2Department of Agricultural Biotechnology, Seoul National University, Korea, Republic of

Introduction: Even the combination of PT and total bilirubin, known for being the most reliable predictive conventional markers shows low sensitivity. Therefore we need to find more relevant biomarkers of liver failure after liver resection focused on the liver metabolites.
Method: A total of 20 pigs were divided into 3 groups sham operation (n=6), 70% hepatectomy group (n=7), and 90% hepatectomy group (n=7). Blood sampling was performed preoperatively and at 1, 6, 14, 30, 38, and 48 hours after the operation we systematically profiled 129 primary metabolites based on gas-chromatography time-of-flight mass spectrometry.
Results: Orthogonal projection to latent structures-discriminant analysis revealed that central carbon metabolism was the most significant factor in the 90% liver-resection group in contrast to the 70% and sham groups. Subsequent binary logistic regression analysis was used to develop a predictive model for the risk of mortality following hepatectomy. The recommended variables were malic acid, methionine, tryptophan, glucose, and γ-aminobutyric acid. The AUC of the linear combination of 5 metabolites was 1.000 (95% confidence interval: 0.940-1.000, sensitivity: 100.0, specificity: 94.87)
Conclusions: Systematic prioritization based on OPLS-DA and binary logistic regression analysis proposed robust biomarker panels that can accurately predict the risk of mortality associated with hepatectomy.
PL05-17 Inclusion of the Brisbane 2000 Terminology of Liver Anatomy and Resections Within SNOMED Clinical Terminology
Richard Bryant, Australia

R. Bryant
Royal Brisbane and Women's Hospital, Brisbane, Australia

Introduction: At the IHPBA meeting in Brisbane in 2000 the Brisbane 2000 Terminology of Liver Anatomy and Resections was accepted as the official terminology of the IHPBA. SNOMED-CT (Systematized Nomenclature of Medicine - Clinical Terminology) is the most comprehensive, multilingual clinical healthcare terminology in the world, and is an important standard in the recording and interchange of coded clinical information. It was initially released in 2002, and is in use in over 80 countries. Up until now SNOMED-CT hasn't included all of the clinical terms and concepts contained within the Brisbane nomenclature.
Methods: The clinical terms and concepts contained within the Brisbane terminology are mapped to the current SNOMED-CT clinical terms. New SNOMED-CT terms and relationships are proposed to enable a full representation of the Brisbane terminology within SNOMED-CT.
Results: The new terms and relationships are presented and the process for endorsement by SNOMED International is discussed.
Conclusions: Clinical information is increasingly stored electronically. Standards for clinical information exchange such as FHIR (Fast Healthcare Interoperability Resources) depend heavily on SNOMED-CT for coded clinical information. It is important therefore that the consensus of wisdom encapsulated within the Brisbane terminology is represented in SNOMED-CT.
PL05-18 Clinical Impact of Herpesvirus Entry Mediator (HVEM) in Malignant Liver Tumors
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

Background: Herpes virus entry mediator (HVEM), also known as tumor necrosis factor receptor (TNFR) superfamily 14, regulates a variety of physiological and pathological responses in both innate and acquired immunity. Recently, HVEM is also suggested to be a critical regulator in tumor immunity. This study aimed to clarify clinical importance of HVEM in human hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM).
Methods: This study examined 150 patients with HCC and 104 patients with CRLM who underwent curative liver resection at Nara Medical University between 2000 and 2014. Immunohistochemical staining was performed using antibodies against HVEM, CD4, CD8, and CD45RO.
Results: High HVEM expression was observed in 66 of 150 patients (44.0%) with HCC, and 49 of 104 patients (47.1%) with CRLM. Expression of HVEM was not associated tumor size, number of tumors, or histologic differentiation. The high-HVEM group exhibited significantly worse overall survival (OS) than the low-HVEM group (HCC: P=0.002, CRLM: P = 0.002). Multivariate analysis showed that independent poor prognostic factors of OS for HCC were high HVEM expression in HCC and tumor size >5 cm, while in CRLM, high HVEM expression in CRLM, age of 70 years or older, and having five or more tumors were prognostic factors of OS. HVEM status was inversely correlated with tumor-infiltrating CD8+ and CD45RO+ lymphocytes in both HCC and CRLM.
Conclusions: Tumour-expressing HVEM might play a critical role in human HCC and CRLM, possibly through regulating immune evasion. Therefore, targeting HVEM may be a novel promising therapeutic strategy for HCC and CRLM.
PL05-19 Hydatidosis and Duodenum: A Systematic Review of the Literature
José Manuel Ramia Ángel, Spain

A. Manuel Vázquez1, R. Latorre Fragua1, V. de la Fuente-Aguilar2, P. Beneite-Mascaraque2, S. Bergua-Arroyo2, M. Fernández-Riesgo2, I. Camón-García2, I. Cruza-Aguilera2, J.M. Ramia Ángel3
1Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Spain, 2Universidad de Alcalá, Spain, 3Hospital Universitario de Alicante, Spain

Introduction: The duodenum is exceptionally affected by hydatid cyst, either primarily or secondarily (compression or fistulization from hydatid cyst located in neighboring organs). Our aim is to perform a systematic review on fistulization of hydatid cysts to the duodenum.
Methods: Following PRISMA guidelines, an unlimited search on duodenal affected hydatid cyst was performed in PubMed, SCielo and EMBASE databases with no limits.
Results: Fourteen papers were found, all case reports, which recorded seven men and seven women, with a mean age of 53.14 years. Three patients had recurrent hydatid cyst.
The most frequent clinical manifestations were abdominal pain, and nausea and/or vomiting. In almost all cases several imaging studies were performed, but abdominal CT scan was the most used (10/14) (71%).
Twelve patients had a fistula between the hydatid cyst and the duodenum, one patient had incidental paraduodenal hydatid cyst and another had severe duodenal compression from liver hydatid cyst without a fistula.
Surgical treatment was performed in 12 patients; different surgical techniques were recorded in the different cases (9 conservative surgery versus 3 total cystectomy).
Post-operative morbimortality is scarcely described and only one dead and 3 uneventful postoperative were reported.
The follow-up period and recurrences could not be determined.
Conclusions: The most common symptoms were abdominal pain, nausea and vomiting; CT scan was the most used imaging technique; and hydatid cyst drainage and fistula closure was the most appropriate treatment.
All diagnostic and therapeutic options for hydatid cyst that fistulize the duodenum have a low level of evidence.
PL05-22 A Case of Hepatic Angiomyolipoma Treated with Laparoscopic Partial Hepatectomy
Hiromasa Komori, Japan

H. Komori1, A. Hirakata1, H. Makino1, T. Yokoyama1, H. Takata1, N. Taniai2, Y. Kawano3, J. Ueda3, H. Yoshida4
1Nippon Medical School Tama Nagayama Hospital, Japan, 2Nippon Medical School Musashi Kosugi Hospital, Japan, 3Nippon Medical School Chiba Hokusou Hospital, Japan, 4Nippon Medical School, Japan

We report a case of hepatic angiomyolipoma (HAML) treated with laparoscopic partial hepatectomy. A 28-year-old man was referred to our hospital for further examination of a hepatic mass. History: tuberous sclerosis, epilepsy, developmental disorders, renal angiomyolipoma. Abdominal ultrasonography revealed a 68 × 55 × 65 mm highly echogenic tumor in the segment 2 of the liver. Abdominal CT with contrast enhancement revealed a high density mass in the same segment. Core needle biopsy was performed, and the tumor was diagnosed as HAML since immunohistochemical stainings was positive for both human melanoma black-45 and α-smooth muscle actin. The Ki-67 index was high, but there was no malignant findings. Abdominl CT revealed that the tumor grew to 75 mm over a 7-month observation period. We decided that an operation was necessary, given the possible danger of rupture or malignant transformation. Laparoscopic partial hepatectomy (S2) was performed. The post-operative period was uneventful, and the patient was discharged after 12 days. Histopathological study showed that the tumor had fatty tissue, spindle-shaped cells and the growth of vessels. Pathology confirmed HAML as the diagnosis. Although follow-up criteria and indications for surgery for HAML are being proposed, there is no established opinion on the surgical procedure. If HAML is diagnosed, minimally invasive laparoscopic partial hepatectomy is effective. HAML was positioned as a benign tumor, but metastasis and recurrence have been reported in some cases, and strict follow-up is necessary as a malignant potentially tumor.
PL05-24 Laparoscopic Radical Surgery for Hydatid Liver Cysts. PSM Based Analysis of Outcomes in Comparison with Conservative Laparoscopic Cystectomy
Mikhail Efanov, Russian Federation

M. Efanov1, K. Kurbonov2, R. Alikhanov1, Z. Azizzoda2, V. Tsvirkun1, I. Kazakov1, N. Elizarova1, A. Vankovich1, A. Koroleva1
1Moscow Clinical Scientific Center, Russian Federation, 2Avicenna Tajik State Medical University, Tajikistan

Introduction: Laparoscopic approach became a common practice for surgery of hydatid liver cysts in many centers worldwide. Immediate outcomes have been shown to be better after laparoscopic procedures in comparison with open surgery. Radical treatment is rarely performed by laparoscopic approach, although it has been suggested that total and subtotal pericystectomy (PE) can contribute to even greater improvement in results compared to conservative cystectomy with partial PE. We aimed to compare immediate and long-term outcomes of laparoscopic conservative treatment and radical surgery.
Methods: Two centers were involved in the study. Radical surgery was performed in specialized HPB center expertized in laparoscopic surgery (group 1) while cystectomy without PE or with partial PE were implemented in the center of surgery located in hyperendemic area (group 2). Logistic regression was used for 1:1 propensity score matching (PSM). Results: The total number of laparoscopic procedures was 96 (40 in group 1 and 56 in group 2). Patients were matched for age, gender, ASA score, type of hydatid cyst (WHO classification), rate of jaundice at presentation, cysto-biliary fistula and recurrent cysts. Finally, 21 pairs were matched. Demographic data and outcomes presented in the table. The duration of radical procedures was significantly longer. The outcomes were significantly better after radical surgery.
Conclusion: Radical laparoscopic surgery when performed in high-volume HPB centers can improve treatment outcomes in selective patients with hydatid liver cysts. Due to the high rate of relapse conservative laparoscopic cystectomy in not justified in non-HPB centers.
FactorsGroup 1 (n=40) before matchingGroup 2 (n=56) before matchingPGroup 1 (n=21) after matchingGroup 2 (n=21) after matchingP
Recurrent cyst, n (%)019 (16)0,007001,00
Postero-superior segments, n (%)24 (60)19 (34)0,01114 (67)5 (24)0,005
Obstructive jaundice, n (%)4 (10)8 (14)0,5312 (10)1 (5)0,549
Cysto-biliary fistula, n (%)13 (32)9 (16)0,0594 (19)2 (10)0,377
Time of operation, min340 (125-660)95 (67-210)<0,001330 (125-600)95 (67-210)<0,001
Time of abdomen draining, day9 (2-90)16 (17-24)<0,0017 (3-37)16 (11-24)<0,001
Severe morbidity, n (%)3 (8)29 (52)<0,0012 (10)12 (57)0,001
Hospital stay, day10 (3-90)18 (11-25)<0,0018 (4-23)18 (11-21)<0,001
Relapse, n (%)1 (3)18 (32)<0,001010 (47)<0,001
[Perioperative data in groups]
PL05-25 Variation in Inpatient Opioid Consumption Following Hepatopancreatic Surgery
Jordan Cloyd, United States

A. Paredes1, M. Hyer1, D. Tsilimigras1, M. Dillhoff1, A. Ejaz1, J. Cloyd1, A. Tsung1, T. Pawlik2
1The Ohio State University Wexner Medical Center, United States, 2Department of Surgery, The Ohio State University Wexner Medical Center, United States

Introduction: The variation in inpatient opioid consumption among patients undergoing Hepatopancreatic surgery are unknown. We sought to examine the variability in inpatient opioid consumption following Hepatopancreatic surgery.
Methods: All Hepatopancreatic cases performed at a single tertiary-care institution between 2015 and 2018 were identified. Only adults, who were prescribed an opioid during inpatient surgical admission and at time of discharge were included in the final cohort. High inpatient opioid consumption was defined as greater than the 75th percentile of average daily oral morphine equivalent (OME) intake.
Results: Overall 891 patients were identified. The majority underwent a pancreatectomy (n=488, 54.8%) whereas a minority underwent a hepatectomy (n=403, 45.2%). Overall, median age was 63 (IQR: 55-71) and median comorbidity burden was 7 (IQR 5-8). Overall, the average daily morphine equivalent was 53 (IQR 25-105). Patients with high inpatient opioid consumption were more likely to be younger (57, IQR 50-66 vs 65, IQR 57-72, p< 0.05) whereas the comorbidity burden (6 IQR 5-8 vs 7 IQR 5-8) and sex (male: 54.2% vs 50.9%) was similar among patients with and without high opioid consumption (p>0.05). Individuals with high inpatient opioid consumption were 1.69 as likely to be readmitted (n=90, 40.0% vs n=157, 23.6%). On multivariable analysis, after adjusting for age, sex, length of operation, comorbidity burden and type of operation, individuals with high inpatient opioid consumption had more than twice the odds of readmission within 30-days (OR: 2.17, 95%CI 1.55-3.05).
Discussion: High inpatient opioid consumption was associated with adverse post-discharge outcomes like readmission.
PL05-28 Tumor-triggered MicroRNA Cocktail Therapy for Hepatocellular Carcinoma
Qida Hu, China

Q. Hu1, S. Shao1, W. Wu1, M. Wang1, J. Huang1, X. Zhao1, G. Tang2, T. Liang1
1Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhejiang University School of Medicine, China, 2Institute of Chemistry Biology and Pharmaceutical Chemistry, Zhejiang University, China

Introduction: As one of the most malignant primary cancer worldwide, hepatocellular carcinoma (HCC) still lacks an efficient therapeutic strategy to date. We aim to develop a tumor-triggered therapy specific for HCC.
Method: We synthesized a pH-responsive nanoparticle PEI-βCD@Ad-CDM-PEG (PCACP) featuring PEGylation detachment and size transformation at tumor site, which was self-assembled from PEI-crosslinked cyclodextrins and functional adamantyl moieties. After evaluating PCACP pH-responsiveness, release profile, cellular uptake, and the subsequent co-delivery of miR-199a/b-3p mimics and antisense-miR-10b to Huh7 cells in culture as well as xenografts derived from cell-lines and patient's tumor (PDX models).
Results: We demonstrated that PCACP showed satisfied corona detachment and controlled release responding to acidic tumor environment, facilitated intracellular miRNA transfection with high specificity and efficiency, significantly inhibited HCC proliferation, migration and invasion both in vitro and in vivo. Meanwhile, cocktail therapy of miR-199a/b-3p and antimiR-10b substantially improved tumor suppression to a greater extent than monotherapy.
Conclusions: Multitarget adjustment of endogenous miRNAs according to personalized miRNA deregulation based on our targeting delivery system, PCACP, could be a potential therapeutic strategy for future adjuvant therapy of HCC treatment clinically.
PL05-29 Manipulation of Intestinal Microbiome Composition Affects Liver Regeneration after 70% Hepatectomy in a Murine Model
Guy Meyerovich, Israel

N. Lubezky, G. Meyerovich, S. Cohen
Surgery, Tel-Aviv Medical Center, Tel-Aviv, Israel

Background: Previous studies demonstrated the effects of Intestinal microbiota composition on physiologic and pathologic processes in the liver. Our aim was to study the effect of the intestinal microbiota composition on the process of liver regeneration (LR) using a model of fecal microbiota transplantation (FMT) prior to partial hepatectomy (PH).
Methods: We used the 70% PH model in mice to induce LR. LR was assessed using liver to mouse weight ratio, KI67 staining, and RT-PCR for Cyclin D1. Intestinal microbiome was manipulated by aggressive antibiotic treatment followed by FMT. Normal, as well as obese mice received FMT by gavage from normal and obese mice, as well as vehicle saline.
Results: LR was not affected by the antibiotic treatment. FMT from healthy normal mice, compared to vehicle resulted in improved LR (Fig. 1 A), and that FMT from obese mice was associated with decreased LR and increased postoperative mortality (45% vs. 8%). Obese mice receiving FMT from obese mice had decreased LR (Fig. 1 B).
Conclusions: LR is affected by microbiome composition, and can be manipulated by FMT. Whereas microbiota transfer from healthy donor mice enhances LR, microbiota transfer of dysbiotic microbiota from HFD donor mice impairs LR, following PH.
[fig 1]
PL05-30 Major Hepatectomy in a Child with Extremely Low Future Liver Remnant Without Posthepatectomy Liver Failure
Dmitry Akhaladze, Russian Federation

D. Akhaladze1, D. Kachanov2, G. Rabaev2, N. Merkulov2, N. Uskova2, K. Avetisyan2, N. Grachev2, N. Miakova2
1Pediatric Oncology and Surgery, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Russian Federation, 2Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Russian Federation

Introduction: The threshold value of future liver remnant volume (FLR-V)-25% for healthy liver is a standard in adults liver surgery. This method was translated in pediatric population without correlation to age, weight and liver function in children. Assessment of future liver remnant function (FLR-F) by means of hepatobiliary scintigraphy (HBS) is supposed to be more precise tool in children undergoing extended liver resection. An experience of major hepatectomy (MH), accomplished despite the extremely low FLR-V in a 27mo boy with advanced hepatoblastoma (HB) is discussed below.
Method: Since June 2017 in our Center investigation of both: FLR-V (CT-volumetry) and FLR-F by means of 99mTc-Mebrofenin HBS before liver resections became a standard practice. The cut-off value of FLR-F is 2.7%/min/m2. The decision about MH was made on the basis of received values.
Results: According to preoperative CT-volumetry, in patient with HB involving segments 4,7,8,1 (POSTTEXT III) the FLR-V in S2,3 came to 16.5%. 99mTc-Mebrofenin HBS showed the FLR-F 3.95%/min/m2. Taking into consideration the sufficient FLR-F, the extended right hepatectomy and caudate lobectomy was implemented instead of two-staged hepatectomy (TSH). The postoperative course was uneventful with no signs of posthepatectomy liver failure (PHLF). Patient was discharged on POD 12 and started adjuvant chemotherapy on time. The repeat FLR-F investigation on POD 30 came to 15.8%/min/m2.
Conclusion: The presented case depicts that FLR-F is more precise than FLR-V in prediction of PHLF. 99mTc-Mebrofenin HBS is a sensitive method in selection of pediatric patients for safe MH instead of TSH or liver transplantation.
PL05-32 Study of the Dynamics of Morphological Changes in Liver Tissue During Irreversible Electroporation with Increasing Electric Field Intensity
Dmitry Panchenkov, Russian Federation

D. Astakhov1,2, D. Panchenkov2,3, F. Zabozlaev1, Y. Ivanov1, S. Dydykin4, T. Dikova4, V. Safonova4
1Federal Research Clinical Center for Specialized Types of Health Care and Medical Technologies of Federal Medical and Biology Agency, Russian Federation, 2Evdokimov Moscow State University of Medicine and Dentistry, Russian Federation, 3State Scientific Center for Laser Medicine of Federal Medical and Biology Agency, Russian Federation, 4I.M. Sechenov First Moscow State Medical University, Russian Federation

Introduction: The purpose of this study is to evaluate morphological changes in liver tissue under the influence of increasing electric field intensity.
Methods: Studies were performed on 70 white outbred male rats. 4 needles were inserted into the liver segment at a distance of 1 cm, to a depth of 5 mm. The electroporation procedure was carried out. Animals were withdrawn from the experiment on the 1st; 3rd; 7th; 14th day. A sequential increase in the electric field was carried out from 400 to 1000 V / cm.
Results: As the voltage of the electric field increased, the necrotic changes increased respectively. Extensive ablation zone with pronounced signs of coagulation necrosis of hepatocytes, erythrocyte hemolysis in destroyed sinusoids, moderately pronounced uneven diffuse and focal lymphocytic leukocyte infiltration. The area of necrotic changes increases with increasing of the electric field strength. The prevalence of necrotic changes over apoptotic changes is noted in case of voltage of 1000 V/sm.
Conclusion: Tissue damage by IRE is a dynamic process with significant differences in morphological manifestation in increasing electric field intensity. In the studied samples, the presence of tissue that underwent both necrosis and signs of apoptotic changes was noted. A further increase in tension leads to the predominance of necrotic changes over apoptotic and seems inappropriate. Based on the morphological assessment, an exposure regimen with 900 V/sm is determined that is sufficient to ensure the devitalization of the tissue segment at the same time while preserving the vascular structures by non-thermal electroporation.
PL05-34 Lipidomic Signatures of Post-Hepatectomy Liver Failure Using Porcine Hepatectomy Models
Hye-Sung Jo, Korea, Republic of

D.-S. Kim1, H.-S. Jo1, H.A. Kim2, J.C. Lee2, K.C. Yoon1, M.H. Moon2
1Division of Hepatobiliary, Pancreas Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Korea, Republic of, 2Chemistry, Yonsei University, Korea, Republic of

Introduction: Clinical diagnosis of post-hepatectomy liver failure (PHLF) can only be made on or after 5th postoperative day. Biomarker for early diagnosis is considered as a critical unmet need.
Method: Pigs underwent sham operation (n=6), 70% (n=7) and 90% (n=7) partial hepatectomy (PH). A comprehensive lipidomic analysis was conducted using sera collected at pre-operation (PO), 14 h, 30 h, and 48 h after PH using nanoflow ultrahigh performance liquid chromatography-electrospray ionization-tandem mass spectrometry.
Results: Of the 184 quantified lipids, 14 lipids showed significant differences between the two resection groups starting at 30 h after surgery. Four phosphatidylcholine (PC) plasmalogen species (p-16:0/16:0, p-18:0/18:2, p-18:0/20:4, and p-18:0/22:6) and PC 32:2 significantly increased in the 90% PH group while these returned to PO level after 30 h in the 70% PH group, presumably implying the failure markers. However, eight triacylglycerol (TG) species (40:0, 42:1, 42:0, 44:1, 44:2, 46:1, 46:2, and 48:3) and sphingomyelin d18:1/20:0 showed an opposite trend, wherein they significantly decreased in the 90% PH group while these in the 70% PH group were abruptly increased until 30 h but returned to near PO levels at 48 h , implying the recovery markers. Same trends were also observed in PC plasmalogen and TG classes in addition to selected individual lipid species.
Conclusions: Characteristic lipidomic signatures of PHLF could be identified using large animal models. These candidates have potentials to serve as a tool for early diagnosis and may open new path to the study to overcome PHLF.
PL05-35 Australia's First Case Series of ICG Directed Liver Resection
Kaveshan Pather, Australia

K. Pather1, O. Mouline1,2, J. Avramovic2,3, P. Palamuthusingam1,2,3
1HPB Surgery, Townsville University Hospital, Australia, 2North Queensland Foregut Surgery Research Collaborative, Australia, 3HPB Surgery, Mater Hospital Townsville, Australia

Introduction: Indocyanine Green (ICG) can be used in assessing liver function and more recently has been employed in liver surgery. ICG uptake by tumours allows intraoperative visualisation with an infrared camera (Stryker SPY-PHI) and may assist in achieving clear resection margins, especially in laparoscopic surgery. Although ICG directed liver surgery was pioneered in Japan in 2009 and later reported in North America and Europe; to our knowledge there have been no reported cases in Australia. Here we report the first three cases in Australia.
Method: Three patients were prospectively consented prior to liver surgery. Each had a different pathology (NET, HCC, and CRCLM). ICG was administered and a Stryker SPY-PHI camera was used intraoperatively to identify tumour extent and guide resection.
Results: The histological resection margins were clear (>10mm) for all three cases. There were no drug allergy events. The equipment was easy to setup and use by the surgical staff. Two of the cases were performed open and one case (HCC) laparoscopically. All three patients made an uneventful postoperative recovery.
Conclusions: ICG directed liver resection can assist in achieving clear resection margins. Here we report the first successful cases of its use in Australia. It has a very low risk profile and can add to the armamentarium of the liver surgeon to assist with achieving clear margins and possibly increase rates of parenchymal preserving surgery.
PL05-36 A Case of Penetrating Hepatic Trauma Caused by Secondary Blast Injury
Shun Sato, Japan

S. Sato, Y. Sakuraoka, T. Shimizu, K.-H. Park, T. Shiraki, S. Mori, Y. Iso, T. Aoki, K. Kubota
Dokkyo Medical University, Japan

Introduction: The damages of the explosion are classified as four-phases and secondary damage is penetrating trauma by flying objects. Here, we illustrate a rare case of penetrating hepatic trauma caused by secondary blast injury.
Case: The patient was a 58-year-old man. When he was walking in the park, an explosion occurred behind him. Although his consciousness was clear and vital signs were almost normal, he had an about 2cm wound on right 6th intercostal space and bleeding.
Imaging showed a right hemopneumothorax, a fracture of the 7th rib, a circular foreign body near the right diaphragm, free air and hemorrhage due to liver injury.
Hepatic hemorrhage was stopped by IVR. However, we decided to perform laparotomy. This is because we had to confirme intestinal damage and remove the foreign body which was doubt to cause the the chemical substance.
We performed laparotomy with J-incision and thoracotomy at the 7th intercostal space. We found the foreign body in the thoracic cavity. It suggested that the foreign body passed and damaged from ribs, lungs, diaphragm, liver, diaphragm and lungs, sequentially. The foreign body was 3cm metallic washer. With regarding to the two hepatic injuries, collagen hemostat was placed into liver damaged area and Felt was put on the sutured line by using 2 PDS. There was a bile leak after surgery, which gradually settled down with endoscopic treatment, and he was discharged 43 days after the operation.
Conclusion: In blast injury, accurate diagnosis and the timing of operation were important.
PL05-37 Inter-Surgeon Variability is Associated with Likelihood to Undergo Minimally Invasive Hepatectomy and Post-operative Mortality
Diamantis Tsilimigras, United States

Q. Chen1, D. Tsilimigras1, A. Paredes1, G. Spolverato1, F. Bagante1, T. Pawlik2
1The Ohio State University Wexner Medical Center, United States, 2Department of Surgery, The Ohio State University Wexner Medical Center, United States

Introduction: While minimally invasive surgery(MIS) has become increasingly adopted for liver resection, factors associated with receipt of MIS have not been well-defined. We sought to characterize inter-surgeon variability in operative approach (MIS vs. open) as well as the impact of seeing a specific provider on the likelihood of undergoing MIS liver resection.
Methods: Medicare Standard Analytic Files were used to identify patients who underwent hepatectomy between 2013-2017. Surgeon-specific operative variation (number of MIS/total hepatectomies) was stratified into tertiles. Multilevel, multivariable logistic regression was used to determine the association of surgeon specific variation in operative approach on the likelihood of MIS using median odds ratios(MOR).
Results: Overall 5,135(92.0%) patients underwent open liver resection, while 446(8.0%) patients had MIS. Surgeons in the lowest MIS tertile performed 0% of cases using a MIS technique; in contrast, surgeons in the highest tertile used an MIS approach in nearly one-fourth(24.1%) of all hepatic resections(Figure 1a). While females(OR=1.23,95%CI:1.00-1.51) were more likely to undergo MIS, patients with a higher Charlson comorbidity score were less likely(>5 OR=0.60, 95%CI:0.44-0.81). On multivariable analysis, after controlling for patient and procedure characteristics, there was over a two-fold variation in the odds that a patient underwent MIS versus open hepatectomy based on the individual surgeon provider(MOR=2.79, 95%CI:2.42-3.16). Patients who had a hepatectomy performed by a low-volume MIS surgeon had 29% higher odds of death within 90-days(OR=1.29, 95%CI:1.00-1.65)(Figure 1b).
Conclusion: The likelihood of undergoing MIS liver resection and post-operative mortality were heavily influenced by the individual surgeon provider rather than patient or procedure factors.
PL05-38 Prediction of Liver Histology Using Skin Autofluorescence Measurement in Patients Undergoing Liver Resection
Maciej Krasnodębski, Poland

M. Krasnodębski1, M. Grąt1, M. Morawski1, J. Borkowski1, K. Grąt2, M. Skalski1, 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) is an indirect measure of advanced glycation end-products (AGEs), which are associated with liver injury. The study aimed to assess the utility of sAF in preoperative prediction of non-tumoral liver status in patients undergoing liver resection.
Methods: This prospective study comprised 120 patients undergoing liver resection in the Department of General, Transplant and Liver Surgery of the Medical University of Warsaw between September 2018 and November 2019. Liver fibrosis and steatosis was the primary and secondary end-point, respectively. Patients with cirrhosis were excluded from the study. sAF was assessed preoperatively in all patients using a device based on photodiodes (measurements were expressed in arbitrary units [AU]).
Results: Liver fibrosis was found in 28.3% (34 of 120) and steatosis>10% in 29.2% (35 of 120) patients. There were no differences in sAF between obese or overweight patients and those with BMI< 25 (p=0.276). sAF≥2.4 AU was an independent predictor of liver fibrosis (odds ratio [OR] 2.94; 95% confidence interval [95% CI] 1.288 - 6.731; p=0.011) with positive (PPV) and negative (NPV) predictive values of 40.0% and 81.5%, respectively. The median sAF was higher in patients with liver steatosis>10% (p=0.024). The optimal cut-off for sAF in prediction of steatosis>10% was ≥2.5 AU (area under the curve 0.631, 95% CI 0.520-0.742; p=0.021), with PPV and NPV of 42.9.2% and 80.3%, respectively.
Conclusion: Skin autofluorescence as non-invasive and clinically applicable test can potentially be used to initially predict the presence of hepatic fibrosis and steatosis in patients scheduled for liver resection.
PL05-41 Comparison of Immediate and Long-term Outcomes after Laparoscopic and Open Radical Surgery for Hydatid Liver Cysts
Mikhail Efanov, Russian Federation

M. Efanov1, K. Kurbonov2, R. Alikhanov1, Z. Azizzoda2, V. Tsvirkun1, N. Elizarova1, I. Kazakov1, A. Vankovich1, A. Koroleva1
1Moscow Clinical Scientific Center, Russian Federation, 2Avicenna Tajik State Medical University, Tajikistan

Introduction: According to latest meta-analyses, radical surgery of liver hydatid cysts provides better immediate and long-term outcomes in comparison with conservative cystectomy. Laparoscopic approach also contributes to improvement of treatment outcomes. Nevertheless, there are limited number of studies analyzed outcomes of laparoscopic radical surgery. We aimed to compare immediate and long-term outcomes of laparoscopic and open radical cystectomy for hydatid liver cysts.
Methods: Two centers were involved in the study. Laparoscopic radical surgery was performed in specialized HPB center expertized in laparoscopic surgery (group 1) while open radical procedures were implemented in the center of surgery located in hyperendemic area (group 2).
Results: The total number of patients was 77 (40 in group 1 and 37 in group 2). Demographic data and outcomes presented in the table. The duration of laparoscopic procedures was significantly longer. Open cystectomy significantly more often was performed in patients with obstructive jaundice, recurrent disease and with large number of cysts (>2). Immediate outcomes (rate of severe morbidity, wound infection, duration of abdominal drainage, hospital stay) were significantly better after laparoscopic radical cystectomy. No differences were found in relapse after radical surgery between groups.
Conclusion: Radical laparoscopic surgery improves treatment outcomes in selective patients with hydatid liver cysts in comparison with open radical cystectomy. Laparoscopic approach for radical cystectomy is justified in high-volume HPB centers specialized in minimally invasive liver resection. Further accumulation of experience is needed to overcome the heterogeneity of compared groups.
FactorsGroup 1 (n=40)Group 2 (n=37)P
Recurrent cyst, n (%)05 (12)0,016
Number of cysts >2, n (%)4 (10)17 (46)<0,001
Obstructive jaundice, n (%)18 (49)4 (10)<0,001
Time of operation, min340 (125-660)87 (67-119)<0,001
Time of abdomen draining, day8 (2-90)17 (9-24)<0,001
Wound infection, n (%)012 (32)<0,001
Severe morbidity, n (%)3 (8)20 (54)<0,001
Hospital stay, day10 (3-90)19 (13-25)<0,001
Relapse of disease, n (%)1 (3)4 (11)0,139
[Perioperative data in groups]
PL05-42 Surgical Portosystemic Shunts - Still an Important Tool in the Current Management of Portal Hypertension
Lauren Wancata, United States

L. Wancata, V. Sandoval, C.K. Enestvedt, S. Orloff
Oregon Health and Science University, United States

Background: Historically, surgical portosystemic shunts (PSS) were lifesaving procedures for variceal bleeding and ascites management in patients with portal hypertension (PHT), but currently are rarely utilized with the advent of Interventional Radiology (IR) decompressive procedures. We present two recent cases of patients managed with surgical PSS.
Methods: Two patients on the liver transplant waiting list with nodular regenerative hyperplasia (NRH) induced PHT who suffered from life threatening variceal bleeding were identified. Their clinical course, surgical intervention, pathology and recovery were reviewed.
Results: Patient 1 is a 41yo male who presented with life threatening variceal bleeding and underwent unsuccessful IR TIPS placement, Sengstaken Blakemore (SB) tube placement who then required a life-saving surgical central spleno-renal shunt for decompression. Post-operatively he required IR shunt stent placement due to shunt stenosis from compression by the SB tube. 5.5 years post procedures his varices have resolved, he has had no additional complications and is thriving. Patient 2 is a 59yo female with refractory variceal bleeding not amenable endoscopic therapy and anatomy precluded IR decompression. She underwent a surgical central spleno-renal shunt with unremarkable post-operative course and at 1 year has resolution of her varices. Both patients had pathologic features of NRH and were subsequently removed from the transplant waiting list.
Conclusions: While IR techniques to manage sequelae of cirrhosis and PHT have become standard practice, surgical PSS remain an important tool in the management of refractory variceal bleeding and can provide durable results that obviate the need for liver transplantation in select cases.
PL05-43 3D Printed Models for Planning and Intraoperative Assistance in Complex Hepatic Surgeries
Felipe Alconchel, Spain

M. López-León1, F. Alconchel2, L. Alcalá3, A. Luque Molina3, T. Jodral3, A. Luna-Alcalá3, P. López-Cillero4
1Surgery, Reina Sofía University Hospital, Spain, 2Hepatobiliary Surgery and Liver Transplantation, Virgen de la Arrixaca University Hospital (IMIB-Virgen de la Arrixaca), Spain, 3Departamento de Cirugía, Hospital San Juan de Dios, Spain, 4Departamento de Cirugía, Hospital San Juan de Dios, Spain

We evaluate the usefulness of 3D-printed models generated from registered CT and MRI images in order to plan liver resection surgery and to locate lesions during surgery.
The segmentation of anatomical structures and lesions is performed, and a different 3D-model is generated for each part to be printed. In this stage, hepatic parenchyma molds are designed. Finally, anatomical structures, lesions and molds are 3D-printed, and molds are filled with transparent resin.
Our prospective case and control series included 19 cases in which surgery was planned by using a 3D printed model and another 19 cases whose planning was carried out without a 3D printed model. The cases in which a 3D liver model was used showed more complex surgeries than in the control cases. The number of lesions were statistically higher, and there was a statistically significant greater predisposition to request a printed model when there was vascular involvement or a bilobar resection was going to be performed (Figure). Despite this greater complexity, the use of 3D printed models allowed to reduce average surgery and hospitalization days, and to decrease mortality to zero (Figure).
In our experience, 3D printing is a useful tool for the preoperative planning of complex hepatic resections, leading to a safer surgery. During the intervention, the 3D printed model makes the identification and location of all lesions easier for the surgeon, reducing intraoperative complications. Given its increasingly common use and the results obtained, 3D printing is changing the way surgeons plan liver resection surgeries.
PL05-45 Factors Related to Prolonged Hospital Stay in Patients with Pyogenic Liver Abscesses
Nuno Dias Machado, Portugal

N. Dias Machado1, C. Soares2, M. Costa1, M. Rocha2, M. Oliveira2
1General Surgery, Centro Hospitalar do Tâmega e Sousa, Portugal, 2Hepatobiliary and Pancreatic Surgery, Centro Hospitalar do Tâmega e Sousa, Portugal

Background: Pyogenic liver abscesses (PLA) are an uncommon source of intra-abdominal infection which is usually associated with prolonged length of hospital stay (LHS). We aimed to identify factors that could be associated with a prolonged LHS in patients with PLA.
Methods: All patients admitted to our institution with the diagnosis of PLA between 2013 and 2018 were retrospectively reviewed. Predictors that could influence treatment results and LHS were analyzed.
Results: A total of 72 patients were included in the study. The most common presenting symptoms were abdominal pain (71%) and fever (63%). C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) on admission were generally elevated, being >100 mg/L and >5 in 93% and 95,8% of the patients respectively. Most patients (83%) underwent abscess drainage. Median length of hospital stay was 17 days (range 2-89). A total of 9 patients (12,5%) needed more than one drainage procedure. In hospital mortality rate was 4,2%. LHS was independently associated with time until abscess drainage (p=0,005), length of antibiotic therapy (p=0,012) and the need for a second drainage procedure (p=0,001). Low hemoglobin levels on admission (p=0,01), before drainage (p=0,033) and after drainage (p=0,014), as well as low albumin levels after drainage (p< 0,001) were associated with longer inpatient antibiotic courses and LHS.
Conclusions: Early diagnosis is essential in PLA management as effective and timely drainage may lead to shorter hospital stays. Early identification of patients at risk for delayed/inadequate treatment response may be of utility for the future development of treatment guidelines.
[Dercreased albumin and hemoglobin values after drainage and lenght of inpatient antibiotic course]
PL05-46 Generalized Hydatosis of the Liver - When Almost All Segments Are Affected - A Case Report
Octav Ginghina, Romania

A. Spanu1, M. Mardare1, R. Iosifescu1, M. Zamfir1, C. Calin2, A.B. Vacarasu1, N. Iordache1, O. Ginghina1
1Surgery, St John Emergency Hospital, Romania, 2Anesthesiology, St John Emergency Hospital, Romania

Introduction: Although we live in the 21st century, hydatidosis is still a common disease Eastern Europe, especially in families with precarious economic and health status.
Methods: We present a rare case of a voluminous hepatic hydatic cyst disseminated in both hepatic lobes with peritoneal hydatosis. After the anti-parasitic oral treatment, we performed a laparotomy with the excision of the cysts from segments 7-8, 4A and 4B, 5 and 2, partial omentectomy and cholecystectomy. The patient developed a large volume biliary fistula and although we performed an ERCP procedure with papilosfincterotomy and stenting with a significant decrease of the flow, the hospitalization period was still very long (8 weeks).
Results: Patient never came for postoperative follow-up control and presented herself 5 months later, with a segment 7-8 hepatic abscess, that needed reoperation. Paradoxically, no biliary leak was developed after the second procedure, with smooth postoperative evolution.
Conclusion: Managing such an advanced disease is challenging for the surgeon, not only technically, but also strategically, with a lot of costs for the hospital and treatments for all the postoperative complications. Difficult patients from rural areas are sometime difficult to manage, with fluctuant follow-up and an increase risc of complications.
PL05-47 Surgery for Hepatic Cysts: Robotic Is Equivalent to Laparoscopy
Michael Watson, United States

M. Watson, M. Baimas-George, P. Salibi, E. Baker, L. Ocuin, D. Vrochides, D. Iannitti, J. Martinie
Division of HPB Surgery, Carolinas Medical Center, United States

Introduction: Minimally invasive approaches are increasingly utilized for surgical treatment of nonmalignant hepatic cyst disease. We evaluated the characteristics and surgical outcomes for patients with nonmalignant hepatic cysts treated at our institution.
Methods: Patients undergoing surgical treatment of nonmalignant hepatic cysts at our institution between January 2008 and July 2019 were identified. Demographic data, preoperative symptoms, cyst characteristics, surgical details, and postoperative outcomes were determined retrospectively. Patients undergoing open surgery were infrequent (n=6), and excluded from analysis. Patients undergoing laparoscopic and robotic surgery were compared.
Results: 114 patients were treated with minimally invasive surgery (MIS), with 23 (20.2%) undergoing robotic and 91 (79.8%) laparoscopic surgery. Age and sex were similar between groups (p>0.05). Rate of polycystic kidney disease (21.7% vs 3.3%; p=0.0002) and ASA class 3 (65.2% vs 41.8%;p=0.044) were higher in the robotic group. Cyst size was similar between groups (p=.485). The robotic cohort had higher rate of preoperative symptoms (100% vs 83.5%; p=0.037) with abdominal pain the predominant symptom (100% vs 80.2%; p=0.020). EBL was similar (p=0.124) while robotic had higher operative time (156 min vs 112 min; p< 0.001). Rate of simultaneous hepatectomy was higher in the robotic group, but not statistically significant (34.8% vs 17.6%; p=0.071). Postoperative outcomes (LOS, complications, and recurrence requiring reoperation) were similar between groups (p>0.05).
Conclusions: For surgical treatment of non-malignant hepatic cystic disease, robotic surgery has similar outcomes compared to laparoscopy. Robotic surgery is an effective treatment for large hepatic cysts and polycystic liver disease, especially if hepatectomy is required.
PL05-48 Effect of Hepatic Cyst Size on Postoperative Outcomes: Size Is Irrelevant
Michael Watson, United States

M. Watson, M. Baimas-George, P. Salibi, K. Murphy, E. Baker, L. Ocuin, J. Martinie, D. Vrochides, D. Iannitti
Division of HPB Surgery, Carolinas Medical Center, United States

Introduction: Simple hepatic cysts may present with a wide range of sizes and symptomatology. Previous studies have used various cut-offs to define a “giant” hepatic cyst but there are few studies of the clinical implications of hepatic cyst size.
Methods: Patients undergoing surgical treatment of simple hepatic cysts between January 2008 and July 2019 were identified retrospectively. Demographics, preoperative symptoms, cyst characteristics, surgical details and outcomes were collected. Cyst size was defined as greatest measured diameter of the largest cyst on axial imaging. Correlations between variables was performed with linear or logistic regression.
Results: 120 patients were identified for analysis. Average cyst size was 12.0±5.5 cm, 85.8% of patients were symptomatic, and pain (83.3%) was the predominant symptom. 114 (95%) patients were treated with minimally invasive surgery, mean EBL was 193±413mL, mean operative time was 123±59min, open conversion rate was 1.8%, and rate of simultaneous hepatectomy was 23.3%. Rate of reoperation for recurrence was 4.2%. Size was weakly correlated with operative time (R2=0.0683; p=0.0056) but not with EBL, simultaneous hepatectomy, LOS, complications, Clavien-Dindo complication grade, or reoperation for recurrence (all p>0.05). Using size cutoff of 10th, 25th, 50th, 75th, and 90th percentile did not demonstrate correlation with operative time, EBL, hepatectomy, LOS, complications, or Clavien-Dindo complication grade (all p>0.05).
Conclusions: Despite weak correlation between cyst size and operative time, there is no correlation with clinically relevant patient outcomes. For patients with simple hepatic cysts, cyst size does not predict patient outcomes. Traditional definitions of “giant” simple hepatic cysts appear irrelevant.
PL05-50 Importance of Platelet - Endothelial Cell Interaction during Postoperative Liver Regeneration
Sina Najarnia, Austria

S. Najarnia1, D. Pereyra1, J. Fuxsteiner1, A. Assinger2, P. Starlinger1,3
1Department of Surgery, Medical University of Vienna, General Hospital Vienna, Austria, 2Institute of Physiology, Medical University of Vienna, Austria, 3HPB Surgery, Mayo Clinic, United States

Introduction: Interleukin-6 (IL-6) is a well-known regulator of liver regeneration, specifically during the early period. Within this project, we wanted to identify the time course of IL-6 production within the human liver during the early phase of liver regeneration as a result of the potential interaction of platelets and liver sinusoidal endothelial cells (LSECs).
Method: Electron microscopy was used to determine the behavior of platelets in the liver sinusoids shortly after induction of liver regeneration. IL-6 mRNA was analyzed in liver tissue at the same time point. Further, IL-6 serum levels were evaluated preoperatively.
Results: Platelets were shown to adhere to LSECs and even translocated in the space of Disse early after induction of liver regeneration. Circulating IL-6 levels significantly increased after liver resection. Within liver tissue we observed a significant induction of IL-6 expression (mean: 13 fold). Intriguingly, patients developing postoperative liver dysfunction (LD) displayed a significantly higher induction of IL-6 (LD: 25 fold, no LD 9.3 fold, P=0.001) already two hours after induction of liver regeneration. Ultimately, IL-6 induction by platelets could also observed in co-culture experiments with LSECs.
Conclusion: Platelets adhere to LSECs early after induction of liver regeneration in humans and might be the central trigger for induction of IL-6 expression. This initial burst of IL-6 might be crucial for induction of liver regeneration. Nevertheless, an overshooting IL-6 production seems not to be beneficial for patients undergoing liver resection.
PL05-53 Use of BNP in Management Algorithm of Congenital and Infantile Hepatic Hemangioma
Sifat Khan, United Kingdom

S. Khan1,2
1Department of Pediatric Hepatobiliary and Liver transplant Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom, 2Dhaka Medical College Hospital, Dhaka, Bangladesh

Background: Pediatric Hepatic hemangiomas mostly responsive to propanolol treatment and USS are done to follow up the trend of its involution. In this study a correlation is found between the decreasing levels of BNP with the decreasing size of hepatic hemangiomas.
Methods: Clinical notes of 63 patients in last 20 years was analyzed retrospectively. Among them 13 patients with hepatic hemangioma had pre and post treatment BNP level measured. BNP level was determined using immunoassay and the size of the lesion was assessed by USS.
Results: All the patients were diagnosed in post-natal period presented with shortness of breath (69.35%), feeding difficulty (76.9%), jaundice (23%), heart failure (30%) and abdominal distension (23%). Nine patients had multiple hepatic hemangiomas and four patients had hemangiomas involved in other organs. The pre-treatment BNP level is 2762.2 pg/ml (range: 291-38784) and the post treatment BNP level is 83 pg/ml (range: 21-148) (P=< 0.01). The size of lesion (largest lesion in multiple hemangiomas) was 6.7x5.7x3.9 cm (Range 2.3x2.2x1.5-12.6x13.4x13.4) which decreased in size in response to treatments (e.g. propanolol, vincristine and embolization of feeding vessels) 0.97x0.58x0.44 cm (range no visible lesion to 1.2x1.1x0.88) (P=< 0.01). The serum BNP level shows positive correlation with the size of the lesion in hepatic hemangiomas (r=0.529, P=< 0.01).
Conclusion: BNP level is related with the regression of size of hemangioma. Measurement of BNP level can be a sensitive indicator in evaluation congenital and hepatic hemangioma.
PL05-54 Laparoscopic Resection of Idiopathic Necrotizing Granuloma of the Liver
Izhar-Ul Haque, Australia

I.-U. Haque1, L. Santos2, A. Das3
1Hepato Pancreatico Biliary Surgery, Bankstown Hospital, Australia, 2Pathology, Liverpool Hospital, Australia, 3Hepato Pancreatico Biliary Surgery, Liverpool Hospital, Australia

Introduction: Isolated Hepatic Granulomas are hard to diagnose and can be mistaken for Cholangiocarcinoma or Metastasis.
Methods: This is a retrospective review of a Laparoscopic Liver Lesion resection which surprisingly turned out to be a hepatic granuloma.
Results: A 50 yo female presented with vague abdominal pain, nausea and vomiting. A 16 mm lesion was found on CT abdomen in segment IVA adjacent to Falciform ligament. Patient proceeded to a Laparoscopic US-guided resection of the lesion. Histology revealed a large lesion surrounded by numerous epitheloid Histiocytes/Macrophages mixed with multinucleated giant cells, consistent with necrotizing granuloma of the liver. Mycobacterium Tuberculosis testing on the specimen was negative as was serum Interferon, Hep B and Hep C serology. No other infectious cause was found. Patient made an uneventful recovery.
Hepatic granulomas are uncommon. They can be associated with TB, Hep B or C, Brucellosis, Sarcoidoisis, Schistosomiasis, Leishmaniasis and other rare infections. However, 10-20% remain idiopathic. Preoperative diagnosis is difficult as US / CT / MRI may be unable to differentiate benign from malignant lesions such as Cholangiocarcinoma and Liver metastases. Preoperative Biopsy may be inconclusive as Necrotic cells can be found in both benign and malignant conditions. Laparoscopic surgery with Ultrasound guidance can be safely used in enbloc resection for these uncommon lesions.
Conclusions: Hepatic granulomas are uncommon and should be considered as a differential diagnosis for lesions unclear on CT /MRI. Checking for Tuberculosis, Hepatitis and serology for other chronic infections is helpful but a minority remain idiopathic.
PL05-55 Leiomyomatosis Peritonealis Disseminata Mimicking Liver Tumor
Yu Ni Lee, Korea, Republic of

Y.N. Lee, W.Y. Kim, C.G. Park
Department of Surgery, Presbyterian Medical Center, Korea, Republic of

Leiomyomatosis peritonealis disseminata(LPD) is a rare entity characterized by the presence of multiple, small nodules of smooth muscle on the peritoneal and omental surfaces. We report a case of huge tumor(27x18cm) which compressed the liver medially.
Thirty three year-old woman was brought here for vague abdominal discomfort and palpable mass in right upper abdomen for 2 months. She had the history of the laparoscopic myomectomy 5 years ago and then laparotomy for removal of disseminated myomatosis peritonealis 2 years ago. Abdominal CT showed 27x18 cm abdominal mass compressing the liver medially and multiple nodules in abdominal cavity. So she underwent multiple resection showing leiomyomatosis peritonealis disseminata with positive desmin, positive smooth muscle actin, positive endothelial cell. She had smooth postoperative course and discharged on postoperative 8th day.
PL05-56 Liver Gas Gangrene after Biliary Surgery
Yuma Suno, Japan

Y. Suno1, H. Kashiwagi1, Y. Igarashi1, T. Murata1, N. Isogai1, R. Shimoyama1, J. Kawachi1, T. Kawahara1, K. Watanabe2
1Shonan Kamakura General Hospital, Japan, 2Tokyo Nishi Tokusyukai Hospital, Japan

Introduction: Liver gas gangrene is a rare condition with a highly mortality rate. It is mostly associated with host factors, such as malignancy and immunosuppression. Here we report three cases of liver gas gangrene after biliary reconstruction surgery.
Method: Three cases diagnosed as liver gas gangrene were retrospectively analyzed. All cases had malignant diseases such as pancreas cancer and biliary cancer, and received curative surgery with biliary reconstruction. After diagnosis was made by CT scan, two patients had open drainage surgery for liver gas gangrene and a patient selected conservative therapy such as intensive antibiotics infusion.
Results: All patients had the cardio-vascular risk such as hypertension and diabetes mellitus. Two cases (57y/o female and 71 y/o female) died within 2 days after diagnosis although intensive care was performed. One case (82y/o male) survived after open drainage surgery. This patient's condition improved immediately after surgery and he was discharged on the 28 th post-operative day.
Enterococcous species and Klebsiella species was detected in the blood and drainage samples in two thirds cases. Clostridium species were not recognized.
Conclusion: Hepatic gas gangrene progresses rapidly and has a high mortality rate. Malignant disease and reconstructive surgery may be predisposing factors. Open surgical drainage may be a crucial treatment for this dismal disease.
PL05-57 Single Unit Experience of Simple Hepatic Cyst Management over Twenty Years Period
Badriya Alaraimi, Oman

B. Alaraimi, D. Albaali, M. Alfarsi, A. Alkindy
General Surgery, Armed Forces Hospital, Oman

Introduction: Hepatic cysts are common with prevalence of 2.5 to 10% of general population. It has different classifications ranging from benign to malignant conditions. It varies in its origin, aetiology, manifestations and treated approaches. Generally, majority of affected patients are asymptomatic and required no interventions. Laparoscopic fenestration is a well described treatment for benign hepatic cysts. We aimed to assess the outcome of hepatic cysts patients who underwent intervention in our unit over twenty years' period
Methods: Retrospective study of adult patients who were diagnosed with symptomatic benign hepatic cysts and received intervention in our unit between 1998 and 2018. Outcome of the management included clinical and radiological recurrence, re-intervention, and malignant transformation. In surgical intervention we analysed operative time, hospital stay, intraopera­tive blood loss and postoperative complications.
Results: 68 out of the 120 patients underwent intervention and were followed up for at least 18 months' post intervention. Symptoms included pain (54/68), pressure/distention (41/68), haemorrhage (7/68), and infection (6/68).
30 and 12 patients had cyst fenestration; laparoscopic and open respectively,12 had radiological percutaneous aspiration and 6 underwent open cyst excision. 21 patients had symptomatic and radiological recurrence and 11 required repeat intervention. Complications included bleeding, intra-abdominal collection and chest sepsis and those were reported in older, higher BMI and patients who had open surgery.
Conclusions: Laparoscopic cyst fenestration is recommended in managing symptomatic patients provided careful patient selection and stratification. In morbid patients repeated radiological aspiration can provide symptomatic relieve with small risk of iatrogenic bleeding or infection.
PL05-59 Peliosis Hepatis In Marrow Transplant Patient: A Case Report
Stephanie Cheng, Singapore

S. Cheng, N.A. Mohd Noor, S. Gunasekaran, M.Y. Tan, T.J. Tan
Khoo Teck Puat Hospital Singapore, Singapore

Introduction: Peliosis hepatis (PH) is a rare condition defined by multiple blood-filled cysts in liver parenchyma. The etiology of PH remains unclear, however it has been associated with autoimmune mechanisms, malignancies and infections. Drugs including steroids have been associated as well. The presentation of PH is often non-specific, such as vague recurring abdominal pain. However it can also rarely have a potentially fatal presentation.
Results: We report a case of a 22 year-old Malay man who came with acute onset of abdominal pain and hemorrhagic shock. He has a background of dyskeratosis congenita, which was complicated by bone marrow failure. He has undergone allogenic bone marrow transplant 2 years prior. Relevant history of note is patient's previous steroid therapy for immunosuppression post-marrow transplant which was completed 1 year ago.
Computed tomography (CT) showed hemoperitoneum at time of presentation and widespread hepatic lesions, largest one measuring 8x5cm. On angiography, multiple blushes of contrast were seen with dilated vascular channels suggestive of PH. Angioembolization was done patient was resuscitated with blood products to good effect after.
Conclusion: Peliosis hepatis is a condition that can be easily overlooked due to its rarity, and is potentially fatal. In patients with complex haematological issues, this is particularly dangerous as there may be increased risk of bleeding. PH should be considered in patients with relevant medical or drug history presenting with atypical widespread liver lesions seen on imaging.
[CT image showing the largest hepatic lesion with haemoperitoneum]
PL05-62 Anatomical Variations in Intrahepatic Bile Ducts: A Systematic Review, Meta-analysis, and Creation of a Prevalence-based Classification System
Boris Janssen, United Kingdom

B. Janssen1,2, S. van Laarhoven1, M. Elshaer1, H. Cai3, R. Praseedom1, S.-S. Liau1
1Department of Surgery, Addenbrooke’s Hospital and University of Cambridge, United Kingdom, 2Department of Surgery and Cancer Center, Amsterdam University Medical Center, Netherlands, 3Department of Statistical Science, University College London, United Kingdom

Introduction: In the current era of advanced liver surgery, awareness of intra- and extrahepatic biliary anatomical variants is becoming increasingly crucial. If a surgeon is unaware of these variants, hepatic surgery may result in otherwise avoidable complications. We aim to construct a systematic review and meta-analysis of intrahepatic biliary anatomical variants and their prevalence.
Methods: We performed a literature search of the MEDLINE and EMBASE databases on September 10th, 2019. We performed a meta-analysis using a multinomial logistic mixed effect model, with study heterogeneity captured by a random intercept, to estimate the overall proportion of each anatomical type across all studies. Additionally, we carried out a population analysis. We also constructed a novel prevalence-based classification system.
Results: The literature search resulted in 1709 individual studies. Thirty-five studies were included in this analysis, covering 11706 patients. The meta-analysis showed an estimated average type 1 proportion of 64.1 %, a type 2 proportion of 14.4 %, a type 3 proportion of 11.6 %, a type 4 proportion of 6.5 %, a type 5 proportion of 1.4 %, and an 'Other' proportion of 2.5 %. Our populational analysis based on ethnic and geographical backgrounds demonstrated different anatomical distributions between regions.
Conclusion: This systematic review represents the most comprehensive overview of intrahepatic biliary anatomical variants to date, taking into account the different anatomical prevalence between populations. Based on our summative findings, we propose a prevalence-based classification system which if widely adopted, may serve as a unifying descriptive system internationally.
[Figure 1. Novel prevalence based classification system]
PL05-63 Src-phosphorylation at the α1-Na/K-ATPase Modulates Liver Cell Senescence and Microbiota Communuty Changes on Diet Induced NASH in the Rodent
Juan Sanabria, United States

J.D. Sanabria1, A. Mallick1, M. Schade1, J.A. Sanabria1, U. Udoh1, P. Rajan1, J. Sanabria1,2,3
1Surgery, Marshall Institute for Interdisciplinary Research, United States, 2Surgery, Marshall University, United States, 3Nutrition and Preventive Medicine, Case Western Reserve University, United States

Background: The global incidence of chronic liver disease and its sequels ESLD and HCC are increasing due to obesity and increase in life expectancy. We hypothesized Western diet accelerates aging cell processes inducing liver cell portfolio to senescence/apoptotic activity with altered metabolic cycles and disturbed gut-microbiota communities mainly though a Src pathway.
Methods: Mice were exposed to NMC or HFD. Livers and plasma were collected at weeks 12, 24 and 48. Body compartments were determined by MRI spectroscopy. The terminal ileum (TI) and its microbiota were collected. Total DNA was extracted from contents of ileum and microbial community profiling was achieved by sequencing 16S rRNA v3-v4 hypervariable regions. Quantitative protein expression of Tp53, mTOR1, Src, SIRT7, FOX01, Grb2 were determined by Western Blots. Principal component analyses (PCA) was conducted.
Results: TBW increases with aging manly due to an increase in the fat compartment with decreased lean mass and total body water (p< 005); changes that correlated with an increased proportion of liver cells in senescence/apoptosis (p< 0.05). Morphological changes correlated with Src peak gene expression. A significant increase in Verrucomicrobia was observed in the HFD group when compared to the NMC group (p< 0.05). Additionally, a significant decrease in Bacteroidetes was noted (p< 0.05). pNaKtide, a 33 amino-peptide that blocks the activation of Src at the α1-Na/K-ATPase subunit abrogated metabolic, genetic and morphologic changes establishing a wild phenotype.
Conclusions: Blockage of the α1-Na/K-ATPase//Src amplification loop restored both physiological liver cell aging, and wild type gut-microbiota communities.
PL05-64 Incidence of Neoplasm in a Complex Cyst in Liver - Can We Predict Preoperatively?
Nagappan Kumar, United Kingdom

N. Kumar, A. Gupta, T. Duncan, D. O'Reilly
Cardiff Liver Unit, University Hospital of Wales, United Kingdom

Introduction: Liver cysts are reported in around 10% of population and increasingly picked up by cross sectional imaging. Simple cysts need treatment only if symptomatic. However, complex cyst needs to be treated irrespective of symptoms because of the risk of malignancy or a premalignant condition. We analysed our database to explore this further.
Methods: We analysed retrospectively a prospective liver database from January 2004 to December 2019 for all patients operated for liver cysts at the Cardiff Liver unit. Demography, type of cyst, liver function, imaging findings and histology was recorded.We excluded patients with polycystic liver disease. Patients with multiple cysts but do not belong to the spectrum of polycystic liver were considered. Cross sectional imaging was CT scan and most cases MRI liver. Complex cyst was defined by septations, debris within cyst or nodules in the wall.
Results: There were 63 patients. 53 females. Median age 63 (40-92). 12 patients with polycystic liver, 27 simple cysts and 24 complex cysts. Among patients with complex cysts 9 (38%) had a neoplastic lesion (7 cystadenoma, 2 malignancy). The imaging findings of solid nodule and thick septations did not differentiate patients with malignancy.
Conclusion: Our results show that we should continue to offer resectional surgery for all patients with complex cysts (enucleation or resection). If at surgery the anatomy precludes safe resection, deroofing with frozen section of the wall and internal contents may help avoid missing a neoplasm. Imaging cannot safely predict a neoplastic pathology.
PL05-66 Influence of Platelet Degranulation on Postoperative Liver Regeneration
Jonas Santol, Austria

J. Santol1, D. Pereyra1,2, M. Salzmann2, J. Pointner2, W. Schrottmaier2, J. Schmid2, C. Brostjan1, A. Assinger2, P. Starlinger1,3
1Department of Surgery, Medical University of Vienna, General Hospital Vienna, Austria, 2Institute of Physiology, Medical University of Vienna, Austria, 3HPB Surgery, Mayo Clinic, United States

Introduction: Recently, we reported on the association of site-specific alpha-granule release in patients undergoing liver regeneration and in the development of liver dysfunction. While platelets were shown to have a central role in liver regeneration, the causal interaction of platelet degranulation and liver regeneration has not been investigated as far. Thus, we aimed to provide evidence for an effect of platelet activation on liver regeneration in genetically altered mice undergoing partial hepatectomy (pHx).
Method: Two mouse stems were used for this study: While fl-IKK2-fl/PF-4-Cre mice showed a tendency towards more reactivity of platelets, Nbeal-2 knock-out mice (Nbeal2-/-) were found to have unfunctional alpha-granules, while other compartments of platelets are not functionally altered. PHx was performed in 8 mice per group and litter mate wild-type mice served as controls. Liver regeneration was assessed via liver-to-body-weight ratio and immunohistochemically in liver tissue.
Results: fl-IKK2-fl/PF-4-Cre mice were found to have a tendency towards increased liver regeneration at 48 hours after pHx (p=0.077). However, mortality rates were equal in genetically altered and in wild-type mice. Interestingly, Nbeal2-/-mice showed a higher incidence of postoperative mortality, while none of the wild-type controls died after pHx. In regard to liver regeneration, Nbeal2-/-mice tended to show lower liver-to-body-weight ratios at 72 hours after pHx.
Conclusion: In conclusion, a role of platelet degranulation was found within this study. While higher platelet reactivity was found to contribute beneficially to liver regeneration, depletion of alpha-granules as seen in Nbeal2-/-mice, lead to decreased liver regeneration and was even associated to postoperative mortality.
PL05-67 Remnant Hepatocellular Uptake Index (Rhui) as a Novel Functional Assessment of the Future Liver Remnant after Major Hepatectomy
Tsuyoshi Notake, Japan

T. Notake, A. Shimizu, K. Kubota, T. Ikehara, H. Hayashi, K. Yasukawa, A. Kobayashi, Y. Soejima
Department of Surgery, Shinshu University, Japan

Background: The aim of this study was to identify whether quantitative measurements with gadoxetate disodium-enhanced magnetic resonance imaging (EOB-MRI) could predict post-hepatectomy liver failure (PHLF) after major hepatectomy.
Methods: This study included 105 patients (including 58 biliary malignancies and 47 liver tumors) who underwent EOB-MRI before major hepatectomy. On preoperative MR images, future remnant liver (FRL) volume (FRLV) and mean signal intensities of FRL (rL20) and spleen (S20) were obtained. The remnant hepatocellular uptake index (rHUI) was calculated with following formula: FRLV × [(rL20/S20) - 1]. We evaluated ability of rHUI to predict PHLF which was graded PHLF grade B or C according to the criteria proposed by ISGLS and compared its accuracy with that of conventional indices, including proportion of FRLV (FRLVR) and ICGK-F (calculated as ICG-K x FRLVR).
Results: Among 105 patients, 11 met the criteria for PHLF. In entire cohort, rHUI was accurately predict PHLF with AUROC 0.89 (p< 0.01). The univariate analysis revealed rHUI (< 0.41), ICGK-F (< 0.08) and FRLVR (< 0.50) significantly associated with PHLF. But in multivariate analysis, only rHUI (< 0.41) was detected as independent risk factors for PHLF (OR 7.3x107, 95%CI N/A, p< 0.01). In patients with regional heterogeneity in liver function, FRLVR (< 0.50) and ICGK-F (< 0.08) could not predict PHLF, but only rHUI (< 0.41) accurately predict PHLF (portal vein embolization; p=0.018, pre-operative biliary drainage; p< 0.001).
Conclusion: The rHUI obtained from EOB-MRI could be a useful predictor of the future liver remnant after major hepatectomy.
PL05-69 13 Years Experience of Laparoscopic Management of Hydatid Disease at a Tertiary Care Centre
Prasanth Jayaraj, India

A. Krishna1, M. Jain1, P. Om1, H. Bhattacharjee1, S. Kumar1, M. Misra2, V. Bansal1, P. Jayaraj1
1Department of Surgical Disciplines, AIIMS, New Delhi, India, 2Department of Surgical Disciplines, Mahatma Gandhi University of Medical Sciences, Jaipur, India

Introduction: Human echinococcosis is a global parasitic zoonosis endemic in sheep raring countries like the Indian subcontinent, Australia, New Zealand etc. Surgery is the main stay of treatment and minimally invasive techniques offer similar outcomes with faster recovery, shorter hospital stay and lesser overall mortality and morbidity. We aim to report our experience in laparoscopic management of hydatid disease of the liver and lung over a period of 13 years at a tertiary care center.
Methods: A cohort of fifty eight patients of hydatid cyst disease who were managed by laparoscopic techniques between 2006 and 2019 were retrospectively reviewed. Surgical strategy, operative complication, operative time, postoperative morbidity and recurrence was evaluated.
Results: Of the 58, there was a male preponderance with mean age of 37 years. 8 patients had thoracic hydatidosis, 43 had abdominal disease and 7 involved both thoracic and abdominal involvement. 38 patients underwent deroofing and pericystectomy was performed in 12 patients and 8 patients underwent pericystectomy of lung hydatid in combination with deroofing of liver hydatid. 7 patients had spillage during the procedure. The mean operative time was 130+/-4 minutes with open conversion in 13 cases. The mean hospital stay was 4 +/- 1 days. In post op period 5 patients had bile leak, 1 underwent re exploration.
Conclusion: Laparoscopic management of hydatid disease is feasible and results are comparable to that of open surgery with faster recovery and lower morbidity and should be the standard of care provided.
PL05-71 Hepatotoxicity from Dengue Viral Infection: Treatment and Outcome: Experience from the Pacific Island Country of Tuvalu
Arnold Waine, Tuvalu

A. Waine
Princes Margaret Hospital, Funafuti, Tuvalu

Introduction: Small island pacific countries are often faced with health dilemmas. Limited health resources, unique disease burdens admix with incidences of public health diseases outbreaks often challenges the already health constraints. Recent Dengue Viral infection in children of Tuvalu has highlighted this issue. In this report, we aim to highlight on clinical management of hepatotoxicity from dengue infection.
Methodology: A prospective study was done using case audit of patients with sero-positive for dengue. Charts were assessed for age, gender, duration of admission. Continuous assessment for clinical progression and type of complication including hepatotoxicity. Treatment for complications and overall outcomes including mortality were assessed.
Result/discussion: There were 132 patients seen at outpatients with symptoms of Dengue. Febrile illness was the most common. About 27 % were confirm sero-positive on admission. The average age was five years and more common among male. Ten had severe elevated liver enzymes or hepatotoxicity with prolonged hospital stay (average of 14 days), two had fatality and one had severe hepato encephalopathy and needed overseas referral. There were no delayed complication after discharge.
Conclusion: Clinical management of severe complications from Dengue infection can be difficult and challenging in small developing countries in the Pacific.
PL05-72 Inflammatory Pseudotumor of the Liver, a Diagnostic Dilemma with Therapeutic Uncertainty in a Cohort of Bangladeshi Patients
Mahmud Mohammad Sarder, Bangladesh

M. Mohammad Sarder1, H. Rabbi2, H.A.N. Hakim3, M.M. Rashid2, T. Ahmed2, A.Q. Chowdhury3, M. Ali1
1Hepatobiliary and Pancreatic Surgery, BRB Hospitals Limited, Bangladesh, 2Hepatobiliary and Pancreatic Surgery, BIRDEM General Hospital, Bangladesh, 3Hepatobiliary and Pancreatic Surgery, Dhaka Medical College Hospital, Bangladesh

Background: Inflammatory pseudotumor (IPT) is a benign lesion seldom encountered in clinical practice. It's mysterious in origin and remains ambiguous. Infection, stone, autoimmune disease, systemic inflammatory response, trauma, foreign body and neoplasm attributed to be the etiological factors. Advanced imaging modalities help in increased detection of focal liver lesion.
Material and methods: The objective of this retrospective observational cohort study is to analyze its clinical significance. Thirty-three patients with focal liver lesions were evaluated and treated surgically as hepatic neoplasm consecutively from July 2013 to January 2020.
Results: There were 14 male (42.42%) and 19 female (57.58%) subjects in our study, mostly in the 3rd decade of life. Clinically only 21% of the patients presented with fever. In 24 patients (73%) the lesions were located in left lobe of liver. The operative procedures were: wedge resection in 3 patients (9.09%), limited resection in 05 patients (15.15%), Left Hepatectomy 07 patients (21.21%), Left lateral hepatic segmentectomy in 17 patients (51.51%), right hepatectomy in 02 patients (6.06%) and central hepatectomy in one patients (3.03%). Only 8 patients (24.24%) required bilioenteric anastomosis as additional procedure. Histopathological study revealed Tuberculosis in 7 patients (21.21%), fungal granuloma in 03 patients (9%), foreign body granuloma in 03 patients (9%), ductal calculi with abscess in 9 patients (27.27%) and idiopathic in 7 patients (21.21%).
Conclusions: Inflammatory pseudotumor of liver represents a rare entity usually mistaken as malignant lesion. Despite the low prevalence of hepatic inflammatory pseudotumors, it often creates a diagnostic dilemma resulting into therapeutic uncertainty.
PL05-75 Imaging Bioactivated Hepatic Spheroids, An Ideal Model System for Drug Hepatotoxicity Evaluations
Juan Liu, China

Y. Wang1, J. Liu2, R. Li3
1Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China, 2Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, China, 3Tissue Engineering Lab, Beijing Institute of Health Service and Transfusion Medicine, China

Introduction: Drug-induced liver injury (DILI) is a leading cause of acute liver failure. A major obstacle in prediction or evaluation of DILI is lack of an experimental model(s) that recapitulates stable and physiologically relevant liver functions and reflects accurately the level of drug hepatotoxicity. A hepatic spheroid model system, aggregates of Hepatic cells, which were treated with cryopulverized liver biomatrix scaffolds (LBSs), has been established for DILI investigations.
Methods: We obtained the LBS by a perfusion method to decellularize rat liver. The model was established with LBS treatment. We compared the liver specific functions and metabolic activity of spheroids with or without LBS treatment using flow cytometry, qRT-PCR, Elisa, and immunohistochemistry. The drugs with known hepatotoxicity were used to study sensitivity of spheroids. Multiparametric high-content imaging and analysis (HCA) was used to analyze the possible mechanisms of hepatotoxicity triggered by different drugs.
Results: The LBS-bioactivated hepatic spheroids were maintained for up to 4 weeks and demonstrated enhanced liver specific functions, CYP3A4 metabolic activity, bile excretion, and increased expression of metabolism enzymes, collectively hypothesized to result from increased cell-cell and cell-matrix interactions. Using established staining procedures with 10 fluorescence molecular probes, we achieved multiparametric confocal readouts, including marker-specific cell numbers, on viability, apoptosis, cholestasis, steatosis, oxidative stress and mitochondrial damage. By tracking key cell events, we could deduce the possible liver injury type.
Conclusion: This simple and robust high-throughput-compatible imaging hepatic spheroid model may have potential for use in toxicity screening, and represents an alternative to animal models for studying DILI.